MIPS Deep Dive
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Get an in-depth look at how MIPS works for providers and learn how to prepare for MIPS' implementation.
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MIPS Deep Dive
- 1. This event is live as of XYZ MIPS Deep Dive Alexis Isabelle Senior Manager Quality Performance
- 2. 2
- 3. Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf; Projected Medicare Fee-for- service Payment Cuts per the ACA 2014 2015 2016 2017 2018 2019 2020 Projected number of Medicare beneficiaries 54M 56M 57M 59M 61M 63M 64M -14B -21B -25B -32B -42B -53B -64B Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf
- 4. FFS versus FFV Eliminates incentive to increase volume Eliminates incentive to provide high-cost services over equally effective low-cost services Quality-based incentives Shared risk Emphasizes the role of primary care providers Encourages coordination of care Fees billed per units of service Income maximized through volume No penalty for poor quality Providers lose money if they reduce unnecessary services Volume Driven Health Care Value- Based Health Care Fee-for-service Value-based payments
- 5. • Medicare Access and CHIP Reauthorization Act (MACRA) signed into law April 16th, 2015 • Repealed the flawed sustainable growth rate (SGR) formula • Extends Children’s Health Insurance Program (CHIP) for two years • New two-track Medicare physician payment system emphasizing value-based payment models Landmark legislation alters how Medicare reimburses physicians
- 6. 6
- 7. APMACI APM Entity Eligible Clinician MIP S QP Advanced APM CPIAQPP Partial QP CPS PQR S CPIA MU VM MACRA CHIP ACI
- 8. 8 QPP APM MIPS Merit-based Incentive Payment System combination of MU, PQRs, VM, and new CPIA Alternative Payment Model Quality Payment Program the overarching name that covers MIPS and APM tracks CPS MIPS composite performance score
- 10. 10 MU PQRS VMMIPS Merit-Based Incentive Payment System Consolidates three existing programs, adds in additional performance category APM Alternative Payment Models Incentive payments available to qualified and eligible APM 1 2
- 11. 11 MIPS Eligibility – Years 1 and 2 • Physicians (MD/DO and DMD/DDS) • PAs • NPs • Clinical nurse specialists • CRNs • Anesthetists • Groups (defined by TIN) that include such clinicians
- 12. 12 MIPS Eligibility – Years 3+ • Physical or occupational therapists • Speech-language pathologists, • Audiologists, • Nurse midwives • Clinical social workers • Clinical psychologists • Dietitians/Nutritional professionals
- 14. 14 Three clinician groups not subject to MIPS Exclusions ECs can volunteer to reporting but won’t receive any money Has not submitted claims under any group prior to performance period Qualifying participants (QPs) Partial qualifying participants who opt not to report MIPS <$10k in Medicare billing AND ≤ 100 Part B enrolled beneficiaries Newly enrolled Medicare clinicians APM participantsLow threshold NOTE: MIPS does not apply to hospitals or facilities
- 16. Category weight varies over time 16 25 25 25 15 15 15 10 15 30 50 45 30 2019 2020 2021+ Four Categories That Determine MIPS Score Relative Weight Over Time Quality Resource Use Clinical practice improvement activities (CPIA) Advancing Care Information (ACI)
- 17. Quality1
- 18. 18 Quality (currently PQRS) 1 • 6 measure selection • 1 cross-cutting measure and 1 outcome measure, or another high priority measure if outcome is unavailable • Select from individual measures or a specialty measure set • Population measures automatically calculated • Providers and groups measured and graded against the performance of their peers
- 20. 20 Advancing Care Information (currently EHR Incentive or MU) 2 • Scoring based on key measures of patient engagement and information exchange • Flexible scoring for all measures to promote care coordination for better patient outcomes • Points are awarded based on performance; only the highest performers will be able to earn full credit
- 22. 22 Clinical practice improvement activities 3 New category • Minimum selection of one CPIA activity (from 90+ proposed activities) with additional credit for more activities • Full credit for patient-centered medical home (PCMH) • Minimum of half credit for APM participation • Activities are weighted as High or Medium weight with corresponding points
- 23. Resource Use4
- 24. 24 Resource Use (currently VM) 4 • Medicare claims; no reporting • Minimum thresholds of 20 patients/cases • Adjusted for geographic payment, beneficiary risk factors Total per capita cost measure (part A+B across VM chronic conditions for COPD, CHF, CAD, DM) as seen in VM with slight modification • Expanded list of primary care services to include TCM, CCM • Excluded SNF MSPB measure as seen in VM with slight modifications Episode-based measures (41 across specialties)* 1 2 3
- 25. MIPS has different set of “rules” and scoring going forward Weighting of Cost & Quality categories will change over time with Quality declining and Cost increasing (from 10% to 30% by 2019) Source: CMS 25 Category Weight (Year 1) Scoring Quality 50% • Each measure 1-10 points compared to historical benchmark • 0 points for a measure that is not reported • Bonus for reporting outcomes, patient experience, appropriate use, patient safety and EHR reporting • Measures are averaged to get a score for the category Advancing Care Information (ACI) 25% • Base score of 50 percentage points achieved by reporting at least one use case for each available measure • Performance score of up to 80 percentage points • Public Health Reporting bonus point • Total cap of 100 percentage points available Clinical practice improvement activities (CPIA) 15% • Each activity worth 10 points; double weight for “high” value activities; sum of activity points compared to a target Resource Use 10% • Similar to quality
- 26. Composite performance score calculation 26 A single MIPS composite performance score will factor in performance in 4 weighted performance categories on a 0- 100 point scale Quality Resource Use CPIAACI MIPS Composite Performance Score (CPS)
- 27. Payment adjustment scale has more complexity, less middle ground 27 Demonstrative only MIPS Budget-neutral program, 2019 payment based on 2017 performance CPS Threshold has not yet been released CMS estimates only 0.3% of providers will have a score exactly equal to the CPS threshold Provider payment adjustment Based on distance from CPS Threshold score (Example) CPS Threshold - 60 Lowest quartile or non reporters get flat 4% downward adjustment 0 10 20 30 40 50 60 70 80 90 100 14 12 10 8 6 4 2 0 -2 -4 -6 All providers with <60 CPS receives downward adjustment All providers with >60 CPS receive an upward adjustment Payment Adjustment (%) Payment Adjustment (%) (high performers)
- 28. -1% +1% Payment adjustment will increase over time 28 30% 20% 10% 0% -10% PaymentAdjustment -4% 4% 12% 2019 -5% 5% 15% 2020 -7% 7% 21% 2021 -9% 9% 27% 2022 High performers eligible for additional incentive Budget neutrality adjustment: Scaling factor up to 3x may be applied to upward adjustment to ensure payout pool equals penalty pool Non-reporting groups given lowest score
- 30. 30 Fast timeline for clinicians to follow MACRA Implementation Timeline 2016 2017 2018 Today Final Rule Released Providers may not be certain which track they will fall into when reporting in 2017 Not much time for many providers to get involved in QPP Performance period Providers notified of track assignment Payment adjustment Based on Merit Based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APM) Preparing Performing Reporting Payment Starts January 1st, 2017 Source: CMS
- 31. Payment adjustments vary with different sizes of clinician groups 31 87.00% 69.90% 59.40% 44.90% 18.30% 45.50% 12.90% 29.80% 40.30% 54.50% 81.30% 54.10% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Solo 2-9 10-24 25-99 100 or more Overall CMS Estimated Penalties and Bonuses in 2017, By Practice Size Percent likely to be penalized Percent likely to receive bonus
- 32. 32 Historically, our clients perform better. Meaningful Use Stage 2 attestation % of HCPs avoiding PQRS penalties in 2015 NATIONAL AVERAGE 60% ATHENAHEALTH CLIENTS 93.6% NATIONAL AVERAGE 33% ATHENAHEALTH CLIENTS 98.2%MU and PQRS Client Guarantee
- 33. 33 Currently estimating our clients’ performance in real-time
- 34. athenaNet provider performance on Meaningful Use Stage 2 measure: Use Secure Electronic Messaging NETWORK WIDE CHANGES: 1. NEW FUNCTION: Now easier for practices to register patients to the patient portal. 2. FUNCTION UPDATE: Now easier for providers to send patients secure messages through the patient portal. 100% 90% 80% 70% OCT. 2014 NOV. 2014 DEC. 2014
- 35. 35 We will take on your busy work
- 36. 36 We will make sense of the 200measures and choose which are right for you
- 37. 37
- 38. Thank You
- 40. ACI Advanced APM APM Advanced Care Information, formerly known as Meaningful Use Alternative Payment Model Alternative Payment Model which CMS has designated “eligible”
- 41. APM Entity CPS CPIA EC The TIN(s) participating in an APM or Advanced APM Clinical Practice Improvement Activities MIPS composite performance score Eligible Clinician, the new definition of professionals who fall under this category under MACRA
- 42. MIPS QPP QP Partial QP Merit Based Incentive Payment System, the combination of MU, PQRS, VM and new CPIA Qualifying APM Participant Quality Payment Program, the overarching name that covers MIPS and APM tracks Partial Qualifying APM participants
Editor's Notes
- Welcome and introduction
- It’s pretty clear that the government has fundamentally shifted the way our country provides health care since the arrival of the Affordable Care Act in 2010. Within recent years, these changes are specifically felt in how providers are reimbursed for giving care. But, what is the real reason prompting all these changes?
- Well, the number of Medicare beneficiaries continues to grow, payer reimbursements are a huge target for Medicare cuts to try and offer a solution to a cumulating financial problem. Rather than cutting public payer programs altogether, the government has decided to tie payments to the demonstration of quality rather than just cut public payer programs altogether. It is by the Affordable Care Act, the government continues to move toward a consistent delivery of quality care. As you can see the number of Medicare beneficiaries has been and will continue to increase exponentially over the next five to ten years, mostly driven by the “baby-boomers” hitting the retirement age. So as to not bankrupt the country, the Medicare fee cuts have to be cut just as much to compensate. As a result the payment system is shifting from fee-for-service to fee-for-value
- The big shift is moving from what is known as a “fee-for-service” environment to a “fee-for-value” environment, or “value based”. These value based payments are very different in that they really incentivize quality based care. Instead of high volume where money is made from providing more care, it is all about high quality, where payments come from the type of care that is provided.
- And this shift happened in a big way last year. On April 16th, the Medicare Access and CHIP Reauthorization Act (MACRA), H.R. 2 was signed into law. While this law permanently repealed the flawed sustainable growth rate (SGR) formula, the new legislation included a small addition that has huge repercussions on the Medicare framework for paying physicians called MACRA. Sources: http://www.familydocs.org/payment-reform/macra https://www.acponline.org/advocacy/where_we_stand/assets/macra_handout_need_to_know_2015.pdf Image source: http://www.healthcarefinancenews.com/news/icd-10-debate-hits-washington-most-prepared-worry-persists
- New legislation, rulings, announcements, proposals, and constant changes from the government surrounding the healthcare community… Just remembering all these developments can feel a bit like you’ve wandered off the path into uncharted territory, especially now that you’re put in the position of needing to know more about new reporting and documentation measures than ever before. Image source: https://www.flickr.com/photos/33346716@N03/8036177029
- Before we dive into these measures, there are a whole score of new acronyms that have come out of the MACRA legislature, adding to what already might have felt like an “acronym soup”.
- The four pertaining most to our conversation today are the following
- Okay, now let’s take a deeper look into what MIPS is all about and how this will affect ECs going forward from 2017 on.
- So, under MACRA, two new systems of payment are set to begin in 2017. Both methods allow practices to be awarded incentives for providing improved care. The first option is MIPS, or the merit-based incentive payment system. MIPS combines the MU, PQRS, and VM programs will all merge into one system with adjustments for that year implemented in 2019. The second track is the option to become an Alternative Payment Model Entity. APMs are for clinicians who can demonstrate that a significant portion of their revenue comes from two-sided risk contracts and who utilize a certified EHR technology.
- The MIPS ECs will include those listed here.
- Secretary may broaden Eligible Clinicians group to include others
- Despite the previous list of eligibility, CMS states that all ECs will report MIPS in 2017. CMS will then determine which ECs are excluded from MIPS due to APM, low volume threshold or new to Medicare. This means about 90% of providers in country will be performing in MIPS in 2017 based on CMS 2019 payment adjustment estimation. This leaves less than 10% of providers, to become QPs through Advanced APMs and receive incentive payments for 2019.
- Even so, there are three groups not subject to MIPS. ECs excluded from MIPS include newly Medicare-enrolled eligible clinicians, clinicians that fall under the proposed low-volume threshold (<$10k Medicare charges AND <= 100 Medicare patients), Qualifying APM Participants (QPs), and certain Partial Qualifying APM Participants (Partial QPs). Hospitals are not affected by this rule and hospital-based MIPS eligible clinicians are not required to participate in the information technology portions of MACRA, since they may not have direct control over the software implemented by the hospital.
- There are four performance categories under MIPS.
- The first performance category is quality, what the currently program of PQRS will shift into.
- Select from individual measures or a specialty measure set 50% weighting for the first performance year and reduces to 30% by 2019 performance year 6 individual measures or measures from a specialty-specific set with at least 1 cross cutting measure and outcome measure - if an outcome measure is not available, then report one other ‘high priority’ measure (appropriate use, patient safety, efficiency, patient experience, care coordination) specialty-specific measures sets are the same measures that are within the individual set, they are just sorted for ease of identifying potential measures for an EC’s specialty Minimum reporting must contain at least 1 quality measure for at least 1 Medicare patient Reporting threshold: third party vendors (EHR, Registry) - 90% of EC’s or group’s patients for ALL payers claims and Web Interface - 80% of EC’s or group’s patients for Medicare Part B If an EC has less than 12 months of data, they would report partial year (examples provided: illness, maternity leave) Year 1 weight: 50%
- The second performance category is Advancing Care Information, which is evolving out of the EHR Incentive or Meaningful Use.
- Year 1 weight: 25% and remains consistent
- The third performance category is clinical practice improvement activities, a totally new program.
- The last performance category is Resource Use, currently known as the Value-based Modifier, or VM.
- Year 1 weight: 10% Total per capita cost measure (part A+B across VM chronic conditions for COPD, CHF, CAD, DM) as seen in VM with slight modification Expanded list of primary care services to include TCM, CCM Excluded SNF MSPB measure as seen in VM with slight modifications remove specialty adjustment edit the expected to cost calculation and average such that each episode is considered for observed/expected (current is sum observed/agg sum expected)
- The MIPS composite performance score will factor in performance in 4 weighted performance categories on a 0-100 point scale : Unified scoring system: Converts measures and activities to points ECs will know in advance what they need to do to achieve top performance Partial credit available https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MACRA-NPRM-Slides.pdf
- In order to calculate your CPS, scorings from each category must be added up MIPS composite performance scoring method that accounts for: Weights of each performance category Exceptional performance factors Availability and applicability of measures for different categories of clinicians Group performance The special circumstances of small practices, practices located in rural areas, and non-patient-facing MIPS eligible clinicians
- CPS: payment adjustment (pre threshold raises at 0.89 pts/CPS pt; post threshold raises at 0.1 pts/CPS pt; additional raises at 0.325 pts/CPS pt above CPS of 71) 20: -3.56 30: -2.67 40: -1.78 50: -.89 60: 0 70: 1 80: 2 + additional 3.4 90: 3 + additional 6.99 100: 4 + additional 10 For VM, adjustment was at TIN level no matter what MIPS payment adjustment is at TIN/NPI- more control over own destiny as long as you submit individually Because there is an option under MIPS, athena can use this as a value-add for our clients
- The payment adjustments for MIPS has gone through an overhaul and is completely new. Unlike previous CMS programs, like VM, where a majority of groups that fell into an average quality & cost performance (no payment adjustment in the 9-box grid), under MIPS only providers exactly at Composite Performance Score (CPS) threshold will see NO payment adjustment. For 2019, only 0.3% of ECs will receive that 0% adjustment (2,527 clinicians out of 761,342). Providers 1 point above the threshold will receive a bonus, 1 point below the threshold will receive a penalty. The further a provider’s CPS is below the threshold, the larger the penalty, up to a 4% max in 2019. A MIPS EC’s payment adjustment percent
- So, with all that in mind, how best to prepare for 2017, the start of the new MACRA performance period?
- In just about 6 more months, the final rule is slated to come out in November with solidified details on reporting for both tracks under the new Quality Payment Program, QPP, from MACRA. But this means preparation has to start as soon as possible, making learning all that you can before very important. Once January 1st, 2017 hits, you’ll need to dive right into performing and then reporting going forward. How we prepare on behalf of prospects/clients
- actual payment adjustments won't vary, it is just that the estimated % of providers getting the payment adjustment will vary CMS estimates that 45.5% of ECs will be subject to negative payment adjustment; 60% of groups under 25 clinicians CMS EC distribution by size solo: 13.5% (ATHN 19.5%) 2-9: 16.2% (ATHN 29.8%) 10-24: 10.7% (ATHN 19.2%) 25-99: 19.4% (ATHN 20.9%) 100+: 40.1% (ATHN 10.5%) something important to call out is that this includes ACO groups who currently do not need to report PQRS but would be included in MIPS in 2017 2016 VM results indicated that 5418/13813 (39%) received automatic penalty for failure to report data 59% of all EPs are neutral (98% of those who reported). 0.7% of reported get downward and 1.5% of reported get upward Unfortunately, CMS has designed this program so half of ECs are below threshold in Year 1. They estimate about 45.5%, so almost half, of ECs to receive a penalty based on their Year 1 MIPS performance. Especially if you’re a small practice, as CMS has also estimated that most are most likely to “fail” in Year 1 of QPP. CMS estimates that 87% of solo practitioners will see a negative adjustment whereas only 18.3% of groups with 100 or more eligible clinicians will be penalized. Conversely, 81.3% of groups with 100 or more eligible clinicians will see upward adjustment in 2019. It is worthwhile to note that practices with <15 ECs get a break with only needing 2 activities (weighted 30pts. each)
- Considering our track record, we feel more than confident in our ability to help our providers to stay on track with all that comes with the MACRA ruling. Feeling really good about this, historical evidence, speak to what’s coming
- We provide real time visibility into how you’re doing. In fact, we are already at work estimating our clients current performance under the proposed requirements.
- We are able to use our web-based solution to push solutions out in real time for our client across the whole network. We did this back in 2014 to ensure that our clients could easily meet the MU requirement for Secure Messaging via product functionality.
- CMS has estimated a significant cost and amount of time it will take for clinicians to report under MIPS categories. athena is prepared to tackle all the busy work for you.
- We will also select the measures for you just as we have done before for PQRS and MU and we will make sure our selections align with your practice best.
- All the work we do is to allow for the real work to happen
- athena is in the unique position to deliver results to our clients even now.
- Choose either this slide or the last