Quality Payment Program. Quality Payment Program (QPP) Overview

Transcription

1 Quality Payment Program (QPP) Overview 1

2 The Quality Payment Program Mission: We will work to earn the trust of clinicians and patients by designing, implementing and constantly evolving a quality payment program that aims to improve health outcomes, promote smart spending, minimize burden of participation, is fairly administered and provides transparency in operations. Vision: Clinicians are supported in providing quality care and improved health outcomes for the people they serve through CMS payment programs that are patient-centered, clinician-driven and responsive in moving from volume to value. 2

3 QPP Strategic Goals 1. Improve Beneficiary Outcomes and engage patients through patient-centered Advanced APM and Merit-based Incentive Payment System (MIPS) policies 2. Enhance clinician experience through flexible and transparent program design and interactions with easy-to-use program tool 3. Increase the availability and adoption of Advanced Alternative Payment Models 4. Promote program understanding and maximize participation through customized communication, education, outreach, and support that meet the needs of the diversity of clinician practices and patients, especially the unique needs of small practices. 5. Improve data, information sharing capabilities to provide accurate, timely, and actionable feedback to clinicians and other stakeholders. 6. Deliver IT systems capabilities that meet the needs of users and are seamless, efficient and valuable on the front and back-end 7. Ensure operational excellence in program implementation and ongoing development. 3

4 The Quality Payment Program Replaces the Sustainable Growth Rate formula and sunsets the PQRS, EHR Incentive Program and Value Modifier Program.

5 When Does the Merit-based Incentive Payment System Officially Begin?

6 Eligible Clinicians: Exempt Clinicians:

7 Pick Your Pace for Participation for the Transitional Year

8 MIPS Performance Category: Quality 60% Clinicians receive 3-10 points per measure depending on performance to benchmarks Bonus Points are available

9 MIPS Performance Category: Cost 0% Clinicians earn a maximum of 10 points per episode cost measure

10 MIPS Performance Category: Improvement Activities 15%

11 MIPS Performance Category: Improvement Activities

12 MIPS Performance Category: Advancing Care Information 25%

13 Calculating the Final Score Under MIPS

14 Transition Year 2017

15 Alternative Payment Models An Alternative Payment Model (APM) is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. APMs may offer significant opportunities to eligible clinicians who are not immediately able or prepared to take on the additional risk and requirements of Advanced APMs. Advanced APMs are a Subset of APMs APMs Advanced APMs 15

16 Advanced APMs Must Meet Certain Criteria To be an Advanced APM, the following three requirements must be met. The APM: Requires participants to use certified EHR technology; Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk

17 Advanced APM Criterion 1: Requires use of Certified EHR Technology 1. Requires participants to use certified EHR technology Requires that at least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other health care professionals. Shared Savings Program requires that clinicians report at the group TIN level according to MIPS rules. 2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category. Ties payment to quality measures that are evidence-based, reliable, and valid. At least one of these measures must be an outcome measure if an appropriate outcome measure is available on the MIPS measure list. 17

18 Advanced APM Criterion 3: Bear a More than Nominal Amount of Financial Risk 3. Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority, OR (2) requires participants to bear a more than nominal amount of financial risk. Financial Risk Bearing financial risk means that the Advanced APM may do one or more of the following if actual expenditures exceed expected expenditures: Withhold payment for services to the APM Entity and/or the APM Entity s eligible clinicians Reduce payment rates to the APM Entity and/or the APM Entity s eligible clinicians Require direct payments by the APM Entity to CMS Total Amount of Risk The total amount of that risk must be equal to at least either: 8% of the average estimated total Medicare Parts A and B revenues of participating APM Entities; OR 3% of the expected expenditures for which an APM Entity is responsible under the APM. 18

19 Advanced APM Criterion 3: Medical Home Expanded Under CMS Authority 3. Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority, OR (2) requires participants to bear a more than nominal amount of financial risk. Medical Home Model Financial Risk Standard Bearing financial risk means that the Medical Home Model may do one or more of the following if actual expenditures exceed expected expenditures: Withhold payment for services to the APM Entity or the APM Entity s eligible clinicians Reduce payment rates to the APM Entity or the APM Entity s eligible clinicians Require direct payments by the APM Entity to CMS, or Cause the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments. Medical Home Model Nominal Risk Standard To be an Advanced APM, the amount of risk under a Medical Home Model must be at least the following amounts: 2.5% of estimated average total Medicare Parts A and B revenue (2017) 3% of estimated average total Medicare Parts A and B revenue (2018) 4% of estimated average total Medicare Parts A and B revenue (2019) 5% of estimated average total Medicare Parts A and B revenue (2020 and later) 19

20 Advanced APMs In 2017, the following models are Advanced APMs Comprehensive End Stage Renal Disease Care Model (Two-Sided Risk Arrangements) Comprehensive Primary Care Plus (CPC+) Shared Savings Program Track 2 Shared Savings Program Track 3 In 2018, the following models are Advanced APMs Acute Myocardial Infarction (AMI) Track 1 CEHRT Coronary Artery Bypass Graft (CABG) Track 1 CEHRT Surgical Hip/Femur Fracture Treatment (SHFFT) Track 1 CEHRT Medicare-Medicaid ACO Model (for participants in SSP Tracks 2 and 3) Next Generation ACO Model Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 - CEHRT) Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model) Oncology Care Model (Two-Sided Risk Arrangement) Medicare Accountable Care Organization (ACO) Track 1+ Model The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements as needed. Keep in mind: The Physician-Focused Payment Model Technical Advisory Committee (PTAC) will review and assess proposals for Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee. 20

21 How do Eligible Clinicians become Qualifying APM Participants? Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements) Performance Year and later Percentage of Payments through an Advanced APM Percentage of Patients through an Advanced APM 21

22 Technical Assistance for Clinicians CMS has free resources and organizations on the ground to provide help to clinicians who are eligible for the Quality Payment Program:

23 National Coverage of Technical Assistance for Small, Underserved and Rural Clinicians 11 uniquely experienced organizations to provide national coverage to eligible clinicians in small practices. 23

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26 Jean Moody-Williams

27 Workgroup for Electronic Data Interchange WEDI Keys to Quality Payment Program Success Crystal Ewing, Cooperative Exchange, The National Clearinghouse Association 27

28 Benefits of Quality Payment Program Participation - Develops fundamental competencies for long term value based payment. - Lays the groundwork for how volume to value works. - Identifies opportunities for improvement in patient care, coordination, and cost savings. - Supports informed decisions about Alternative Payment Models (APM). - Builds a successful portfolio for Accountable Care Organization (ACO) participation. 28

29 Keys to a Successful Transition Understand what success means to your organization and what the journey looks like to get there. Understand your organization s current performance as well as your unique strengths so that you can effectively prioritize programs that can have the most impact. Set meaningful, objective and achievable goals based on your unique circumstances and capabilities. Engage all stakeholders and create a culture of improvement by providing accurate and timely data and taking action to maximize revenue, reduce care variation and improve patient outcomes. Set up systems and processes that enables you to reach your maximum reimbursement potential in a predictable and sustainable manner. 29

30 Plan and Organize Create a project plan and identify point person/persons to lead the project initiative. Identify who within the organization should be part of the project team take the time to ensure you have the right resources. Create a dedicated Quality Team that will include: - Clinical Education - Quality and Patient Experience - Financial and Budget Oversight - Technology - Vendors and Collaborators Establish clear communications to ensure all stakeholders understand their roles and responsibilities. 30

31 Assess Identify existing program participation- what are you already doing? - Using a Certified EHR? - Reported PQRS? - Participated in Value Based Modifier Program? - Attested to Meaningful Use? - Identify what track to choose based on eligibility (MIPS/APM) Evaluate Performance Categories and perform a high level impact assessment of subcategories and measures - Interdisciplinary Operational Team to determine forecasted range of opportunity or risk (include financial risk). - Ensure correct resources are assigned. - Review the previous QRQR reports to know how well you have done in the past. 31

32 Assess Evaluate operational and system processes and identify if updates are needed. Identify critical clinical practice improvement needs. Identify what technology is being utilized and what additional technology is needed. Decide if you will work with a third party intermediary. Document and communicate impact assessment findings to the team 32

33 Quality Improvement - Complete data picture of each patient - Clear and actionable insights - Gaps in Care - Point of Care-Gaps in Medical History Cost and Utilization - Provider Performance Scorecards - HCC Risk Scores - Cost and Utilization Analysis Reports Risk Management Analyze - Highest risk and highest cost patient cohort opportunities for care coordination intervention - Patient Risk Scores and Profiles - Adopt solutions that will provide the advice, data and processes necessary to operate in a sustainable and predictable way. 33

34 Train Identify staff who should be trained on clinical measurement analysis Know your metrics, know your cohort s metrics Identify monitoring, analysis and resolution procedures Implement ongoing training program Leverage technology - Dashboards - Data metric management - Reporting 34

35 Implement and Evaluate Utilize Quality Team Meet regularly to closely monitor progress (at a minimum with quarterly data submissions) Update financial statement impacts based on most recent information Establish concrete targets and operational action plans 35

36 Resources CMS Quality Payment Program Resources - CMS Quality and Resource Use Reports (QRQRs) - Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html American Medical Association - payment-delivery-changes?gclid=cj0keqjwnspgbrdo4c6rqk- Oqu8BEiQAwNviCZsjSQrh_wouhJ2ydvpKB7Sc1kQJV0-7QO4eRoEwEsAaArb38P8HAQ Technology vendors, clearinghouses, and consultants 36

37 Questions The speakers will answer as many questions as the time allows. If your question is not answered during the webinar, please contact the Quality Payment Program Service Center at or

38 Thank you 38