Proposals for the Quality Payment Program in 2019David Heller
Corporate Counsel, Regulatory Affairs
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• Overview
• Who’s in, who’s out?
• Reporting and scoring
• Promoting Interoperability
• Quality and Clinical Practice Improvement Activities
• Alternative Payment Models
Agenda
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Adjusted Medicare Part B payment to clinician
MIPS Payment Adjustments
2022+
±4% for 2017’s
performance
±5% for 2018’s
performance
±7% for
2019’s
performance
±9% for 2020’s
performance and
future years
• The potential
maximum adjustment
% will increase each
year from 2019 to
2022.
Maximum
adjustments
• Composite
performance score,
clinicians will receive
+/- or neutral
adjustments up to the
percentages shown
here.
Based on MIPS
2021
2020
2019
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Top takeaway: full MIPS implementation marches forward
Heightened thresholds
Promoting Interoperability
Expanded eligibility
Other notable themes
21st Century Cures
Patients over
Paperwork
Meaningful
Measures
Overview
The House The Senate Bottom line
92 yeas
2 nays
392 yeas
37 nays
2 abstained
MACRA, MIPS, APMs are not going away
MACRA, by the votes
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Provider
flexibility
Interoperability
Physician
burden a
serious
concern
Looking at
possible
scaleback
of MU, ACI
Support
from both
sides of
the aisle
Measures
cost and
quality
It’s here to stay, with some tweaks possible.
MACRA
8 I
What is MACRA?
MACRA MIPS (standard)
MIPS (MIPS APMs)
Advanced APMs
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A single MIPS composite performance score will factor in performance in four weighted
categories on a scale of 0-100.
What is MIPS?
QUALITYRESOURCE
USE/COST
CLINICAL PRACTICE
IMPROVEMENT
ACTIVITES
PROMOTING
INTEROPERABILITY
Replaces PQRS.
Accounts for 45%
of total
performance
score in year
two.
Replaces VBM.
Accounts for 15%
of total
performance
score in year
two.
Accounts for 15%
of total
performance
score in year
two.
Replaces
Medicare MU.
Accounts for 25%
of total
performance
score in year
two.
Medicaid MU goes on separately
Medicaid meaningful
useMIPS
Regulatory cycle: H1
Jan. Feb. March April May June
• NQF MAP convenes.
• Quality MUC template published.
• Call for ACI measures.
• Call for IA measures.
• Call for quality measures.
• Measures from prior year’s process
implemented.
• MACRA proposed
regulation issued, notice
and comment begins.
• CMMI may issue new
innovation models.
• IA measures
submission
closes EOM.
• Closure of call for new
quality measures.
• CMMI may issue new
innovation models.
• CMMI new innovation
models may issue.
• PTAC votes on physician
designed APMs (quarterly
meetings).
Regulatory cycle: H2
July Aug. Sep. Oct. Nov. Dec.
• MACRA notice and comment
closes early in the month.
• Proposed Physician Fee Schedule
is issued, notice and comment
opens.
• CMMI may issue new innovation
models.
• Proposed Physician Fee Schedule
notice and comment continues.
• PTAC meets on proposed APMs.
• CMMI may issue new innovation
models.
• PTAC meets on
proposed APMs.
• PTAC issues RFP for
new APMs.
• MACRA final regulation issued by Nov. 1, final
list of new measures.
• Physician fee schedule finalized (may be
combined with MACRA regulation).
• PTAC votes on physician designed APMs
(quarterly meetings).
• Proposed Physician Fee Schedule
notice and comment closes early in
the month.
• PTAC meets on proposed APMs.
Who’s in, who’s out?
Who is eligible to participate in MIPS?
Years
1 and 2Years
3+
Proposing to also include physical and
occupational therapists, clinical social
workers, and clinical psychologists.
HHS Secretary
proposed to
broaden EC groups
to include others,
such as:
Physicians (MD/DO and DMD/DDS),
PAS, NPS, clinical nurse specialists,
certified registered nurse anesthetists.
Less than
$90,000 in
Part B
revenue.
Fewer than
200 Medicare
unique
beneficiaries
Less than
200 covered
professional
services
under PFS
Meet 1-2, can
voluntarily opt-in.
Meet all 3,
mandatory
exclusion.
Exclusionary thresholds and the MIPS “opt-in”
Reporting & scoring
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Eligible clinicians can participate in MIPS as an individual or group.
Eligible clinician reporting
GROUP
A group, as defined by taxpayer
identification number (TIN), would be
assessed as a group practice across all
four MIPS performance categories.
INDIVIDUAL VIRTUAL
Implemented in 2018
performance period, defined
with a virtual group identifier,
TIN, and NPI combination.
Reporting timelines for 2019 and future years
90 days for Promoting Interoperability.1
90 days for Improvement Activities.
Full year for Quality.
Full year for Cost.
2
3
4
Virtual Group Reporting’s second year
Up to 10 ECs
per Tax ID.
Election by
Dec. 1.
Allows small practices
to scale reporting and
performance.
Assess quality
and cost
uniformly.
Applications open in
September.
No limit on the
number of TINs.
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Performance thresholds, the MIPS composite score, and your bottom line
0 30 80 100
In the 2019 performance period,
ECs who earn a composite score
between 0-30 are subject to a 0%-
7% penalty in 2021. 30 is the
performance threshold, increased
from 15 in 2018.
ECs who earn a composite score
between 30-80 are eligible for a
0%-7% incentive in 2021.
ECs who exceed 80 are eligible
for increased MIPS bonuses,
which will be paid out of a
pool of $500 million that is not
subject to budget neutrality.
60%15%
25%
0%Promoting
Interoperability
Quality
Clinical Practice
Improvement
Activities
MIPS scoring in 2017
50%
15%
25%
10%Quality
Clinical Practice
Improvement
Activities
Final Rule: MIPS scoring in 2018
Cost
Promoting Interoperability
45%
15%
25%
15%Quality
Clinical Practice
Improvement
Activities
Proposed MIPS scoring in 2019
Cost
Promoting Interoperability
40%
15%
25%
20%Quality
Clinical Practice
ImprovementActivities
Proposed MIPS scoring in 2020
Cost
Promoting Interoperability
35%
15%25%
25%
Quality
Clinical Practice
Improvement
Activities
Proposed MIPS scoring in 2021
Cost
Promoting Interoperability
30%
15%25%
30%
Quality
Clinical Practice
Improvement
Activities
MIPS scoring in 2022
Cost
Promoting Interoperability
Small practice bonus
2024
Bonus
moved to
Quality
Complex patient bonus continues
Bonus based
on average
HCC scores
Facility-based measurement has arrived
Cost
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• Medicare Spending per Beneficiary (MSPB).
• Introducing 8 episode-based measures.
How is Cost measured?
Promoting Interoperability
What’s in a name?
Meaningful UseAdvancing Care
InformationPromoting
Interoperability
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Which certified edition?
2015 Certified
Edition of EHR
Technology is
required
The new objectives
BUSINESS
ECOSYSTEM
E-prescribing
Up to 10 points
Public Health and Clinical
Data Exchange
Up to 10 points
Provider to Patient Exchange
Up to 40 pointsVerify Opioid Treatment
Agreement
Up to 5 bonus points
Health Information Exchange
Up to 40 points
Promoting
Interoperability
PDMP
Up to 5 bonus points
Security Risk Analysis still required to receive any credit.
Other notable changes
Receive summary of care and
clinical information
reconciliation combined
“Support Electronic
Referral Loops”
Performance scoring
CommonWell to become
Carequality implementer.Future projects and
integration.
Working to create Carequality
compliant version of CommonWell
record locator service.Initial C-CDA
integration.
Carequality and CommonWell Health Alliance partnership
Quality & Clinical Practice Improvement Activities
Quality proposals
Clinical
GuidelinesIf clinical guidelines for a measure become
outdates its impact on your score is neturalized.
Reporting ECs, Groups, and Virtual Groups may use more
than one collection type.
Removing
measuresPhase out process introduced for topped out
measures.
Data Data completeness threshold remains at 60%.
More outcomes measures and more high priority measures.
What’s coming with Quality
COMPANY 41
1
May see continued focus on EHR reporting/eCQMs.
Opioid measures.
Proposed new scoring methodologies for future years.
2
3
4
More improvement activities
CEHRT bonus
removed from
this category.
6 new activities,
5 activities
modified, one
activity removed
Alternative Payment Models
Advanced APM impact to providers
20242026+
202020182016
5%
Lump
Sum
Bonus
Revenue-based risk definition extended through 2024
Nominal risk Revenue standard
8% of average estimated total
Medicare Parts A & B revenue
The Medical Home Model – A more gradual ramp
Or
General
definition
Quality
incentive or
PMPM at risk
2018: 2% 2019:
3%
2020:
4% 2021:
5%
RISK
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New minimum CEHRT threshold proposed
75%
Which payers?
1
2
3
All payer combination options
Medicaid & CHIP
CMS Multi-Payer models
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• Comprehensive Primary Care Plus (CPC+) (Medical Home Model)
• Next Generation ACO
• MSSP Track 1+, Track 2, Track 3
Sample Advanced APMs
Who’s in the APM track?
201720152024+20232022202120202019
Payments
25%
Patients
20%
Payments
50%
2019-2020
• Medicare APMs
only
2021+
•Include private
payers
Payments
75%
Patients Patients
35% 50%
Performance thresholds and Cost in the future
0 3 30 80 100
The performance threshold in
2022 will be set as the mean or
median of prior MIPS composite
scores, unless Congress amends
MACRA.
30%
15%25%
30%
Cost
To change how CMS sets
thresholds and Cost’s portion of
the score for future years, an act
of Congress would be required.
1
2
3
Measure quality and costFirst, clinicians become accustomed to
capturing metrics and measuring
performance on quality and cost.
Implement technological and clinical processesAs MIPS ramps up, clinicians are incented to implement
process changes that can quanitifiably move the needle
on quality and cost.
Prepare for riskBy changing the way the clinicans deliver care over time, clinicans are
equipped to take advantage of risk-bearing contracts that reward superior
care over volume.
Congress’ vision: From MIPS to APMs
Questions
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• ACI: Advancing Care Information
• APM: Alternative Payment Model
• CPIA: Clinical Practice Improvement Activities
• EC: Eligible Clinician
• HHS: The US Department of Health & Human Services
• MACRA: Medicare Access & CHIP Reauthorization Act of 2015
• MIPS: Merit-based Incentive Payment System
• MU: Meaningful Use
• NP: Nurse Practitioner
• NPRM: Notice of Proposed Rulemaking
• PA: Physician Assistant
Acronyms cheat sheet
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• Medicare Program; Revisions to Payment Policies Under the Physician Fee
Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings
Program Requirements; Quality Payment Program; and Medicaid Promoting
Interoperability Program
• Proposed Rule for the Quality Payment Program Year 3 fact sheet
• CMS webinar on Proposed Rule for Quality Payment Program Year 3
• Qpp.cms.gov
• CMS Quality Payment Program training videos
Resources