what you should know about macra - domoa.org · what we know so far macra was designed to offer...
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Michigan Osteopathic AssociationAnnual Conference
Grand RapidsNovember 3, 2017
What You Should Know About MACRA
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Learning Objectives
❖ Explain MACRA
❖ Identify two payment tracks
❖ Illustrate how the PCMH model and existing Value-
based reimbursement (VBR) support Clinical Practice
Improvement Activities
❖ Give examples of what a practice can do to prepare
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What Do You See?
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Observations
❖ Medicare Access and CHIP Reauthorization Act
(MACRA) signed into law April 16, 2015: (Fix-It Bill)
❖ ACA was signed into law on March 23, 2010
❖ MACRA and ACA are often confused
❖ MACRA is complex
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Observations
❖ MACRA, MIPS, and AAPM are used interchangeably
❖ Many of the “new” requirements are revisions to the
current FFS program
❖ One goal of MACRA is to simplify administrative
processes and reduce administrative burden
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Observations
❖ MACRA has strong bipartisan support
❖ Repeals are unlikely due to the continued strong
bipartisan support for MACRA
❖ The Senate and the House voted in favor of
MACRA 92-8 and 392-37 respectively
❖ Critically, any delay to MACRA would have to go
through Congress and due to the strong bipartisan
support this is also unlikely
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Building MACRA
❖ Uses the Triple Aim as a unifying strategy
Better Care
Healthier People
Smarter Spending
❖ CMS Quality Strategy is to optimize health
outcomes by leading clinical quality improvement
and health system transformation
Builds upon the three National Quality Strategy Goals and applies six priorities
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Building MACRA
❖ Six priorities: Make care safer by reducing harm caused while care
is delivered
Strengthen person and family engagement as partners in their care
Promote effective communication and coordination of care
Promote effective prevention and treatment of chronic illness
Work with communities to help people live in better health
Make care affordable
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What We Know So Far
❖ The Quality Payment Program makes Medicare
better by helping physicians focus on care quality
and the one thing that matters most – making their
patients healthier
❖ The Quality Payment Program ends the Sustainable
Growth Rate formula and gives physicians new
tools, models, and resources to help them give their
patients the best possible care
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What We Know So Far
❖ MACRA was designed to offer physicians a choice
between two payment pathways:
A modified fee-for-service model (MIPS)
New payment models that reduce costs of care and/or support high-value services not typically covered under the Medicare fee schedule (APMs)
❖ CMS named the physician payment system created
by MACRA the Quality Payment Program (QPP)
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What We Know So Far
❖ Physicians can choose how they want to participate
based on their practice size, specialty, location, or
patient population
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MACRA Revised Opportunities
Bonus opportunities (APMs and MIPS)
Greater support for physicians that want to pursue new models
Improvement Activities requirement
PQRS, MU and VBM
Penalties reduced in absolute terms & through partial credit
Reduce net administrative burdens
Greater flexibility for physicians
Low score in one area can be made up by high score in other components
No more double jeopardy for failing PQRS (trigger VBM failure)
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What Happens If You Choose MIPS
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❖ Physicians can now pick their own reporting
options
❖ There are exemptions
Medicare allowed charges of $30,000
100 or fewer Medicare patients
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MIPS
❖ Started January 2017
❖ Leverages and expands PQRS, Value-Based
Modifier (VBM) and Meaningful Use
❖ Increases and consolidates financial impacts
❖ Ranks peers nationally and reports scores publicly
❖ MIPS is budget neutral
Incentives to high performers will be funded by
penalties applied to low performers
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MIPS
❖ Beginning July 1, 2018, CMS must make available
to each MIPS EP information about items and
services furnished to the EP’s patients by other
providers and suppliers for which payment is
made under Medicare
❖ Information about the performance of MIPS EPs
must be made available on Physician Compare
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MIPS Eligible Clinicians
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Medicare Part B Clinicians Affected
❖ MIPS approximately 800,000 out of 1.25 million
providers
❖ MIPS “new default” for Medicare Part B
participating providers
❖ Advanced APM < 20,000 providers
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Pick Your Pace: 2017 Transitional Performance Reporting Options
• Report some data at any point in CY 2017 to demonstrate capability
• 1 quality measure, or 1 improvement activity, or 4/5 required ACI measures
• No minimum reporting period
• No negative adjustment in 2019
MIPS Testing
• Submit partial MIPS data for at least 90 consecutive days
• 1+ quality measure, or 1+ improvement activities, or 4/ 5 required ACI measures
• No negative adjustment in 2019
• Potential for some positive adjustment ( < 4%) in 2019
Partial MIPS reporting
• Meet all reporting requirements for at least 90 consecutive days
• No negative adjustment in 2019
• Maximum opportunity for positive 2019 adjustment ( < 4%)
• Exceptional performers eligible for additional positive adjustment (up to 10%)
Full MIPS reporting
• No MIPS reporting requirements (APMs have their own reporting requirements)
• Eligible for 5% advanced APM participation incentive in 2019
Advanced APM
participation
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The only physicians who will experience negative payment adjustments (-4%) in 2019 are those who report no data in 2017
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Low-volume Threshold Exemption
❖ Physicians with Medicare allowed charges of $30,000 or less or 100 or fewer Medicare patients
❖ Eligibility calculated by CMS
Notification should occur in December (notification for 2017 is late)
Based on recent 12-month historical data (September-August)
Includes Part B drug costs, but not Part D
❖ Exempted physicians receive annual fee schedule updates, but no bonuses or penalties
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Components of the CY2017 MIPS Score
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MIPS Components
Quality Reporting (was
PQRS)
Cost (was Value-based
Modifier)
Advancing Care Information
(was MU)
Improvement Activities
MIPS
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MIPS aims:• Align 3 current independent programs• Add 4th component to promote
improvement and innovation• Provide more flexibility and choice of
measures• Retain a fee-for-service payment
option
Clinicians exempt from MIPS:• First year of Part B participation• Medicare allowed charges < $30K or <
100 patients • Advanced APM participants
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Improvement Activities Categories
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety and Practice Assessment
Achieving Health Equity
Emergency Response and Preparedness
Integrated Behavioral and Mental Health
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Improvement Activities (CPIA)
❖ New component, intended to provide credit for
practice innovations that improve access and quality
Over 90 activities that cross 8 categories
No required categories
❖ 40 points required for medium and large practices
(2-4 activities)
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Improvement Activities (CPIA)
❖ Only 1-2 activities required for groups < 15, rural and
HPSA practices, non-patient facing specialists
Most physicians fall into this category
❖ Participation in 2017 MIPS APMs and non-advanced
medical homes worth 40 points
PCMH definition expanded to include national, regional, state, private payer, and other certifications
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Milestones
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2017Jan 1: First transitional performance period begins
Spring: PQRS, VBM, MU pay adjustments (2015 performance)
Oct 1: Last chance to start 90-day reporting period
Nov 1: 2018 performance threshold announced
Dec: Notification of LVT exception (9/1/16-8/31/17)
2018Jan 1: Second transitional performance period begins
Jan 2-Mar 31: Submission period for 2017 performance data
Spring: Final PQRS, VBM, MU pay adjustments (2016 performance)
Nov 1: 2019 performance threshold announced
Dec: Notification of LVT exception (9/1/17-8/31/18)
2019 Jan 1: QPP transitional reporting completed
Spring: First QPP pay adjustments implemented (2017 performance)
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Check if You’re in MIPS
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Check if You’re in MIPS
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Check if You’re in MIPS
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Check if You’re in MIPS
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Many MACRA Checklists Available
✓ Are you exempt from MIPS?✓ Low volume provider?
✓ Qualified participant in an advanced APM?
✓ Do you want to participate as an individual or as a group?
✓ Do you meet requirements for small, rural, non-patient-facing accommodations?
✓ Do you/can you participate in a qualified clinical data registry?
✓ Do your PQRS and QRUR reports reveal areas for improvement?
✓ Which Improvement Activities are you engaged in now? What are you interested in doing?
✓ Is your EHR certified? If so, is it the 2014 or 2015 edition?
✓ Does your vendor support Medicare quality reporting?
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CMS Measure Selection Tool
www.qpp.cms.gov Explore Measures Explore Quality Measures
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MIPS Adjustment/Bonuses
❖ Based on composite performance score EPs may
receive an upward, downward or no payment
adjustment
❖ Exceptional Performers see significant opportunities
for additional bonuses/adjustments on top of
traditional MIPS incentives
Available in 2019 through 2024
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Clinical Practice Improvement Activity (CPIA) Scoring
❖ Each area in CPIA activity list is worth a certain
number of points
Most are worth 10 points
Some activities have higher weight
❖ To get maximum credit EP must achieve 60 points
❖ Certified PCMHs receive highest potential score
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CPIA Capabilities
❖ Expanded Practice Access
Same day appointments for urgent needs
After hours clinician advice
Patient experience of care survey
❖ Population Management
Monitoring health conditions and providing timely intervention
Participation in a qualified clinical data registry
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CPIA Capabilities
❖ Care Coordination
Timely communication of test results
Timely exchange of clinical information with patients AND providers
Use of remote monitoring
Use of telehealth
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CPIA Capabilities
❖ Beneficiary Engagement
Establishing care plans for complex patients
Beneficiary self-management assessment and training
Employing shared decision making
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Advancing Care Information
❖ Scoring based on HIT interoperability promoting
exchange and patient/caregiver engagement
❖ Flexible scoring to promote care coordination
❖ Medicare Meaningful Use
Dropped “all or nothing” threshold for measure
Eliminated Computerized Provider Order Entry (CPOE) and Clinical Decision Support (CDS)
Reduced number of required public health registries reported
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Advancing Care Information: Base Score 6 Measures
❖ Protect Patient Health Information
❖ E-Rx
❖ Patient access to EHR
❖ Care coordination with pat8ient engagement
❖ HIE
❖ Public health and clinical data
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Advancing Care Information: Performance Score
❖ Physicians select measures that fit their practice:
Patient access to EHR
Care coordination through patient engagement
HIE
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Performance Period Determinations
❖ During the performance period of a calendar year,
CMS will make eligibility determinations using data
from PECOS on a quarterly basis (if technically
feasible) to identify new Medicare-enrolled eligible
clinicians who will be exempt from MIPS
participation for the applicable performance period.
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PECOS
❖ Provider Enrollment, Chain and Ownership System
(PECOS) is an electronic Medicare enrollment
system through which providers and suppliers can:
Submit Medicare enrollment applications
View and print enrollment information
Update enrollment information
Complete the enrollment revalidation process
Voluntarily withdraw from the Medicare Program
Track the status of a submitted Medicare enrollment application
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CMS Website: MIPS Measures and Activities
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CMS Website: MIPS Measures and Activities
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CMS Website: MIPS Measures and Activities
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CMS Website: MIPS Measures and Activities
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What If I’m Not Included in MIPS
❖ Won’t be subject to a positive or negative
Medicare Part B payment adjustment in 2019
under MIPS
❖ No further action is required unless your TIN
decides to participate as a group and is above one
of the low volume thresholds
❖ Can voluntarily participate in the program
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Pick Your Pace
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Five Things to Do Now to Prepare for MIPS
❖ Educate your team or organization
❖ Estimate your MIPS score
❖ Optimize MU (ACI) and PQRS/VBM Quality to
maximize MIPS score
❖ Evaluate staff, resources and organizational
structure
❖ Focus on QI and how 2017 impacts reimbursement
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Summary
❖ MACRA greatly influenced by practice transformation
success
❖ Quality performers receive substantially higher
bonuses
❖ There is significant financial penalty
❖ Current rules are still in effect until December 2018
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What Should You Do?
❖ Fee for service payment methods are blurring and
morphing into new payment models
❖ Increased focus on accountability for total cost of
care, while maintaining quality
❖ Growing emphasis on care coordination, health IT
and patient satisfaction
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What Should You Do?
❖ Practices with a sophisticated understanding of
financial and clinical analytics will be best
positioned for evolving payment models
❖ Stay ahead of the curve and thoughtfully consider
if certain voluntary programs are right for your
practice
❖ Be aware of the changing landscape by engaging
with your PO
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What Practices Can Do Now
❖ Expect MACRA implementation to proceed
Elections estimated to have limited impact
❖ Assess your performance under current programs
Review how your group perform in PQRS and MU
Download your Quality and Resource Use Report
❖ Engage in ongoing learning about MACRA
Look to the MOA and AOA for more information and resources
Look to other sources
❖ Consider participating in a public or private value-based
payment initiative
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Assistance for PCPs
❖ Engage in evolving ‘value-based’ reimbursement
programs
❖ Review and become familiar with defined, but
limited set of quality measures
❖ POs provide transformation resources to support
development of advanced primary care capabilities
over time
❖ Focus on quality measurement and identifying costs
for the practice’s population
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MACRA Resources
❖ CMS Innovation Center
http://innovation.cms.gov/
❖ MACRA
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
http://www.aafp.org/practice-management/payment/medicare-payment/faq.html
http://waysandmeans.house.gov/UploadedFiles/HR_1470_Section_by_Section.pdf
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Failure Isn’t an Option
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Open Discussion
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