MACRA: What you can do in 2016 to get 2017 MACRA Ready: Merit-Based Incentive Payment System (MIPS) program. Path to value-based Volume to value Leadership is an education and the best leaders think of themselves as the student not the teacher. MIPS & APMs Christina Perez, MHA, ACHE Certified Meaningful Use Professional

Disclaimer Although the information contained in this power point has been produced and processed from sources believed to be reliable, no warranty, expressed or implied, is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of the information. Any reliance you place on such information is therefore strictly at your own risk. All information is gathered is from the Federal Register on 05/09/2016 by the Department of Health and Human Services, Centers for Medicare & Medicaid Services, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models Version: (NPRM) Notice of Proposed Rulemaking Status

MACRA Background

MACRA: Medicare Access and CHIP Reauthorization Act - Piece of legislation passed by senate and signed into law April 16,2015 - Repeals the SGR formula (1997-2015) - Ties payments to quality and extended CHIP (Children’s Healthcare Insurance Pgm) funding. MACRA consolidates PRQS, VM, EHR (MU) These programs are not ending, or dead, but are sunsetting of the payment adjustment of all pgms. EPs can participate in MIPS or meet requirements to be a qualifying APM participant. SGR: Sustainable Growth Rate: ROE x (1 - dividend-payout ratio) ROE: Return on Equity

Admin Approving MACRA Along with Congress Burwell- mother mayor and father optometrist. Preseident of the bill and melinda gates foundation, president of walmart, Dir. Of the white house office of mgt and budget. DeSalvo- New Orleans health commissioner. NEW Director of ONC Kathleen Blake, vice president of performance improvement at the American Medical Association Salvitt-was the VP for Optum ,UHC 4 days consulted and approved MACRA And the Physician-Focused Payment Model Technical Advisory Committee (PTAC) Sylvia Matthews Burwell Secretary of HHS Dr. Karen DeSalvo Director of the ONC/ Asst. Secretary of HHS Andy Slavitt Acting Administrator at CMS

At A Glance Confusion Explained

How it All works

regulations.gov BY June 27, 2016 Affecting payments in 2019! Meaning January 2017 first performance year MIPS (Merit-based Incentive Program System) MACRA replacing the SGR EPs under MIPS: Physicians, PA, NPs, CRNAs, CNS All PFS (Physician Fee Schedules) adjusted Jan 1, 2019 all other payments retire as of Dec 31, 2018. All in draft phases, subject to change. Look at proposed rules and give feedback via regulations.gov BY June 27, 2016 APMs (Alternative Payment Model System) Mid-levels impacted in 2019 with 2017 data.

MIPs EPs who are not in APMs Incorporates existing programs within new entity (MIPs) - Physician Quality Reporting System (PQRS) Value-Based Payment Modifier (VM) Meaningful Use of certified EHR technology (MU) (referred to in this proposed rule as “Advancing Care Information”) *QI: Clinical Improvement (NEW) Proposed Clinical Practice Improvement Activities Inventory (CPIA) Projected to affect the 2019 payment period using 2017 data Starting at -/+4% adjustment

Overview Overview of consolidated pgms: -PQRS -MU “Advancing Care Information” -QI: Clinical Improvement (New) MACRA Data submission period would occur from January 2, 2018, through March 31, 2018 for period performance of Jan 1- Dec 31, 2017. Deadline has always been 2/28 so gives more time… CMS is interested in receiving feedback on whether it is advantageous to either (1) have a shorter time frame following the close of the performance period, or (2) have a submission period that would occur throughout the performance period, such as bi-annual or quarterly submissions; and (3) whether January 1 should also be included in the submission period. CMS welcomes comments on these items. CMS heard from numerous commenters a desire to move away from “all-or-nothing” scoring. Therefore, in MIPS, we propose that MIPS eligible clinicians receive credit for measures that they report, regardless of whether or not the MIPS eligible clinician meets the quality performance category submission criteria.

PQRS Individual EP’s Reporting Measured by Clinical Quality Measures: 255 measures and 19 new measures 2016: Report at least 9 measures, covering at least 3 of the CQM domains 2017: no longer require reporting across multiple NQS domains, 6 measures at least 1 from the outcomes & 1 cross-cutting measure. 2017 Proposed MIPS Specialty Measure Sets The MACRA ends the PQRS adjustment after CY 2018 and provides for the inclusion of various aspects of PQRS in MIPS as part of the quality component of the overall performance score. CMS also believe that appropriate use, patient experience, safety, and care coordination measures are more relevant than clinical process measures for improving care of patients. Through future rulemaking, CMS plasn to increase the requirements for reporting on these types of measures over time. Cross-cutting measures are any measures that are broadly applicable across multiple clinical settings and eligible professionals (EPs) or group practices within a variety of specialties.  Groups must report all measures and the first 248 consecutively beneficiaries and CAHPS for MIPS Survey

MU “Advancing Information” MU 1 (Must attest Min. 1yr, Max 2yrs to move to MU 2) Eligible professionals must meet:- -13 core objectives, 5 of 9 menu objectives. Total of 18 objectives, 9 CQMs MU2 MODIFIED (Can attest 2015 -2017) (CURRENT) 9 Core objectives plus 1 public health obj., 3 of 6 menu objectives, 9 CQMs MU3 (2018 reporting MACRA) Advancing Care Information - 6 core objectives1 being a public health CQM BUT there is an ALT. proposal of 8 core obj. SRA: Security Risk Analysis Assessment. -Certified EHR Letter with certification No. *90 reporting period possible for 2015 bc of MOD, usually CY. 2016 CY or 1st timers 90 days. 2017 all EP 90days Public Health Reporting: The EP, eligible hospital or CAH is in active engagement with a public health agency to submit electronic public health data from CEHRT, except where prohibited and in accordance with applicable law and practice. One approach we considered would be to maintain the current structure of the Medicare EHR Incentive Program and award full points for the advancing care information performance category for meeting all of the objectives and measures finalized in the 2015 EHR Incentive Programs final rule In defining the advancing care information performance category for the MIPS, CMS considered stakeholder feedback and lessons learned from our experience with the Medicare EHR Incentive Program. Of 5% of audits it is failed for no SRA.

QI: Clinical Improvement (NEW) Proposed Clinical Practice Improvement Activities Inventory (CPIA) Subcategories: Expanded Practice Access (4) Population Management (16) Care Coordination (14) Beneficiary Engagement (24) Patient Safety and Practice Assessment (21) Achieving Health Equity (5) Emergency Response and Preparedness (2) Integrated Behavioral and Mental Health (8) Scoring Weights: High or Medium

MIPS SCORING

MIPS Composite Score Eps who are not in an APMs 1. Quality (PQRS) QRUR, CAHPS (group >20) , Three-based claims (Cost) Graded by National Benchmark 6 measures: (appropriate use, patient safety, efficiency, patient experience, and care coordination outcome measures) 2. Resource Use (cost measures) ,Quality and Resource Use Reports (QRURs) and (MYQRUR) (cmsportal.gov) 3. Clinical Improvements (CCM and PCMH guidelines crosswalk) 4.Meaningful use of certified EHR Measures & Objectives and CQM (outcome measures) Tip: We also propose a process for public reporting of MIPS information through the Physician Compare Web site. This determines payment upward or downward adjustment MYQRUR :performance on the six cost and three quality outcomes measures that we calculate directly from Medicare claims,

MIPs Scoring

MIPS Merit Based Incentive Payment Composite Score QRUR(VBM cost) (10pts), MU (25pts) and PQRS/VBM quality (40pts) Resource Use (efficacy) 10pts Clinical Improvements 15pts (Apply or renew PCMH or MSSP/ NextGen ACO; if done exempt from MIPS can enter APMs. If ACO reporting unsuccessful you still get guaranteed 7.5pts) Source: CMS, The Medicare Access& CHIP Reauthorization Act of 2015: Path to Value

Don’t forget 2019 pymt adj. based on 2017 performance Upward or Downward http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips Don’t forget 2019 pymt adj. based on 2017 performance

How To Report -Attestation -QCDR (Qualified Clinical Data Registry Reporting) or group practices participating via GPRO (>20 Ep’s) -Qualified registry -EHR -Administrative claims (if technically feasible, no submission required) From what is known now, you chose just one system to submit data too.

Alternative Payment Model APMs Alternative Payment Model Eligible Members -ACO: MSSP -PCMH: Patient Centered Medical Homes -Bundle Payment Models -CPC +: Comprehensive Primary Care Plus Model If qualify for APM; 5% lum sum based in aggregate payment amts. for the preceding year 2017-2024. If NOT qualifying can join MIPS CMS says 30% of providers will be in this program

Advanced APMS different from APMs Advanced APMS have three requirements: 1. Require participants to use certified EHR technology 2. Provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of MIPS. 3.Be either a Medical Home Model expanded under section 115A or bear more than a nominal amt. of risk for monetary loses (Successful ACOs and the CPC+ model)

APMs No Composite score but Categories Category 1: Fee for service; no link to quality Category 2:Fee for service; link to quality Category 3:APMs built upon Fee for service Architecture (PCMH Model) Category 4: Population-based payment

MIPs (Score of 100) APMs (Categories 1-4) MACRA Review PQRS VM MU QI ACO PCMH CPC+ APMs (Categories 1-4)

Health IT of MACRA 2015-2017 Send, receive, find and use a common clinical data set to improve health and health care quality. By 2018 -2020 expand interoperable health it and users to improve health and lower cost. 2021-2024 A nationwide learning health system

Top 3 Prep Activities to focus on to Implementation or Reorganize Final Rule November 1, 2016- Final Rule on MIPs measures available. CQM in PQRS & EHR pgm EHR (Cores) Run monthly or even weekly reports to max. % NCQA has a new redesign program PCMH- NCQA Certification Top 3 Prep Activities to focus on to Implementation or Reorganize

$100 million dollars allocated by HHS to ONC Assistance ONC regional offices REC centers ; gives technical assistance to small practices. FREE! $100 million dollars allocated by HHS to ONC   Texas REC Contact Information Gulf Coast Regional Extension Center (GCREC): University of Texas Health Science Center Houston For more information, call (713) 500-3479 or visit the GCREC website.    North Texas Regional Extension Center (NTREC): Dallas Fort-Worth Hospital Council For more information, call (469) 648-5140 or visit the NTREC website.  CentrEast Regional Extension Center (CentrEast REC): Texas A&M Health Science Center For more information, call (979) 436-0390 or visit the CentrEast website.    West Texas Regional Extension Center (WTxHITREC): Texas Tech Health Science Center For more information, call (806) 743-7960 or visit the WTxHITREC website.  FHQC http://dashboard.healthit.gov/dashboards/health-information-technology-data-summaries.php?state=Texas&cat9=all+data#summary-data

?Questions? Questions can also be emailed Christinaperezmha@gmail.com We invite comments on these proposed regulatory changes.

reference DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 495. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Proposed Rule.