Overview of Alternative Payment Models QPP Performance Year 2018 An Introductory Guide for CRNAs in Year 2. August 2018

Transcription

1 Overview of Alternative Payment Models QPP Performance Year 2018 An Introductory Guide for CRNAs in Year 2 August 2018

2 Learning Objectives MACRA and Quality Payment Program Overview Alternative Payment Models (APMS) o Types of APMS o Analysis of Payment Models Advanced APMs o Advanced APMS for CY 2018 o Qualifying Participant (QP) Status o Payment and Patient Threshold Requirements o Benefits MIPS APMs o MIPS APMS for CY 2018 o Partial Qualifying Participant (QP) Status o Payment and Patient Threshold Requirements o Benefits Review - Putting the Pieces Together

3 MACRA Overview

4 Evolution of Medicare Payments Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) which was signed into law by President Obama on April 16, MACRA repealed the Sustainable Growth Rate (SGR) Formula that was established in 1997 to control the cost of Medicare payments to physicians. MACRA also authorized the establishment of the Quality Payment Program (QPP). The QPP transitions Medicare reimbursement away from a volumebased fee-for-service payment system to a value-based payment system. This means clinicians are rewarded financially based on the quality and cost of care they provide Medicare beneficiaries.

5 APM Overview An APM is a payment approach that gives added incentive payments to eligible clinicians who provide high-quality and cost-efficient care. An APM can apply to a specific clinical condition, a care episode, or a population. Examples of APMs are bundled payments, accountable care organizations (ACOs) and medical homes. Advanced APMs are a subset of APMs that let group practices and clinicians earn more for taking on some risk related to their patients' outcomes.

6 Types of Alternative Payment Models Alternative Payment Model (APM) Advanced APM PFPM CMS Definition of an Alternative Payment Model (APM) Innovation Center Models (other than a health care innovation award) Demonstration under the Health Care Quality Demonstration Program Medicare Shared Savings Program Demonstration under federal law Advanced Alternative Payment Model (Advanced APM) Is an Alternative Payment Model Requires participants to use certified EHR technology Bases payment on quality measures comparable to those in MIPS Participants bear more than nominal financial risk or APM is a Medical Home expanded under Innovation Center authority Physician-Focused Payment Model (PFPM) Is an Alternative Payment Model Includes Medicare as a payer Physicians and other eligible clinicians play a core role in implementing the payment methodology Targets quality and costs of services that eligible clinicians provide, order, or significantly influence

7 QPP Two Paths: Advanced APMs and MIPS Quality Payment Program Advanced Alternative Payment Models (AAPM) If you sufficiently participate in an Advanced APM you may qualify for a Medicare incentive payment Merit Based Incentive Payment System (MIPS) If you are a MIPS eligible clinician you will be subject to a performance based payment adjustment

8 Analysis of QPP Program Models Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Advanced APM 5% bonus ends in 2024 Quality Payment Program (QPP) Merit Based Incentive Payment Program (MIPS) possible 4% in 2019 to 9% in 2022 CMMI Medical Home Financial Risk Standard Nominal Risk Standard plus Patient/Payment Thresholds (e.g. CPC and CPC+) Advanced APM Risk EHR Quality Measures plus Patient/Payment Thresholds (e.g. Next Generation ACO) MIPS APMs Quality Cost Advancing Care Info Improvement Activities utilizes APM scoring standard* (e.g. MSSP ACO Track 1) MIPS Quality Cost Promoting Interoperability Improvement Activities

9 Requirements for Advanced APMs Advanced APM must meet 3 criteria The APM is required to use a certified EHR (50% of participating providers must use CEHRT) The APM bases payment on quality measures comparable to those in the MIPS Quality category The APM must bear more than nominal financial risk OR be a medical home model under CMMI Source: Payment-Program-MACRA-NPRM-Slides.pdf

10 Advanced APM Financial Risk Criterion Total potential risk under the APM must be equal to at least either: 8% of the average estimated Parts A and B revenue of providers and suppliers in participating APM entities for QP performance periods 2017, 2018, 2019 and OR 3% of the expected expenditures an APM entity is responsible for under the APM for all performance years.

11 Advanced APMS Performance Year 2018 Bundled Payment for Care Improvement (BPCI) Classic and Advanced * Comprehensive Care for Joint Replacement (CJR) Track 1 CEHRT Oncology Care Model (OCM) (two-sided risk) Vermont Medicare ACO Initiative (part of Vermont All- Payer ACO)*** Next Generation ACOs Medicare Shared Savings ACOs Tracks 1+, 2 and 3 Comprehensive ESRD Care (CEC) (LDO and non-ldo) Comprehensive Primary Care Plus Model** *Starts October 2018, QP status or APM Scoring Standard starting in performance year 2019 ** Duel eligible in CPC+ and MSSPs will have their APM status determined by the MSSP Track; and for practices that start CPC+ in 2018 with more the 50 ECs in parent org will not qualify for the Medicare Home Model financial risk standard (8%) and therefore not be considered an AAPM *** Vermont ACOs will be participating in AAPMs and MIPS APMs in 2018 via a version of the Next Gen ACO Model. CMS anticipates that Vermont Medicare ACOs will be separate AAPMs and MIPS APMs starting in 2019.

12 Qualifying Participants (QP) Qualifying APM Participants (QPs) are clinicians who have a certain percentage of Part B payments for professional services or provide care to a certain percentage of patients through an Advanced APM. It is important to distinguish that Part B payments made to the eligible clinician is not allowed charges. If you are determined to be a QP in an Advanced APM you may earn a 5% incentive lump sum bonus until the end of the 2022 performance period which will be paid in the 2024 payment period. QP determinations are generally made at the APM entity level. The two exceptions are when a eligible clinician participates in multiple Advanced APMs or when the Affiliated Practitioner List is used for QP determinations. CMS estimates that 185,000 to 250,000 clinicians will be QPs in QPP Final rule 2018.

13 Full QP Threshold Requirements for 5% Bonus Payments Performance Year Percentage of Medicare Payments through AAPM 25% 25% 50% 50% 75% 75% Percentage of Medicare Patients through AAPM 20% 20% 35% 35% 50% 50%

14 What are the benefits of being a QP in an Advanced APM? May qualify for the 5% lump sum bonus until payment year 2024 for performance in year 2022 Excluded from MIPS payment adjustments Potential to gainshare if one s APM Entity allows one to do so (depends on the APM model) After payment year 2024 the PFS update is 0.75%.

15 MIPS APMS

16 MIPS APMS for the CY 2018 Performance Period Bundled Payment for Care Improvement (BPCI) Advanced * Oncology Care Model (OCM) (one and two-sided) Vermont Medicare ACO Initiative (part of Vermont All-Payer ACO)*** Medicare Shared Savings ACOs Tracks 1, 1+, 2 and 3 Next Generation ACOs Comprehensive Primary Care Plus Model** Comprehensive ESRD Care (CEC) Model (LDO and non-ldo) *Starts October 2018, QP status or APM Scoring Standard starting in performance year 2019 ** Duel eligible in CPC+ and MSSPs will have their APM status determined by the MSSP Track; and for practices that start CPC+ in 2018 with more the 50 ECs in parent org will not qualify for the Medicare Home Model financial risk standard (8%) and therefore not be considered an AAPM *** Vermont ACOs will be participating in AAPMs and MIPS APMs in 2018 via a version of the Next Gen ACO Model. CMS anticipates that Vermont Medicare ACOs will be separate AAPMs and MIPS APMs starting in 2019.

17 Snap Shot Dates for MIPS APM Scoring To be included in the APM Entity group for the purposes of the MIPS APM scoring standard, an eligible clinician s APM participant identifier must be present a Participation List of a MIPS APM on one of the following dates. The December 31 date only applies to ECs in Medicare Shared Savings ACOs to determine which ECs joined the ACO between September 1st and December 31st of the performance year. March 31 June 30 August 31 Dec 31

18 Partial Qualifying Participants (Partial QPs) Allows eligible clinicians who do not meet the full QP threshold levels in an Advanced APM to qualify for Partial QP status. Partial QP threshold levels for Part B payments for professional services or patients furnished through the Advanced APM are lower. As a Partial QPs in an Advanced APM you have the option not be subject to the MIPS payment adjustments and exclude yourself from MIPS participation If the Partial QPs choose to participate in MIPS will have the MIPS APM scoring standard apply to their performance scores.

19 Partial QP Threshold Requirements Performance Year Percentage of Medicare Payments through AAPM 20% 20% 40% 40% 50% 50% Percentage of Medicare Patients through AAPM 10% 10% 25% 25% 35% 35%

20 Weighting Performance Categories under the MIPS APM Special Scoring Standard 2018 Quality 50% IA 20% PI 30% Cost 0% Quality 0% IA 25% PI 75% Cost 0% General MIPS APM Scoring In all MIPS APMs Cost performance category will not be counted. MIPS APMS not reporting Quality Eligible clinicians not reporting Quality will have their performance reweighted. In addition Cost will not counted.

21 NEW!! All Payer Combination Option Beginning in 2019 performance year (2021 payment year) the patient or payment thresholds may be reached through a combination of Medicare and non- Medicare payer arrangements. The new payers included in the All Payer Combination option are: Medicaid APMS, Medicare Advantage APMS and other APMS used by commercial payers.

22 REVIEW Putting the Pieces Together

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24 How does a CRNA verify if they are a Qualifying Participant in an Advanced APM? Participation agreement Advanced APM QP You will be excluded from MIPS and will receive a 5% lump sum bonus ( ). Source:

25 Research and Quality Division Lorraine Jordan, PhD, CRNA, CAE, FAAN Chief Research, Quality, and Policy Officer Jihan Quraishi MS, BSN, AE-C, CCRC Assistant Director of Research and Quality Ruby Hoyem, PhD Research Associate Trinidad Legaspi JD, LLM Health Policy Analyst Rayna Scott, MS, RHIA, CCS Health Policy Analyst Contact us Telephone: (847)

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