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The Medicare Access & Chip Reauthorization Act of 2015
QUALITYPAYMENT
PROGRAM
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This presentation was current at the time it was published oruploaded onto the web. Medicare policy changes frequently solinks to the source documents have been provided within thedocument for your reference.
This presentation was prepared as a service to the public and isnot intended to grant rights or impose obligations. Thispresentation may contain references or links to statutes,regulations, or other policy materials. The information providedis only intended to be a general summary. It is not intended totake the place of either the written law or regulations. Weencourage readers to review the specific statutes, regulations,and other interpretive materials for a full and accuratestatement of their contents.
2
Disclaimer
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3
KEY TOPICS:
1) The Quality Payment Program and HHS Secretary’s Goals
2) What is the Quality Payment Program?
3) How do I submit comments on the proposed rule?
4) The Merit-based Incentive Payment System (MIPS)
5) Incentives for participation in Advanced Alternative PaymentModels (Advanced APMs)
6) What are the next steps?
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In January 2015, the Department of Health and Human Services announcednew goals for value-based payments and APMs in Medicare
4
The Quality Payment Program is part of a broaderpush towards value and quality
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Medicare Payment Prior to MACRA
The Sustainable Growth Rate (SGR )
• Established in 1997 to control the cost of Medicare paymentsto physicians
Fee-for-service (FFS) payment system, where clinicians are paid based onvolume of services, not value.
5
TargetMedicare
expenditures
Overallphysician
costs
>IF Physician paymentscut across the board
Each year, Congress passed temporary “doc fixes” to avert cuts
(no fix in 2015 would have meant a 21% cut in Medicare paymentsto clinicians)
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INTRODUCING THE QUALITY
PAYMENT PROGRAM
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First step to a fresh start
We’re listening and help is available
A better, smarter Medicare for healthier people
Pay for what works to create a Medicare that is enduring
Health information needs to be open, flexible, and user-centric
Quality Payment Program
The Merit-basedIncentive
Payment System(MIPS)
AdvancedAlternative
Payment Models(APMs)
or
Repeals the Sustainable Growth Rate (SGR) Formula Streamlines multiple quality reporting programs into
the new Merit-based Incentive Payment System (MIPS) Provides incentive payments for participation in
Advanced Alternative Payment Models (APMs)
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When and where do I submit comments?
• The proposed rule includes proposed changes not reviewed in thispresentation. We will not consider feedback during the call as formalcomments on the rule. See the proposed rule for information onsubmitting these comments by the close of the 60-day comment period
on June 27, 2016. When commenting refer to file code CMS-5517-P.
• Instructions for submitting comments can be found in the proposed rule;FAX transmissions will not be accepted. You must officially submit yourcomments in one of the following ways: electronically through
• Regulations.gov• by regular mail• by express or overnight mail• by hand or courier
• For additional information, please go to:http:// go.cms.gov/QualityPaymentProgram
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http://go.cms.gov/QualityPaymentProgramhttp://go.cms.gov/QualityPaymentProgramhttp://go.cms.gov/QualityPaymentProgram
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MIPS: First Step to a Fresh Start
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MIPS is a new program
• Streamlines 3 currently independent programs to work as one and toease clinician burden.
• Adds a fourth component to promote ongoing improvement andinnovation to clinical activities.
MIPS provides clinicians the flexibility to choose the activities andmeasures that are most meaningful to their practice to demonstrateperformance.
Quality Resource use
:
Clinical practiceimprovement
activities
Advancing care
information
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Currently there are multiple quality and value reporting programs for Medicare clinicians:
10
Medicare Reporting Prior to MACRA
Physician QualityReporting Program
(PQRS)
Value-Based PaymentModifier (VM)
Medicare ElectronicHealth Records (EHR)
Incentive Program
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PROPOSED RULE
MIPS: Major Provisions
11
Eligibility (participants and non-participants)
Performance categories & scoring
Data submission
Performance period & payment adjustments
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Years 1 and 2 Years 3+
Physicians (MD/DO and DMD/DDS),PAs, NPs, Clinical nurse specialists,
Certified registered nurseanesthetists
Physical or occupational therapists,Speech-language pathologists,Audiologists, Nurse midwives,Clinical social workers, Clinical
psychologists, Dietitians /Nutritional professionals
Affected clinicians are called “MIPS eligible clinicians” and will participate in MIPS. The types of Medicare Part B eligibleclinicians affected by MIPS may expand in future years.
12
Who Will Participate in MIPS?
Secretary maybroaden Eligible
Clinicians group toinclude others
such as
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There are 3 groups of clinicians who will NOT be subject to MIPS:
13
Who will NOT Participate in MIPS?
1FIRST year of Medicare
Part B participationCertain participants inADVANCED Alternative
Payment Models
Below low patientvolume threshold
Note: MIPS does not apply to hospitals or facilities
Medicare billing charges less than or equal to$10,000 and provides care for 100 or fewer Medicare
patients in one year
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Note: Most clinicians will be subject to MIPS.
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Not in APMIn non-Advanced
APMQP in Advanced
APM
Note: Figure not to scale .
Some people may be in
Advanced APMs butnot have enough
payments or patientsthrough the Advanced
APM to be a QP.
In Advanced APM, but
not a QP
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Eligible Clinicians can participate in MIPS as an:
15
PROPOSED RULE
MIPS: Eligible Clinicians
Or
Note: “Virtual groups” will not be implemented in Year 1 of MIPS.
A group, as defined by taxpayer
identification number (TIN),would be assessed as a grouppractice across all four MIPS
performance categories.
GroupIndividual
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PROPOSED RULE
MIPS: PERFORMANCECATEGORIES & SCORING
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QualityResource
use
:
Clinicalpractice
improvementactivities
Advancingcare
information
A single MIPS composite performance score will factor in performance in 4 weighted performance categories on a 0-100 pointscale:
17
MIPS Performance Categories
MIPSComposite
PerformanceScore (CPS)
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Year 1 Performance Category Weights for MIPS
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QUALITY50%
ADVANCING CAREINFORMATION
25%
CLINICAL PRACTICEIMPROVEMENT
ACTIVITIES15%
COST10%
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QualityResource
use
:
Clinicalpractice
improvementactivities
Advancingcare
information
*Proposed qualitymeasures are available in
the NPRM
*clinicians will be able tochoose the measures onwhich they’ll be evaluated
The MIPS composite performance score will factor in performance in4 weighted performance categories on a 0-100 point scale :
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What will determine my MIPS score?
MIPSComposite
PerformanceScore (CPS)
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Summary:
Selection of 6 measures
1 cross-cutting measure and 1 outcome measure, or another highpriority measure if outcome is unavailable
Select from individual measures or a specialty measure set
Population measures automatically calculated
Key Changes from Current Program (PQRS):
• Reduced from 9 measures to 6 measures with no domain
requirement
• Emphasis on outcome measurement
• Year 1 Weight: 50%
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PROPOSED RULE
MIPS: Quality Performance Category
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QualityResource
use
:
Clinicalpractice
improvementactivities
Advancingcare
information
*Will compare resources used totreat similar care episodes and
clinical condition groups acrosspractices
*Can berisk-adjusted toreflect external
factors
The MIPS composite performance score will factor in performancein 4 weighted performance categories on a 0-100 point scale :
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What will determine my MIPS score?
MIPSComposite
PerformanceScore (CPS)
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Summary:
Assessment under all available resource use measures, as applicableto the clinician
CMS calculates based on claims so there are no reporting
requirements for clinicians Key Changes from Current Program (Value Modifier):
• Adding 40+ episode specific measures to address specialtyconcerns
• Year 1 Weight: 10%
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PROPOSED RULE
MIPS: Resource Use Performance Category
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QualityResource
use
:
Clinicalpractice
improvementactivities
Advancingcare
information
*Examples include care coordination,
shared decision-making, safety
checklists, expanding practice access
The MIPS composite performance score will factor in performance in4 weighted performance categories on a 0-100 point scale :
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What will determine my MIPS score?
MIPSComposite
PerformanceScore (CPS)
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Summary:
Minimum selection of one CPIA activity (from 90+ proposedactivities) with additional credit for more activities
Full credit for patient-centered medical home
Minimum of half credit for APM participation
Key Changes from Current Program:
• Not applicable (new category)
• Year 1 Weight: 15%
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PROPOSED RULE
MIPS: Clinical Practice Improvement ActivityPerformance Category
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QualityResource
use
:
Clinicalpractice
improvementactivities
Advancingcare
information
* % weight of this
may decrease as moreusers adopt EHR
The MIPS composite performance score will factor in performance in4 weighted performance categories on a 0-100 point scale :
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What will determine my MIPS score?
MIPSComposite
PerformanceScore (CPS)
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Who can participate?
PROPOSED RULEMIPS: Advancing Care Information
Performance Category
Those Not EligibleInclude: NPs, PAs,Hospitals, Facilities &Medicaid
Individual
Group
Participatingas an..
or
All MIPS EligibleClinicians
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The overall Advancing Care Information scorewould be made up of a base score and a
performance score for a maximum score of 100
points
PROPOSED RULEMIPS: Advancing Care Information
Performance Category
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PROPOSED RULEMIPS: Advancing Care Information
Performance Category
Base ScoreAccounts for 50 points of the total Advancing
Care Information category score.
To receive the base score, physicians must simplyprovide the numerator/denominator or yes/no for each
objective and measure
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PROPOSED RULEMIPS: Advancing Care Information
Performance Category
CMS proposes six objectives and their measures that would require
reporting for the base score:
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PROPOSED RULEMIPS: Advancing Care Information
Performance Category
THE PERFORMANCE SCOREThe performance score accounts for up to 80 points towards the total
Advancing Care Information category score
Physicians select the measures that best fit their practice from the
following objectives, which emphasize patient care and informationaccess:
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PROPOSED RULE
MIPS: Performance Category Scoring
Summary of MIPS Performance CategoriesPerformance Category Maximum Possible
Points per PerformanceCategory
Percentage of OverallMIPS Score
(Performance Year 1 -2017)
Quality: Clinicians choose six measures to report to CMS that best
reflect their practice. One of these measures must be an outcome
measure or a high-value measure and one must be a crosscuttingmeasure. Clinicians also can choose to report a specialty measure
set.
80 to 90 points
depending on group
size
50 percent
Advancing Care Information: Clinicians will report key measures
of interoperability and information exchange. Clinicians arerewarded for their performance on measures that matter most to
them.
100 points 25 percent
Clinical Practice Improvement Activities: Clinicians can choose
the activities best suited for their practice; the rule proposes over90 activities from which to choose. Clinicians participating inmedical homes earn “full credit” in this category, and those
participating in Advanced APMs will earn at least half credit.
60 points 15 percent
Cost: CMS will calculate these measures based on claims and
availability of sufficient volume. Clinicians do not need to report
anything.
Average score of all
cost measures that can
be attributed
10 percent
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A single MIPS composite performance score will factor in performance in4 weighted performance categories on a 0-100 point scale :
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PROPOSED RULE
MIPS: Calculating the Composite Performance Score(CPS) for MIPS
Quality Resourceuse
Clinicalpractice
improvementactivities
:
Advancingcare
information
=
MIPSComposite
PerformanceScore (CPS)
The CPS will becompared to the MIPS
performance threshold
to determine the
adjustment percentage
the eligible clinician will
receive.
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MIPS composite performance scoring method that accounts for:
• Weights of each performance category
• Exceptional performance factors
• Availability and applicability of measures for different categories
of clinicians
• Group performance
• The special circumstances of small practices, practices located inrural areas, and non-patient- facing MIPS eligible clinicians
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PROPOSED RULE
MIPS: Calculating the Composite Performance Score(CPS) for MIPS
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Calculating the Composite Performance Score (CPS)for MIPS
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Category Weight Scoring
Quality 50% • Each measure 1-10 points compared to historicalbenchmark (if avail.)
• 0 points for a measure that is not reported• Bonus for reporting outcomes, patient experience,
appropriate use, patient safety and EHR reporting
• Measures are averaged to get a score for the categoryAdvancingcareinformation
25% • Base score of 60 points is achieved by reporting at leastone use case for each available measure
• Up to 10 additional performance points available permeasure
• Total cap of 100 percentage points available
CPIA 15% • Each activity worth 10 points; double weight for “high”
value activities; sum of activity points compared to a target
Resource Use 10% • Similar to quality
Unified scoring system:1.Converts measures/activities to points2.Eligible Clinicians will know in advance what they need to do to achieve top performance
3.Partial credit available
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HOW DO I GET MY DATA TO CMS?
DATA SUBMISSION FOR MIPS
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PROPOSED RULE
MIPS Data Submission OptionsQuality and Resource Use
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Quality
Resource use
Group Reporting
Claims QCDR Qualified Registry EHR Vendors Administrative Claims (No
submission required)
QCDR Qualified Registry EHR Vendors CMS Web Interface
(groups of 25 or more) CAHPS for MIPS Survey
Administrative Claims (Nosubmission required)
Administrative Claims(No submission required)
Administrative Claims(No submission required)
Individual Reporting
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PROPOSED RULE
MIPS Data Submission OptionsAdvancing Care Information and CPIA
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Attestation QCDR Qualified Registry EHR Vendor
Attestation QCDR Qualified Registry EHR Vendor CMS Web Interface
(groups of 25 or more)
Attestation QCDR Qualified Registry EHR Vendor Administrative Claims (No
submission required)
Attestation QCDR Qualified Registry EHR Vendor CMS Web Interface
(groups of 25 or more)
:
Advancingcare
information
CPIA
Group ReportingIndividual Reporting
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PROPOSED RULE
MIPS PERFORMANCE PERIOD& PAYMENT ADJUSTMENT
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A MIPS eligible clinician’s payment adjustment percentage is based onthe relationship between their CPS and the MIPS performancethreshold.
A CPS below the performance threshold will yield a negative paymentadjustment; a CPS above the performance threshold will yield a neutral
or positive payment adjustment.
A CPS less than or equal to 25% of the threshold will yield themaximum negative adjustment of -4%.
41
PROPOSED RULE
MIPS: Payment Adjustment
=
MIPSComposite
PerformanceScore (CPS)
Quality Resourceuse
Clinicalpractice
improvementactivities
:
Advancingcare
information
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+/-Maximum
Adjustments
AdjustedMedicare PartB payment to
clinician
Merit-Based Incentive Payment System(MIPS)
+4%+5%
+7%+9%
2019 2020 2021 2022 onward
Based on a CPS, clinicians will receive +/- or neutral adjustments up to the percentages below.
43
How much can MIPS adjust payments?
-4%The potential maximum
adjustment % will
increase each year from
2019 to 2022
-5%-7%-9%
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+/-Maximum
Adjustments
Merit-Based Incentive Payment System(MIPS)
+4%+5%
+7%+9%
2019 2020 2021 2022 onward
Note: MIPS will be a budget-neutral program. Total upward and downward adjustments will be balanced so that the average change is0 .
44
How much can MIPS adjust payments?
-4%-5%-7%-9%
*Potential for
3Xadjustment
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MIPS: Scaling Factor Example
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Dr. Joy Smith, who receives the +4% adjustment for MIPS, could
receive up to +12% in 2019. For exceptional performance she couldearn an additional adjustment factor of up to +10%.
Note: This scaling process will only apply to positive adjustments, notnegative ones.
*Potential for
3Xadjustment
+ 4%
+ 12%
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2017 2018 July 2019 2020
PROPOSED RULE
MIPS Timeline
46
PerformancePeriod
(Jan-Dec)
1st FeedbackReport(July)
Reportingand DataCollection
Analysis and Scoring
2nd FeedbackReport(July)
TargetedReview Basedon 2017 MIPSPerformance
MIPSAdjustments
in Effect
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Incentives for Advanced APM Participation
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APMs are new approaches to paying for medical care through Medicare thatincentivize quality and value.
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What is an Alternative Payment Model (APM)?
CMS Innovation Center model (undersection 1115A, other than a Health CareInnovation Award)
MSSP (Medicare Shared Savings Program)
Demonstration under the Health CareQuality Demonstration Program
Demonstration required by federal law
As defined byMACRA,
APMs
include:
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The APM requires participants to usecertified EHR technology.
The APM bases payment on qualitymeasures comparable to those in theMIPS quality performance category.
The APM either: (1) requires APM
Entities to bear more than nominalfinancial risk for monetary losses;OR (2) is a Medical Home Modelexpanded under CMMI authority.
Advanced APMs meet certain criteria.
49
As defined by MACRA,advanced APMs must meet
the following criteria:
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PROPOSED RULEMedical Home Models
50
Medical Home Models:
Have a unique financial risk criterion for becoming an AdvancedAPM.
Enable participants (who are notexcluded from MIPS) to receive the
maximum score in the MIPS CPIAcategory.
A Medical Home Model is an APM that hasthe following features: Participants include primary care
practices or multispecialty practices thatinclude primary care physicians andpractitioners and offer primary careservices.
Empanelment of each patient to aprimary clinician; and
At least four of the following:• Planned coordination of chronic and
preventive care.• Patient access and continuity of care.• Risk-stratified care management.
• Coordination of care across themedical neighborhood.• Patient and caregiver engagement.• Shared decision-making.• Payment arrangements in addition
to, or substituting for, fee-for-service payments.
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NOTE: MACRA does NOT change how any particular
APM functions or rewards value. Instead, it createsextra incentives for APM participation.
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PROPOSED RULE
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PROPOSED RULE
Advanced APM Criterion 1:Requires use of CEHRT
52
An Advanced APM must requireat least 50% of the eligibleclinicians in each APM Entity touse CEHRT to document and
communicate clinical care. Thethreshold will increase to 75%after the first year.
For the Shared Savings Programonly, the APM may apply a
penalty or reward to APMentities based on the degree of CEHRT use among its eligibleclinicians.
:
CertifiedEHR use
Example: An Advanced APM has a
provision in its participationagreement that at least 50% of an
APM Entity’s eligible clinicians must
use CEHRT.
APMEntity
EligibleClinicians
PROPOSED RULE
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PROPOSED RULE
Advanced APM Criterion 2:Requires MIPS-Comparable Quality Measures
53
An Advanced APM must base payment on qualitymeasures comparable to those under the proposedannual list of MIPS quality performance measures;
No minimum number of measures or domainrequirements, except that an Advanced APM must have
at least one outcome measure unless there is not anappropriate outcome measure available under MIPS.
Comparable means any actual MIPS measures or other measures that areevidence-based, reliable, and valid. For example:
• Quality measures that are endorsed by a consensus-based entity; or
• Quality measures submitted in response to the MIPS Call for Quality Measures;or
• Any other quality measures that CMS determines to have an evidence-based focus to be reliable and valid.
QualityMeasures
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PROPOSED RULE
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PROPOSED RULE
Advanced APM Criterion 3:Financial Risk Criterion
55
OR
Financial Risk Standard
Withhold of payment to the APM Entityor eligible clinicians
OR
Reduction in payment rates to the APMEntity or eligible clinicians
Direct payment from the APM Entity
The Advanced APMrequires one or
more of thefollowing if actual
expendituresexceed expected
expenditures:
PROPOSED RULE
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PROPOSED RULE
Advanced APM Criterion 3:Financial Risk Criterion
56
The amount of risk underan Advanced APM must atleast meet the followingcomponents:
Total risk of at least4% of expectedexpenditures
Marginal risk of atleast 30%
Minimum loss ratio(MLR) of no more than4%.
Nominal AmountStandard
Illustration of the amountof risk an APM Entity mustbear in an Advanced APM:
PROPOSED RULE
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PROPOSED RULE
Advanced APM Criterion 3:Example
57
An APM consists of a two-sided shared savingsarrangement:
If the APM Entity’s actual expendituresexceed expected expenditures (the“benchmark”), then the APM Entity must pay
CMS 60% of the amount that expendituresthat exceed the benchmark .
The APM Entity does not have to make anypayments if actual expenditures exceed thebenchmark by less than 2% of thebenchmark amount.
There is a stop-loss provision so that theAPM Entity could pay up to but no more thana total amount equal to 10% of thebenchmark.
The following is anexample of a riskarrangement that wouldmeet the Advanced APMfinancial risk criterion:
PROPOSED RULE
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PROPOSED RULE
Advanced APM Criterion 3:Medical Home Model Financial Risk Criterion
58
OR
Medical Home Model FinancialRisk Standard
Withhold of payment to the APM Entity oreligible clinicians
OR
Reduction in payment rates to the APMEntity or eligible clinicians
Direct payment from the APM Entity
Reduces an otherwise guaranteedpayment or payments
OR
The Medical Home
Model requiresone or more of the
following if theAPM Entity fails
to meet aspecified
performancestandard:
PROPOSED RULE
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PROPOSED RULE
Advanced APM Criterion 3:Medical Home Model Nominal Amount Standard
59
To be an Advanced APM, the amountof risk under a Medical Home Modelmust be at least the followingamounts:
2.5% of Medicare Parts A andB revenue (2017)
3% of Medicare Parts A and Brevenue (2018)
4% of Medicare Parts A and B
revenue (2019) 5% of Medicare Parts A and B
revenue (2020 and later)
Medical Home Model NominalAmount Standard:
Subject to Size Limit
The Medical Home Model standardsonly apply to APM Entities with ≤ 5
eligible clinicians in the APM Entity’sparent organization
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Shared Savings Program (Tracks 2 and 3)
Next Generation ACO Model
Comprehensive ESRD Care (CEC) (large dialysis
organization arrangement)
Comprehensive Primary Care Plus (CPC+)
Oncology Care Model (OCM) (two-sided risk track
available in 2018)
Proposed RuleAdvanced APMs
Based on the proposed criteria, which current APMs willbe Advanced APMs in 2017?
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How do I become a Qualifying APM Participant (QP)?
61
You must have a certain % of yourpatients or payments through an
Advanced APM.
QPAdvanced APM
Be excluded from MIPS
QPs will:Receive a 5% lump sum bonus
Bonus applies in 2019-2024; thenQPs receive higher fee schedule
updates starting in 2026
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1. QP determinations are made at theAdvanced APM Entity level.
2. CMS calculates a “Threshold Score”for each Advanced APM Entity.
3. The Threshold Score for each methodis compared to the correspondingQP threshold.
4. All the eligible clinicians in theAdvanced APM Entity become QPs forthe payment year.
QPEligible Clinicians
Eligible Clinicians toQP in 4 STEPS
The period of assessment (QP Performance Period) for each payment year will bethe full calendar year that is two years prior to the payment year (e.g., 2017performance for 2019 payment).
Aligns with the MIPS performance period.
PROPOSED RULE
How do Eligible Clinicians become QPs?
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PROPOSED RULE
How do Eligible Clinicians become QPs?
63
STEP 1
QP determinations aremade at the AdvancedAPM Entity level.
All participating
eligible clinicians areassessed together.
Advanced APM
Advanced APM Entities
Eligible Clinicians
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PROPOSED RULE
How do Eligible Clinicians become QPs?
64
STEP 2
CMS will calculate a percentage “Threshold Score” for each Advanced APMEntity using two methods (payment amount and patient count).
Methods are based on Medicare Part B professional services andbeneficiaries attributed to Advanced APM Entities.
CMS will use the method that results in a more favorable QP determinationfor each Advanced APM Entity.
Attributed (beneficiaries for whose cost andquality of care the APM Entity is responsible)
Attribution-eligible (all beneficiarieswho could potentially be attributed)
These definitionsare used for
calculatingThreshold Scoresunder both
methods.
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PROPOSED RULE
How do Eligible Clinicians become QPs?
65
Payment Amount Method
$$$ for Part B professionalservices to attributedbeneficiaries
$$$ for Part B professionalservices to attribution-eligible beneficiaries
Payments
=ThresholdScore %
Patient Count Method
# of attributedbeneficiaries given Part Bprofessional services
# of attribution-eligiblebeneficiaries given Part Bprofessional services
=ThresholdScore %
Patients
STEP 2
The two methods for calculation are Payment Amount Method and PatientCount Method.
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PROPOSED RULE
How do Eligible Clinicians become QPs?
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Medicare Option – Payment Amount Method
PaymentYear
2019 2020 2021 2022 2023 2024+
QPPaymentAmountThreshold
25% 25% 50% 50% 75% 75%
Partial QP
PaymentAmountThreshold
20% 20% 40% 40% 50% 50%
Medicare Option – Patient Count Method
PaymentYear
2019 2020 2021 2022 2023 2024+
QPPatientCountThreshold
20% 20% 35% 35% 50% 50%
Partial QP
PatientCountThreshold
10% 10% 25% 25% 35% 35%
PatientsPayments
STEP 3
The Threshold Score for each method is compared to the correspondingQP threshold table and CMS takes the better result.
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STEP 4
All the eligibleclinicians in theAdvanced APM Entitybecome QPs for thepayment year.
PROPOSED RULE
How do Eligible Clinicians become QPs?
Advanced APM
Advanced APM Entities
Eligible Clinicians
ThresholdScores above
the QPthreshold =QP status
Threshold Scoresbelow the QP
threshold = no QPs
Wh b i M di id APM
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What about private payer or Medicaid APMs?Can they help me qualify to be a QP?
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Starting in 2021, some arrangements with othernon-Medicare payers can count toward
becoming a QP.
IF the “Other Payer APMs” meet criteria similar to those for Advanced
APMs, CMS will consider them “Other Payer Advanced APMs”:
“All-PayerCombination
Option”
QualityMeasures
FinancialRisk
:
CertifiedEHR use
O O
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PROPOSED RULE
APM Incentive Payment
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The “APM Incentive Payment” will be based on the estimated aggregatepayments for professional services furnished the year prior to thepayment year.
E.g., the 2019 APM Incentive Payment will be based on 2018 services.
Be excluded from MIPS
QPs will:
Receive a 5% lump sum bonus
Bonus applies in payment years 2019-2024;then QPs receive higher fee schedule updates
starting in 2026
PROPOSED RULE
QP Determination and
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QP Determination andAPM Incentive Payment Timeline
2017 2018 2019
QP PerformancePeriod
Incentive PaymentBase Period
Payment Year
QP status based onAdvanced APM
participation here.
Add up payments for aQP’s services here.
+5% lump sumpayment made here.(and excluded from MIPS
adjustments)
2018 2019 2020
QP Performance
Period
Incentive Payment
Base Period
Payment Year
Repeat the cycle each year…
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When will these Quality PaymentProgram provisions take effect?
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MIPS adj st ts a d APM I ti Pa t
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2017 2018 2019 2020 2021 2022 2023 2024 2025
+5% +7% +9%+4%MIPS
APM
QP inAdvanced
+5% bonus
(excluded from MIPS)
MIPS adjustments and APM Incentive Payment
will begin in 2019.
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-4% -5% -7% -9%Maximum MIPS Payment Adjustment (+/-)
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2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
2026
& on
FeeSchedule
Fee schedule updates begin in 2016.
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+0.5 each year No change
+0.25
or
0.75
QPs will also get a +0.75%update to the fee scheduleconversion factor each year.
Everyone else will get a +0.25 update.
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2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
2026
& on
FeeSchedule
Putting it all together:
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+0.5 each year No change
+0.25
or
0.75
MIPS
APM
QP inAdvanced
4 5 7 9 9 9 9
ax Adjustment
(+/-)
+5
bonus
excluded from MIPS)
MACRA provides additional rewards for
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MACRA provides additional rewards forparticipating in APMs.
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Not in APM In APM In Advanced APM
Potential financial rewards
The Quality Payment Program provides
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The Quality Payment Program providesadditional rewards for participating in APMs.
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Not in APM In APM In Advanced APM
MIPS adjustments
Potential financial rewards
The Quality Payment Program provides
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The Quality Payment Program providesadditional rewards for participating in APMs.
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Not in APM In APM In Advanced APM
MIPS adjustments
APM-specificrewards
+MIPS adjustments
APM participation =favorable scoring in
certain MIPS categories
Potential financial rewards
The Quality Payment Program provides additional
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The Quality Payment Program provides additionalrewards for participating in APMs.
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Not in APM In APM In Advanced APM
MIPS adjustments
APM-specificrewards
5% lump sumbonus
APM-specificrewards
+MIPS adjustments
+If you are a
Qualifying APMParticipant (QP)
Potential financial rewards
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TAKE-AWAY POINTS
1) The Quality Payment Program changes the way Medicare paysclinicians and offers financial incentives for providing high valuecare.
2) Medicare Part B clinicians will participate in the MIPS, unless theyare in their 1st year of Part B participation, become QPs through
participation in Advanced APMs, or have a low volume of patients.
3) Payment adjustments and bonuses will begin in 2019.
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Other than payment adjustments,what else does MACRA change?
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MACRA supports care delivery
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Such as:
Allocates $20 million / yr. from 2016-2020 to small practices toprovide technical assistance regarding MIPS performance criteria or
transitioning to an APM.
Creates an advisory committee to help promote development of
Physician-Focused Payment Models
MACRA supports care deliveryand promotes innovation.
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PFPM = Physician-Focused Payment Model
Goal to encourage new APM options for Medicareclinicians
Independent PFPM Technical Advisory Committee
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TechnicalAdvisory
CommitteeSubmission of
model proposalsby Stakeholders
11 appointed care deliveryexperts that review proposals,
submit recommendations to HHSSecretary
Secretarycomments on CMS
website, CMSconsiders testingproposed models
For more information on the PTAC, go to: https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee
PROPOSED RULE
https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committeehttps://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committeehttps://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committeehttps://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee
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PROPOSED RULE
Physician-focused Payment Model (PFPM)
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Any PFPM that is selected for testing by CMS and meets the criteria for anAdvanced APM would be an Advanced APM.
Proposed definition:
An Alternative Payment Model wherein Medicareis a payer, which includes physician group practices (PGPs) or
individual physicians as APM Entities and targets the quality and
costs of physician services.
Payment incentivesfor higher-value care
Care deliveryimprovements
Informationavailability andenhancements
Proposedcriteria fallunder 3categories
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APPENDIX
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What if I’m in an Advanced APM but don’t quite meet
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If you meet a slightly reduced threshold (% of patients or payments in anAdvanced APM), you are considered a “Partial Qualifying APM Participant”(Partial QP) and can:
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What if I m in an Advanced APM but don t quite meetthe threshold to be a QP?
Opt outof MIPS
Participate inMIPSor
No payment
adjustment
Receivefavorable
weightsin MIPS
Partial QPAdvanced APM
CMS will publish the list of APMs that
use the standard on website prior tofirst day of performance period
Eligible clinicians must be included in
the APM participant list maintained by
CMS (as of 12/31/2017)
PROPOSED RULE
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PROPOSED RULE
APM Scoring Standard
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How does it work?
Streamlined MIPS reporting and scoring for eligible clinicians in certain APMs.
Aggregates eligible clinician MIPS scores to the APM Entity level.
All eligible clinicians in an APM Entity receive the same MIPS compositeperformance score.
Uses APM-related performance to the extent practicable.
Goals:
Reduce eligible clinician reporting burden.
Maintain focus on the goals and objectives of APMs.
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PROPOSED RULE
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APM Scoring Standard
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Shared Savings Program (all tracks)
Next Generation ACO Model
Comprehensive ESRD Care (CEC) (large dialysisorganization arrangement)
Comprehensive Primary Care Plus (CPC+)
Oncology Care Model (OCM)
All other APMs that meet criteria for the APM scoring
standard
To which APMs willthe APM scoringstandard apply?
PROPOSED RULE
APM S o i St d d
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APM Scoring StandardShared Savings Program
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Shared Savings Program ACOssubmit to the CMS WebInterface on behalf of their MIPSeligible clinicians.
The MIPS quality performancecategory requirements andbenchmarks will be used at the ACOlevel.
50%
No reporting requirement. N/A 0%
All MIPS eligible clinicianssubmit through ACO participantTINS according to the MIPSrequirements.
ACO participant TIN scores will beaggregated, weighted and averagedto yield one ACO level score.
20%
All MIPS eligible clinicianssubmit through ACO participantTINS according to the MIPSrequirements.
ACO participant TIN scores will beaggregated, weighted and averagedto yield one ACO level score.
30%
Quality
Resource use
ReportingRequirement Performance Score Weight
CPIA
:
Advancing careinformation
PROPOSED RULE
APM Scoring Standard
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APM Scoring StandardNext Generation ACO Model
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Next Generation ACOs submitto the CMS Web Interface onbehalf of their MIPS eligibleclinicians.
The MIPS quality performancecategory requirements andbenchmarks will be used at the ACOlevel.
50%
No reporting requirement. N/A 0%
All MIPS eligible clinicianssubmit individually according tothe MIPS requirements.
ACO participant individual scores willbe aggregated, weighted andaveraged to yield one ACO level score.
20%
All MIPS eligible clinicianssubmit individually according tothe MIPS requirements.
ACO participant individual scores willbe aggregated, weighted andaveraged to yield one ACO level score.
30%
Quality
Resource use
ReportingRequirement Performance Score Weight
CPIA
:
Advancing careinformation
PROPOSED RULE
APM Scoring Standard
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APM Scoring StandardAll Other APMs under the APM Scoring Standard
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Quality
Resource use
No assessment for the first MIPSperformance year. APM-specificrequirements apply as usual.
N/A 0%
No reporting requirement. N/A 0%
All MIPS eligible clinicianssubmit individually according tothe MIPS requirements.
APM Entity participant individualscores will be aggregated, weightedand averaged to yield one APMEntity level score.
25%
All MIPS eligible clinicianssubmit individually according tothe MIPS requirements.
APM Entity participant individualscores will be aggregated, weightedand averaged to yield one APMEntity level score.
75%
ReportingRequirement Performance Score Weight
CPIA
:
Advancing careinformation
H ill th Q lit P t P ff t
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Am I in an APM?
• Excluded from MIPS• 5% lump sum bonus payment (2019-2024),
higher fee schedule updates (2026+)• APM-specific rewards
Subject toMIPS
Favorable MIPSscoring & APM-specific rewards
Bottom line: There will befinancialincentives for participating in an
APM, even if you don’t become aQP.
Am I in anAdvanced
APM?
Yes
Do I have enough paymentsor patients through my
Advanced APM?
Is this my first year inMedicare OR am I below
the low-volumethreshold?
Notsubject to
MIPS
Qualifying APM Participant (QP)
No
Yes No
Yes No
Yes No
How will the Quality Payment Program affect me?
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Disclaimer
This presentation was current at the time it was published or uploaded ontothe web. Medicare policy changes frequently so links to the sourcedocuments have been provided within the document for your reference.
This presentation was prepared as a service to the public and is notintended to grant rights or impose obligations. This presentation maycontain references or links to statutes, regulations, or other policy materials.The information provided is only intended to be a general summary. It is notintended to take the place of either the written law or regulations. Weencourage readers to review the specific statutes, regulations, and other
interpretive materials for a full and accurate statement of their contents.