MACRA Roadmap: An Overview of the Quality Payment Program in 2019 Suzanne Falk, MPP Senior Associate, Regulatory Affairs sfalk@acponline.org
Today s Game Plan: At a Glance: Major Proposed QPP Changes QPP Deep Dive: What you need to know in 2019 * Not-yet finalized proposals noted throughout ACP Advocacy in Action: 2019 QPP Proposals Live Q&A 2
But first, a few housekeeping items... Please save Questions for the end, or... Chat with me after the presentation or over lunch Email me at sfalk@acponline.org Yes... slides will be made available! 2019 changes are proposed and subject to change. Remember: this presentation is a summary! 3
Major 2019 MIPS Proposals at a Glance Increase both MIPS performance thresholds Expand low-volume threshold and add opt-in option Overhaul Promoting Interoperability scoring Require 2015 CEHRT Retire quality measures deemed to be low-value Add new facility-based scoring option Increase weight of Cost Category Introduce 8 new episode-based cost measures Make changes to reporting terminology 4
Just as important what didn t change? Minimum reporting periods (quality still a full-year) Quality measure data completeness requirements for most reporting mechanisms remains at 60% 5
Major 2019 APM Proposals at a Glance Maintain 8% revenue-based risk threshold through 2024 Allow QP determinations at TIN-level Increase APM CEHRT threshold to 75% New All-Payer Combination Option in 2019 Medicaid, MA & CMMI multi-payer models would count in 2019 Strictly private payer APMs would not count until 2020 Allow Other Payer APM determinations to remain in effect for multiple years provided there are no changes Must provide evidence that CEHRT threshold is being met 6
Important Dates/Deadlines Aug. 13 2018 MIPS Participation & APM QP Status Info Available Through QPP Look-Up Tool Oct. 2 Last day to start 90-day reporting for PI & IA Categories Jan. 1 2019 MIPS Payment Adjustments & APM QP Bonuses Applied Based on 2017 Data March 31 Reporting Deadline for 2018 MIPS Data July 1 2017 MIPS Performance Available in QPP portal using EIDM credentials Oct. 1 2017 MIPS Targeted Review Requests Due Dec. 31 Deadline for 2018 MIPS Hardship Exception Applications Feb. 28 Deadline for 2018 CAHPS Data Want more? Check out ACP s Physician Practice Timeline >> 7
QPP Deep Dive: What you Need to Know in 2019 8
MIPS 9
Who Participates in MIPS? Physicians, PAs, NPs, CNSs, CRNAs Proposed Additions for 2019: Physical Therapists Occupational Therapists Clinical Social Workers Clinical Psychologists 10
Who does NOT participate in MIPS? Automatic Exclusions: 1st year enrolled in Part B QP or Partial QP in AAPM Proposed: neutral adjustment for ECs who join a TIN in Oct-Dec if the practice is not reporting as a group or TIN is newly formed Application-Based Exceptions: Extreme & uncontrollable circumstances hardship exceptions Due Dec. 31 st of performance year Below low-volume threshold Excluded practitioner types Proposed: Can apply at TIN-level! MAQI Demonstration for those with significant participation in MA alternative payment arrangements 11
Low-volume Threshold Excluded individuals or groups must meet one of the following criterion: $90,000 Part B allowed charges OR 200 Part B patients OR 200 covered professional services under the PFS ^ Proposed for 2019! Proposed: Clinicians, groups or APM Entities could opt-in to MIPS if they meet 1-2 criteria (but not all 3) 12
Proposed Streamlined MIPS Determination Period Aligns with fiscal year & features two segments: 1 st : Oct. 2017 - Sept. 2018 (30-day claims run-out) 2 nd : Oct. 2018 - Sept. 2019 (no claims run-out) *Clinicians/groups would only have to qualify during one Would apply to the following determinations: Low-volume threshold ASC-based Non-patient facing Virtual groups* Small practice Facility-based* Hospital-based *Use only 1st segment 13
MIPS Payment Adjustments Standard MIPS adjustments are budget neutral Based on allowed charges for Part B covered prof. services BBA excluded Part B drugs from MIPS $ adjustments & extended MIPS performance threshold flexibility through 2021 2018 2019 4% -4% 5% -5% 7% -7% 9% -9% 2017 2018 2019 2020+ 100 pts 70 pts 15 pts 3 pts max bonus Exceptional performance threshold performance threshold max penalty 100 pts 80 pts 30 pts 7.5 pts 14
MIPS Bonuses and Special Scoring Scenarios MIPS Bonus for Complex Patients 1-5 points depending on severity based on HCC score Small Practices ( 15 eligible clinicians) Increased low-volume threshold 5-point bonus *CMS proposes to move to Quality 3 pts for quality measures that fail data completeness 3 pt bonus for reporting at least 1 quality measure MIPS APM Scoring Standard (more on that later) Facility-Based Scoring Option 15
New Facility-Based Scoring Option Uses data from Hospital VBP Program for performance period Automatically applied when it benefits a clinician s/group s score CMS would assign corresponding percentile score in MIPS Groups would need to report data for 1 other category as a group Eligibility Attribution Clinicians Bill at least 1 service with POS codes 21,23 & furnish 75%+ of covered professional services in POS codes 21,22,23 during a prior determination period hospital where they provide services to most patients Groups 75%+ of clinicians qualify as individuals hospital where most clinicians are attributed 16
Minimum Reporting Period Performance Category 2018 2019 Quality Full calendar year No change Cost Improvement Activities Promoting Interoperability No reporting required 90 consecutive days 90 consecutive days No change No change No change 17
Reporting Options Individual Clinician under an NPI number and TIN where they reassign benefits Group 2+ clinicians who have reassigned their billing rights to a single TIN Virtual Group 10 or fewer ECs who come together virtually (regardless of specialty or location) to participate in MIPS for a performance period Proposed for 2019: can inquire about eligibility prior to making an election through QPP Portal APM Entity 18
Proposed Terminology Changes MIPS CQMs: formally registry measures (since other vendors can report them) Collection type: set of quality measures with specs & completeness criteria (e.g. ecqms, MIPS CQMs, QCDR measures, claims measures, Web Interface measures, CAHPS measures & admin claims measures) Submitter type: MIPS eligible clinician, group, or 3rd party intermediary Submission type: mechanisms that submit data to CMS (e.g. direct log in, upload, attestation, Part B claims & Web Interface) 3rd party intermediaries: Entities that have been approved to submit data on behalf of a MIPS EC, group, or virtual group (e.g. QCDRs, qualified registries, health IT vendors & CMS-approved survey vendors) 19
Proposed Changes to Data Submission Oversight: CMS proposes to strengthen oversight of & penalties for vendors who submit inaccurate, unusable, or compromised data. Part B claims: would ONLY be available to small groups (regardless whether they reported at NPI or TIN level) Web Interface: would no longer report IA or PI data; no more high priority bonus pts; soliciting input on expanding to groups of 16+ clinicians & incorporating specialty-specific measures QCDRs and Qualified Registries: new vendor criteria proposed CAHPS: measures that don t meet sampling req s would = 0 pts but Quality would be scored out of 50 pts (valid for 1 year only) 20
Data Submission Types: Individual Reporters 21
Data Submission Types: Group Reporters 22
Genesis Registry Reports data for PI, Quality & Cost Categories Performance results & measure feedback National benchmark & peer specialty comparisons 23
Performance Category Weighting Performance Category 2018 2019 Quality 50% 45% Cost 10% 15% Improvement Activities 15% 15% Promoting Interoperability 25% 25% * BBA extended flexibility for setting weight of Cost Category through 2021 (though it cannot be <10%) 24
Quality: What hasn t changed? 45%???? 60-70 pts Must report 6 measures OR specialty set (or all applicable) Points scored /10 pts based on performance against benchmarks* At least 1 outcome or high-priority measure Potential bonus points worth up to 10% of Quality score Can earn points for quality improvement if fully participate 60% data completeness for most submission mechanisms * Measures that fail = 1 point for most; 3 points for small practices Topped out measures: 4-year process to remove; max 7 pts* * All-cause readmissions but only for groups with 16 or more clinicians with at least 200 attributed cases. 25
Quality: What has changed? 45%???? 60 pts 34 low-value measures removed (updated inventory) Extremely topped out measure may be removed sooner QCDR measures wouldn t qualify as topped-out Measures significantly impacted by clinical guideline changes/ patient safety concerns would not be scored. To compensate, Quality would be scored out of 50 points. Benchmarks would be based on collection type. Measure validation would only be applied to MIPS CQMs & claims collection types (not ecqms). Opioid-related measures would be considered high-priority. 26
Cost 15%???? 20-100 pts No reporting required (pulled from admin claims) BBA: No credit for cost improvement until 2022 MSPB and TPCC measures Risk adjustment based on HCC scores 8 brand-new episode-based measures proposed... Risk-adjusted and payment-standardized Based on allowed amount from Parts A & B claims Case min. = 10 for procedural; 20 for acute inpatient condition episodes Procedural episodes attributed based on trigger HCPCS/CPT codes Acute inpatient medical condition episodes attributed based on clinician who bills E&M claim lines during trigger inpatient hospitalization under TIN that renders 30%+ of inpatient E&M claim lines in that hospitalization 27
Proposed 2019 Episode-Based Cost Measures 28
Improvement Activities 15%???? 40 pts Yes/no attestation; scored on all-or-nothing basis Flexible documentation requirements Only 1 clinician in group has to perform activity High-weighted = 20 pts; medium-weighted = 10 pts Small practices, non-patient facing clinicians & clinicians located in rural/hpsas get double credit MIPS APMs, PCMHs & PCSPs get full credit (must attest) 6 new activities added; 1 removed; 5 modified See Tables A and B in Exhibit 2 29
Promoting Interoperability 25%???? 100 pts 2015 CEHRT required No more separate performance, base & bonus scores Each measure scored independently; on performance Must meet all 6 required measures or claim an exclusion Would remove bonus points for end-to-end reporting, but add new bonus points for opioid-related measures 30
2019 Proposed PI Objectives & Measures 31
PI Category Level Exceptions Automatic Exceptions : Non-patient facing (<100 patient-facing encounters or groups where this applies to 75%+ of clinicians) Hospital- or ASC-based clinicians (75%+ of services performed in POS 21, 22, 23; or ASC) Non-physicians Certain extreme circumstances determined by CMS * Note: PI Category will be scored if you submit data Application-Based Exceptions: Small practices 25% would be redistributed to Quality Category Lack of control over availability of CEHRT 32
PI Measure-Specific Exclusions E-Prescribing Support Electronic Referral Loops by Sending Health Information Support Electronic Referral Loops by Receiving & Incorporating Health Information Provide Patients Electronic Access to Their Health Information Two Public Health and Clinical Data Exchange measures If exclusions are claimed, points will be reallocated amongst remaining measures 33
Advanced Alternative Payment Models (APMs) 34
Step 1: What Makes an Advanced APM? 1. Use CEHRT Proposed: 75%+ of clinicians must use CEHRT (up from 50%) Proposed: Must provide evidence that threshold is being met 2. Base payment on quality measures comparable to MIPS 3. Either: Are a Medical Home Model under CMMI; OR Bear more than nominal financial risk 8% of average estimated Parts A & B revenue; OR 3% of estimated expenditures (e.g. benchmark) Proposed: maintain 8% revenue-based standard through 2024 35
Proposed 2019 Medicare Advanced APMs Medicare Shared Savings Program Tracks 1+, 2, 3* Next Generation ACOs Comprehensive Primary Care Plus (CPC+) Comprehensive ESRD Care (2-sided risk) Oncology Care (2-sided risk) Comp Care for Joint Replacement (CEHRT track) BPCI Advanced * A separate proposed rule would drastically restructure MSSP & solicit applications for a July 1, 2019 start date. 36
Step 2: Do I qualify as a Qualified Participant? Can qualify through Medicare Option OR All-Payer Combination Option *new in 2019! Medicaid, MA & CMMI multi-payer models count in 2019 Private payer APMs would not count until 2020 Payers and clinicians/practices will be able to begin submitting APMs for approval next year Other Payer APM determinations could remain in effect for up to 5 years provided there are no changes to design 37
Step 2: Do I qualify as a Qualified Participant? 2019-2020 Medicare Threshold Option Payments Patients QP 50% 35% Partial QP 40% 25% 2019-2020 All-Payer Combination Threshold Option Payments Patients QP 50% (25%)* 35% (20%)* Partial QP 40% (20%)* 25% (10%)* ()* = Medicare Minimum 38
QP Status Snapshot Dates #1 #2 3 snapshots all start Jan 1 & end Mar 31, June 30, or Aug 31 Must surpass threshold during at least 1 snapshot 4th snapshot added on Dec. 31 st for MIPS APMs only Proposed for 2019: QP determinations at TIN level Check your QP status: https://data.cms.gov/qplookup #3 B #4 MIPS APMs only! Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 39
Step 3: What s the incentive? Qualified Participants ( QPs ): 1. NOT subject to MIPS 2. Receive 0.5% higher PFS update for 2026 onward 3. Share in rewards of APM 4. Receive 5% lump sum bonus in 2019-2024 2017 2018 2019 QP Status Bonus Calculated Bonus Paid Partial QPs: 1. Have the option to participate in MIPS 2. Receive favorable scoring if they do 3. Share in rewards of APM 40
APMs: A Visual Breakdown APMs Advanced APMs Partial QPs QPs MIPS APMs Not a QP MIPS APM scoring standard 41
More About the MIPS APM Scoring Standard Streamlines certain MIPS reporting & scoring Ex: ACO reports quality data (*but not PI data!!) MIPS scores aggregated at the APM entity level Performance Categories are weighted differently Quality: 50% Cost: 0% IA: 20% PI: 30% Generally full credit toward IA 42
ACP Advocacy in Action Stay tuned for 2019 PFS/QPP comments APM stakeholder coalition Patients Before Paperwork Initiative Feedback; Statement to Ways and Means Subcommittee on Health for Medicare Red Tape Relief Initiative Meetings with senior CMS staff including CMS Administrator Seema Verma & CMMI Director Adam Boehler Group of 6 coalition released principles; held fly-in on reducing admin. burdens 43
ACP Top QPP Advocacy Asks: Reduce admin. burden in MIPS; implement consistent 90-day min. reporting period across categories & provide more opportunities for cross-category credit. Reduce MIPS complexity; streamline scoring across categories. Maximize MIPS participation, including finalizing the proposed opt-in option for those currently excluded under the low-volume threshold. Increase MIPS flexibility, including a set of optional measures for the PI Category and expanded opportunities for Advanced APM participation. Allow for a more gradual implementation of 2015 CEHRT. Avoid low-reliability measures, including proposed new cost measures. Implement MIPS gradually; don t rush to increase Cost weight while adding new measures or double MIPS performance threshold based on non-mips data. Provide more opportunities for small and rural practices to succeed. 44
Resources CMS fact sheet (with comparison chart) CMS press release FR version of proposed rule ACP press release CMS QPP Resource Center CMS QPP Participation Lookup Tool ACP Physician Practice Timeline ACP QPP Resource Page 45
Questions? 1. Got a good question for the group? Ask me now! 2. Chat with me later today. (I ll be hanging out immediately following the presentation and will be at lunch.) 3. E-mail me at sfalk@acponline.org. 46