The Merit-Based Incentive Payment System (MIPS) CONTINUED SHIFT FROM VOLUME TO VALUE presented by: AARON ELIAS, MSHA
MACRA 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 ! Page 1
Transition to MIPS Through Starting December 31, 2018 J anuary 1, 2019 • 0.5% annual MPFS • Annual MPFS update update (2016-2019) • 0% in 2020 - 2025 • Payment adjustments • 0.25% thereafter (0.75% for participants in • 2% PQRS reporting qualifying APMs) penalty • Single payment • 3% EHR meaningful use adjustment based on penalty composite performance • +/ - 4% Value-Based score (CPS) Modifier bonus/ penalty • Incentives for participation in APMs Page 2
MIPS Regulation CMS “Listening Tour” Proposed Rule published April 26, 2016 (“Quality Payment Program” ) Comments due to CMS by June 27, 2016 Final rule to be published prior to November 1, 2016 First performance year commences January 1, 2017 Payment adjustments commence January 1, 2019 Page 3
MIPS Eligible Clinicians (MECs) Years 3+ * Years 1 and 2 Physical or occupational therapists, speech-language pathologists, Physicians (MD/DO & DMD/DDS), audiologists, nurse midwives, clinical PAs, NPs, CNSs, CRNA social workers, clinical psychologists, dieticians/nutritional professionals * 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 4
Non-MECs 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) Page 5
Advanced APMs • 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) Page 6
QPs and Partial QPs Minimum % of patients/ payments through Advanced APM Higher threshold Advanced APM QP for Partial QPs Be excluded from MIPS QPs will: Receive 5% lump sum bonus Bonus applies in 2019-2024; Partial QPs not eligible for bonus, QPs receive higher MPFS but can opt out of MIPS payment updates starting in 2026 adjustments Page 7
MIPS Decision Tree YES YES Will you have less than $10,000 Q: Are you a physician or eligible Will you be newly enrolled in in charges or see less than 100 non-physician practitioner? Medicare in 2017? Medicare patients in 2017? NO NO NO Are you a participant in an YES Alternative Payment Model? NO Is your APM on the list of MIPS Participation Choice Advanced APMs for 2017? NO YES Determined to be a Qualified NO Participant (QP)*? YES EXEMPT APM ENTITY GROUP INDIVIDUAL from MIPS MIPS Reporting MIPS Reporting MIPS Reporting * Or partial qualifying APM Participant (Partial QP) and elects not to be subject to MIPS Page 8
Composite Score Components Advancing Care 25% 25% 25% Information (ACI) Clinical Practice 15% 15% 15% Improvement Activities (CPIA) 10% 15% 30% Resource Use ($) 50% 45% 30% Quality 2019 2020 2021 (and beyond) Page 9
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 6+ measures 80% of MIPS eligible Individual MIPS Eligible Part B Claims Including: one cross-cutting clinicians’ patients Clinicians (ECs) and one outcome** QCDR 6+ measures 90% of MIPS eligible Individuals MIPS Eligible Qualified Registry Including: one cross-cutting clinicians’ or groups’ Clinicians (ECs) or Groups EHR and one outcome** patients* Report on all measures Sampling requirements for Groups CMS Web Interface included Medicare Part B patients CMS-approved survey vendor paired with other Sampling requirements for Groups CAHPS for MIPS Survey mechanism, counts as one Medicare Part B patients measure * 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 10
Quality Measure Component Scoring Methodology § 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 Page 11
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 12
Resource Use Component Scoring Methodology § 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 Page 13
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 14
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 • Monitoring health • Timely communication • Establishment of care • Use of clinical and appointments conditions of test results plans surgical checklists • After-hours access to • Participation in qualified • Implement regular care • Use of shared decision- • Practice assessments clinician advice data registries coordination training making mechanisms • Use decision support • Use of tele-health • Participate in Million • Develop care plans for • Use group visits for and protocols services Hearts at-risk patients common chronic conditions • Collect patient • Participate in research experience and for targeted patient satisfaction data populations Patient Safety Expanded Population Care Beneficiary Practice Practice Access Management Coordination Engagement Assessment • See new and follow-up • Participate in • Engage patients with Medicaid patients in a humanitarian volunteer behavior health timely manner work conditions • Use QCDR to screen for • Participate in Disaster • Offer behavioral health social determinants of Medical Assistance services health Teams Emergency Integrated Achieving Health Response and Behavioral and Equity Preparedness Mental Health Page 15
CPIA Component Scoring Methodology § 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 Page 16
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 Base Score Performance Score § Points for submitting numerators and § Based on reported results for base score denominators: measures § Protection of patient health § Patient electronic access information* § Coordination of care § Electronic prescribing § Health information exchange § Patient electronic access § Bonus percentage point for public health § Coordination of care through patient registry engagement § Health information exchange § Public health and clinical data registry reporting *Must attest to a “yes” response to protection of patient health information to receive a non-zero base score Page 17
ACI Component Scoring Methodology Base Score Performance Score Composite ACI Score 100 Points (Maximum) 50 Points 80 Points **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 18
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