Quality Payment Program (aka MACRA) What You Need to Know for 2018

Quality Payment Program (aka MACRA) What You Need to Know for 2018
Medicare Quality Payment Program (aka MACRA) What You Need to Know for 2018

Table of Contents – Click the heading to go directly to that section
Background Advanced APMs Participation Status MIPS Overview MIPS APMs MIPS Scoring Submitting Your Data Quality Advancing Care Information (ACI) Special Circumstances ACP Resources Improvement Activities Cost APMs

Background – Congress Passed MACRA Landmark, Bipartisan Law – April 2015
Medicare Access and CHIP Reauthorization Act of (MACRA) – focused on Part B Medicare Congressional Intent of MACRA: Sustainable Growth Rate repeal Improve care for Medicare beneficiaries Change our physician payment system from one focused on volume to one focused on value MACRA has been recast as the Quality Payment Program, or QPP

POSITIVE Changes in 2018 Extreme and Uncontrollable Circumstances –exceptions for areas impacted by hurricanes and other natural disasters This automatically applied for 2017 for clinicians in certain areas of the country Applications will be available for 2018 as needed More options for small practices (ACP ASKED FOR THESE!) Increased low volume threshold 5 bonus points for small practices (≤15 eligible clinicians) Virtual group option Extra points if not able to meet data completeness requirements MIPS Bonus for Complex Patients (ACP ASKED FOR THIS TOO!)

Quality Payment Program In a Nutshell
Law intended to align physician payment with value The Medicare Access and CHIP Reauthorization Act of (MACRA) Or now the… Quality Payment Program Merit-Based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMs)

Merit-based Incentive Payment System (MIPS)
Back

MIPS replaces other Medicare reporting programs
There are currently multiple individual quality and value programs for Medicare physicians and practitioners: Physician Quality Reporting Program (PQRS) Value-Based Payment Modifier (quality and cost of care) “Meaningful use” of EHRs MACRA streamlined those programs into MIPS: Merit-Based Incentive Payment System (MIPS)

Who Participates in MIPS in 2018?
Excluded for 2018 (no change from 2017): New to Medicare (first year enrolled in Part B) Below low-volume threshold Significant participation in Advanced APM Types of eligible clinicians (ECs): Clinical Nurse Specialists Certified Registered Nurse Anesthetists Physicians Physician Assistants Nurse Practitioners

Low-volume Threshold Increased from 2017
2018 Performance Period Excluded individuals or groups must have: ≤ $90,000 Part B allowed charges OR ≤ 200 Part B patients Note: CMS is considering allowing excluded ECs to opt-in in 2019 or later years. The 2018 threshold is expected to exclude approximately 134,000 additional clinicians from MIPS from the approximately 700,000 clinicians that would have been eligible based on the low-volume threshold that was finalized in the CY 2017 Quality Payment Program final rule. Almost half of the additionally excluded clinicians are in small practices and approximately 17 percent are clinicians from practices in designated rural areas. Applying this criterion decreases the percent of the MIPS eligible clinicians that come from small practices. Approximately 37 percent of individual MIPS eligible clinicians and groups (or about 572,000 ECs) would be in MIPS based on the low-volume threshold exclusion (and the other exclusions). However, 65 percent of Medicare payments would still be captured under MIPS.

How Much Can MIPS Adjust Payments?
Based on the MIPS composite performance score, eligible clinicians will receive positive, negative, or neutral adjustments up to the %s below MIPS adjustments are budget neutral. MAXIMUM Adjustments Merit-Based Incentive Payment System (MIPS) 5% 9% -9% onward -7% -5% -4% 7% 4% Adjustment to clinician’s base rate of Medicare Part B payment (including Part B drugs) Those who score in top 25% are eligible for an additional annual performance adjustment of up to 10%, (NOT budget neutral)

Performance Category Weighting for the Composite Score
Transition Year (2017 performance → 2019 payment) Year 2 Final (2018 performance → 2020 payment) Year 3 Proposed (2019 performance → 2021 payment) Quality 60% 50% 30% Cost 0% 10% Improvement Activities 15% Advancing Care Information 25%

Total Percentage Weight
MIPS Scoring in 2018 MIPS Category Measures Top Score Total Percentage Weight Quality Each measure worth up to 10 points and evaluated based on performance relative to benchmarks Bonus for reporting additional outcome or high-priority measures and for end-to-end reporting 60 + more for bonus reporting 50% Advancing Care Information Base score 0-50 points + Performance score 0-90 points + Bonus points 0-15 points 100 (even though you can actually get up to 155) 25% Improvement Activities High weighted activities = 20 points Medium weighted activities = 10 points 40 (small practices or those in rural or HPSA areas, each activity worth double points) 15% Cost Total Cost per Capita Medicare Spending per Beneficiary 10 (average of the two measures if both are applicable) 10% Back

What’s New for 2018 Performance Year?
No more “pick your pace” options Must earn 15 points to receive a neutral adjustment Must earn 70 points to be eligible for “exceptional performance” bonus Quality – full year of data required Cost – full year of data will be assessed (no reporting required) Improvement Activities & Advancing Care Information – 90-day performance period

MIPS Performance Thresholds
Performance threshold = points needed for neutral adjustment Increases from 3 points in 2017 to 15 points in 2018 2018 Final Score 2018 Payment Adjustment ≥ 70 points Positive adjustment Eligible for exceptional performance bonus 16-69 points 15 points Neutral adjustment 0-14 points Maximum -5% adjustment (depends on score between points; <3.75 gets -5%) 0 points = does not participate

Improvement Activities
How to get 15 points minimum performance threshold in 2018 (for a neutral adjustment) Quality Improvement Activities Advancing Care Info Submit 6 measures that meet data completeness Report 2 high-weighted or 4 medium-weighted activities for 90 days Meet Base Score plus 1 quality measure (OR 1 performance measure) Report 1 medium weighted activity PLUS ACI Base Score Small practices: Report enough quality measures to achieve 10 points (in addition to the 5 automatic points). Example: score well on 2 complete measures and submit 4 other incomplete measures. Small practices: 1 high-weighted or 2 medium-weighted activities for 90 days Small practices: Base score plus enough quality measures to achieve 5 points.

New Bonus Points in MIPS
Complex patient bonus 1-5 bonus points toward composite score Calculated as average HCC risk score Boost to practices with medically complex patients Small practice bonus Small practice – ≤15 ECs 5 bonus points toward composite score Must submit data in 1 performance category to be eligible Complex patient bonus: The score calculated is the average of the HCC risk score for all patients for an EC or group. It is calculated using the model adopted for Medicare Advantage. The bonus is added to the composite performance score (overall, not per patient). The maximum bonus is three points. The EC, group, virtual group or APM Entity must submit data on at least one measure or activity in a performance category during the performance period to receive the complex patient bonus.

Virtual Groups – NEW for 2018
At least 2 TINs with 10 or fewer clinicians each (can be solo) can join – but each one must exceed the LVT – and it requires a formal written agreement Can get the benefits of a MIPS APM, if one TIN meets those criteria Must have elected for 2018 by December 31, 2017 All ECs will have their performance assessed as part of the group

Individual v. Group Reporting
A unique billing TIN and NPI combination Group A single TIN with 2 or more clinicians (NPIs) who have assigned billing rights to the TIN An APM Entity A virtual group Clinicians reporting for MIPS as a group must do so for all 4 performance categories

Submission Mechanisms
Performance Category Submission Mechanisms for Individuals Submission Mechanisms for Groups Quality Claims QCDR Qualified registry EHR Qualified registry EHR CMS Web Interface (groups of 25 or more) CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with another data submission mechanism.) Administrative claims (for readmission measure – no submission required) Cost Administrative claims (no submission required) Administrative claims (no submission required) Advancing Care Information Attestation Qualified registry EHR Improvement Activities

Genesis Registry Quality Reporting
Meets reporting requirements for MIPS composite score Quality (50%) Improvement Activity (IA) ( 15%) Advancing Care Information (ACI) (25%) Gap analysis performance results and measure feedback Comparisons by practice and specialty to: National benchmarks Peer comparisons Earn bonus points in Quality for using a QCDR such as Genesis

MIPS Timeline – 2018 (Yr 2) Source:

Merit-based Incentive Payment System (MIPS) – Breakdown of the Four Major Categories: Quality Advancing Care Information Improvement Activities Cost

Quality Performance Category
Policy 2017 (Transition Year) 2018 (Year 2) Measures Required 6 measures Special Requirements 1 outcome/high priority measure Data Completeness 50% for full credit Other measures get 3 points 60% for full credit Others get 1 point or 3 points for small practices Performance Period 90-day minimum Full year Population-based Measures All-cause readmissions * Weight 60% 50% in 2018 30% for 2019 and after Note: CMS Web Interface and CAHPS are covered by separate requirements for the number of measures and types of measures Groups in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: Report quality measures through your APM. You do not need to do anything additional for MIPS quality * All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases. Back

Quality Performance Category – Additional Information
Three population measures are automatically calculated from administrative claims, but only one (all-cause readmissions) is used for performance score. Groups using the web interface: Report 15 quality measures for a full year. Groups in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: Report quality measures through your APM. You do not need to do anything additional for MIPS quality. CAHPS for MIPS reporting is voluntary (and credit is provided under Improvement Activities) Population measure to be kept: all-cause hospital readmissions (ACR) measure and will apply it to groups with 16 or more clinicians instead of the proposed approach of groups of 10 or more. A 200 case minimum must be met for the measure to count as part of a group’s quality performance score. * All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases.

Quality Performance Category – Overview
Weight: 50% for 2018; 30% in subsequent years Most participants: Report up to 6 quality measures, including an outcome measure Full year of data required for year 2 (2018) Three population measures automatically calculated from administrative claims, but only one* used for performance score. Groups using the web interface: Report 15 quality measures for a full year. Groups in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: Report quality measures through your APM. You do not need to do anything additional for MIPS quality. CAHPS for MIPS reporting is voluntary (and credit is provided under Improvement Activities) Population measure to be kept: all-cause hospital readmissions (ACR) measure and will apply it to groups with 16 or more clinicians instead of the proposed approach of groups of 10 or more. A 200 case minimum must be met for the measure to count as part of a group’s quality performance score. * All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases.

Quality – Data Completeness Criteria
Policy 2017 (Transition Year) 2018 (Year 2) Data Completeness Claims only: 50% of Medicare Part B patients Other reporting mechanisms: 50% of patients from all payers Claims only: 60% of Medicare Part B patients Other reporting mechanisms: 60% of patients from all payers Points Based on Completeness 3 points for measures that do not meet data completeness 1 point for measures that do not meet data completeness 3 points for measures that small practices report that do not meet data completeness For the CMS Web Interface and CAHPS, clinicians report on all of the measures within the reporting mechanism for the sample of the Medicare Part B patients CMS provides. So groups reporting under these mechanisms don't have the traditional 6 measures including one outcome measure requirement. The CMS Web Interface has something like 15 measures, and you report on the first 248 consecutively ranked patients for all of the measures. CAHPS counts as one quality measure, but the survey is not a traditional quality measure. The CAHPS survey can count as a high priority measure in absence of an outcome measure. Groups using the CAHPS survey must also report 5 additional quality measures. For Web Interface & CAHPS: groups must meet data submission req’s on the Part B sample CMS provides

Quality – Scoring of Measures Data
Policy 2017 (Transition Year) 2018 (Year 2) Measures Scored Against a Benchmark* 3-point floor up to 10-point maximum Measures without a Benchmark 3 points Measures Not Meeting Case Minimums Measures Not Meeting Data Completeness 1 point; 3 points for small practices Bonuses Up to 10% - additional high priority measure Up to 10% - end-to-end electronic reporting * Must meet data completeness criteria to be scored against a benchmark

Quality – Topped Out Measures for 2018
Starting with 2018 performance period, 7-point cap for measures considered “topped out” Measures identified as topped out will be removed after 3 years, through rulemaking for in the 4th year CMS Web Interface measures are excluded from the topped out measures policies

Advancing Care Information (ACI) Performance Category
Policy 2017 (Transition Year) 2018 (Year 2) Measures Required 4-5 Base Measures (50%) Performance Score Measures Bonus points available Base measures – no change Some small changes to performance score and bonus point measures Certification Requirements 2014 or 2015 Edition CEHRT No change 10% bonus if using 2015 Edition CEHRT Performance Period 90 days Exceptions If not sufficient measures available for a clinician NEW 21st Century Cures Act exceptions Weight 25% What are the 21st Century Cures Act exceptions? Back

Advancing Care Information – 2018
Hardship applications now due December 31 of performance period New hardship exceptions available for 2018: EHR decertification Small practices (≤ 15 ECs) Clinicians in ambulatory surgical centers (ASCs) Hospital-based clinicians (clarifies previous policy) For ECs granted a hardship exception, ACI is weighted 0% and the 25% from ACI is reweighted to quality Hospital-based clinicians must furnish at least 75% of services in inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), or emergency room (POS 23) setting.

Advancing Care Information – Scoring
Base measures – worth 50 points of ACI score All-or-none…must report all required base measures to get any credit for ACI 4 or 5 measures depending on CEHRT edition All base measures are numerator/denominator or yes/no measures Performance measures – worth up to 50 points Choose to submit from up to 7 or 9 measures (up to 90 points) for additional credit toward ACI score Points awarded based on % met Bonus credits – worth up to 15 or 25 points (depending on CEHRT edition) 5 points for attesting to additional registries (in addition to the registry used for the performance score) 10 points for attestation of Improvement Activity (uses CEHRT) 10 points for exclusive use of 2015 CEHRT

Advancing Care Information – Base Measures
Advancing Care Information Objectives and Measures (2015 CEHRT edition) Base Score Required Measures Advancing Care Information Transition Objectives and Measures: (2014 CEHRT edition) 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

Advancing Care Information – Performance Score Measures
Advancing Care Information Transition** Objectives and Measures: Performance Score Measures Advancing Care Information Objectives and Measures: Performance Score 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 * Indicates performance measure that is included in base measures ** Transition measures utilize 2014 CEHRT Edition

Advancing Care Information – Exemptions for 2018
ACI may be reweighted to zero if: Small practice (≤ 15 ECs) Extreme and uncontrollable circumstances (fires, storm, etc.) Lack of control over availability of CEHRT, including decertification and insufficient internet Certain clinicians (Non-patient-facing, NP, PA, CNRA, CNS, hosp- based, ASC-based) Hospital-based clinicians have at least 75% of their billing from place of service (POS): inpatient, on-campus outpatient department, or emergency department Hardship application due by Dec 31 of performance period

Advancing Care Information – Exemptions for 2018
For ECs granted a hardship exemption, ACI is weighted 0% and the 25% from ACI is reweighted to quality (i.e., quality would be worth 75% of the total composite score) BUT, if exempt clinicians choose to submit data for ACI, CMS will score their performance and ACI will be worth 25%

Improvement Activities Performance Category
Policy 2017 (Transition Year) 2018 (Year 2) Measures/Activities Required Most participants: Up to 4 improvement activities Groups with fewer than 15 participants or in rural or health professional shortage areas: Up to 2 activities No change Activities Available 92 112 Special Options PCMH & PCSP – Full credit* Other APMs – Either full or partial credit Overall no change, BUT PCMH and PCSP TINs must have 50% of practices certified/recognized Reporting/Scoring Attestation Performance Period 90 days Weight 15% * If one practice in the TIN is a PCMH or PCSP Back

Improvement Activities – Additional Information
Achieve 40 points for conducting high weighted (20 points) or medium weighted (10 points) activities Receive double points if ≤15 eligible clinicians OR located in rural, medically underserved, or health professional shortage area Only 1 clinician needs to do the activity in the TIN Flexibility in documentation requirements

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

Improvement Activities Eligible for ACI Bonus Score - 2018
Quality Payment Program Improvement Activities Eligible for ACI Bonus Score Improvement Activity Subcategory Activity Name Weight Expanded Practice Access Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record Medium Population Management Anticoagulant management improvements High Chronic care and preventative care management for empanelled patients Implementation of methodologies for improvements in longitudinal care management for high risk patients Implementation of episodic care management practice improvements Implementation of medication management practice improvements Glycemic screening services Glycemic management services Glycemic referring services Provide clinical-community linkages Advance care planning Care Coordination Implementation of use of specialist reports back to referring clinician or group to close referral loop Implementation of documentation improvements for practice/process improvements Implementation of practices/processes for developing regular individual care plans Practice improvements for bilateral exchange of patient information Practice improvements that engage community resources to support patient health goals Primary care physician and behavioral health bilateral electronic exchange of information for shared patients PSH care coordination From Table 6 in the proposed rule

Improvement Activities Eligible for Bonus Score - 2018
In addition to the improvement activities eligible for the ACI bonus in 2017, CMS proposes to add the following new eligible activities for 2018: Improvement Activity Subcategory Activity Name Weight Beneficiary Engagement Use of certified EHR to capture patient reported outcomes Medium Engagement of patients through implementation of improvements in patient portal Engagement of patients, family and caregivers in developing a plan of care Integrated Behavioral and Mental Health Implementation of integrated PCBH model High Electronic Health Record Enhancements for BH data capture Medium32 Patient Safety and Practice Assessment Use of decision support and standardized treatment protocols Communication of unscheduled visit for adverse drug event and nature of event Consulting AUC using clinical decision support when ordering advanced diagnostic imaging Cost display for lab and radiology orders Achieving Health Equity Promote use of patient-reported outcome tools (depends on CEHRT edition) High/Medium Engage patients and families to guide improvement in the system of care These are additional new IAs that are eligible for the bonus starting in The 2017 IAs will remain in place as options as well.

Cost Performance Category
Policy 2017 (Transition Year) 2018 (Year 2) Measures Used Medicare Spending per Beneficiary (MSPB), Total per capita cost, and 10 episode-based measures MSPB and total per capita cost, but NOT the episode-based measures* Reporting/Scoring Calculated by CMS, based on claims No change Performance Period Full year Weight 0% 10% in 2018 10-30% in Episode-based measures will not be part of the score, but CMS will provide feedback on them in 2018. Bonus points if you improved your score (if you submitted a full data set) CMS has the flexibility to weight Cost between 10-30% for the next 3 yrs. Back

Cost – Additional Information
Risk adjustment will be based on HCC scores Bonus points if you improved your score (if you submitted a full set of data)

2018 MIPS Cost Measures Defined
Medicare Spending Per Beneficiary (MSPB) Total Per Capita Costs (TPCC) You / your TIN must have 35+ attributed cases to be scored. If < 35 cases, this measure will not be scored Attribution = person / group that provided the most Part B charges during the hospitalization All Part A and Part B claims surrounding a specified inpatient admission – 3 days prior to hospitalization THRU 30 days post discharge You / your TIN must have 20+ unique beneficiaries attributed to be scored. If < 20, this measure will not be scored Attribution = person / group with most primary care type claims (preventive care, office visits, etc.) during a prior year All Part A and B claims submitted by ALL providers who treated Medicare FFS patients attributed to you (or your group), including providers who are NOT part of your group

Medicare Spending per Beneficiary (MSPB)
Definition: the total Part A and Part B costs to Medicare per episode (3 days before, during hospitalization, and thru 30 days post discharge) during a measure year, attributed to a person (TIN- NPI combination) or group (TIN) Numerator: sum of the ratio of payment-standardized observed to expected episode costs for all MSPB episode. Payment standardization takes into account payment factors unrelated to care (geographic variation, teaching hospital, etc.) Denominator: Total MSPB episodes

MSPB Attribution Model
Each episode is attributed to the TIN-NPI responsible for the plurality of Part B physician services during the index admission (not based on readmission) If Part B charges are the same for two or more TIN-NPI combinations, the attribution is awarded to the TIN-NPI with the most “bill lines”

Total Per Capita Costs (TPCC)
Definition: TPCC is payment-standardized, risk and specialty adjusted measure of overall cost of care (Medicare Part A and B) for attributed beneficiaries. Part D spending is not included Numerator: sum of annualized, risk-adjusted, specialty-adjusted Medicare Part A and B costs, attributed to a person (TIN-NPI) or group (TIN) Denominator: the number of attributed beneficiaries (to the person or group)

TPCC Attribution Model
Two-step process – determined during performance period 1st step – can attribution be made to a PCP Most primary care type services (PCS) from PCPs PCS = office visits, wellness charges, etc. If PCP attributed charges equal between two or more PCPs – tie breaker is most recent charge 2nd step – can attribution be made to a non-PCP Most primary care type services from a non-PCP Some beneficiaries may not be attributed to a TIN-NPI or TIN

Alternative Payment Models (APMs)
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Advanced Alternative Payment Models (APMs)
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. Initial definitions from MACRA law, APMs include: 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 Back

You Can Earn Additional Rewards for Participation in Advanced APMs
Most clinicians who participate in APMs will be subject to MIPS and will receive favorable scoring under the MIPS improvement activities performance category – these are called MIPS APMs. APM participants Advanced APMs Those who participate in the most Advanced APMs may be determined to be qualifying APM participants (“QPs”). As a result, QPs: Are not subject to MIPS Receive 5% lump sum bonus payments for years Receive a higher fee schedule update for 2026 and onward QPs The 2020 APM Incentive Payment will be based on 2018 services

Advanced APMs (2018) include:
Comprehensive Primary Care Plus (CPC+) Medicare Shared Savings Programs – Tracks 1+, 2 & 3 Next Generation ACO Model Comprehensive End-Stage Renal Disease Care Model (Two- Sided Risk Arrangements) Oncology Care Model (Two-Sided Risk Arrangement) Comprehensive Care for Joint Replacement (CJR) Model – Track 1 with CEHRT requirement Vermont Medicare ACO Initiative (as part of the Vermont All- Payer ACO Model) For 2019: Bundled Payments for Care Improvement (BPCI)

Advanced APMs: First – Are you in an Advanced APM entity?
nominal risk standards: 8% of average estimated Parts A & B revenue for the APM entities (originally planned to count as an option only for and 2018); or 3% of the expected expenditures for which an APM entity is responsible The 3% of expected expenditures is still an option. The 8% of Parts A&B revenues was added in the final rule as a second option for nominal risk. It was only proposed as an option at that level for the first two years. The rule leaves 8% as an option for an additional two years. I believe the Track 1+ ACO fits under the 8% A & B standard.

Advanced APMs: Medical Home Model
Medical Home Model is an APM with the following features: Primary care practices or multispecialty practices that include PCPs Empanelment of each patient to a primary care clinician At least 4 of the following elements: Planned coordination of chronic and preventive care Patient access and continuity of care Risk-stratified care management Coordination of care across the medical neighborhood Patient and caregiver engagement Shared decision-making Payment arrangements in addition to, or substituting for, fee-for-service payments

Advanced APMs: Medical Home Model
2018 (Year 2) changes: CPC+ Round 1 participants are not limited to having fewer than 50 clinicians in parent organization to be an Advanced APM CPC+ Round 2 participants and future medical home models must have fewer that 50 clinicians in the parent organization to be an Advanced APM The medical home model nominal amount standard is modified to increase risk more slowly as outlined in chart Medical home nominal risk standard: percentage of estimated average of Parts A & B revenue at risk Performance Year Transition Year Rule 2018 (Year 2) 2017 2.5% 3% 2.5%* 2019 4% 2020 5% 2021 and after

Second – Are you a Qualifying Participant (in an Advanced APM)?
Payments Patients QP 25% 20% Partial QP 10% 2018 thresholds are same as for 2017 QPs are eligible to receive a 5% bonus payment plus any rewards associated with the APM, and are excluded from MIPS. Partial QPs have the option to participate in MIPS, and are eligible for APM rewards (but don’t qualify for 5% bonus). If in an APM that is not advanced OR in an Advanced APM but do not meet the thresholds to be excluded from MIPS, you are in a MIPS APM with favorable scoring and APM rewards (and a chance at positive adjustment). Back

Advanced APMs: More on Partial Qualifying Participants
Partial QPs meet a lower APM threshold In 2017 & 2018 performance periods, must have 20% of payments through an Advanced APM or 10% of patients Do not qualify for 5% Advanced APM bonus Continue to receive any shared rewards from APM May opt into MIPS participation under MIPS APM scoring standard Benefit from streamlined MIPS reporting and scoring based on APM, so may have good opportunity for positive MIPS adjustment

What is a MIPS APM? A special scoring standard for participants in certain APMs Initially, most MIPS APMs will be one of the following: Partial QPs in Advanced APMs who opt into MIPS ECs in Advanced APMs below the Partial QP threshold ECs in certain APM tracks that do not meet the nominal risk or other Advanced APM standards (i.e., MSSP Track 1, etc.) Back

In other words… Some ECs are in APMs but do not meet the requirements to become QPs or Partial QPs (and are therefore subject to MIPS), or are a Partial QP (and therefore can choose to participate in MIPS). This APM scoring standard applies to APMs that: Participate under an agreement with CMS; Include one or more MIPS ECs on a Participation List; and Base payment incentives on performance (either at the APM entity level or EC level) on cost/utilization and quality.

How does a being a MIPS APM help?
Streamlines MIPS reporting & scoring for ECs in certain APMs (e.g., no add’l quality reporting beyond APM) MIPS scores aggregated at the APM entity level All ECs in an APM receive the same MIPS final score – category weighting is slightly different Full credit in the Improvement Activities category Continued participation in APM’s reward program Added advantage for virtual groups in 2018

MIPS APMs Scoring 2017 (Transition Year) 2018 (Year 2) Performance Category MSSP & Next Gen ACOs Other MIPS APMs All MIPS APMs Quality 50% 0% Cost Improvement Activities 20% 25% Advancing Care Information 30% 75% 2018: Non-ACO APM participants will now receive a score for the quality component based on their APM participation; same weighting used across all APMs A 4th snapshot date (December 31st) will be used to determine if additional ECs in full TIN APMs should be included under MIPS APM scoring Essentially, the ACOs use the CMS web interface, which is also a reporting option in MIPS. Their data was easy to translate into something to compare with others participating via the MIPS pathway. Those in other APMs are not submitting data in a format that was easy to covert into a comparison with other MIPS participants. Therefore, CMS did not count their quality score in the first year while CMS determined how to compare it with others. Due to limitations in how quality data is submitted for the non-ACO APMs (the non-ACOs do not submit data through a MIPS reporting mechanism), CMS could not easily translate the quality data into a MIPS score. However, beginning in the second performance period, CMS will be able to account for the quality data for all APMs. Therefore, all MIPS APMs will be under the same performance category weighting system. The first column represents anyone in a Medicare/CMMI ACO, regardless of whether it is advanced. So it would include Track 1 MSSP ACO participants as well as those in Track 2, 3, and Next Gen that fall below the threshold.

APM Snapshot Dates To determine QP status, CMS uses 3 “snapshots” to determine whether an APM entity meets the threshold: March 31st June 30th August 31st Reaching the QP threshold for any snapshot dates will result in QP status for the eligible clinicians in the Advanced APM Entity Starting in 2018, CMS has added a fourth snapshot on December 31st to determine any additional ECs for MIPS APMs only These snapshots have a claims runout period following the date, so actual notifications of QP status may be 2–3 months after the snapshot date. QP determinations must be based off of the first three snapsots in order to ensure that ECs know whether they meet the threshold in time to be able to submit data for MIPS if necessary.

How to Determine Participation Status
MIPS Lookup Tool: lookup Qualifying APM Participant Lookup Tool:

Submitting Your Data in the QPP Portal
Real time initial scoring. (If no benchmark, you’ll get 3 points until they have enough data to re-score) There is no save or submit button – if you see data on the screen, they received it. You can add or edit data up until March 31 Format: QRDA III or QPP JSON (your vendor can help) Upload for each EC or entire group Claims data will be automatically entered by CMS You will need your EIDM credentials Back

Submit Your Data https://qpp.cms.gov/login January 2 – March 31
Except: January 22 – March 16 for CMS Web interface users April 2018 – review and dispute period begins

Special Circumstances
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What if… My EHR is decertified?
You qualify as for a hardship exception and ACI will be reweighted to Quality I made a mistake in my reporting and need to appeal the decision? The new data submission system provides real time feedback and the ability to edit or add data up until March 31, so start early to ensure there are no data errors.

What if…. I change practices?
Payment adjustments apply to each unique TIN/NPI combination. It makes a difference whether you reported as a group vs individual at the prior vs new practice. I can’t find my EIDM user ID and password? You may have to set a new password or call QPP.

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Quality Payment Program (aka MACRA) What You Need to Know for 2018

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Quality Payment Program (aka MACRA) What You Need to Know for 2018

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