9/9/2016 1 Surviving the New Program Requirements and the Financial Penalties Under MIPS September 2016 Selena Hood • Steps to take to prepare for MIPS • Introduction and Evaluation of the Merit-Based Incentive Payment System (MIPS) − Quality Performance Category − Resource Performance Category − Clinical Practice Improvement Activities Performance Category − Advancing Care Information Performance Category − Data Submission − Payment Adjustment • Surviving the payment penalties under MIPS Agenda 9/9/2016 2
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9/9/2016
1
Surviving the New Program Requirements
and the Financial Penalties Under MIPS
September 2016
Selena Hood
• Steps to take to prepare for MIPS
• Introduction and Evaluation of the Merit-Based Incentive Payment System (MIPS)− Quality Performance Category− Resource Performance Category− Clinical Practice Improvement Activities Performance Category− Advancing Care Information Performance Category− Data Submission− Payment Adjustment
• Surviving the payment penalties under MIPS
Agenda
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2
Survival Guide
Things to think about NOW
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1. Check your Medicare PQRS feedback reports.
2. Check your Medicare QRUR reports
3. Review proposed rule’s list of Clinical Practice Improvement Activities (CPIA)
4. Review your place in the EHR Incentive program– Do you have a CEHRT, were you exempt last program year?
5. General Considerations – Determine your Medicare status, do you plan to report as an individual or group, are you a non-patient facing EC?
6. Alternative Payment Models– Confirm whether you are participating in an APM. If not, check with your specialty society to see if there's and
opportunity.
7. How do you plan to submit data?
8. Make sure you submit data!– If you do not submit data, the law requires CMS to give a zero performance score and a negative payment
adjustment (-4% for 2019)
9. Understand the Proposed Rule.
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Proposed Rule:Steps to take to prepare for MIPS:
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New Payment Tracks For Provider Groups:
The Merit-Based Incentive Payment System (MIPS)
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• MIPS is a new program
– Streamlines three currently independent programs to work as one and to ease clinician burden
– Adds a fourth component to promote improvement and innovation to clinical activities
– MIPS provides clinicians the flexibility to choose the activities and measure that are most meaningful to their practice to demonstrate performance
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Proposed Rule:
Introduction to MIPS
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“MIPS eligible clinicians” replaces the previous use of “Eligible Professional (EP)”
• Physical or occupational therapists, Speech-language pathologists, Audiologists, Nurse midwives, Clinical social workers, Clinical psychologists, Dietitians/Nutritional professionals.
Proposed Rule:Who will NOT Participate in MIPS
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FIRST year of Medicare Part B
participation
Below low patient volume threshold
Medicare billing charges less than or equal to $10,000 and provides care for 100 or fewer Medicare
patients in one year.
Certain participants in ADVANCED
Alternative Payment Models
Note: MIPS does not apply to hospitals or facilities
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Proposed Rule:MIPS: Eligible Clinicians
Eligible Clinicians can participate in MIPS as an:
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Individual Group
• An individual is a define as a unique NPI or TIN. (Same as before)• A group is 2 or more, as defined by taxpayer identification number (TIN), would be
assessed across all four MIPS performance categories.• “Virtual groups” will not be implemented in year 1 of MIPS.
• All MIPS performance categories are aligned to a performance period of one full calendar year.
• A single MIPS composite performance score will factor in 4 weighted performance categories on a 0-100 point scale
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MIPS Composite
Performance Score (CPS)
Proposed Rule:Year 1 Performance Category Weights for MIPS
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Quality
50%
Advancing Care Information 25%
Clinical Practice Improvement activities 15%
Resource Use 10%
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Proposed Rule:MIPS: Performance Category Scoring
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MIPS:
Quality Performance Category
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Proposed Rule:MIPS: Quality Performance Category
Summary:
• Selection of 6 measures
• 1 cross-cutting measure and 1 outcome measure, or another high priority measure if outcome is unavailable
• Select from individual measures or a specialty measure set
• Population measures automatically calculated
• Year 1 weight: 50%
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Proposed Rule:Key Changes from Current Program (PQRS)
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Base Score Performance
Score
Bonus Points Composite
Score
PQRS Quality Performance Category
Scoring Report all required measures to avoid payment adjustment
Report all required measures. Credit received for those measures that meet the data completeness threshold
Data Submission Criteria Required 9 measures across 3 NQS domains
Requires 6 measures; no NQS domain requirement
Face-to-face Encounter 1 encounter required for the cross-cutting measure requirement
25 or less encounters required for cross-cutting requirement
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Requirement
CAHPS required for groups with 100 or more EPs
CAHPS no longer required for groups of 100 or more, bonus points for submitting survey
MAV Secondary outcome to determine successful reporting
Yet to be determined. Open for comments.
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Proposed Rule:Assigning Points Based on Deciles
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0% 7% 16% 23% 36% 41% 62% 69% 79% 85% 100%
Proposed Rule:Assigning Points Based on Deciles
McKesson Corporation Confidential and Proprietary18
Benchmark Deciles Benchmark Ranges (Hypothetical)
Points Scored
1 0% ‐ 6.9% 1.0 – 1.9
2 7% ‐ 15.9% 2.0 – 2.9
3 16% ‐ 22.9% 3.0 – 3.9
4 23% ‐ 35.9% 4.0 – 4.9
5 36% ‐ 40.9% 5.0 – 5.9
6 41% ‐ 61.9% 6.0 – 6.9
7 62% ‐ 68.9% 7.0 – 7.9
8 69% ‐ 78.9% 8.0 – 8.9
9 79% ‐ 84.9% 9.0 – 9.9
10 85% ‐ 100% 10
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• Eligible clinicians with performance in the top decile will receive the maximum 10 points.
• Eligible clinicians who do not report enough measures will receive 0 points for each measure not reported, unless they could not report these measures due to insufficient applicable measures.
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Proposed Rule: Converting Measure to Points Based on Deciles
• Up to 10% “extra credit” total in bonus points.
• Additional high priority measure (up to 5% of possible total)− 2 bonus points award for additional outcome/patient experience− 1 bonus point for the other high priority measures
• CEHRT Bonus (up to 5% of possible total)− 1 bonus point for each measure reported using CEHRT for end-to-end
• Assessment under all available resource use measure, as applicable to the clinician
• CMS calculates based on claims so there are no reporting requirements for clinicians
• Key changes from Current Program (Value-Based Payment Modifier):− Adding 40+ episode specific measures to address specialty concerns− Year 1 Weight: 10 points
• Note: No additional submission requirements
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Proposed Rule:MIPS: Resource Use Performance Category
Proposed Rule:Key Changes from Current Program (Value Modifier)
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Base Score Performance
Score
Bonus Points Composite
Score
Value ModifierProposed MIPS Resource
Use Category
6 measures:
• Total per capita costs for all attributed beneficiaries,
• Medicare Spending per Beneficiary (MSPB),
• Total per capita cost measures for the four condition-specific groups (chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, and diabetes mellitus).
• Attribution to the group practice (TIN)
2 of the 6 VM measures:
• Total per capita costs for all attributed beneficiaries,
• Medicare Spending per Beneficiary (MSPB),
• Removes total per capita cost measures for the four condition-specific groups.
• Attribution to group (TIN) or individual (TIN/NPI)
• Proposes up to 41 other episode based measures
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Proposed Rule:Proposed Clinical Episode Groups
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Proposed Rule: Scoring: Resource Use Performance Category Example
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Each measure is
converted to points (1-10))
Minimum Case Volume (20 including for MSPB)
Total Points
Total Points Total Possible points
Quality Performance
Category Score
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MIPS:
Clinical Practice Improvement Activity (CPIA) Performance Category
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Summary:
• Minimum selection of one CPIA activity (from 90+ proposed activities) 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 points
− The more activities completed, the more points are rewarded to the clinician
− Examples: care coordination, safety checklist, and after hours care
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Proposed Rule:MIPS: Clinical Practice Improvement Activity Performance Category
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Proposed Rule:CPIA Performance Category
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Proposed Rule:Subcategories of Clinical Practice Improvement Activities
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Base Score Performance
Score
Bonus Points Composite
Score
Subcategories are specified in MACRA
Three additional subcategories are
proposed in the NPRM
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In general:
• Each activity in the CPIA activity list is worth a certain number of points − Most are worth 10 points (medium weight)− Some activities have high weight, and are worth 20 points
• To get maximum credit, must achieve 60 points–Can be achieved by selecting any combination of activities:− High-and medium-weight− All high-weight− All medium-weight activities
• Special scoring considerations for specific types of eligible clinicians and groups are discussed later.
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Proposed Rule: CPIA Scoring Overview
Proposed Rule: Scoring: CPIA Performance Category Example
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Total points for high-weight
activities
Total points for medium-weight
activities
Total CPIA Points
Total CPIA Points
Total Possible points
CPIA Performance
Category Score
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MIPS:
Advancing Care Information Performance Category
Summary:
• CEHRT required
• Key changes from current program (EHR Incentive):− Eliminated Clinical Provider Order Entry and Clinical Decision Support
objectives− Reduced the number of required public health registries to which clinicians must
report− Year 1 Weight: 25 points
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Proposed Rule:MIPS: Advancing Care Information Performance Category
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Proposed Rule: Changes from EHR Incentive Program to Advancing Care Information
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Past Requirements fro the Medicare EHR Incentive Program
New Proposal for Advancing Care Information Category
One-size-fits-all-every objective reported and weighed equally
Customizable – clinicians can choose which categories to emphasize in their scoring
Requires across-the-board levels of achievement or “thresholds,” regardless of practice or experience
Flexible. Allows for diverse reporting that matches clinician’s practice and experience.
Measurements emphasizing process Measurement emphasizing patient engagement and interoperability
Disjointed and redundant with other Medicare reporting programs
Aligned with other Medicare reporting programs. No need to report redundantquality measures.
No exemptions for reporting Exemptions for reporting for clinicians.• Advanced alternative payment model• First year with Medicare• Have low Medicare volumes
Proposed Rule: Who can participate
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Similar exclusions will carry over from EHR incentive. Hardship exceptions.
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Proposed Rule:MIPS: Advancing Care Information Performance Category
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CMS Proposes six objectives and their measures that would require reporting for the base score:
Base Score:
• The base score accounts for 50 points of the total Advancing Care Information category score.
• To receive the base score, physicians and other clinicians must simply provide the numerator/denominator or yes/no for each objective and measure.
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Proposed Rule: MIPS Advancing Care Information Performance Category
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Performance Score:
• The 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 information access:
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Proposed Rule:MIPS: Advancing Care Information Performance Category
• The performance category score is capped at 100 percentage points (out of a possible 131 percentage points).
• 50 percentage points for the base score, which consists of: − Reporting privacy and security− Reporting a numerator/denominator or yes/no statement for each measure as required Note: for numerator/denominator measures, ECs must report at least a one in the numerator; for yes/no
statement measures, ECs must report a yes for credit.
• 80 percentage points for the performance score, which is determined based on achievement above the base score requirements for three objectives:– Patient Electronic Access, Coordination of Care Through Patient Engagement, Health
Information Exchange
• 1 “bonus” percentage point for Public Health and Clinical Data Registry Reporting
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Proposed Rule:Advancing Care Information Break Down
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Proposed Rule:MIPS: Advancing Care Information Performance Category
Example Scoring:
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Account for
50 points of the total
Advancing Care Information
Performance Category Score
Account for
80 points of the total
Advancing Care Information
PerformanceCategory Score
Up to
1 pointof the total
Advancing Care Information
Performance category score
Earn 100+ pts receive
Full 25 points
in the Advancing Care Information
Category of MIPS composite
score
Base Score PerformanceScore
Bonus Points
Composite Score
+ + =
The overall Advancing Care Information score would be made up of a base score and a performance score for a maximum score of 100 points.
Proposed Rule: Scoring: Advancing Care Information Performance Category
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Base Score
50 points
Privacy and Security
Performance Score
80 points
Electronic Access, Care Coordination,
Health Information Exchange
Bonus for Public Health and Clinical
Data Registry Reporting
Total Points
Total Points Total Possible points
Advancing Care Performance
Category Score
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MIPS:
Data Submission Options
McKesson Corporation Confidential and Proprietary44
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MIPS:
Payment Adjustment
• Based on a CPS, clinicians will receive +/- or neutral adjustment up to the percentage below.
• MIPS will be a budget-neutral program. Total upward adjustment could
reach 3x the potential adjustment.
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Proposed Rule:How much can MIPS adjust payments?
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Composite Performance Score
In review
This is a test Footer47
Proposed Rule: Unified Scoring Principles
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10 point scoring system Actionable and transparent data. Eligible clinicians will know in advance what they need to do to perform well.
Moves away from “all-or-nothing” scoring
Receive scores for submitted information.
Performance at any level would help improve the CPS
Zero scores for any required items that are not submitted
No improvement scoring for year 1.
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Proposed Rule:Scoring Rules for each category
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Proposed Rule: Relationship between CPS and Payment
2. AMA (American Medical Association) “MACRA Checklist: Steps You Can Take Now to Prepare”http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-new-payment-systems.page
3. Health Catalyst “Why you Need to Understand Value-Based Reimbursements and How to Survive it”https://www.healthcatalyst.com/understand-value-based-reimbursement