The Merit-Based Incentive Payment System (MIPS) CONTINUED SHIFT - - PowerPoint PPT Presentation

presented by:

AARON ELIAS, MSHA

CONTINUED SHIFT FROM VOLUME TO VALUE

The Merit-Based Incentive Payment System (MIPS)

Page 1

Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”) FFS payment adjustments based on individual composite performance score Quality Efficiency and Resource Use Advancing Care Information (Meaningful Use) Clinical Practice Improvement Activities Exception for qualifying APM participants

!

MACRA

Page 2

Through December 31, 2018

• 0.5%

annual MPFS update (2016-2019)

• Payment adjustments
• 2%

PQRS reporting penalty

• 3%

EHR meaningful use penalty

• +/ - 4%

Value-Based Modifier bonus/ penalty

Starting J anuary 1, 2019

• Annual MPFS update
• 0%

in 2020 - 2025

• 0.25%

thereafter (0.75% for participants in qualifying APMs)

• Single payment

adjustment based on composite performance score (CPS)

• Incentives for

participation in APMs

Transition to MIPS

Page 3

Payment adjustments commence January 1, 2019 First performance year commences January 1, 2017 Final rule to be published prior to November 1, 2016 Comments due to CMS by June 27, 2016 Proposed Rule published April 26, 2016 (“Quality Payment Program” ) CMS “Listening Tour”

MIPS Regulation

Page 4

Years 1 and 2 Years 3+*

Physicians (MD/DO & DMD/DDS), PAs, NPs, CNSs, CRNA

Physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dieticians/nutritional professionals

MIPS Eligible Clinicians (MECs)

*Clinicians ineligible the first 2 years may voluntarily

report to gain experience in the MIPS program, though these clinicians will not receive a MIPS adjustment during the period.

Page 5

1. First year of M edicare Part B participation 2. Below low volume threshold

§ M edicare billed charges of $10,000 or less and § Provide care for 100 or fewer M edicare beneficiaries

3. Qualifying Participants (QPs) in Advanced APM s

Note: MIPS does not apply to Part A providers (including hospitals, rural health clinics, federally qualified health centers)

Non-MECs

Page 6

• Medicare Shared Savings Program
• Tracks 2 & 3 only
• Next Generation ACO Model
• Comprehensive ESRD Care
• Comprehensive Primary Care Plus (CPC+)
• Oncology Care Model (OCM)
• Two-sided risk track only (available in

2018)

Advanced APMs

Page 7

Be excluded from MIPS

Minimum % of patients/ payments through Advanced APM

Receive 5% lump sum bonus Bonus applies in 2019-2024; QPs receive higher MPFS updates starting in 2026

QPs will:

QP Advanced APM Higher threshold for Partial QPs Partial QPs not eligible for bonus, but can opt out of MIPS payment adjustments

QPs and Partial QPs

Page 8

MIPS Decision Tree

Are you a physician or eligible non-physician practitioner?

Q:

NO YES

Will you be newly enrolled in Medicare in 2017? Will you have less than $10,000 in charges or see less than 100 Medicare patients in 2017? Are you a participant in an Alternative Payment Model? MIPS Participation Choice Is your APM on the list of Advanced APMs for 2017?

GROUP MIPS Reporting INDIVIDUAL MIPS Reporting

Determined to be a Qualified Participant (QP)*?

APM ENTITY MIPS Reporting EXEMPT from MIPS

* Or partial qualifying APM Participant (Partial QP) and elects not to be subject to MIPS

YES NO NO YES YES YES NO NO NO

Page 9

Composite Score Components

50% 45% 30% 10% 15% 30% 15% 15% 15% 25% 25% 25% 2019 2020 2021 (and beyond)

Quality Resource Use ($) Clinical Practice Improvement Activities (CPIA) Advancing Care Information (ACI)

Page 10

Quality Measure Component

§ Closely related to historic PQRS § Reporting requirements less strict; various reporting mechanisms available § Specialty-specific measures groups or individual measures § Plus 3 population-based measures (no reporting necessary)

Measure Type Reporting Mechanism Criteria Data Completeness Individual MIPS Eligible Clinicians (ECs) Part B Claims 6+ measures Including: one cross-cutting and one outcome** 80%

• f MIPS eligible

clinicians’ patients Individuals MIPS Eligible Clinicians (ECs) or Groups QCDR Qualified Registry EHR 6+ measures Including: one cross-cutting and one outcome** 90%

• f MIPS eligible

clinicians’ or groups’ patients* Groups CMS Web Interface Report on all measures included Sampling requirements for Medicare Part B patients Groups CAHPS for MIPS Survey CMS-approved survey vendor paired with other mechanism, counts as one measure Sampling requirements for Medicare Part B patients

* This includes all patients, not just Medicare patients, which is a major change for some groups who have historically participated in PQ RS . ** If less than 6 measures apply, then report on each measure that is applicable. Choice between individual measures or specialty specific measures.

Page 11

Quality Measure Component

§ Quality measure benchmarks established prior to performance period (benchmarks for 2017 based on 2015) § Points given for actual performance, split into deciles

§ Decile 1 = 1 point (lowest possible) § Decile 10 = 10 points (highest possible)

§ Bonus points for:

§ Reporting high priority measures (1-2 bonus points per measure) § Using QCDR or CEHRT for reporting (1 bonus point)

§ If you report more than the minimum, CMS will select your best measures

Scoring Methodology

Page 12

Resource Use Component

§ Incorporate current VBM total cost of care measures § No reporting requirements – CMS automatically calculates based on administrative claims

§ Still using a beneficiary attribution process § Change from VBM: over 40 episode-specific measures to account for differences among specialties

§ Greater than 20-patient sample § Score based on total score divided by highest possible score

Page 13

Resource Use Component

§ Resource use benchmarks set during the actual performance year (benchmarks for 2017 based on 2017 actual) § Points given for actual performance, split into deciles:

§ Decile 1 (highest cost) = 1 point § Decile 10 (lowest cost) = 10 points

§ Average of points for all applicable resource measures

Scoring Methodology

Page 14

Resource Use Component

§ Measures development (for future years)

§ CMS to develop new classification codes in 2016-17

§ Care episode groups § Patient condition groups § Patient relationship categories

§ Beginning J anuary 1, 2018, claims must include new codes as appropriate

Page 15

CPIA Component

§ Clinical Practice Improvement Activities § Activities weighted as either “high” or “medium” § Eight different subcategories of activities, plus participation in an APM

• Same day

appointments

• After-hours access to

clinician advice

• Use of tele-health

services

• Collect patient

experience and satisfaction data Expanded Practice Access

• Monitoring health

conditions

• Participation in qualified

data registries

• Participate in Million

Hearts

• Participate in research

for targeted patient populations Population Management

• Timely communication
• f test results
• Implement regular care

coordination training

• Develop care plans for

at-risk patients Care Coordination

• Establishment of care

plans

• Use of shared decision-

making mechanisms

• Use group visits for

common chronic conditions Beneficiary Engagement

• Use of clinical and

surgical checklists

• Practice assessments
• Use decision support

and protocols Patient Safety Practice Assessment

• See new and follow-up

Medicaid patients in a timely manner

• Use QCDR to screen for

social determinants of health Achieving Health Equity

• Participate in

humanitarian volunteer work

• Participate in Disaster

Medical Assistance Teams Emergency Response and Preparedness

• Engage patients with

behavior health conditions

• Offer behavioral health

services Integrated Behavioral and Mental Health

Page 16

CPIA Component

§ Maximum score = 60 points

§ Medium weight = 10 points § High weight = 20 points

§ Exceptions:

§ Small groups (<=15 professionals), HPSA, etc. must only report on two activities (30 points given for any activity) § APM participants start with 30 points § Patient-Centered Medical Homes automatically receive 60 point max

Scoring Methodology

Page 17

Advancing Care Information (ACI)

§ Formerly known as Meaningful Use (MU) § Component is split into two parts: base score and performance score § Performance measures correlate to MU Stage 3 or modified Stage 2

*Must attest to a “yes” response to protection of patient health information to receive a non-zero base score

§ Points for submitting numerators and denominators:

§ Protection of patient health information* § Electronic prescribing § Patient electronic access § Coordination of care through patient engagement § Health information exchange § Public health and clinical data registry reporting

§ Based on reported results for base score measures

§ Patient electronic access § Coordination of care § Health information exchange

§ Bonus percentage point for public health registry

Performance Score Base Score

Page 18

ACI Component

Scoring Methodology

Base Score

50 Points

Performance Score

80 Points Composite ACI Score 100 Points (Maximum)

**Opportunity for 1 bonus point for public health registry participation

Note: Potential to score more than 100 points based on performance score; however, score will be capped at 100.

Page 19

Composite Performance Score

§ Composite Performance Score = CPS § Assigned lowest potential score for a category if fail to report required information § Multiple reporting methods; option to be assessed as a group, as an individual, or with your APM entity

§ Score will ultimately be tied to a TIN/ NPI combination number § CPS will follow the individual, regardless of reporting mechanism

§ Starting in 2020, formula to reward year-to-year score improvement

Page 20

Composite Performance Score

§ CMS to provide Eligible Clinicians (ECs) with regular performance feedback reports

§ Beginning 07/ 01/ 17, ECs to receive confidential feedback

• n quality and resource use measures

§ Beginning 07/ 01/ 18, ECs to receive patient claims data

§ CMS to establish informal review process; limits on administrative and judicial review § CMS to calculate CPS of 1 to 100 for each EP at conclusion of performance period

Page 21

Composite Performance Score

Quality Score Resource Use Score CPIA Score Advancing Care Information Score

Component Weight Component Weight Component Weight Component Weight ACI Points CPIA Points Resource Use Points Quality Points

COMPOSITE PERFORMANCE SCORE (CPS), 1 – 100

Page 22

Threshold Value

• Must be the mean or median of

composite performance score for all EPs

• 2019 threshold will be modeled

based on 2014 and 2015

• CMS will aim to set the threshold

such that 50%

• f ECs will fall

above/ below

• By Year 3, CPS must be at or

above prior year values Impact on Eligible Clinicians

• Score below threshold = penalty
• Score above threshold = bonus
• Must remain a budget neutral

program

• Scaling factor, like VM, for

additional upward potential

Performance Threshold

Page 23

MIPS Payment Adjustments

2019 2022

(and beyond)

2020 2021

+4%

• 4%

+5%

• 5%

+7%

• 7%

+9%

• 9%

Plus: Scaling Factor Plus: Scaling Factor Plus: Scaling Factor Plus: Scaling Factor

Composite Performance Score Impact on Medicare Part B Payments:

Performance Threshold

Page 24

Physician Compare

For each eligible clinician, MIPS composite score and performance category scores For each EC in a qualifying APM, name and performance of APM (when feasible) Periodically, aggregate information on the MIPS (range of scores for all eligible clinicians)

Page 25

2018 2019

No change in payments; eligible clinicians report on 2017 performance MECs receive payments based on 2019 adjustment factor (+ exceptional performance incentives); MECs report on 2018 performance CMS calculates MIPS composite performance score for each MEC based on 2017 performance CMS calculates MIPS composite performance score for each MEC based on 2018 performance CMS calculates and announces mean/ median composite performance score CMS calculates and announces mean/ median composite performance score CMS calculates and announces each MEC’s 2019 adjustment factor (based on 2017 performance compared to mean/ median composite performance score) CMS calculates and announces each MECs 2020 adjustment factor (based on 2018 performance compared to mean/ median composite performance score) CMS calculates and announces 2019 exceptional performance incentive payments CMS calculates and announces 2020 exceptional performance incentive payments

Timing

Note: Information in this presentation was from the Notice for Proposed Rulemaking (NPRM) on MIPS and APMs published on April 26, 2016. The final rule is expected to be released Fall 2016.

Questions?

PERSHING YOAKLEY & ASSOCIATES, P.C. 800.270.9629 | www.pyapc.com

AARON ELIAS, MSHA

Consulting Senior aelias@ pyapc.com (404) 266-9876

• “Simple is better”
• Advisory practice focused on value transformation and strategy
• Analytic focus