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Register for Webinars or Access Recordingshttp://mingleanalytics.com/webinars
Dr. Dan Mingle
2017 Proposed RuleMIPS Composite Performance Score –Resource Use Performance Category
Starting atNoon EDT8/22/2016
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Agenda
• Context - Review– Evolution from PQRS to QPP– MIPS Adjustment Factor– MIPS Composite Performance Score
• Details of the Resource Use Performance Category
• Watch for Future Webinars– Alternate Payment Mechanisms
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Networking Opportunities• Florida Bones Society, Manalapan, FL, Sept 16 – 19: Speaking• HBMA Revenue Cycle Conference, Atlanta, GA, Sept 21 – 23: Speaking• NH/VT HFMA Fall Conference, Manchester, VT, Sept 28: Speaking• CAPG Annual Conference, Washington, DC, Sept 28 – 30: Attending• HIMSS Big Data Conference, Boston, MA, Oct 24 – 25: Attending• Maine Health Management Coalition / Maine Medical Association,
Annual Conference, Portland, ME: Attending• AMBA Annual Conference, Las Vegas, NV, October 27 – 28: Attending• MGMA Annual Conference, San Francisco, CA, October 30 – Nov 2:
Attending
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MACRAMedicare Access and CHIP Reauthorization Act of 2015
Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive
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Proposed Rule for QPP Published May 9, 2016
Final Rule to be Published by November 1 Annually
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Introducing Medicare’s New
Quality Payment Program
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Quality Payment Program(QPP)
Merit-Based Incentive Payment
System (MIPS)
Alternate Payment Mechanisms (APM)
Eligible Clinicians
Qualified Providers (QP)
APM Type
APM Entity
Advanced APM
Partial QP
Split TIN
Virtual Groups
2017 First Reporting Year
March 31, 2018 First Submission Due
2019 First Payment Adjustments Applied
2016 Last Reporting Year
March 31, 2017 Last Submission Due
2018 Last Payment Adjustments Applied
Physician Quality Reporting System (PQRS)
Medicare EHR Incentive Program (aka: meaningful use)
Value Based Modifier (VBM or VM)
Quality Tiering
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$Value Based Purchasing
Quality / Cost
$$$Fee For Service
Volume Based Payment
Revenues Increasingly at Risk$50B Medicare Revenue will be at risk by 2022
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ProgramYear
Reporting (Service Year)
Adjustment Expected
PhysicianAverage
2019 2017 ± 4% ± $4,000
2020 2018 ± 5% ± $5,000
2021 2019 ± 7% ± $7,000
2022 2020 ± 9% ± $9,000
CMS 2013 PQRS Experience Report
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Estimated Impact in 2019
Program Applies to NegativeAdjustments
PositiveAdjustments
MIPS Adjustments 687k to 747k providers $833m $833mExceptional Performance Payments $500mAdvanced APM Incentives 30k – 90k Providers $146m - $429m
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2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q2Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 Submissions
Jan Feb Mar Apr May Jun
Full Year Data Set
2016 Submissions
Providers: Provide Care | Document Care | Accumulate Data
Monitor Extractions, Data Exchange, and Performance. Remediate Problems
PQRS EndsMIPS Begins
Submission Portal Opens
EHR & QCDR QRDA Due
Registry & QCDR XML Due
GPRO Web Interface Due
GPRO 2016 Self Nomination Due
2015 Feedback Reports
and QRUR
Available
Submission Portal Opens
EHR & QCDR QRDA Due
Registry & QCDR XML Due
GPRO Web Interface Due
2017 Penalty Notices
2017 Q1
PQRS Timeline
Apply for Informal Review
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Quality Tiering – How it was done
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5% 90% 5%
Low Quality
AvgQuality
High Quality
0 +2x% +4x% Low Cost 5%
-2% 0 +2x% AvgCost 90%
-4% -2% 0 High Cost 5%
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Conceptual Model of MIPS Year 1
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From the CMS Proposed Rule2017ReportingYear
2019Payment or ProgramYear
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Conceptual Model of MIPS Year 1
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From the CMS Proposed Rule
PmtYear
AdjFactor
2019 ± 4%
2020 ± 5%
2021 ± 7%
2022 ± 9%
2017ReportingYear
2019Payment or ProgramYear
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Conceptual Model of MIPS Year 1
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From the CMS Proposed Rule
PmtYear
AdjFactor
2019 ± 4%
2020 ± 5%
2021 ± 7%
2022 ± 9%
2019 2020 2021
Quality 50 45 30
Cost 10 15 30
ACI 25 25 25
CPIA 15 15 15
2017ReportingYear
2019Payment or ProgramYear
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Conceptual Model of MIPS Year 1
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From the CMS Proposed Rule
PmtYear
AdjFactor
2019 ± 4%
2020 ± 5%
2021 ± 7%
2022 ± 9%
2019 2020 2021
Quality 50 45 30
Cost 10 15 30
ACI 25 25 25
CPIA 15 15 15
2017ReportingYear
2019Payment or ProgramYear
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Each Performance Category must be submitted with a Single Mechanism
Medicare Encourages Groups and Individuals to use the same Vendor for 3 Performance
Categories
Resource Use is the one Performance Category that Requires no Submission
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Submission Mechanisms
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Mechanism
ResourceUse
Quality AdvancingCare
Information
Clinical Practice Improvement
Activities
Attestation Ind | Grp Ind | Grp
Qualified Registry Ind | Grp Ind | Grp Ind | Grp
Qualified Clinical Data Registry (QCDR) Ind | Grp Ind | Grp Ind | Grp
Electronic Health Record /Data Submission Vendor Ind | Grp Ind | Grp Ind | Grp
Web Interface Grp ≥ 25 Grp ≥ 25 Grp ≥ 25
Survey Vendor Grp ≥ 2
Administrative Claims Ind | Grp SelectMeasures Maybe
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Proposed Components of the Resource Use Performance Category
• Total Costs per Capita for All Attributed Beneficiaries• Medicare Spending per Beneficiary (MSPB)• Episode Based Measures (New)
– 31 Method A Measures– 7 Method B Measures
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Resource Use Dynamics
• Performance Period– 2 Calendar years Prior to Payment Period
• Claims Data Run-out– 60-day floor (March 1)– 90-day goal (March 31)
• Partial Year Practitioners evaluated for all available data– Subject to low-volume thresholds
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MIPS Excluded Clinicians
• Newly Medicare-enrolled eligible clinicians• Qualifying APM Participants (QPs)• Certain Partial Qualifying APM Participants (Partial QPs),• Clinicians that fall under the low-volume threshold
– Individual or Group with ≤ $10,000 Allowable ChargesAND≤ 100 unique Medicare Beneficiaries
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Resource Use Exclusions
• Will not apply to Shared Savings Plan and Next Gen ACO Model Participants– Distribute weight evenly between ACI & CPIA
• All other APM– 0% Quality – Quality reporting will be specific to the APM type– 0% Resource Use – Resource Use analysis will be specific to the APM
type– 25% CPIA– 75% ACI
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Adjustments
• Geographic Payment Rate• Beneficiary Risk (HCC Codes)• Specialty Adjustment applied only to Total per Capita Costs
Measure
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Plans to Develop
• Additional Episode Measures• Additional Patient Condition Groups• Patient Relationship Categories• Risk Adjustment on Socio-Economic Status• Include Part D Costs
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Change from VBM
• Track Resource Use by Group (TIN) AND Individual (NPI)• For the MSPB measure
– Eliminate Specialty adjustment (Risk Adjustment appears to be adequate
– Drop case minimum from 125 to 20
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Attribution Methodology
Total Per Capita Cost1. When there is at least one Primary
Care Provider Visit– Attribute to the TIN with the Plurality of PC
visit codes by PCPs
2. When there is no Primary Care Provider Visit– Attribute to the TIN with the Plurality of PC
visit codes by Specialists
Medicare Spending per Beneficiary• Attribute to the TIN providing the
Plurality of MC Part B charges during the hospitalization
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Episode Groupers
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Proposed Method A Episode Measures• Breast
– Mastectomy for Breast Cancer• Cardiovascular
– Acute Myocardial Infarction (AMI) without PCI/CABG– Abdominal Aortic Aneurysm– Thoracic Aortic Aneurysm– Aortic/Mitral Valve Surgery– Atrial Fibrillation (AFib)/Flutter, Acute Exacerbation– Atrial Fibrillation (AFib)/Flutter, Chronic– Ischemic Heart Disease (IHD), Chronic– Pacemaker– Percutaneous Cardiovascular Intervention (PCI)
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Proposed Method A Episode Measures• Cerebrovascular
– Ischemic Stroke– Carotid Endarterectomy
• Gastrointestinal– Cholecystitis– Clostridium difficile Colitis– Diverticulitis of Colon
• Genitourinary– Prostatectomy for Prostate Cancer
• Infectious Disease– Kidney and Urinary Tract Infection (UTI)
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Proposed Method A Episode Measures
• Metabolic– Osteoporosis
• Neurology– Parkinson Disease
• Musculoskeletal– Rheumatoid Arthritis– Hip/Femur Fracture or Dislocation Treatment, Inpatient (IP)-Based– Hip Replacement or Repair– Knee Arthroplasty (Replacement)– Spinal Fusion
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Proposed Method A Episode Measures
• Respiratory– Asthma/Chronic Obstructive Pulmonary Disease (COPD), Acute Exacerbation– Asthma/Chronic Obstructive Pulmonary Disease (COPD), Chronic– Pneumonia, Community Acquired, Inpatient (IP)-Based– Pneumonia, Community Acquired, Outpatient (OP)-Based– Pulmonary Embolism, Acute– Upper Respiratory Infection, Acute, Simple
• Vascular– Deep Venous Thrombosis of Extremity, NOS, Acute
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Proposed Method B Episode Measures
• Gastrointestinal– Cholecystectomy and Common Duct Exploration– Colonoscopy and Biopsy– Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia
• Infectious Disease– Kidney and Urinary Tract Infection (UTI)
• Ophthalmology– Lens and Cataract Procedures
• Musculoskeletal– Hip Replacement or Repair– Knee Arthroplasty (Replacement)
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Scoring the Resource Use Performance Category
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Resource Use Scoring Basics
• Score Each Measure on a 10 point scale• Compare to Measure-Specific Performance Period Benchmarks• Consider Improvement Scoring after the First Year• 20 case minimum to be included in Benchmark• Composite Score is a Straight Average of All Calculated
Standardized Components that have a 20 case Minimum
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Converting Resource Use to a Standard Score
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Analysis by CMSResource Use expressed as
$ Value
$xxx
Output to Practices and the PublicResource Use Expressed as a
Normalized Score
1.0 – 10.0
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Converting a Performance Rate to a Standard Score
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BenchmarkDecile
HypotheticalResource Use
Scored
1 ≥ $100,000 1.0 – 1.9
2 $75,893-$99,999 2.0 – 2.9
3 $69,003-$75,892 3.0 – 3.9
4 $56,009-$69,002 4.0 – 4.9
5 $50,300-$56,008 5.0 – 5.9
6 $34,544-$50,299 6.0 – 6.9
7 $27,900-$34,543 7.0 – 7.9
8 $21,656-$27,899 8.0 – 8.9
9 $15,001-$21,655 9.0 – 9.9
10 $1,000-$15,000 10
($56008 – $50300)/10 = $571
Every $571 increments 0.1 Score
Performance Score
$56,008 to $55,437 5.0
$55,436 to $54,866 5.1
$54,865 to $54,295 5.2
$54,294 to $53,724 5.3
$53,723 to $53,153 5.4
$53,152 to $52,582 5.5
$52,582 to $52,011 5.6
$52,010 to $51,440 5.7
$51,439 to $50,869 5.8
$50,868 to $56,008 5.9
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Measure Type Cases Performance$ Median Points Total
Possible
1Medicare
Spending PerBeneficiary
20 $15,000 $13,000 4.0 10
2 Total PerCapita Costs 21 $12,000 $10,000 4.2 10
3 Episode 1 22 $15,000 $18,000 5.8 10
4 Episode 2 10 $11,000 $9,000BelowCase
ThresholdNA
5 Episode 3 45 $7,000 $10,000 8.3 10
TotalPoints 22.3 40
Hypothetical ScoringExample
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Measure Type Cases Performance$ Median Points Total
Possible
1Medicare
Spending PerBeneficiary
20 $15,000 $13,000 4.0 10
2 Total PerCapita Costs 21 $12,000 $10,000 4.2 10
3 Episode 1 22 $15,000 $18,000 5.8 10
4 Episode 2 10 $11,000 $9,000BelowCase
ThresholdNA
5 Episode 3 45 $7,000 $10,000 8.3 10
TotalPoints 22.3 40
4 Resource Use Measures Scored
Total Possible Points = 40
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Measure Type Cases Performance$ Median Points Total
Possible
1Medicare
Spending PerBeneficiary
20 $15,000 $13,000 4.0 10
2 Total PerCapita Costs 21 $12,000 $10,000 4.2 10
3 Episode 1 22 $15,000 $18,000 5.8 10
4 Episode 2 10 $11,000 $9,000BelowCase
ThresholdNA
5 Episode 3 45 $7,000 $10,000 8.3 10
TotalPoints 22.3 40
Actual Total Score = 22.3
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Measure Type Cases Performance$ Median Points Total
Possible
1Medicare
Spending PerBeneficiary
20 $15,000 $13,000 4.0 10
2 Total PerCapita Costs 21 $12,000 $10,000 4.2 10
3 Episode 1 22 $15,000 $18,000 5.8 10
4 Episode 2 10 $11,000 $9,000BelowCase
ThresholdNA
5 Episode 3 45 $7,000 $10,000 8.3 10
TotalPoints 22.3 40
22.3 Possible÷ 40 Total Points= 55.8%
Max Resource Use Category Score for 2017 = 10
55.8% of 10 = 5.6
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Conceptual Model of MIPS Year 1
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From the CMS Proposed Rule
PmtYear
AdjFactor
2019 ± 4%
2020 ± 5%
2021 ± 7%
2022 ± 9%
2019 2020 2021
Quality 50 45 30
Cost 10 15 30
ACI 25 25 25
CPIA 15 15 15
2017ReportingYear
2019Payment or ProgramYear
In our Example:Resource Use (Cost)= 5.6
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Pulling it All Together
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From the CMS Proposed Rule
Component Presented
Quality 7/13/2016 37.3 of 50
Cost
ACI
CPIA
Composite Performance
![Page 42: 2017 Proposed Rule MIPS Composite Performance Score ...€¦ · Networking Opportunities • Florida Bones Society, Manalapan, FL, Sept 16 – 19: Speaking • HBMA Revenue Cycle](https://reader033.vdocuments.net/reader033/viewer/2022050717/5f05ad987e708231d414279f/html5/thumbnails/42.jpg)
Pulling it All Together
8/24/2016 ©2016 Mingle Analytics 42
From the CMS Proposed Rule
Component Presented
Quality 7/13/2016 37.3 of 50
Cost
ACI 7/28/2016 21.9 of 25
CPIA
Composite Performance
![Page 43: 2017 Proposed Rule MIPS Composite Performance Score ...€¦ · Networking Opportunities • Florida Bones Society, Manalapan, FL, Sept 16 – 19: Speaking • HBMA Revenue Cycle](https://reader033.vdocuments.net/reader033/viewer/2022050717/5f05ad987e708231d414279f/html5/thumbnails/43.jpg)
Pulling it All Together
8/24/2016 ©2016 Mingle Analytics 43
From the CMS Proposed Rule
Component Presented
Quality 7/13/2016 37.3 of 50
Cost
ACI 7/28/2016 21.9 of 25
CPIA 8/4/2016 12.5 of 15
Composite Performance
![Page 44: 2017 Proposed Rule MIPS Composite Performance Score ...€¦ · Networking Opportunities • Florida Bones Society, Manalapan, FL, Sept 16 – 19: Speaking • HBMA Revenue Cycle](https://reader033.vdocuments.net/reader033/viewer/2022050717/5f05ad987e708231d414279f/html5/thumbnails/44.jpg)
Pulling it All Together
8/24/2016 ©2016 Mingle Analytics 44
From the CMS Proposed Rule
Component Presented
Quality 7/13/2016 37.3 of 50
Cost 8/24/2016 5.6 of 10
ACI 7/28/2016 21.9 of 25
CPIA 8/4/2016 12.5 of 15
Composite Performance
![Page 45: 2017 Proposed Rule MIPS Composite Performance Score ...€¦ · Networking Opportunities • Florida Bones Society, Manalapan, FL, Sept 16 – 19: Speaking • HBMA Revenue Cycle](https://reader033.vdocuments.net/reader033/viewer/2022050717/5f05ad987e708231d414279f/html5/thumbnails/45.jpg)
Pulling it All Together
8/24/2016 ©2016 Mingle Analytics 45
From the CMS Proposed Rule
Component Presented
Quality 7/13/2016 37.3 of 50
Cost 8/24/2016 5.6 of 10
ACI 7/28/2016 21.9 of 25
CPIA 8/4/2016 12.5 of 15
Composite Performance 76.3
![Page 46: 2017 Proposed Rule MIPS Composite Performance Score ...€¦ · Networking Opportunities • Florida Bones Society, Manalapan, FL, Sept 16 – 19: Speaking • HBMA Revenue Cycle](https://reader033.vdocuments.net/reader033/viewer/2022050717/5f05ad987e708231d414279f/html5/thumbnails/46.jpg)
Pulling it All Together
8/24/2016 ©2016 Mingle Analytics 46
From the CMS Proposed Rule
Component Presented
Quality 7/13/2016 37.3 of 50
Cost 8/24/2016 5.6 of 10
ACI 7/28/2016 21.9 of 25
CPIA 8/4/2016 12.5 of 15
Composite Performance 76.3