Transcript Update on MACRA/MIPS - Najeeb Mohideen, MD, FASTRO, FACR

Update on MACRA/MIPS
Najeeb Mohideen MD, FASTRO,FACR
ACR Commission on RO, Economic Committee Chair
ASTRO Health Policy Committee
ASTRO Payment Reform Committee
Northwest Community Hospital, Arlington Heights, IL
Milestones in Healthcare Transformation
2010 Patient Protection and Affordable Care Act (PACA)
• Healthcare expansion & Payment Reform
 Transitioning payment for healthcare from volume based to
value based will reduce the cost of care and bend the cost curve
(ACOs, PCMH, SIMs, P4P, HC Innovation Awards, etc…)
HHS Secretary Silva Burwell’s Spring 2015 Announcement

30% of all Medicare payments will be tied to quality or value
through Alternative Payment Models by the end of 2016 and 50%
by 2018.
2015 Medicare Access and CHIP Reauthorization Act (MACRA)
• Eliminated the Sustainable Growth Rate (SGR) formula
• Establishes a combination of automatic rate increases and
incentives for docs to participate in pay-for-performance programs
and alternative payment models.
MACRA:Overhaul in Medicare Payment
Overview of Medicare Access & CHIP Reauthorization Act (MACRA)
• Physicians can choose between a Merit-Based Incentive Payment System (MIPS) or
Alternative Payment Models (APM)
Merit-Based Incentive System
(MIPS)
Physicians are scored based on
Quality,
Resource use,
Clinical practice improvement,
Meaningful use of EHR.
Physicians receive a score of 1100, and will be paid on an
adjusted scale.
APMs– Alternative Payment Models
Qualified APMs will pay lump sum
incentive payments (5%) to health
care providers starting in 2019.
Medicare payments under
MACRA
Baseline
PFS
Updates
MIPS*
APMs
0.5%
0.25%
0%
±4% ±5% ±7%
±9%
5% lump sum bonus
0%
+0.5%
PFS
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
* Additional bonus available for exceptional performance
Merit-Based Incentive Payment
System
4 Categories:
• Quality Performance(50%)
• Builds of PQRS program and some parts of the VM.
• Resource Use (10%)
• Builds off the cost component of the VM.
• Advancing Care Information (25%)
• Builds off of and replaces the Meaningful Use program.
• Clinical Practice Improvement Activities (15%)
• Activities that improve the clinical practice or delivery of care.
• Expanded practice access, population management; care
coordination; shared decision-making; telehealth; patient
safety and practice assessment; maintenance of certification;
etc.
Quality Performance
• Similar to existing PQRS program, and will adopt
measures from existing program.
• Measures:
• 6 measures
• One cross-cutting measure
• One outcome measure OR a high priority measure
(appropriate use, patient safety, efficiency, patient
experience, or care coordination)
• Can also choose to report a specialty measure set.
Some Existing PQRS Measures
Avoidance of Overuse of Bone Scan for Staging Low
Risk Prostate Cancer Patients
Adjuvant Hormonal Therapy for High Risk or Very
High Risk Prostate Cancer
Pneumonia Vaccination Status for Older Adults:
Documentation of Current Medications
Oncology: Medical and Radiation – Pain Intensity
Oncology: Medical and Radiation – Plan of Care for
Pain
Preventive Care and Screening: Tobacco Use
Quality Performance
• If the measures are reported using a QCDR, EHR, or
a qualified registry, then the measures must be
reported for 90 percent of all patients to which
each the denominator of the measure applies,
regardless of the payer.
• If the measures are reported via claims, then the
measures must be reported for 80 percent of
Medicare Part B patients to which each measure
applies.
Quality Performance
Resource Use
• CMS will calculate these measures based on claims.
Providers do not report any measures.
• Measures:
• Episode-based measures.
• Medicare Spending Per Beneficiary Measure
• Total Per Capita Cost Measure
MACRA Requires Development
of Three New Types of Codes
• Care Episode Groups (and associated
codes)
• Patient Condition Groups (and associated
codes)
• Patient Relationship Categories (and
associated codes)
Patient Relationship Categories
• (i) considers themself to have the primary responsibility for the
general and ongoing care for the patient over extended periods
of time;
• (ii) considers themself to be the lead physician or practitioner and
who furnishes items and services and coordinates care furnished
by other physicians or practitioners for the patient during an
acute episode;
• (iii) furnishes items and services to the patient on a continuing
basis during an acute episode of care, but in a supportive rather
than a lead role;
• (iv) furnishes items and services to the patient on an occasional
basis, usually at the request of another physician or practitioner;
or
• (v) furnishes items and services only as ordered by another
physician or practitioner
Episode Grouping
Advancing Care Information
• Eliminates Meaningful Use all-or-nothing scoring
methodology for the entire category.
• Base Score and Performance Score
• Base Score Objectives:
•
•
•
•
•
•
Protect Patient Health Information
Electronic Prescribing
Patient Electronic Access to Health Information
Care of Coordination Through Patient Engagement
Health Information Exchange
Public Health and Clinical Data Registry Reporting
• Modified Stage 2 available for 2017.
Advancing Care Information
Advancing Care Information
Advancing Care Information
Clinical Practice Improvement
Activity
• Providers can select from over 90 activities:
• Participating in a Qualified Clinical Data Registry (QCDR)
• Participation in AHRQ patient safety organization.
• Use of telehealth services and analysis of data for
quality improvement.
• Provide episodic care management, including
management across transitions and referrals.
• Activities fall into two categories: medium- and
high-weighted activities.
• Reporting Period:
• 90 continuous days during the performance period
CPIA Subcategories
MIPS: CPIA
• Minimum Selection of one activity for a
partial score
• Activities categorized as “medium” or
“high” weight earning 10 or 20 points
respectively
• Full Credit for 60 points
• Year One Weight: 15%
MIPS Performance Category
Scoring
APMs
• APM is a generic term describing a payment model in
which providers take responsibility for cost and
quality performance and receive payments to
support the services and activities designed to
achieve high value
• APMs offer greater potential inherent risks and
rewards than MIPS
• Under MACRA, qualifying APM participants in
“eligible” APMs:
What makes an APM “eligible”?
Under MACRA, “eligible” APMs must:
 Base payment on quality measures that are
comparable to MIPS
 Require use of certified EHRs
 Bear more than “nominal financial risk” or be a
medical home model
Pick Your Pace
First Option: Test the Quality
Payment Program.
• With this option, as long as you submit some
data to the Quality Payment Program,
including data from after January 1, 2017, you
will avoid a negative payment adjustment.
• This first option is designed to ensure that
your system is working and that you are
prepared for broader participation in 2018
and 2019 as you learn more.
Second Option: Participate for part
of the calendar year.
• Submit Quality Payment Program information
for a reduced number of days and qualify for a
small positive payment adjustment
– submit information for part of the calendar year
for quality measures,
– how your practice uses technology
– what improvement activities your practice is
undertaking
Third Option: Participate for the
full calendar year.
• For practices that are ready to go on January
1, 2017, you could qualify for a modest
positive payment adjustment
– Quality measures,
– How your practice uses technology, and
– What improvement activities your practice is
undertaking
Fourth Option: Participate in an
Advanced APM in 2017.
• Join an Advanced Alternative Payment Model,
such as Medicare Shared Savings Track 2 or 3
or the OCM in 2017.
• If you receive enough of your Medicare
payments or see enough of your Medicare
patients through the Advanced Alternative
Payment Model in 2017, then you would
qualify for a 5 percent incentive payment in
2019.
Why Participate in MIPS?
• Many advantages over current quality programs:
• Sliding scale assessment (partial credit) vs. old “all or nothing”
approach
• Credit for improvement, not just attainment
• Risk adjustment for health status and other socioeconomic factors
• Timely feedback reports and more attainable performance targets
• Flexibility beyond existing quality measures (beyond NQF-endorsed)
• Reporting via QCDRs for group practices
• Substantial bonuses for high performance
• Up to 3x more than the maximum penalty levels (up to 27%)
• Total MIPS bonuses and penalties must balance each other
• $500 million per year (up to 10%) for “exceptional performance”
from 2019-2024
Care Episode Under MACRA
• The patient’s clinical problems at the time
items and services are furnished during an
episode of care
• Clinical conditions or diagnoses,
• Whether or not inpatient hospitalization
occurs
• The principal procedures or services
furnished and other factors determined
appropriate
Patient Condition Groups Under
MACRA
• The patient’s clinical history at the time of a
medical visit
– combination of chronic conditions,
– current health status, and recent significant history
(such as hospitalization and major surgery during a
previous period, such as 3 months)
– other factors determined appropriate by the
Secretary