MACRA From Meaningful Use to MIPS The “Doc Fix” Legislation NOHIMSS: November 5, 2015 Cathy Costello, JD Director of CliniSyncPLUS Services

OVERVIEW

Intersection of Cost/Quality/MU Metrics Year Legislation or Program 1997 SGR- Sustainable Growth Rate 2003 IQR 2006 PQRI 2009 HITECH 2010 Affordable Care Act (Alternative Payment) 2011 Stage 1 Meaningful Use (MU) 2012 Value-Based Purchasing 2013 Hospital Readmissions 2014 Stage 2 MU 2015 QRUR Reports (Cost/Quality) SGR Repealed; MACRA Passed 2018 Stage 3 MU 2019 MIPS/Alternative Payment Models (APM) Quality Meaningful Use Cost

Old/New Terms in the CMS Alphabet SGR: “Sustainable Growth Rate” (1997): Now retired MACRA: “Medicare Access and CHIP Reauthorization Act” (2015) Two new payment avenues: MIPS: “Merit Based Incentive Payment System” (modified traditional fee-for service payment) APM: “Alternative Payment Model” (other payment models Medicare is encouraging)

Phases of MACRA Phase 1 (2015 – 2019): Repeals SGR statute and implements a stepwise adoption of the 1st overall Physician Fee Schedule increase in over a decade. Consistent payment structure for all physicians. Phase 2 (2019 – 2025): Begins new payment mechanisms through MIPS and Alternative Payment Mechanisms (APMs) Phase 3 (2026 and Beyond): All incentives stop. Increase of fees by 0.25% for MIPS providers; increase of 0.75% for APM providers. Other changes unclear ???????????????? Notes SGR, if not repealed, would have resulted in a 21% decrease in physicians Medicare Part B payments in 2015. Net cost of MACRA is $102 billion Additional updates of $500 million/year plus a 5% bonus will stop in 2025. Thus physicians would have a payment decrease in 2026. “Absent a change in the method or level of update by subsequent legislation, we expect access to Medicare-participating physicians to become a significant issue in the long term.” Office of the Actuary for CMS

Who Is Covered by MIPS/APM Current MU Providers: Already recognized EPs under the Medicare program: Physicians Dentists Podiatrists Optometrists Chiropractors 2019: Expanded to include nurse practitioners (NPs), clinical nurse specialists (CNS), physician assistants (PAs) and certified registered nurse anesthetists (CRNAs). Although most previously covered by Medicaid EHR incentive program, now specifically covered for Medicare reimbursement. 2021: Other professionals may be included if have the performance thresholds developed. Exclusions: Being developed for low volume providers and alternative payment models (APMs). Notes Remember: CMS works 2 years in advance on changes and reimbursement matters, so you must be reporting for providers in 2017 if they are going to be eligible in 2019 for MIPS payments/penalties.

Timeline between 2015 and 2019 2019 Last +0.5% PFS Begin MIPSl 2015 MU Blended 90 Days PQRS +0.5% PFS (6 Mo.) No SGR 2016 MU Blended 365 Day +0.5% PFS 2017 MU Blended 365 Days or Stage 3 90 Days 2018 Stage 3 MU 365 Days eCQMs for PQRS Last +0.5% PFS Begin MIPSl 2019

Merit-Based Incentive Payment System MIPS: Merit-Based Incentive Payment System Notes MIPS is really the continuation of the fee-for-service model but includes quality and cost metrics. MIPS is the combination of PQRS, MU and Value-Based Payment Modifier programs.

(1) MIPS Payment Structure Meaningful Use 2019: 25% Quality Reporting 2019: 30% Resource Use Clinical Practice Improvement 2019: 15% Unsettled Area Notes The provider is scored on a scale of 0 – 100 points. Takes into account both benchmarking against a national average and also against a provider’s own performance from one year to another when compared the baseline. Combines Meaningful Use with Cost, Quality and “Clinical Practice Improvement;” % can change each year.

Additional Physician Fee Schedule (PFS) Increases for MIPS Track 2015 – 2019: An additional 0.5% automatic increase in the Physician Fee Schedule, bringing total increase from 2015 – 2019 to 2.5% for the 4 years. 2020 – 2025: No increase in PFS. 2026: If participating in MIPS (non-alternate payment), then 0.25% annual increase. If participating in Alternative Payment Models (APMs) then receive a 0.75% annual increase.

Alternative Payment Model APM: Alternative Payment Model

(2) Alternative Payment Model (APM) Meaningful Use Quality Reporting Resource Use Clinical Practice Improvement Combines areas of technology use, quality reporting, cost factors and care management into one bundle under the specific APM model; reporting is different than MIPS, driven by reporting requirements for that particular APM model

Alternative Payment Models (APMs) Specifically lists Patient Centered Medical Homes (PCMH) as an Alternative Payment Model that does not rely on risk sharing to meet the APM requirements. Includes Medicare Shared Savings Program, Comprehensive Primary Care Initiative (CPCI) and other payment models designated under CMS’s Innovation Center. List of potential APM’s not completely identified yet. Alternatives must include risk sharing for losses over a nominal amount or be PCMH. May include some component of Chronic Care Management and Transitions Care Management programs initiated by CMS.

REWARDS PENALTIES

A. What Are the Rewards/Penalties Under MIPS? MIPS adjustment factor is for each MIPS EP/year in the form of a percentage: Determined by comparing the composite performance score to the performance threshold Scoring is either positive, negative , or zero Potential rewards: Besides the MIPS Adjustment Factor, EPs can also earn an additional positive percent (EPs composite performance score has to be ≥ to the performance threshold): 2019: 4% Maximum bonus for exceptional performance is 14.5% 2020: 5% Maximum bonus for exceptional performance is 15.0% 2021: 7% Maximum bonus for exceptional performance is 17.0% 2022 and beyond: 9%

All payment adjustments have to be budget neutral A. What Are the Rewards/Penalties Under MIPS? Potential penalties: If falling below the national benchmarks and quality thresholds, then adjustment downward can be at the maximum: 2019: -4.0% 2020: -5.0% 2021: -7.0% 2022 – 2025: -9.0% All payment adjustments have to be budget neutral

B. What Are the Rewards/Penalties Under APM? 2019 to 2024, APM providers will receive a 5% annual lump-sum bonus on MPFS payments at the end of the reporting year. Not all providers participating in APMs would be designated as APM providers; depends on % of Medicare patients covered by the APM in its billing structure: 2019 – 2020: 25% of Medicare payments for covered professional services must be attributable to APM. 2021 – 2022: 50% of Medicare payment for covered professional services must be attributable to APM. 2023 & Forward: 75% of Medicare payments for covered professional services must be attributable to APM OR 75% of all-payer revenue (with >25% from Medicare payments) attributable to APM. N.B. If provider is close but doesn’t meet the Medicare threshold for APM participation, then may be exempted from MIPS penalties but will not receive the 5% bonus payment for APMs for that year. Other Identified Risks/Payments: Subject to additional risk/reward under specific APM model. Notes If provider does not report any MIPS quality metrics, then will be given the lowest score with the greatest negative adjustment on fees, unless an exception applies: APM participation Partial qualification for APM but did not file MIPS measures Low volume provider as determined by thresholds established by CMS

Rewards/Penalties for MIPS and APM Tracks Year MIPS Incentive Adjustment* MIPS Potential Penalties MIPS Maximum Bonus for Exceptional Performance APM Adjustment 2019 +4.0% -4.0% 14.0% +5.0% 2020 -5.0% 15.0% 2021 +7.0% -7.0% 17.0% 2022 +9.0% -9.0% 19.0% 2023 2024 2025 N/A 0% *MIPS positive adjustment can be increased up to 3x MIPS incentive adjustment, if sufficient funds available. No additional decrease in penalties. All payments must be budget neutral.

Areas Undecided: Questions Raised by CMS in RFI

Areas Undecided: Seeking Comments Low volume threshold Minimum # patients during reporting period Minimum # items or services provided Minimum allowed charges Clinical practice improvement: what should be included to show additional value provider is adding to the healthcare system; some proposed areas looking for comments Access to practice: same day appointments; 24/7 access Monitoring of health conditions; Participation in data registry Care coordination; telehealth Use of care plans; patient self-monitoring or assessment Patient safety and practice assessments Advanced certification of practice or provider Participation in alternative payment model (APM) for private payers or Medicaid How to document areas of clinical practice improvement

Areas Undecided: Seeking Comments 3. Other issues raised Need for separate new identification # for providers for MIPS MU: whether to make it an “all or nothing” attestation or to allow partial credit for measures met MU: in APM track, what should be standard for legislative requirement for use of certified EHR technology? Should it be same as MU measures? PCMH: in MIPS track, how to weight PCMH’s work in Medicaid medical home models Areas affecting specialties Establishes Physician Focused Payment Model Technical Advisory Committee to review new proposals for APM models and make recommendations as to their adoption Asks for guidance as to how the committee should function and how to comment on new payment proposals going forward The committee must put out criteria for Physician Focused Payment Models (PFPM) for the APM track by November 1, 2016

Areas Undecided: Seeking Comments To comment on the RFI for MACRA, list CMS-3321-NC on all comments. Submit comments electronically to: http://www.regulations.gov Link to the RFI: https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-24906.pdf To submit by mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-3321-NC, P.O. Box 8016, Baltimore, MD 21244-8016 Comments must be received by November 17, 2015

PREPARING FOR MACRA

What to Do in 2016 MIPS Providers: APM Providers: Report PQRS Follow federal reports as to PCMH status Look for guidelines establishing low volume thresholds and clinical practice improvement initiatives Change workflows to support chronic care management and transitional care management APM Providers: Analyze Medicare patient panels to determine % of Medicare professional services provided through APM Analyze crosswalk between APM reporting and MIPS reporting, especially for quality metrics.

Cathy Costello 614-664-2607 ccostello@ohiponline.org www.clinisync.org - While visiting our website don’t forget to sign up for our newsletter!