1. Success in Quality Payment Programs (QPP) September 29, 2017

2. Health Insurance Specialist
MACRA Implementation:
A Review of the Quality Payment Program
Neal Logue
Health Insurance Specialist
Centers for Medicare and Medicaid Services, Region IX, September 29, 2017

3. Disclaimer
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. .

4. Objectives for today Overview of CMS Priorities
Shifting from Volume to Value-Based payments
Program alignment and streamlining
Health System Transformation: MACRA 2015
Review of the Medicare Access and CHIP Reauthorization Act
The Quality Payment Program Final Rule
Key updates and resources
Options for participation in 2017
Opportunities for technical support

5. Key CMS Priorities in health system transformation

6. Origins of the Quality Payment Program: MACRA
Bipartisan Legislation: the “Medicare Access and CHIP Reauthorization Act,” 2015
Increases focus on quality of care delivered
Clear intent that outcomes needed to be rewarded, not number of services
Shifts payments away from number of services to overall work of clinicians
Moving toward patient-centric health care system
Replaces Sustainable Growth Rate (SGR)
SGR ELIMINATED
BY MACRA

7. Medicare Payments Prior to MACRA
Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value.
Medicare
Fee Schedule
Final payment to clinician
Services provided
Adjustments
Physician Quality Reporting Program (PQRS)
Value-Based Payment Modifier
Medicare EHR
Incentive Program

8. MACRA changes how Medicare pays clinicians.
The Quality Payment Program policy will reform Medicare Part B payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system
Medicare
Fee Schedule
Final payment to clinician
Adjustments
Services provided

10. The Timeline for the Quality Payment Program
2017

11. Quality Payment Program Strategic Goals
Improve beneficiary outcomes
Enhance clinician experience
Increase adoption of Advanced APMs
Maximize participation
Improve data and information sharing
Ensure operational excellence in program implementation
Quick Tip:
For additional information on the Quality Payment Program, please visit QPP.CMS.GOV

12. The Quality Payment Program
The Quality Payment Program policy will:
Reform Medicare Part B payments for more than 600,000 clinicians
Improve care across the entire health care delivery system
Clinicians have two tracks to choose from:

13. Introduction to the Merit-based Incentive Payment System (MIPS)

14. What is the Merit-based Incentive Payment System?
Combines legacy programs into single, improved reporting program
PQRS VM
EHR
Legacy Program Phase Out
Last Performance Period
PQRS Payment End
2016
2018

15. What is the Merit-based Incentive Payment System?
Performance Categories
Quality
Cost
Improvement Activities
Advancing Care Information
Moves Medicare Part B clinicians to a performance-based payment system
Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice
Reporting standards align with Advanced APMs wherever possible

16. When Does the Merit-based Incentive Payment System Officially Begin?
submit
adjustment
Performance year
Feedback available
2017
Performance Year
March 31, 2018
Data Submission
Feedback
January 1, 2019
Payment Adjustment
Performance: The first performance period opens January 1, 2017 and closes December 31, During 2017, you will record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can provide care during the year through that model.
Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, In order to earn the 5% incentive payment for participating in an Advanced APM, just send quality data through your Advanced APM. 
Feedback: Medicare gives you feedback about your performance after you send your data. 
Payment: You may earn a positive MIPS payment adjustment beginning January 1, 2019 if you submit 2017 data by March 31, If you participate in an Advanced APM in 2017, then you could earn 5% incentive payment in 2019.

17. Who Participates in the Merit-based Incentive Payment System?

18. These clinicians include:
Eligible Clinicians:
Quick Tip:
Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function.
Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than Medicare patients a year.
These clinicians include:
Physicians
Physician Assistants
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetists

19. Who is excluded from MIPS?
Clinicians who are:
Significantly participating in Advanced APMs
Newly-enrolled in Medicare
Below the low-volume threshold
Enrolled in Medicare for the first time during the performance period (exempt until following performance year)
Medicare Part B allowed charges less than or equal to $30,000 a year OR
See 100 or fewer Medicare Part B patients a year
Receive 25% of your Medicare payments OR
See 20% of your Medicare patients through an Advanced APM

20. From the Quality Payment Program
Eligibility Scenario
To be eligible for the Quality Payment Program, a clinician must bill more than $30,000 AND see more than 100 Medicare beneficiaries.
Quick Tip:
“And” is the key to eligibility
BILLING
≥$30,000
≥100
In the example provided in this incident where a clinician billed $29,000 and saw 101 patients, this clinician would be EXEMPT from the program because the clinician did not bill more than $30,000.
BILLING
$29,000
101
EXEMPT
From the Quality Payment Program + =

21. Non-Patient Facing Clinicians
Non-patient facing clinicians are eligible to participate in MIPS as long as they exceed the low-volume threshold, are not newly enrolled, and are not a Qualifying APM Participant (QP) or Partial QP that elects not to report data to MIPS
The non-patient facing MIPS-eligible clinician threshold for individual MIPS-eligible clinicians is < 100 patient facing encounters in a designated period
A group is non-patient facing if > 75% of NPIs billing under the group’s TIN during a performance period are labeled as non-patient facing
There are more flexible reporting requirements for non-patient facing clinicians

22. How do Eligible Clinicians Participate in the Merit-based Incentive Payment System?

23. Pick Your Pace for Participation for the Transition Year
Participate in an Advanced Alternative Payment Model
MIPS
Test Pace
Partial Year
Full Year
Some practices may choose to participate in an Advanced Alternative Payment Model in 2017
Submit some data after January 1, 2017
Neutral or small payment adjustment
Report for 90-day period after January 1, 2017
Small positive payment adjustment
Fully participate starting January 1, 2017
Modest positive payment adjustment
Not participating in the Quality Payment Program for the Transition Year will result in a negative 4% payment adjustment.

24. MIPS: Choosing to Test for 2017
Submit minimum amount of 2017 data to Medicare
Avoid a downward adjustment
You Have Asked: “What is a minimum amount of data?” OR OR
4 or 5
Required Advancing Care Information Measures 1
Quality
Measure
1 Improvement Activity

25. MIPS: Partial Participation for 2017
Submit 90 days of 2017 data to Medicare
May earn a positive payment adjustment
“So what?” - If you’re not ready on January 1, you can start anytime between January 1 and October 2
Need to send performance data by March 31, 2018

26. MIPS: Full Participation for 2017
Submit a full year of 2017 data to Medicare
May earn a positive payment adjustment
Best way to earn largest payment adjustment is to submit data on all MIPS performance categories
Key Takeaway:
Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted.

27. Individual vs. Group Reporting
OPTIONS
Individual
Group
Individual—under an NPI number and TIN where they reassign benefits
As a Group
2 or more clinicians (NPIs) who have reassigned their billing rights to a single TIN*
As an APM Entity
* If clinicians participate as a group, they are assessed as group across all 4 MIPS performance categories

28. Get your Data to CMS Individual Group Quality
QCDR (Qualified Clinical Data Registry)
Qualified Registry
EHR
Claims
Administrative Claims
CMS Web Interface (groups of 25 or more)
CAHPS for MIPS Survey
Attestation
QCDR
EHR Vendor
Quality
Advancing Care Information
Improvement Activities

29. Group Registration
Registration is required for eligible clinicians participating as a group that wish to report via:
Group registration closes on June 30, 2017.
Web Interface
CAHPS for MIPS survey

30. Improvement Activities
MIPS Vendor Reporting
Health information technology (HIT) vendors submit data on behalf of clinicians for:
Quality
Improvement Activities
Advancing Care Information
If data for activities is derived from CEHRT, vendors must indicate data source and transmit data in a CMS-specified form and manner
Quality
Improvement Activities
Advancing Care

31. The Merit-based Incentive Payment System Performance Categories

32. What are the Performance Category Weights?
Weights assigned to each category based on a 1 to 100 point scale Transition Year Weights— 25%
60% 0%
15%
25%
Quality
Cost
Improvement Activities
Advancing Care Information
Note: These are defaults weights; the weights can be adjusted in certain circumstances

33. MIPS Scoring for Quality (60% of Final Score in Transition Year)
Select 6 of the approximately 300 available quality measures (minimum of 90 days)
Or a specialty set
Or CMS Web Interface measures
Quick Tip:
Easier for a clinician that participates longer to meet case volume criteria needed to receive more than 3 points
Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks
Bonus points are available
Failure to submit performance data for a measure = 0 points

34. MIPS Scoring for Cost (0% of Final Score in Transition Year)
No submission requirements
Clinicians assessed through claims data
Clinicians earn a maximum of 10 points per episode cost measure

35. MIPS Performance Category: Improvement Activities
Attest to participation in activities that improve clinical practice
Examples: Shared decision making, patient safety, coordinating care, increasing access
Clinicians choose from 90+ activities under 9 subcategories:
1. Expanded Practice Access
2. Population Management
3. Care Coordination
4. Beneficiary Engagement
5. Patient Safety and Practice Assessment
6. Participation in an APM
7. Achieving Health Equity
8. Integrating Behavioral and Mental Health
9. Emergency Preparedness and Response

36. MIPS Performance Category: Improvement Activities
No clinician or group has to attest to more than 4 activities
Special consideration for:
Keep in mind: This is a new category
Practices with 15 or fewer clinicians
Rural or geographic HPSA
Non-patient facing
APM
Certified Medical Home

37. Alternate Activity Weights*
MIPS Scoring for Improvement Activities (15% of Final Score in Transition Year)
Total points = 40
Activity Weights
Medium = 10 points
High = 20 points
Alternate Activity Weights*
Medium = 20 points
High = 40 points
*For clinicians in small, rural, and underserved practices or with non- patient facing clinicians or groups
Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice

38. MIPS Performance Category: Advancing Care Information
Promotes patient engagement and the electronic exchange of information using certified EHR technology
Ends and replaces the Medicare EHR Incentive Program (also known as Medicare Meaningful Use)
Greater flexibility in choosing measures
In 2017, there are 2 measure sets for reporting based on EHR edition:
2017 Advancing Care Information Transition Objectives and Measures
Advancing Care Information Objectives and Measures

39. MIPS Performance Category: Advancing Care Information
Clinicians must use certified EHR technology to report
For those using EHR Certified to the 2015 Edition:
For those using Certified EHR Technology:
Option 1
Option 2
Option 1
Option 2
Advancing Care Information Objectives and Measures
Combination of the two measure sets
2017 Advancing Care Information Transition Objectives and Measures
Combination of the two measure sets

40. MIPS Performance Category: Advancing Care Information
Advancing Care Information Objectives and Measures:
Base Score Required Measures
2017 Advancing Care Information Transition Objectives and Measures:
Base Score Required Measures
Objective
Measure
Protect Patient Health Information
Security Risk Analysis
Electronic Prescribing
e-Prescribing
Patient Electronic Access
Provide Patient Access
Health Information Exchange
Send a Summary of Care
Request/Accept a Summary of Care
Objective
Measure
Protect Patient Health Information
Security Risk Analysis
Electronic Prescribing
e-Prescribing
Patient Electronic Access
Provide Patient Access
Health Information Exchange

41. MIPS Performance Category: Advancing Care Information
Advancing Care Information Objectives and Measures
2017 Advancing Care Information Transition Objectives and Measures
Objective
Measure
Patient Electronic Access
Provide Patient Access*
Patient-Specific Education
Coordination of Care through Patient Engagement
View, Download and Transmit (VDT)
Secure Messaging
Patient-Generated Health Data
Health Information Exchange
Send a Summary of Care*
Request/Accept a Summary of Care*
Clinical Information Reconciliation
Public Health and Clinical Data Registry Reporting
Immunization Registry Reporting
Objective
Measure
Patient Electronic Access
Provide Patient Access*
View, Download and Transmit (VDT)
Patient-Specific Education
Secure Messaging
Health Information Exchange
Health Information Exchange*
Medication Reconciliation
Public Health Reporting
Immunization Registry Reporting

42. Advancing Care Information: Requirements for the Transition Year
Test means:
Submitting 4 or 5 base score measures
Depends on use of 2014 or Edition
Reporting all required measures in the base score to earn any credit in the Advancing Care Information performance category
Partial and Full means:
Submitting more than the base score in the Transition Year
For a full list of measures, please visit QPP.CMS.GOV

43. Transition Year 2017 >70 points 4-69 points 3 points 0 points
Final Score
Payment Adjustment
>70 points
Positive adjustment
Eligible for exceptional performance bonus—minimum of additional 0.5%
4-69 points
Not eligible for exceptional performance bonus
3 points
Neutral payment adjustment
0 points
Negative payment adjustment of -4%
0 points = does not participate

44. Getting Started

45. Getting Started
Start by: Determining if you are included in MIPS and need to actively participate.
How:
Review the Clinician Participation Letter provided by CMS.
This letter will tell you who is included in MIPS and who is exempt.
The letters were sent at the TIN level rather than to individual clinicians, so check-in with the representative of your practice group for details.
This letter was mailed beginning on April 27, 2017.

46. Getting Started: Clinician Participation Letter
Attachment A: What is this?
Explains who is included in MIPS and should actively participate.
Identifies included vs. exempt status.
Lists the NPIs associated with the TIN.
Provides contact information for the Quality Payment Program for direct support.

47. Getting Started: MIPS Participation Look-Up Tool
You could also check your participation status by:
Using the MIPS Participation Look-up Tool on qpp.cms.gov.

48. Getting Started: MIPS Participation Look-Up Tool
Enter your NPI into the search field and select “Check Now.”

49. Prepare to Participate

50. Preparing and Participating in MIPS: A Checklist
Determine your eligibility and understand the requirements.
Choose whether you want to submit data as an individual or as a part of a group.
Choose your submission method and verify its capabilities.
Verify your EHR vendor or registry’s capabilities before your chosen reporting period.
Prepare to participate by reviewing practice readiness, ability to report, and the Pick Your Pace options.
Choose your measures. Visit qpp.cms.gov for valuable resources on measure selection and remember to review your current billing codes and Quality Resource Use Report to help identify measures that best suit your practice.
Verify the information you need to report successfully.
Care for your patients and record the data.
Submit your data by March 2018.

51. Prepare to Participate
How Do I Do This?
Consider your practice readiness.
Have you previously participated in a quality reporting program?
Evaluate your ability to report.
What is your data submission method?
Are you prepared to begin reporting data between January 1, 2018 and March 31, 2018?
Review the Pick Your Pace options for Transition Year 2017.
Test
Partial Year
Full Year

52. Choose Your Measures/Activities

53. Choose Your Measures/Activities
How Do I Do This?
Go to qpp.cms.gov.
Click on the tab at the top of the page.
Select the performance category of interest.
Review the individual Quality and Advancing Care Information measures as well as Improvement Activities.

54. Choose Your Measures/Activities
Tips for Reviewing and Selecting Measures/Activities
Consider the following:
Your patient population and the clinical conditions that you treat
Your practice location
Your practice improvement goals
Quality data that you may submit to other payers
If you’re currently participating in one the legacy quality programs, consider your current billing codes and Quality Resource Use Report (QRUR) to help identify suitable measures

56. Submit Your Data Early

57. Submit Your Data Early How Do I Do This?
Care for your patients and record the data.
Submit your data to CMS prior to the March, 2018 deadline using your chosen submission method.
CMS anticipates the data submission window to open January 1, 2018.
You are encouraged to submit as early as possible following this date to ensure the timely receipt and accuracy of your data.

58. MIPS Summary The Merit-based Incentive Payment System:
Streamlines the Legacy Programs
Moves Medicare Part B clinicians to a performance-based system
Measures clinicians on four Performance Categories:
Quality, Cost, Improvement Activities, and Advancing Care Information
Calculates a Final Score for clinicians based on their performance in the four Performance Categories and adjusts payments based on the Final Score

59. Where can I go to learn more?

60. Small, Underserved & Rural Support
5-year technical assistance program authorized under MACRA. Designed for MIPS eligible clinicians in small practices with 15 or fewer clinicians. Assistance in selecting & reporting MIPS Quality Measures and Improvement Activities; optimizing their Health Information Technology; evaluate options for joining an Advanced Alternative Payment Model (APM). In Arizona, HSAG provides technical assistance to small practices.

61. Technical Assistance for Clinicians
CMS has free resources and organizations on the ground to provide help to clinicians who are participating in the Quality Payment Program:

62. Quality Payment Program:
How to get help
Ashby Wolfe, MD, MPP, MPH Chief Medical Officer, Region IX Centers for Medicare and Medicaid Services

63. Quality Payment Program:
Year 2
Comments on Notice of Proposed Rule for Quality Payment Program Year 2 were due on August 21, 2017

64. Questions?