The Quality Payment Program: 2018 Rule Updates and Strategies for Successful Participation

Transcription

1 The Quality Payment Program: 2018 Rule Updates and Strategies for Successful Participation Bruce Maki, MA M-CEITA / Altarum Regulatory & Incentive Program Analyst May 3,

2 Disclaimer This presentation was current at the time it was presented, published or uploaded onto the web. Medicare and Medicaid policies change frequently, so links to source documents have been provided for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage participants to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. 2

3 Today s Agenda Brief Overview of M-CEITA Due to time constraints, some slides are provided for reference only. Slides with a will not be discussed. QPP Overview MIPS changes for 2018 Eligibility and Exemptions Special Status Considerations Performance Period and Reporting Options The 4 MIPS Performance Categories Performance Thresholds and Payment Adjustments Additional Scoring Considerations Alternative Payment Models Advanced APMs and Qualified Participant Status Current Advanced APM Options APM Incentives and Scoring Available Technical Assistance Questions 3

4 Who is M-CEITA? Michigan Center for Effective Information Technology Adoption (M-CEITA) One of 62 ONC Regional Extension Centers (REC) providing education & technical assistance to primary care providers across the country Founded as part of the HITECH Act to accelerate the adoption, implementation, and effective use of electronic health records (EHR), e.g. 90-days of MU Funded by ARRA of 2009 (Stimulus Plan) Purpose: support the Triple Aim by achieving 5 overall performance goals 3 Improve Quality, Safety & Efficiency THE TRIPLE AIM Improve patient experience Improve population health Reduce costs Engage Patients & Families Performance Measurement Improve Care Coordination Improve Population And Public Health Meaningful Use Ensure Privacy And Security Protections Certified Technology Infrastructure 4

5 M-CEITA Services Meaningful Use Support Security Risk Assessment & Network Security Evaluation Audit Preparation Consulting Services Great Lakes Practice Transformation Network (GLPTN) Chronic Care Management (CCM) Quality Payment Program Resource Center MICH-EHR 5

6 The Quality Payment Program MIPS and Advanced APMs The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program (QPP), that provides two participation tracks: 6

7 The Quality Payment Program Program Goals For additional information and support for the QPP, visit and 7

8 What is MIPS? The Merit-based Incentive Payment System Combines multiple legacy Medicare Part B programs into a single program (4) MIPS Performance Categories: Quality (PQRS/Value Modifier-Quality Program) Cost (Value Modifier-Cost Program) Advancing Care Information (ACI) (Medicare MU*) Improvement Activities (IA) *MACRA does not alter or end the Medicaid EHR Incentive Program 8

9 MIPS Year 2 (2018) Who is Included? NO CHANGE in the types of clinicians eligible to participate in 2018 MIPS Eligible Clinicians (ECs) include: 9

10 MIPS Year 2 (2018) Who is Included? As a reminder, the definition of Physician includes: Doctor of Medicine Doctor of Osteopathy (including Osteopathic Practitioners) Doctor of Dental Surgery Doctor of Dental Medicine Doctor of Podiatric Medicine Doctor of Optometry Doctor of Chiropractic Medicine (legally authorized to practice by a State in which he/she performs this function) 10

11 MIPS Year 2 (2018) Who is Included? Change to the Low-Volume Threshold for Includes MIPS eligible clinicians billing more than $90,000 a year in Medicare Part B allowable charges AND providing care for more than 200 Medicare patients a year Transition Year (2017) Final Year 2 (2018) Final Billing >$30,000 AND Medicare Patients >100 Billing >$90,000 AND Medicare Patients >200 Voluntary reporting remains an option for those clinicians who are exempt from MIPS (note data will also be publically available on Physician Compare website) 11

12 MIPS Year 2 (2018) Who is Exempt? Except for the Low-Volume Threshold, no change in basic exemption criteria 12

13 MIPS Year 2 (2018) Non-Patient Facing No change in non-patient facing criteria Transition Year (2017) Final Individual If you have </= 100 patient facing encounters. Groups If your group has >75% of NPIs billing under your group s TIN during a performance period are labeled as non-patient facing. Year 2 (2018) Final No change to individual and group policy NEW VIRTUAL GROUPS are included in the definition. Virtual Groups that have >75% of NPIs within a virtual group during a performance period are labeled as nonpatient facing 13

14 MIPS Year 2 (2018) Other Special Statuses Special Status Component Year 2 (2018) Final Application Small Practice Definition Practices consisting of 15 or fewer billing clinicians (not just MIPS ECs) Rural and Health Professional Shortage Areas (HPSA) Rural and HPSA practice designations An individual MIPS eligible clinician, a group, or a virtual group with multiple practices under it's TIN (or TINs within a virtual group) with more than 75% of NPIs billing under the individual MIPS eligible clinician or group's TIN or within a virtual group in a ZIP code designated as a rural area or HPSA No change to the application of these special statuses from Year 1 to Year 2 14

15 MIPS Year 2 (2018) Performance Period Change: Increase to Performance Period Transition Year (2017) Final Year 2 (2018) Final Performance Category Minimum Performance Period Performance Category Minimum Performance Period Quality 90-days minimum; days was an option Quality 12 Months Cost Improvement Activities (IA) Advancing Care Information (ACI) Not included. 12-months for feedback only 90-days 90-days Cost Improvement Activities (IA) Advancing Care Information (ACI) 12 Months 90-days 90-days 15

16 MIPS Year 2 (2018) Reporting Options 16

17 MIPS Year 2 (2018) Virtual Groups What is a VIRTUAL GROUP? A Virtual Group can be made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together virtually (no matter what specialty or location) to participate in MIPS. To be eligible to join or form a virtual group, you would need to be a: Solo practitioner who exceed the low-volume threshold individually, and are not a newly Medicare-enrolled eligible clinician, a Qualifying APM Participant (QP), or a Partial QP choosing not to participate in MIPS. Group that has 10 or fewer eligible clinicians and exceeds the low-volume threshold at the group level. 17

18 MIPS Year 2 (2018) Virtual Groups What else do you need to know? Solo practitioners and groups who want to form a virtual group must go through the election process. Virtual groups election must occur prior to the beginning of the performance period and cannot be changed once the performance period starts. Election period was October 11 to December 31, 2017 for the 2018 MIPS performance period. 18

19 MIPS Year 2 (2018) Virtual Groups What else do you need to know? Generally, program policies that apply to TIN groups also apply to virtual groups. Virtual groups use the same submission mechanisms as groups. All clinicians within a TIN are part of the virtual group. Virtual groups are required to aggregate their scores across the virtual group for each performance category and will be assessed and scored as a virtual group. If TIN/NPI is participating in both a virtual group and an APM, the TIN/NPI will receive a final score based on the virtual group performance and a final score based on performance in an APM. However, the TIN/NPI will receive a payment adjustment based on the APM score. 19

20 MIPS Year 2 (2018) Submission Mechanisms No Change: All of the submission mechanisms remain the same from Year 1 to Year 2 20

21 MIPS Year 2 (2018) Quality 21

22 MIPS Year 2 (2018) Quality 22

23 MIPS Year 2 (2018) Quality 23

24 MIPS Year 2 (2018) Quality 24

25 MIPS Year 2 (2018) Cost 25

26 MIPS Year 2 (2018) Cost 26

27 MIPS Year 2 (2018) Scoring Improvements New: MIPS Scoring Improvement for Quality and Cost* Performance Categories *Bipartisan Budget Act of 2018 altered 2018 QPP rules 27

28 MIPS Year 2 (2018) Improvement Activities 28

29 MIPS Year 2 (2018) Improvement Activities 29

30 MIPS Year 2 (2018) Advancing Care Information 30

31 MIPS Year 2 (2018) Advancing Care Information 31

32 MIPS Year 2 (2018) Performance Thresholds & Payment Adjustment Change: Increase in Performance Threshold and Payment Adjustment Transition Year (2017) Final 3 Point Threshold Exceptional performer set at 70 points Payment adjustment set at +/- 4% Year 2 (2018) Final 15 Point Threshold Exceptional performer set at 70 points Payment adjustment set at +/- 5% How can an EC/Group achieve 15 points? Report all required Improvement Activities Meet the ACI base score and submit 1 Quality measure that meets data completeness Meet the ACI base score and submit one medium-weight Improvement Activity Submit 6 Quality measures that meet data completeness criteria 32

33 MIPS Year 2 (2018) Performance Thresholds & Payment Adjustment Change: Increase in Performance Threshold and Payment Adjustment Transition Year (2017) Final Year 2 (2018) Final 33

34 MIPS Year 2 (2018) Calculating the Final Score 34

35 MIPS Year 2 (2018) Complex Patient Bonus New: Complex Patient Bonus Up to 5 bonus points available for treating complex patients based on medical complexity. As measured by Hierarchical Condition Category (HCC) risk score and a score based on the percentage of dual eligible beneficiaries. MIPS eligible clinicians or groups must submit data on at least 1 performance category in an applicable performance period to earn the bonus. 35

36 MIPS Year 2 (2018) Small Practice Bonus New: Small Practice Bonus 5 bonus points added to the final score of any MIPS eligible clinician or group who is in a small practice (15 or fewer billing clinicians), so long as the MIPS eligible clinician or group submits data on at least 1 performance category in an applicable performance period. CMS recognizes the challenges of small practices and will provide a 5 point bonus to help them successfully meet MIPS requirements 36

37 Alternative Payment Models (APMs) The other fork in the path to Quality-based Reimbursement 37

38 Alternative Payment Models (APMs) Quick Overview Alternative Payment Model or APM is a generic term describing a payment model in which providers take responsibility for cost and quality performance and receive payments to support the services and activities designed to achieve high value According to MACRA, APMs in general include: Medicare Shared Savings Program (MSSP) ACOs Demonstrations under the Health Care Quality Demonstration Program CMS Innovation Center Models Demonstrations required by Federal Law MACRA does not change how any particular APM pays for medical care and rewards value; program adds incentives to existing model APM participants also participating in MIPS may receive favorable scoring under certain MIPS performance categories Only some APMs are Advanced APMs 38

39 Alternative Payment Models (APMs) Advanced APMs Term established by CMS; these have the greatest risks and offer potential for greatest rewards Advanced APMs Qualified Medical Homes (must be expanded under CMS authority) have different risk structure but are otherwise treated as Advanced APMs Qualified Medical Homes MIPS APMs receive favorable MIPS scoring, but participants must still participate in MIPS track of the Quality Payment Program MIPS APMs 39

40 Criteria for Advanced APMs 50% of participants must use certified EHR Technology (CEHRT) Must report and at least partially base clinician payments on quality measures comparable to MIPS Bear more than nominal risk for monetary losses Defined as the lesser of 8% of total Medicare revenues or 3% of total Medicare expenditures Primary Care Medical Home models with < 50 clinicians have different standards (2.5%-5% total Medicare revenues) Financial Risk EHR Use Advanced APMs Quality Reporting 40

41 Volume Thresholds for APMs A Qualifying APM is one that meets increasing thresholds for the percentage of charges that pass through the APMs methodology An individual Eligible Clinician (EC) in a qualifying APM is a Qualified APM Participant or QP QP status is awarded to all advanced APM participants collectively (or to none as the case may be) What if the threshold for QP status is not met? If the advanced APM does not meet the volume threshold to qualify its members for QP status, members meeting lower, minimum thresholds are considered Partially Qualifying APM Participants or PQPs If a PQP chooses to stay in the APM track, s/he will not receive the 5% bonus, but will not be subject to MIPS If PQP chooses, s/he can report MIPS measures and participate in the MIPS incentive track 41

42 Becoming a Qualified APM Participant (QP) 42

43 Advanced APM Options Comprehensive ESRD Care Model Comprehensive Primary Care Plus (CPC+) (14 states, applications closed) Medicare Shared Savings Track 2 Medicare Shared Savings Track 3 Next Generation ACO Model Oncology Care Model Track 2 43

44 New Advanced APM Options in 2018 ACO Track 1+ Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT) Comprehensive Care for Joint Replacement Payment Model (CEHRT Track) Voluntary bundled payment models Vermont Medicare ACO Initiative (all payer ACO model) Others??? (likely) 44

45 Incentives for Advanced APM Participation Model design APMs have shared savings, flexible payment bundles and other desirable features; these are not affected by the QPP Bonuses In , 5% lump sum bonus payments made to ECs significantly participating in Advanced APMs [all APM members must reach QP (Qualified Participant) status] Higher reimbursement updates Annual baseline payment updates will be higher (0.75%) for Advanced APM participants than for MIPS participants (0.25%) starting in 2026 MIPS exemption Advanced APM participants do not have to participate in MIPS (models include their own EHR use and quality reporting requirements) 45

46 MIPS APMs (non-advanced) Criteria APM entity participates in a model under an agreement with CMS Entity includes at least one MIPS eligible clinician on a participant list Payment incentives based on performance on cost and quality measures 2018 Qualified Models MSSP Track 1 is included (Majority of Medicare ACOs) Advanced APM benefits do not apply Must participate in MIPS to receive any favorable payment adjustments Do not qualify for 5% APM bonus payments Not eligible for higher baseline annual updates beginning 2026 MIPS APM Benefits 2018 MIPS APMs receive full credit in the Improvement Activities performance category APM-specific rewards (e.g., shared savings) Eligible for annual MIPS bonuses, which continue indefinitely (vs. 6 years for 5% APM bonuses) 46

47 APM Scoring Standard Quick Refresher The APM scoring standard offers a special, minimally-burdensome way of participating in MIPS for eligible clinicians in APMs who do not meet the requirements to become QPs and are therefore subject to MIPS, or eligible clinicians who meet the requirements to become a Partial QP and therefore able to choose whether to participate in MIPS. The APM scoring standard applies to APMs that meet the following criteria: 47

48 APM Scoring Standard Category Weighting for MIPS APMs In the 2017 Final Rule, CMS finalized different scoring weights for Medicare Shared Savings Program and the Next Generation ACO model, which were assessed on quality, and other MIPS APMs, which had quality weighted to zero. For 2018, CMS aligned weighting across all MIPS APMs, and assess all MIPS APMs on quality 48

49 APM Scoring Standard Additional Changes for Year 2 CMS finalized additional details on how the quality performance category will be scored under the APM scoring standard for non-aco models, who had quality weighted to zero in In 2018, participants in MIPS APMs will be scored under MIPS using the quality measures that they are already required to report on as a condition of their participation in their APM. Additionally, CMS established a fourth snapshot date of December 31 st for full TIN APMs (Medicare Shared Savings Program) for determining which eligible clinicians are participating in a MIPS APM for purposes of the APM scoring standard. This allows participants who joined full TIN APMs between September 1st and December 31st of the performance year to benefit from the APM scoring standard. 49

50 Bipartisan Budget Act of

51 Technical Assistance Available Resources and Organizations FOR FREE 51

52 Questions? Bruce Maki