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MACRA Ready - Martin
- MACRA: Medicare’s Shift to Value-based Delivery & Payment Models Shawn Martin AAFP Senior Vice President Advocacy, Practice Advancement, & Policy
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- What Does MACRA Do? • Consolidates quality programs Merit-Based Incentive Payment System (MIPS) • Potential for bonus payment for participation Advanced Alternative Payment Models (AAPM) 4
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- 2017/2018 QPP Participants Physicians (MD/DO) Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist MACRA defines eligible clinicians as:
- MIPS Exemptions 7 • Year 1 Medicare • Eligible Advance Alternative Payment Model with Bonus • Below the Low Volume Threshold • 2017: < $30,000 Medicare Part B allowed charges; or cares for < 100 Medicare beneficiaries • 2018: < $90,000 Medicare Part B allowed charges; or < 200 Medicare beneficiaries
- Merit-Based Incentive Payment System (MIPS)
- MIPS Highlights Consolidates existing quality and value programs • Adds a category for Improvement Activities Establishes a Final Score • Weighted scoring by category Provides opportunity for payment adjustments • Both positive and negative 9
- MIPS Performance Categories 10 Quality Cost Improvement Activities Advancing Care Information (ACI)
- Weighting by Category - 2017 Quality, 60% Cost, 0% Improvement Activities1, 15% Advancing Care Information, 25% 1 - “Certified” PCMH receives the full credit for IA; APM Participants receive half credit 11
- Weighting Progression **Proposed for 2018
- Individual vs. Group • If you choose to report as a group, all performance categories must be reported as a group • Groups will be scored as a group and will receive one MIPS score • Groups must report the same measures for all ECs 13
- Quality Measures • Must report on measures • May report more; only the highest scores will be used to calculate the quality score • Most measures need a 20 patient case minimum • One must be an measure – Controlling high blood pressure; A1C Poor Control
- Cost Category Weight- 2017
- Advancing Care Information • ACI replaced Meaningful Use • Must use certified EHR technology (CEHRT) to report for the ACI performance category • In 2017 and 2018, the CEHRT may be the 2014 edition, 2015 edition, or a combination of both (you might change) • Physicians without an EHR are eligible to participate in MIPS, but will not be able to receive any points in the ACI category
- Improvement Activities There are 92 improvement activities available within the following overarching categories: Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Achieving Health Equity Emergency Response and Preparedness Integrated Behavioral and Mental Health 17
- PCMH 18 • Practices recognized or certified by: NCQA, AAAHC, TJC, URAC; and Accrediting bodies that have certified 500 or more practices – 2017: One member of the TIN could have PCMH “recognition” for 100% IA credit – 2018: 50% of TIN members need PCMH “recognition” for the TIN to receive full IA credit**
- Annual Performance Threshold • Established by Secretary years 1 and 2 – For transition year 2017, threshold is 3 – Proposed for 2018, threshold increases to 15 • Below = negative payment adjustments • Above = positive payment adjustments 19
- Adjust Payments -4% -5% -7% -9% 4% 5% 7% 9% 2019 2020 2021 2022 onward *Adjustment to provider’s base rate of Medicare Part B payment *Potential for 3X adjustment 20
- Adjustment Summary 21 Performance Score Payment Adjustment Exceptional Performers (Final Score over 70) = Eligible for up to 10% positive adjustment in 2019 25th Percentile or below = Maximum negative adjustment At threshold = Stable Payment
- “Pick Your Pace” Reporting 22 • Report one quality measure, one improvement activity, or all four of the required measures within the advancing care information (ACI) category Test • Report a minimum of 90 days for more than one quality measure, more than one improvement activity, or the measures within the ACI category. Partial Participation • Report to MIPS for a full 90-day period or full year Full Participation
- Advanced Alternative Payment Models (AAPMs)
- Definitions Qualifying APM • Based on existing payment models Advanced APM • Based on criteria of the payment model Qualifying AAPM Participant • Based on individual physician payment or patient volume 24
- Qualifying APMs 25 • MSSP (Medicare Shares Savings Program) • Expanded under CMS Innovation Center Model* • Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration • “Demonstration required by Federal Law” Qualifying APMs
- Advanced APM Eligibility 26 • Quality measures comparable to MIPS • Use of certified EHR technology • More than nominal risk OR Medical Home model expanded under CMMI authority Qualifying APMs Advanced APMs
- 2017 Primary Care Advanced APMs • Shared Savings Program (Tracks 2 & 3) • Next Generation ACO Model • Comprehensive Primary Care Plus (CPC+) • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model) 27
- Qualifying AAPM Participant 28 • Percentage of patients or payments thru eligible APM • In 2019, the threshold is 25% of Medicare payments or 20% of beneficiaries • QP status will be determined at the group level Qualifying APMs Advanced APMs Qualifying AAPM Participant
- Additional Rewards for Qualifying Participants 29 • Not subject to MIPS • 5% bonus 2019-2024 • Higher fee schedule update to 0.75% 2026
- MACRA Timeline 2017 2018 2019 2020 2021 2022-2024 2025 2026 Medicare Part B Baseline Payment Updates +0.5% +0.5% +0.5% 0% 0% 0% +0.25%* +0.75%** *Non-qualifying APM Conversion Factor **Qualifying APM Conversion Factor Merit-Based Incentive Payment System (MIPS) PQRS, Value-based Modifier, & Meaningful Use Quality, Cost, Advancing Care Information, & Improvement Activities -9% -9%? 0 or +/-4%* “Pick Your Pace” +/-5% +/-7% Qualifying AAPM Participant 5% Incentive payment Excluded from MIPS +0% +/-9% 30
- What Can I Do Right Now? 31 No Participation Test Partial Participation Full Participation ‘Pick Your Pace’
- Employed Physicians and Residents • MIPS scores follow you • MIPS scores are publicly available • Consider a practices’ MIPS score as you evaluate employment contracts *Check out the FPM Employed Physician Supplement
- R. Shawn Martin Senior Vice President Advocacy, Practice Advancement, & Policy smartin@aafp.org @rshawnm
Hinweis der Redaktion
- The Medicare Access and CHIP reauthorization Act (MACRA) is the key legislative piece that moves the healthcare system closer to meeting the goals laid out by the Secretary. The first line in the legislation is spelled out here, and it states clearly what the law is intended to do…To repeal the Medicare Sustainable Growth Rate (the SGR) and strengthen Medicare access by improving physician payments If only the law were this simple!
- As we mentioned previously, MACRA introduces two new payment tracks: One that consolidates quality programs –the Merit Based Incentive Payment System (MIPS) And Alternative Payment Models (APMs) - which have the potential for bonus payments for participation We anticipate many of our members will move through MIPS into the alternative payment model track.
- Here is a graphical representation of the MACRA path you will be venturing on.
- The final rule defines eligible clinicians physicians (MD/DO), Physician Assistants, Nurse Practicioners, Clinical Nurse Specialists and Certified Registered Nurse Anesthetist. Other providers will added *You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as established by the law.
- Lets take a look at MIPS in more detail
- Highlights of MIPS include the consolidation of existing quality and value programs to reduce administrative burden; establishment of a performance score; and sliding scale payment adjustments.
- In addition to the more familiar programs that will be used to calculate a MIPS composite score, a new category of clinical practice improvement activities has been introduced. Physicians will be assessed, and receive payment adjustments, based on a composite score comprised of these four categories. You will see that many primary care providers are already doing something (if not a lot) in each of these categories. Physicians will be assessed, and receive payment adjustments, based on a composite score comprised of these four categories. You will see that many primary care providers are already doing something (if not a lot) in each of these categories. Quality – Physicians will need to report on 6 measures of their choosing- one being an outcome measure. Those that have been reporting PQRS will be familiar with this process. Resource Use- Similar to value-based payment modifier, there will be no data submitted by physicians to CMS for this category. CMS will use claims data to calculate the score. Advancing Care Information- which is the old Meaningful Use, is reported very much the same as the previous program. Then, there is the new category of Clinical Practice Improvement Activities
- This is a breakdown of year 1 scoring. The four categories above contribute points, in a weighted fashion, to make up the performance score. The total number of points scored will range from 0-100, with each category weighted as established in statue. Quality 60% Cost 0% IA 15 ACI 25 You will notice there is a footnote for Improvement Activites. Specifically, a “Certified” patient centered medical home will receive the full 15 points for this category. Those in alternative payment models who do not qualify for the alternative payment model bonus, will get half the credit for the IA category. We will discuss this more in the alternative payment model section. “Certified” patient centered medical home is defined in the proposed rule as those recognized by NCQA, the Joint Commission, URAC, and AAAHC. The AAFP is advocating for state-based and payer programs to be included in this definition as well.
- If choosing to report as a group, then all performance categories must be reported and will be scored as a group. If reporting as a group, all clinicians within the group must report on the same measures
- There are 9 outcomes measures in the Family Medicine set The exception to the 20 patient case minimum is the all cause hospital readmission measure which is a 200 case minimum
- The ACI performance category replaces meaningful use. Similar to meaningful use, eligible clinicians (ECs) must use certified EHR technology (CEHRT) to report for the ACI performance category. The CEHRT may be the 2014 edition, 2015 edition, or a combination of both. Physicians without an EHR are eligible to participate in MIPS, but will not be able to receive any points in the ACI category.
- When MIPS begins in 2019, there is no historical “look back” period of previous MIPS scores to use to set a performance threshold. The law gives authority to the Secretary of Health & Human Services to establish the performance threshold in years one and two. After that, the performance threshold will be based on the mean or median of the previous year’s MIPS scores. MIPS scores will then be compared to the threshold. Scores above the threshold will yield positive payment adjustments and scores below the threshold negative adjustments.
- Beyond the baseline adjustments, written into the law are higher adjustments for the highest performers. These can be up to 3 times the maximum adjustment for that year. But the positive and negative adjustments must still be budget neutral. Also, positive and negative adjustments will be made on a sliding scale, which is important. People will likely get a wide range of adjustments between 0 and the maximum for the year, not necessarily in whole numbers. We may be seeing adjustments carried out several decimal points. At this time, we don’t know. It is important to note, the adjustments are not cumulative, whether positive or negative. Every year, your baseline resets to zero. Outside the budget neutral adjustments, for years 2019-2024, there is $500M set aside for additional positive payment adjustments of up to 10% for “exceptional performers”. As the proposed rule is written, exceptional performers will be those that score in the top 25% of MIPS scores. Before leaving this slide, an important note for lower performers who score in the lowest quartile of MIPS scores: These providers will automatically be adjusted down to the maximum penalty for that year
- Here are some key points to remember: If you score in the lowest quartile of MIPS scores, you will automatically be adjusted down to the maximum payment adjustment for the performance year. If you score at threshold, you receive no adjustment Exceptional performers are eligible for a potential positive payment adjustment up to 10%. This incentive will be paid based on a sliding scale and is outside the budget neutrality. $500M has been set aside to cover this incentive payment. Exceptional has been proposed to be the top 25% of MIPS scores. And it is important to remember, this program is budget neutral, so the total negative adjustments must equal the total positive adjustments.
- Let’s move on to APMs
- As we’ve mentioned, most providers will move through MIPS as they prepare to enter the Alternative Payment Model track. At the highest level, MIPS is based on existing activities with few entry requirements or exceptions making it easy to become a participant. Conversely, in the APM track, you must meet specific qualification and eligibility criteria. Let’s talk about what each of these mean.
- The goal is for you to be a Qualifying APM Participant. The first step to get there is to be practicing in a “qualifying” payment model defined in the law. MACRA is very specific about which models qualify, and they are listed here. Although this is a wide net cast for qualification it does get smaller as we move through the next steps of eligibility and further qualification.
- Step two in the process is for qualified APMs to meet eligibility criteria, listed here. Let’s take a closer look. First, Advanced APMs must report measures comparable to those in MIPS. Second, they must use certified EHR technology And, this last bullet is interesting. The APM needs to either 1) bear more than nominal financial risk for monetary losses, OR 2) be a medical home model expanded under CMMI authority. Nominal financial risk has been defined in the proposed rule and it is very complicated. The AAFP is advocating the definition be simplified.
- In the proposed rule, CMS defined those programs that met the criteria necessary to be considered an Advanced APM. They have said they will release an updated list of Advanced APMs annually.
- The last step after the payment model has been identified as an Advanced APM, is for the participants within the model to be qualified. Qualifying Participants (QPs) are physicians and practitioners who have a certain percentage of their patients or payments coming through an Advanced APM. In 2019 and 2020, the threshold for claims is 25% of payments made by CMS for part B services to Medicare attributed beneficiaries paid through the Advanced APM. The patient threshold is 20% of Medicare unique attributed beneficiaries. This is not a total percentage of your patient panel, this is just a percentage of your Medicare attributed patients. Beginning in 2021, the threshold percentage may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid
- Qualifying APM participants are excluded from MIPS, and will receive an annual 5% bonus payment from 2019-2024. They will also receive a higher Medicare physician fee schedule update (of 0.75%) starting in 2026. Physicians and practitioners who participate in qualifying APMs that are not an Advanced APM are not a “qualifying participant” and will be subject to MIPS. However, APM participation is a clinical practice improvement activity, as defined under MIPS. As a result, these APM participants will receive favorable scoring for this performance category.
- And finally, the full timeline. The timeline illustrates the payment updates, and the penalties and/or benefits by year for both MIPS and Qualifying APM Participants. This timeline is available on the AAFP website
- So, What Can You Do Right Now to take advantage of the payment opportunities?