1. NOSORH WHAT WILL MIPS MEAN? Bill Finerfrock President Capitol Associates, Inc.

2.  Passed House 3/26/2015- Senate 4/14/2015  Signed into Law 4/16/2015  Repeals 1997 Sustainable Growth Rate Physician Fee Schedule (PFS) Update  Changes Medicare PFS Payment  Merit-Based Incentive Payment System (MIPS)  Incentives for participation in Alternate Payment Model (APM) MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015 ( MACRA) OVERVIEW: 2

3.  PFS 0.5% update 7/1/15-12/31/15  PFS 0.5% update CY2016 - CY2019  PFS 0.0% update CY 2020-2025  MIPS & APMs will drive payment 2019 onward UNTIL THEN: PHYSICIAN FEE SCHEDULE UPDATES: 3

4.  Payment adjustments under PQRS, VM, and EHR-MU will sunset Dec. 31, 2018  Beginning January 1, 2019 – MIPS and APM incentive payments begin  EPs can participate in either MIPS or meet requirements to be qualifying APM participant  MIPS – Can receive positive, negative or zero payment adjustment MIPS & APM INCENTIVES: 4

5.  Under MIPS the Secretary must develop a methodology to assess EP performance and determine a composite performance score based on a scale of 0 – 100.  Features of PQRS, the Value Modifier and the EHR Meaningful Use program are included in MIPS  The composite score will be used to determine and apply a MIPS payment adjustment factor for 2019 onward  Adjustment Can Be Positive, Negative, or Zero MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS): 5

6.  2019 & 2020 (First two years)  Physicians, PAs, Certified Registered Nurse Anesthetists, NPs, Clinical Nurse Specialists and Groups that include such professionals  2021 onward  Secretary can add EPs to MIPS  Excluded EPs  Qualifying APM participants  Partial Qualifying APM Participants  Low volume threshold exclusions  MIPS DOES NOT apply to RHC or FQHC payments MIPS APPLIES TO INDIVIDUAL EPS, GROUPS OF EPS OR VIRTUAL GROUPS 6

7.  The minimum number of individuals enrolled under Medicare who are treated by the EP for the performance period?  The minimum number of items and services furnished to individuals enrolled under Medicare by the EP for the performance period?  The minimum amount of allowed charges billed by the EP under Medicare for the performance period?  Question – What should those minimums be? LOW-VOLUME THRESHOLD COULD BE BASED ON…

8. Beginning Jan 1, 2019 CMS must assess performance based on performance standards during a performance period for measures and activities in the following 4 performance categories. 8

9. Performance Categories  Quality measures (30% of Score)  Resource Use measures (30% of Score)  Counts for not more than 10% in 2019 and 15% in 2020; additional weight of at least 20% and 15%, respectively, are added to the Quality score in those years  Clinical Improvement Activities (15% of Score)  Sub-Categories- Includes Better Off-Hours Access, Care Coordination  Patient Safety, Beneficiary Engagement  Others as Determined by Secretary  Meaningful Use of EHRs (25% of Score)

10. CMS will propose the initial policies for the MIPS in a forthcoming regulation in 2016 – required to have final policies by Nov. 1 2016 CMS must make available timely (“such as quarterly”) confidential feedback reports to each MIPS EP starting July 1, 2017 Beginning July 1, 2018, CMS must make available to each MIPS EP information about items and services furnished to the EP’s patients by other providers and suppliers for which payment is made under Medicare Information about the performance of MIPS EPs must be made available on Physician Compare 10

11. Expanded Practice Access Same day appointments for urgent needs After hours clinician advice Population Management Monitoring health conditions & providing timely intervention Participation in a qualified clinical data registry Care Coordination Timely communication of test results Timely exchange of clinical information with patients AND providers Use of remote monitoring Use of telehealth Beneficiary Engagement Establishing care plans for complex patients Beneficiary self- management assessment & training Employing shared decision making CLINICAL PRACTICE IMPROVEMENT ACTIVITIES Secretary shall give consideration to practices <15 EPs, rural practices, & EPs in under served areas. The Secretary is required to specify clinical practice improvement activities. Subcategories of activities are also specified in the statute, some of which are:

12. The composite performance score will range from 0 – 100 Performance threshold will be established based on the mean or median of the composite performance scores during a prior period The score will assess achievement & improvement (when data available) 12

13. EPs receive a positive adjustment factor if score is above the performance threshold and a negative adjustment factor if score is below threshold. MIPS applicable percent defined: (positive or negative)  2019 4%  20205%  20217%  2022 & onward9% MIPS INCENTIVE PAYMENT FORMULA 13

14. Quartile 1 – Maximum Update of 4% Quartile 2 – No Update Quartile 3 – No Update Quartile 4 – Negative Update of -4% MIPs Score – EXAMPLE - 2019

15.  MIPS Adjustment for Performance Above Threshold  EPs with performance score above performance threshold receive positive payment adjustment factor.  Scores determined based on sliding scale relative to threshold and the applicable percent.  Additional Adjustment for Exceptional Performance:  For 6 years beginning in 2019, EPs with scores above additional performance threshold (defined in statute) receive additional positive adjustment factor ($500 million is available each year for 6 years for these payments.) MIPS INCENTIVE PAYMENT FORMULA: 15

16.  How should CMS appropriately identify and assess EPs under MIPS? For both individuals and group practices?  How should CMS “take into consideration” non-patient facing specialties (i.e. radiology, pathology, anesthesiology)?  For the four performance categories, what performance criteria should exist? What measures and activities should comprise the four performance categories?  Should CMS still maintain all of the same quality reporting options that exist today under PQRS? What data quality checks should there be for the quality performance category?  For the Meaningful Use performance category, what changes should CMS make to the current structure?  For the Clinical Practice Improvement Activities category, how should CMS receive this data and what types of activities should be given consideration? TOPICS FOR DISCUSSION 16

17. MACRA provides money – already authorized and appropriated – for HHS/CMS to enter into agreements with entities to provide technical assistance to providers located in rural areas or serving underserved populations. Specifically, The Secretary shall enter into contracts or agreements with appropriate entities to provide technical assistance to MIPS eligible professionals in practices of 15 or fewer professionals with priority given to practices located in rural underserved areas. The purpose of which is to offer guidance and assistance to these small practices with respect to: 1. Their MIPS scores; and 2. How to transition to and implement alternative payment models. $20 Million PER YEAR for the next 5 years has already been appropriated for this activity. WHAT ABOUT TECHNICAL ASSISTANCE FOR PROVIDERS IN RURAL/UNDERSERVED AREAS?

18. CMS Wants to Know… For the Technical Assistance to small practices and practices in HPSA areas for MIPS EPs, what best practices should be applied and spread? 18

19. WILL THIS TA MONEY BE AVAILABLE TO SORHS? Maybe… NOSORH was successful at getting language inserted in the FY 2016 Labor-HHS appropriations Senate Committee report stating:

20. Senate Labor-HHS Appropriations Report says: Technical Assistance for Priority Areas.--The Committee notes that the Medicare Access and CHIP Reauthorization Act of 2015 authorizes the Secretary to provide technical assistance on the Merit-based Incentive Payment System to eligible professionals with a priority given to practices located in rural, medically underserved, or health professional shortage areas. Due to their extensive experience working with providers in rural and underserved areas, the Committee highlights the significance of the State Offices of Rural Health and their ability to provide this type of guidance. MACRA MONEY AND SORHS

21. NOSORH would like to thank Senator Bill Cassidy (R-LA) for his work getting this language into the Senate Report. We can report that there are internal discussions occurring within HHS/CMS/HRSA on how this money will be allocated and the entities with whom the Secretary will direct this money. MACRA MONEY AND SORHS

22. Questions? STAY TUNED….