The New CMS Quality Payment Program: What You Need to Know for 2017 Denise Hudson, NR-CMA Health Informatics Specialist Health Services Advisory Group (HSAG) October 11, 2017 CMS = The Centers for Medicare & Medicaid Services
Disclosure I have nothing to report, nor are there any real or perceived conflicts of interest, implied or expressed, in the following presentation. Denise Hudson, NR-CMA Health Informatics Specialist 2
Agenda • Introduce HSAG • MACRA defined • Understand the impact of NOT participating • Overview of the MIPS categories, data submission methods, and scoring methodology • Learn where to find program resources and stay informed • Questions MACRA = Medicare Access and CHIP [Children’s Insurance Program] Reauthorization Act of 2015 3 MIPS = Merit-based Incentive Payment System
HSAG: Your Partner in Healthcare Quality • HSAG is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. • Committed to improving healthcare quality for more than 35 years. • QIN-QIOs in every state/territory are united in a network under the Centers for Medicare & Medicaid Services (CMS). • The Medicare QIO Program is the largest federal program dedicated to improving healthcare quality at the community level. 4
HSAG’s QIN -QIO Territory Nearly 25 percent of the nation’s Medicare beneficiaries HSAG is the Medicare QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. 5
What Is MACRA? MACRA stands for the Medicare Access & CHIP* Reauthorization Act of 2015, bipartisan legislation signed into law on April 16, 2015. * Children’s Health Insurance Program
What Does MACRA Do? • Repeals the Sustainable Growth Rate (SGR) Formula. • Changes the way that Medicare pays clinicians and establishes a new framework to reward clinicians for value over volume. • Streamlines multiple quality reporting programs into one new system: MIPS. • Provides bonus payments for participation in eligible Alternative Payment Models (APMs). 7
The Quality Payment Program (QPP) Clinicians have two tracks from which to choose: Advanced OR MIPS APMs MIPS Advanced APMs If you decide to participate in traditional If you decide to participate in an Advanced APM, Medicare, you may earn a performance- you may earn a Medicare incentive payment for based payment adjustment through MIPS. participating in an innovative payment model. 8 Source: The Centers for Medicare & Medicaid Services
Discussion Structure • Part 1: What do I need to know about MIPS? • Part 2: How do I prepare for and participate in MIPS? 9
Part 1: MIPS Basics What Do I Need To Know?
MIPS Visualization A visualization of how legacy programs streamline into the MIPS performance categories PQRS Quality VM Cost Advancing Care EHR Information Example of legacy program phase out for PQRS Last Performance Period PQRS Payment End 2018 2016 PQRS = Physician Quality Reporting System Source: The Centers for Medicare & Medicaid Services VM = Value-Based Payment Modifier 11 EHR= Electronic Health Record
What is the MIPS? Performance Categories : Advancing Care Improvement Quality Cost Information Activities • Comprised of four performance categories • Provides MIPS-eligible clinician types included in the 2017 Transition Year with the flexibility to choose the activities and measures that are most meaningful to their practice. 12 Source: The Centers for Medicare & Medicaid Services
What Are the Performance Category Weights? • Weights assigned to each category is based on a 1 to 100 point scale. Transition Year Weights Advancing Care Improvement Quality Cost Information Activities 60% 0% 15% 25% Note: These are defaults weights; the weights can be adjusted in certain circumstances. 13
When Does MIPS Officially Begin? Performance Adjustment Submit Feedback available year 2017 March 31, 2018 January 1, 2019 Feedback Performance Year Data Submission Payment Adjustment • CMS provides • Performance period opens • Deadline for submitting data is • MIPS payment performance feedback January 1, 2017. March 31, 2018. adjustments are • Performance period closes • Clinicians are encouraged to after data is submitted. prospectively applied to • Clinicians will receive December 31, 2017. submit data early. each claim beginning on • Clinicians care for patients and feedback before the start January 1, 2019. of the payment year. record data during the year. 14 Source: The Centers for Medicare & Medicaid Services
MIPS Participation What Do I Need to Know?
Participation Basics Must be a MIPS-eligible clinician type billing more than $30,000 a year in Medicare Part B allowed charges AND providing care for more than 100 Medicare patients a year. BILLING AND >$30,000 >100 MIPS-eligible clinician types include: Certified Clinical Physician Nurse Registered Physicians Nurse Assistants Practitioner Nurse Specialist Anesthetists 16 Source: The Centers for Medicare & Medicaid Services
Participation Basics (cont.) The definition of Physicians: Note : The following types of Doctors of Medicine Clinicians may become eligible in Doctors of Osteopathy 2019: Audiologist, Clinical Social Doctors of Dental Surgery Workers, Clinical Psychologist, Doctors of Dental Medicine Dietitians, Nurse Midwives, Doctors of Podiatric Medicine Nutritional Professionals, Doctors of Optometry Occupational Therapist, Physical Doctors of Chiropractic Medicine Therapist and Speech Pathologist. 17 Source: The Centers for Medicare & Medicaid Services
Who Is Exempt From MIPS? Clinicians who are: Advanced APM Significantly Below the low- Newly-enrolled participating in volume threshold in Medicare Advanced APMs • Medicare Part B • • Enrolled in Receive 25% of allowed charges Medicare for the Medicare less than or equal first time during payments to $30,000 a year the performance OR OR • period (exempt See 20% of • See 100 or fewer until following Medicare patients Medicare Part B performance year) through an patients a year Advanced APM 18 Source: The Centers for Medicare & Medicaid Services
If You Are Exempt… • You may choose to voluntarily submit quality data to CMS to prepare for future participation, but you will not qualify for a payment adjustment based on your 2017 performance. • This will help you hit the ground running when you are eligible for payment adjustments in future years. 19 Source: The Centers for Medicare & Medicaid Services
Participation Basics: Individual vs. Group Reporting Options Individual Group 2. As a Group 1. Individual — under a NPI number a) 2 or more clinicians (NPIs) who and TIN where they reassign benefits have reassigned their billing rights to a single TIN* b) As an APM Entity * If clinicians participate as a group, they are assessed as a group across all four MIPS performance categories. NPI = National Provider Identifier 20 TIN = Tax Identification Number
Participation Example: Individual Level — Included in MIPS Dr. “A” is an M.D.: • A MIPS-eligible clinician type • Billed $100,000 in Medicare Part B allowed charges BILLING Included • Saw 110 patients $100,000 in MIPS 110 ≥100 “So what?” Dr. A should actively participate in MIPS during the Transition Year to avoid a 4% reduction in Medicare Part B payments in 2019 and possibly earn a positive payment adjustment. BILLING Remember: To be eligible AND >$30,000 >100 21 Source: The Centers for Medicare & Medicaid Services
Participation Example: Individual Level — Exempt from MIPS Dr. “B” is a D.O: • A MIPS-eligible clinician type • Billed $100,000 in Medicare Part B EXEMPT allowed charges BILLING from • Saw 80 patients $100,000 80 MIPS “So what?” Dr. B. would be EXEMPT from MIPS ≥100 due to seeing less than 100 patients. BILLING Remember: To be eligible AND >$30,000 >100 22 Source: The Centers for Medicare & Medicaid Services
Participation Basics: Group Level Options BILLING Individually Group $100,000 (Assessed at the TIN/NPI level) (Assessed at the TIN level) ≥100 As a Group Dr. “A” Dr. “B” Nurse Practitioner (Dr. A, Dr. B, NP) • Billed $100K • • Billed $50K Billed $100K • Billed $250K • Saw 100 patients • • Saw 80 patients Saw 40 patients • Saw 230 patients Included in MIPS Exempt from MIPS Exempt from MIPS ALL included in MIPS BILLING Remember: To participate AND >$30,000 >100 23 Source: The Centers for Medicare & Medicaid Services
Participation at the Group Level You Have Asked: “Does the $30,000 in Medicare Part B allowed charges AND 100 Medicare Part B patients also apply at the group level if my practice chooses group reporting? “So what?” The low-volume threshold ≥100 exclusion is based on both the individual Yes. For Transition Year 2017, the low- (TIN/NPI) and group (TIN) status. For volume threshold for MIPS also applies group-level reporting, a group (as a at the group level. whole) is assessed to determine if it exceeds the low-volume threshold. 24 Source: The Centers for Medicare & Medicaid Services
MIPS Eligibility Do You Know Your Eligibility Status?
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