1. MACRA and Delivery System Reform
Guidelines International Network
Kate Goodrich, MD MHS
Director, Center for Clinical Standards & Quality
September 25th, 2016

2. THE MEDICARE ACCESS & CHIP REAUTHORIZATION ACT OF 2015
Quality Payment Program
Medicare is evolving from fee-for-service and has set a goal of 50% of payments in alternative payment models by As part of this process, CMS is improving and streamlining its existing quality programs (PQRS, VBP, EHR incentives) into a single one that will reward clinicians for delivering coordinated care with better outcomes with the support of health information technology. These changes are reflective of and in response to the concerns that too many quality programs, technology requirements, and measures get between the clinician and the patient. That is why we are taking a hard look at what is working, what is not working, what is duplicative, and what is missing. We intend to continue to work hard at listening and improving based upon what we hear.

3. Quality Payment Program
Repeals the Sustainable Growth Rate (SGR) Formula
Streamlines multiple quality reporting programs into the new Merit-based Incentive Payment System (MIPS)
Provides incentive payments for participation in Advanced Alternative Payment Models (APMs)
The Merit-based Incentive Payment System (MIPS) or
Advanced Alternative Payment Models (APMs)
The proposed rule is the next step in actually putting the new system envisioned by MACRA into place, in the form of the new Quality Payment Program. I want to thank you for all that you did to make this happen. It was thanks to strong support from medical associations and other stakeholders, that MACRA was signed into law last year. I also want to ask for your continued help, support, and input as we move forward with implementation.
MACRA replaced a patchwork collection of quality programs with a single system where every Medicare physician and clinician has the opportunity to be paid more for better care. Doctors will be able to practice as they always have, but will also have the chance to get paid more for high quality care and investments that support patients. There are two paths to quality in this program:
O The Merit-based Incentive Payment
O The Advanced Alternative Payment Models
In developing the rule, we were guided by the core goals of the legislation –streamlining and strengthening quality-based payments for all physicians; rewarding participation in Advanced Alternative Payment Models that create the strongest incentives for quality and coordinated care; and giving clinicians flexibility to choose how to participate in the new system.
We will be providing tools and education to help you get ready for performance year Clinicians can visit go.cms.gov/QualityPaymentProgram for more information. In addition, we’re organizing groups across the country, so you can have local help as you get ready.
First step to a fresh start
We’re listening and help is available
A better, smarter Medicare for healthier people
Pay for what works to create a Medicare that is enduring
Health information needs to be open, flexible, and user-centric

4. APMs

5. What is an Alternative Payment Model (APM)?
APMs are new approaches to paying for medical care through Medicare that incentivize quality and value.
CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)
MSSP (Medicare Shared Savings Program)
Demonstration under the Health Care Quality Demonstration Program
Demonstration required by federal law
As defined by MACRA, APMs include:
So what is an alternative payment model, or APM? Some of you may have heard of this term or even be in an APM yourself. Alternative Payment Models are new approaches to paying for care in ways that incentivize quality and value. Broadly speaking, these models differ from regular fee-for-service in that providers are accountable for both the cost AND the quality of care of patients in their model.
It’s important to note that MACRA has a specific definition for APMs. According to MACRA statute, APMs include: CMS Innovation Center models, the Medicare Shared Savings Program, demos under the Health Care Quality Demonstration program, and demos required by federal law.

6. Advanced APMs meet certain criteria.
As defined by MACRA, advanced APMs must meet the following criteria:
The APM requires participants to use certified EHR technology.
The APM bases payment on quality measures comparable to those in the MIPS quality performance category.
The APM either: (1) requires APM Entities to bear more than nominal financial risk for monetary losses; OR (2) is a Medical Home Model expanded under CMMI authority.
So that’s what APMs in general include. But now we want to talk about advanced APMs, which are the most sophisticated APMs. According to MACRA, advanced APMs have to meet certain criteria which include:
basing payment on quality measures comparable to those in MIPS,
requiring use of EHR, and
either bearing more than nominal financial risk OR being a medical home model expanded under CMMI authority.
That all might sound pretty technical – the main takeaway point here is that advanced APMs are the most advanced APMs and must meet these specific criteria. It is a very high bar to be an “advanced APM.”

7. Note: MACRA does NOT change how any particular APM functions or rewards value. Instead, it creates extra incentives for APM participation.
So how do these special alternative payment models fit into the broader changes in MACRA? The key point is that MACRA creates extra incentives for APM participation. It does NOT change how any particular APM rewards value. That is, its goal is not to replace existing incentives, but to supplement them. You entered an APM to practice care in responsible ways, and MACRA is a way to acknowledge and reward you for that commitment.

8. Technical Advisory Committee Submission of model proposals
Independent PFPM Technical Advisory Committee
PFPM = Physician-Focused Payment Model
Goal to encourage new APM options for Medicare clinicians G 2 *
The Advisory Panel is formally known as the Independent Physician Focused Payment Model Technical Advisory Panel (or P-TAC). MACRA established this special committee whose goal is to encourage new APM options for Medicare clinicians. The TAC is a forum through which the physician community can identify needs and suggest ways to fill any potential gaps in the existing portfolio of CMMI models and advanced APMs.
The committee reviews model proposals and submits recommendations, and CMS can consider testing the proposed models. Of note, models that are proposed by the PFPM will have the same standing and potential to qualify as advanced APMs as other CMS originated models.
Technical Advisory Committee
Secretary comments on CMS website, CMS considers testing proposed model
Submission of model proposals
11 appointed care delivery experts that review proposals, submit recommendations to HHS Secretary

9. In Advanced APM, but not a QP
Note: Most practitioners will be subject to MIPS.
Subject to MIPS
QP in Advanced APM
Not in APM
In non-Advanced APM
While the financial incentives for participating in an advanced APM and getting the bonus are large, it’s important to note that most people will likely not be QPs and therefore will not receive the bonus and instead will be subject to MIPS. No matter which side of the dotted line you fall on in this picture, however, the Quality Payment Program provides multiple ways for practitioners to be rewarded for responsible practice, and multiple incentives to participate in APMs.
In order to avoid duplicative reporting across APMs and MIPS while still holding APM participants accountable for MIPS goals to the extent feasible, we propose unique reporting and scoring standards for APM participants who do not become QPs.
In Advanced APM, but not a QP
Some clinicians may be in Advanced APMs but not have enough payments or patients through the advanced APM to be a QP.
Note: Figure not to scale.

10. MIPS

11. 2 : a MIPS: First Step to a Fresh Start MIPS is a new program
Streamlines 3 currently independent programs to work as one and to ease clinician burden.
Adds a fourth component to promote ongoing improvement and innovation to clinical activities.
MIPS provides clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance. 2 : a
Talking points:
MIPS Principles
Use a patient-centered approach to program development that leads to better, smarter, and healthier care
Develop a program that is meaningful, understandable and flexible for participating clinicians
Design incentives that drive movement toward delivery system reform principles and APMs
Ensure close attention to excellence in Implementation, operational feasibility, and effective communication with stakeholders
Quality
Resource use
Clinical practice improvement activities
Advancing care information

12. Who Will Participate in MIPS?
Affected clinicians are called “MIPS eligible clinicians” and will participate in MIPS. The types of Medicare Part B health care clinicians affected by MIPS may expand in the first 3 years of implementation.
Years 1 and 2
Years 3+
Secretary may broaden Eligible Clinicians group to include others such as
Affected clinicians are known officially as “eligible professionals” (EPs). In years 1 and 2, EPs will include physicians, PAs, nurse practitioners, clinical nurse specialists and nurse anesthestists.
But the types of Medicare Part B clinicians who will participate in MIPS will likely expand during the first three years of implementation of the law.
For example, in years 3 and beyond, the group of EPs will be expanded to include a much larger group, ranging from physical therapists to dieticians. The exact groups included will be defined in rule-making, expected to be released later in 2016.
Physical or occupational therapists, Speech-language pathologists, Audiologists, Nurse midwives, Clinical social workers, Clinical psychologists, Dietitians / Nutritional professionals
Physicians (MD/DO and DMD/DDS), PAs, NPs, Clinical nurse specialists, Nurse anesthetists

13. 1 Who will NOT Participate in MIPS?
There are 3 groups of clinicians who will NOT be subject to MIPS: 1
So what are the exceptions to participation in MIPS? There are actually three groups of clinicians who will NOT be subject to MIPS. These include
Those in their first year of Medicare Part B participation
Those that have a very low volume of patients. (The exact threshold for “low volume” is also yet to be defined, but will likely be defined in rulemaking to be released later in 2016)
And certain participants in eligible alternative payment models, or “APMs” (we’ll talk more about this later)
In addition to these three groups, it’s very important to clarify that MIPS does NOT apply to hospitals or facilities – it applies to individual clinicians.
FIRST year of Medicare Part B participation
Below low patient volume threshold
Certain participants in ELIGIBLE Alternative Payment Models
Medicare billing charges less than or equal to $10,000 and provides care for 100 or fewer Medicare patients in one year
Note: MIPS does not apply to hospitals or facilities

14. MIPS: Quality Performance Category
Proposed Rule
MIPS: Quality Performance Category
Summary:
Selection of 6 measures
1 outcome measure and 1 cross-cutting measure, or other high priority measure, OR
Selection of a specialty-specific measure set
Key Changes from Current Program (PQRS):
Reduced from 9 measures to 6 measures with no domain requirement
Measure Applicability Validation (MAV) process is retired
Year 1 Weight: 50%

15. Maximum MIPS Payment Adjustment (+/-)
MIPS adjustments and APM Incentive Payment will begin in 2019.
2017
2018
2019
2020
2021
2022
2023
2024
2025
+4%
+9%
+5%
+7%
MIPS
-4%
-5%
-7%
-9%
Maximum MIPS Payment Adjustment (+/-)
QP in Advanced
APM
Bonuses to qualified participants in advance APMs will also begin in 2019 and last till That 5% bonus payment will be based on the estimated total payment received by the provider for the prior year. So that means that a clinician’s bonus in 2019 will be based on payment for services in 2018.
+5% bonus
(excluded from MIPS)

16. The Quality Payment Program:
The Medicare Access & Chip Reauthorization Act of 2015
The Quality Payment Program:
Pick Your Pace!

17. Advanced Alternative Payment Models
Quality Payment Program:
Pick Your Pace in Year One
Clinicians will pick their pace for the first year – both in how they participate and when.  We expect that everyone who is eligible for the Quality Payment Program will participate.
We’ve announced four options that we plan to further describe in the final rule:
Test
Participation or
Partial
Participation or
Full Participation
Pick Your Pace: Physicians will pick their pace for the first year – both in how they participate and when. We designed the final rule to allow physicians to pick how they phase into the program. We’ve announced three choices:
Test: Physicians may choose any point in 2017 to begin. As long as they submit some 2017 quality information to Medicare by March 2018, they will avoid a negative payment adjustment. This first option is designed to help physicians test their systems and prepare for broader participation in 2018 and 2019.
Partial: Physicians may choose to participate for part of the calendar year. This means they could begin later than January 1, 2017 and their practice could still qualify for a small bonus.
Full: For practices ready to go on January 1, 2017, they may choose to participate for a full year and may qualify for a modest bonus. We've seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.
Of course, clinicians can also choose to join an Advanced Alternative Payment Model in 2017 and potentially qualify for a 5 percent bonus. or
Advanced Alternative Payment Models

18. First Year Participation:
Option 1
Choose any point in the 2017 calendar year to begin.
As long as you submit a minimum standard to Medicare, you would avoid a negative payment adjustment.
This option is designed to help test systems and prepare for broader participation in 2018 and 2019.
Test
Participation

19. First Year Participation:
Option 2
Choose to participate for part of the 2017 calendar year.
This option provides the ability to begin later than January 1, 2017 and you would potentially still qualify for a bonus.
Partial
Participation

20. First Year Participation:
Option 3
Choose to participate for a full year (beginning Jan. 1, 2017)
If you’re ready to go on January 1, 2017, you could choose to participate for the full calendar year and qualify for a positive payment adjustment. 
We've seen clinician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.
Full
Participation

21. Advanced Alternative Payment Models:
Option 4
You can also choose to join or stay in an Advanced Alternative Payment Model (Advanced APM) in 2017 and potentially qualify for a 5 percent bonus.
Remember: The Quality Payment Program does NOT change how any particular APM functions or rewards value. Instead, it creates extra incentives for APM participation.
Advanced APMs

22. Quality Measures & MACRA

23. Overview and Purpose of the CMS Quality Measure Development Plan
Mandated by the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) section 102
Provides the strategic framework to support the CMS Quality Payment Program (QPP)
Merit-Based Incentive Payment System (MIPS)
Advanced Alternative Payment Models (APMs)
Informs CMS prioritization of MACRA-funded measure development over the next five years

24. Overview and Purpose of the CMS Quality Measure Development Plan
Initially focuses on measure gaps identified in the portfolio of quality measures currently used in the PQRS, VM, and EHR Incentive Program
Over 80% of MIPS measures are for specialists, but gaps remain
Recommends prioritized approaches to close gaps through the development, adoption, and refinement of quality measures
Sets expectations for MACRA-funded measure developers
Make progress on the data infrastructure for QM development (data elements, testing)

25. Next Steps
Additional research and information gathering in priority gap areas identified in the MDP
Finalization of the CMS QPP rule
MACRA-funded measure development procurement
Expert panel to advise CMS on innovative approaches to measure development and implementation
Ongoing Resource Use measure development

26. Contact Information
Kate Goodrich, MD MHS Director, Center for Clinical Standards & Quality