Transcript Introduction to the QPP and MIPS - The American Society of Retina

Quality Payment Program
Quality Payment Program
November 7, 2016
1
Quality Payment Program
Topics
•
What is the Quality Payment Program?
•
Who participates in the Quality Payment Program?
•
How does the Quality Payment Program work?
•
What is the Merit-based Incentive Payment System (MIPS)
•
What are Advanced Alternative Payment Models (APMs)
•
Where can I go to learn more?
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Quality Payment Program
What is the Quality Payment Program?
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Quality Payment Program
Medicare Payment Prior to MACRA
Fee-for-service (FFS) payment system, where clinicians are paid
based on volume of services, not value.
The Sustainable Growth Rate (SGR)
• Established in 1997 to control the cost of Medicare payments to
physicians
>
IF
Overall
physician
costs
Target
Medicare
expenditures
Physician payments
cut across the board
Each year, Congress passed temporary “doc fixes” to avert cuts
(no fix in 2015 would have meant a 21% cut in Medicare payments
to clinicians)
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Quality Payment Program
The Quality Payment Program
•
The Quality Payment Program policy will reform Medicare Part B payments
for more than 600,000 clinicians across the country, and is a major step in
improving care across the entire health care delivery system.
•
Clinicians can choose how they want to participate in the Quality Payment
Program based on their practice size, specialty, location, or patient
population.
Two tracks to choose from:
Quality Payment Program
Who participates in the Quality Payment
Program?
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Quality Payment Program
Who participates in the Quality Payment
Program?
•
Medicare Part B clinicians billing more $30,000 a year and providing
care for more than 100 Medicare patients a year.
•
These clinicians include:
-
Physicians
-
Physician Assistants
-
Nurse Practitioners
-
Clinical Nurse Specialists
-
Certified Registered Nurse Anesthetists
Quality Payment Program
Who is excluded from the Quality Payment
Program?
•
Newly-enrolled Medicare clinicians
-
•
Clinicians below the low-volume threshold
-
•
Clinicians who enroll in Medicare for the first time during a performance
period are exempt from reporting on measures and activities for MIPS until
the following performance year.
Medicare Part B allowed charges less than or equal to $30,000 OR 100 or
fewer Medicare Part B patients
Clinicians significantly participating in Advanced APMs
Quality Payment Program
How does the Quality Payment Program
work?
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Quality Payment Program
Transition Year— Pick Your Pace
MIPS
Test Pace
•
Submit some data after
January 1, 2017
•
Neutral or small
payment adjustment
Partial Year
•
•
Report for 90-day
period after January 1,
2017
Small positive payment
adjustment
Full Year
•
Fully participate
starting January 1, 2017
•
Modest positive
payment adjustment
Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment
adjustment.
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Quality Payment Program
Choosing to Test for 2017
•
If you submit a minimum amount of 2017 data to Medicare (for
example, one quality measure or one improvement activity), you can
avoid a downward adjustment
Quality Payment Program
Partial Participation for 2017
•
If you submit 90 days of 2017 data to Medicare, you may earn a
neutral or small positive payment adjustment.
•
That means if you’re not ready on January 1, you can choose to start
anytime between January 1 and October 2, 2017. Whenever you
choose to start, you'll need to send in performance data by March
31, 2018.
Quality Payment Program
Full Participation for 2017
•
If you submit a full year of 2017 data to Medicare, you may earn a
moderate positive payment adjustment. The best way to earn the
largest positive adjustment is to participate fully in the program
by submitting information in all the MIPS performance categories.
Key Takeaway:
•
Positive adjustments are based on the performance data on the
performance information submitted, not the amount of information
or length of time submitted.
Quality Payment Program
The Merit-based Incentive Payment System
(MIPS)
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Quality Payment Program
The Merit-based Incentive Program
•
One path of the Quality Payment Program that streamlines 3 legacy
reporting programs (PQRS, Value Modifier and the Medicare EHR
Incentive Program)
•
Moves Medicare Part B clinicians to a performance-based payment
system
•
MIPS provides clinicians the flexibility to choose the activities and
measures that are most meaningful to their practice to demonstrate
performance
•
There are four MIPS performance categories: Quality, Advancing Care
Information, Improvement Activities, and Cost.
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Quality Payment Program
MIPS Performance Category: Quality
Category Requirements
•
Replaces PQRS and Quality Portion of the Value Modifier
•
60% of final score
•
Select 6 of about 300 quality measures (minimum of 90 days); 1 must be:
–
Outcome measure OR
–
High-priority measure – defined as outcome measure, appropriate use
measure, patient experience, patient safety, or care coordination
•
May also select specialty-specific set of measures
•
Readmission measure for group submissions that have > 16 clinicians and a
sufficient number of cases (no requirement to submit)
•
Different requirements for groups reporting CMS Web Interface or those in MIPSAPMs
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Quality Payment Program
Advancing Care Information
•
Promotes patient engagement and interoperability using
certified EHR technology
•
Replaces the Medicare EHR Incentive Program
•
Greater flexibility in choosing measures
•
In 2017, there are 2 measure sets for reporting based on
EHR edition:
1. Advancing Care Information Objectives and Measures
2. 2017 Advancing Care Information Transition Objectives and
Measures
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Quality Payment Program
Advancing Care Information: Reporting
Clinicians must use certified EHR technology to report. Reporting requirements are
dependent on your version of Certified EHR Technology
If you’re reporting via
EHR technology certified
to the 2015 Edition:
Option 1: Advancing Care
Information Objectives and
Measures
Option 2: Combination of the
two measure sets
If you’re reporting via
EHR Technology certified
to the 2014 Edition:
or
Option 1: 2017 Advancing Care
Information Transition
Objectives and Measures
Option 2: Combination of the
two measure sets
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Quality Payment Program
MIPS Performance Category: Advancing Care
Information
Advancing Care Information Objectives and
Measures:
2017 Advancing Care Information Transition
Objectives and Measures:
Base Score Required Measures
Base Score Required Measures
Objective
Measure
Protect Patient Health
Information
Security Risk Analysis
Electronic Prescribing
e-Prescribing
Patient Electronic Access
Objective
Measure
Protect Patient Health
Information
Security Risk Analysis
Provide Patient Access
Electronic Prescribing
e-Prescribing
Health Information
Exchange
Send a Summary of
Care
Patient Electronic Access Provide Patient Access
Health Information
Exchange
Request/Accept a
Summary of Care
Health Information
Exchange
Health Information
Exchange
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Quality Payment Program
MIPS Performance Category: Advancing Care
Information
Advancing Care Information Objectives and
Measures
Objective
Measure
Patient Electronic Access
Provide Patient Access*
Patient Electronic Access
Patient-Specific Education
Coordination of Care through
Patient Engagement
Coordination of Care through
Patient Engagement
Coordination of Care through
Patient Engagement
Health Information Exchange
Send a Summary of Care*
Request/Accept a Summary
of Care*
Clinical Information
Reconciliation
Immunization Registry
Reporting
Health Information Exchange
Health Information Exchange
Public Health and Clinical Data
Registry Reporting
2017 Advancing Care Information
Transition Objectives and Measures
Objective
Measure
Patient Electronic Access
Provide Patient Access*
View, Download and Transmit
(VDT)
Patient Electronic Access
View, Download and
Transmit (VDT)
Secure Messaging
Patient-Specific Education
Patient-Specific Education
Patient-Generated Health
Data
Secure Messaging
Secure Messaging
Health Information
Exchange
Health Information
Exchange*
Medication Reconciliation
Medication Reconciliation
Public Health Reporting
Immunization Registry
Reporting
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Quality Payment Program
Advancing Care Information: Flexibility
1.Clinicians recognized as participating in a MIPS-APM entity will
automatically receive a 50% score in the category
-
Clinicians need to earn the remaining 50% to receive full credit in the category
2.CMS will automatically reweight the Advancing Care Information
performance category to zero for Hospital-based MIPS clinicians, clinicians
with lack of Face-to-Face Patient Interaction, NP, PA, CRNAs and CNS
-
Reporting is optional although if clinicians choose to report, they will be scored.
3.If clinician faces a significant hardship and is unable to report advancing
care information measures, they can apply to have their performance
category score weighted to zero
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Quality Payment Program
MIPS Performance Category: Advancing Care
Information
BASE
SCORE
+
PERFORMANCE
SCORE
+
BONUS
SCORE
Account for
Account for up to
Account for up to
50%
90%
of the total
Advancing Care
Information
Performance
Category Score
of the total
Advancing Care
Information
Performance
Category Score
15%
=
of the total
Advancing Care
Information
Performance
Category Score
The overall Advancing Care Information score
would be made up of a base score, a performance
score, and a bonus score for a maximum score of
100 percentage points
FINAL
SCORE
Earn 100 or more
percent and receive
FULL 25
points
of the total Advancing
Care Information
Performance Category
Final Score
Quality Payment Program
MIPS Performance Category: Improvement
Activities
•
Assesses participation in activities that improve clinical practice
-
•
Examples: Shared decision making, patient safety, coordinating care, increasing access
Clinicians choose from about 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
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Quality Payment Program
Improvement Activities: Flexibilities
•
Groups with 15 or fewer participants, non-patient facing clinicians, or if you are
in a rural or health professional shortage area: Attest that you completed up to
2 activities for a minimum of 90 days.
•
Participants in certified patient-centered medical homes, comparable specialty
practices, or an APM designated as a Medical Home Model: You will
automatically earn full credit.
•
Participants in certain APMs under the APM scoring standard, such as Shared
Savings Program Track 1 or the Oncology Care Model: You will automatically
receive points based on the requirements of participating in the APM. For all
current APMs under the APM scoring standard, this assigned score will be full
credit. For all future APMs under the APM scoring standard, the assigned score
will be at least half credit.
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Quality Payment Program
MIPS Performance Category: Cost
•
No reporting requirement; 0% of final score in 2017
•
Clinicians assessed on Medicare claims data
•
Uses measures previously used in the Physician
Value-Based Modifier program or reported in the
Quality and Resource Use Report (QRUR), but
scoring is different
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Quality Payment Program
Cost: Reporting
Cost Measures from VM
1.
Medicare Spending Per Beneficiary (MSPB)
2.
Total Per-Capita Cost for All Attributed
Beneficiaries
For the transition year, there are no requirements for the Cost Performance
Category
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Quality Payment Program
Cost: Flexibilities
•
For the transition year, the cost performance category will not impact
payment in 2019
•
Clinicians’ Cost performance (episode groupers measures) will be
included in 2018 performance feedback to help clinicians gauge
performance and prepare for year 2 of the program.
•
For data submission, no action is needed from the clinician.
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Quality Payment Program
Example of MIPS Participation for a Cardiologist
Sample Quality Measures:
- Closing the referral loop with referring
provider
- Documentation of current medications
- Statins for primary prevention in high-risk
patients and for treatment in patients
with known CVD
- Beta blockers in patients with LV systolic
dysfunction
- ACE-Inhibitor or ARB in patients with LV
systolic dysfunction
- Antiplatelet therapy in patients with CAD
- *Chronic anticoagulation therapy for
patients with non-valvular atrial
fibrillation (AFib) based on CHADS2 risk
score
- *Avoidance of inappropriate cardiac
stress imaging in low-risk patients
Sample Improvement Activities:
- Telehealth services that expand access
to care
- Participation in a qualified clinical data
registry (QCDR), for example:
- American College of Cardiology
Foundation – CathPCI Registry
- American College of Cardiology
Foundation (ACCF)-PINNACLE
Registry
- American Society of Nuclear
Cardiology ImageGuide Registry
- Implementation of specialist reports
back to referring provider
- Implementation of processes for timely
communication of test results
- Use of certified EHR technology
(CEHRT)
Advancing Care Information (Use of
Technology):
- Electronic Prescribing
- Patient Electronic Access
- Health Information Exchange
- Exchange of patient care records
- Reconciliation of clinical information
Flexibility to CHOOSE WHAT
and HOW you report
Payment adjustments
according to composite score
*measure supported by American College of Cardiology
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Quality Payment Program
Alternative Payment Models
(APMs)
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Quality Payment Program
What is an Alternative Payment Model (APM)?
Alternative Payment Models (APMs) are new approaches to paying for medical care through
Medicare that incentivize quality and value. The CMS Innovation Center develops new payment
and service delivery models. Additionally, Congress has defined – both through the Affordable
Care Act and other legislation – a number of demonstrations that CMS conducts.
As defined by
MACRA, 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
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Quality Payment Program
Alternative Payment Models
•
An Alternative Payment Model (APM) is a
Advanced APMs are a Subset of APMs
payment approach, developed in
partnership with the clinician community,
that provides added incentives to
clinicians to provide high-quality and
APMs
cost-efficient care. APMs can apply to a
specific clinical condition, a care episode,
or a population.
•
APMs may offer significant opportunities
to eligible clinicians who are not
immediately able or prepared to take on
the additional risk and requirements of
Advanced APMs.
Advanced
APMs
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Quality Payment Program
Advanced Alternative Payment Models
(Advanced APMs) Benefits
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Quality Payment Program
Advanced Alternative Payment Models
•
•
Advanced Alternative Payment Models
(Advanced APMs) enable clinicians and
practices to earn greater rewards for taking
on some risk related to their patients’
outcomes.
It is important to understand that the Quality
Payment Program does not change the
design of any particular APM. Instead, it
creates extra incentives for a sufficient
degree of participation in Advanced APMs.
Advanced APMs
Advanced APMspecific rewards
+
5% lump sum
incentive
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Quality Payment Program
What are the Benefits of Participating in an Advanced
APM as a Qualifying APM Participant (QP)?
Are excluded from MIPS
QPs:
Receive a 5% lump sum bonus
Receive a higher Physician Fee Schedule update
starting in 2026
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Quality Payment Program
The Quality Payment Program provides
additional rewards for participating in APMs.
Potential financial rewards
Not in APM
MIPS adjustments
In APM
In Advanced APM
MIPS adjustments
+
APM-specific
rewards
If you are a Qualifying
APM Participant
(QP)
APM-specific
rewards
=
+
5% lump sum
bonus
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Quality Payment Program
Advanced APM Criteria
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Quality Payment Program
Medical Home Model
•
A Medical Home Model is an APM that has the following features:
-
Participants include primary care practices or multispecialty practices that include
primary care physicians and practitioners and offer primary care services.
-
Empanelment of each patient to a primary clinician; and
-
At least four of the following additional 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.
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Quality Payment Program
Advanced APMs Must Meet Certain Criteria
To be an Advanced APM, the following three requirements must be met.
The APM:
Requires
participants to use
certified EHR
technology;
Provides payment
for covered
professional
services based on
quality measures
comparable to
those used in the
MIPS quality
performance
category; and
Either: (1) is a
Medical Home
Model expanded
under CMS
Innovation Center
authority OR (2)
requires participants
to bear a more than
nominal amount of
financial risk.
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Quality Payment Program
Advanced APM Criterion 1:
Requires use of Certified EHR Technology
1. Requires participants to use certified EHR technology
•
Requires that at least 50% of the clinicians in each APM Entity
use certified EHR technology to document and communicate
clinical care information with patients and other health care
professionals.
•
Shared Savings Program requires that clinicians report at the
group TIN level according to MIPS rules.
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Quality Payment Program
Advanced APM Criterion 2:
Requires MIPS-Comparable Quality Measures
2. Bases payments on quality measures that are comparable to
those used in the MIPS quality performance category.
•
Ties payment to quality measures that are evidence-based,
reliable, and valid.
•
At least one of these measures must be an outcome measure
if an appropriate outcome measure is available on the MIPS
measure list.
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Quality Payment Program
Advanced APM Criterion 3:
Medical Home Expanded Under CMS Authority
3. Either: (1) is a Medical Home Model expanded under CMS Innovation
Center authority, OR (2) requires participants to bear a more than nominal
amount of financial risk.
Medical Home Model Expansion
Medical Home Models tested under
section 1115A of the Act has an alternate
pathway to meet the financial risk
criterion through expansion under
section 1115A(c) of the Act
Medical Home Model Financial Risk
While no medical home models have yet
been expanded, medical home models
can still be Advanced APMs if they include
financial risk for participants.
The medical home model financial risk
standard acknowledges that risk under
the terms of an APM can be structured
uniquely for smaller entities in a way that
offers the potential of losses without
threatening their financial viability.
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Quality Payment Program
Advanced APM Criterion 3: Bear a More than
Nominal Amount of Financial Risk
3. Either: (1) is a Medical Home Model expanded under CMS Innovation
Center authority, OR (2) requires participants to bear a more than nominal
amount of financial risk.
Financial Risk
Bearing financial risk means that the
Advanced APM may do one or more of the
following if actual expenditures exceed
expected expenditures:
• Withhold payment for services to the
APM Entity and/or the APM Entity’s
eligible clinicians
• Reduce payment rates to the APM Entity
and/or the APM Entity’s eligible clinicians
• Require direct payments by the APM
Entity to CMS.
Total Amount of Risk
The total amount of that risk must be equal to
at least either:
• 8% of the average estimated total Medicare
Parts A and B revenues of participating APM
Entities; OR
• 3% of the expected expenditures for which
an APM Entity is responsible under the
APM.
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Quality Payment Program
Advanced APMs in 2017
For the 2017 performance year, the following models are Advanced APMs:
Comprehensive End Stage Renal
Disease Care Model
(Two-Sided Risk Arrangements)
Comprehensive Primary Care Plus (CPC+)
Shared Savings Program Track 2
Shared Savings Program Track 3
Next Generation ACO Model
Oncology Care Model
(Two-Sided Risk Arrangement)
The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new
announcements on an ad hoc basis.
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Quality Payment Program
Future Advanced APM Opportunities
•
MACRA established the Physician-Focused Payment Model
Technical Advisory Committee (PTAC) to review and assess
Physician-Focused Payment Models based on proposals
submitted by stakeholders to the committee.
•
In future performance years, we anticipate that the following
models will be Advanced APMs:
Comprehensive Care for Joint Replacement
(CJR) Payment Model (CEHRT)
New Voluntary Bundled Payment Model
Advancing Care Coordination through
Episode Payment Models Track 1 (CEHRT)
Vermont Medicare ACO Initiative (as part of
the Vermont All-Payer ACO Model)
ACO Track 1+
44
Quality Payment Program
Qualifying APM Participants (QPs)
45
Quality Payment Program
What is a Qualifying APM Participant (QP)?
•
Qualifying APM Participants (QPs) are clinicians who have a
certain % of Part B payments for professional services or patients
furnished Part B professional services through an Advanced APM
Entity.
•
Beginning in 2021, this threshold % may be reached through a
combination of Medicare and other non-Medicare payer
arrangements, such as private payers and Medicaid.
46
Quality Payment Program
How do Eligible Clinicians become Qualifying
APM Participants? – Step 1

Qualifying APM Participant determinations are made at the Advanced
APM Entity level, with certain exceptions:
 individuals participating in multiple Advanced APM Entities, none
of which meet the QP threshold as a group, and
 eligible clinicians on an Affiliated Practitioner List when that list is
used for the QP determination because there are no eligible
clinicians on a Participation List for the Advanced APM Entity. For
example, gain sharers in the Comprehensive Care for Joint
Replacement Model will be assessed individually.
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Quality Payment Program
How do Eligible Clinicians become Qualifying
APM Participants? – Step 2
 CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity
using two methods (payment amount and patient count).
 Methods are based on Medicare Part B professional services and beneficiaries
attributed to Advanced APM
 CMS will use the method that results in a more favorable QP determination for
each Advanced APM Entity.
These definitions
are used for
calculating
Threshold Scores
under both
methods.
Attributed (beneficiaries for whose cost and quality of
care the APM Entity is responsible)
Attribution-eligible (all beneficiaries who
could potentially be attributed)
48
Quality Payment Program
How do Eligible Clinicians become Qualifying
APM Participants? – Step 2
 The two methods for calculation are Payment Amount
Method and Patient Count Method.
Payment Amount Method
Patient Count Method
$$$ for Part B professional
services to attributed
beneficiaries
# of attributed beneficiaries
given Part B professional
services
$$$ for Part B professional
services to attributioneligible beneficiaries
=
Threshold
Score %
=
Threshold
Score %
# of attribution-eligible
beneficiaries given Part B
professional services
49
Quality Payment Program
How do Eligible Clinicians become Qualifying
APM Participants? – Step 3
 The Threshold Score for each method is compared to the
corresponding QP threshold table and CMS takes the better
result.
Requirements for Incentive Payments
for Significant Participation in Advanced APMs
(Clinicians must meet payment or patient requirements)
Performance Year
2017
2018
2019
2020
2021
2022 and
later
Percentage of
Payments through an
Advanced APM
Percentage of
Patients through an
Advanced APM
50
50
Quality Payment Program
How do Eligible Clinicians become Qualifying
APM Participants? – Step 4
Advanced APM
 All the eligible
clinicians in the
Advanced APM
Entity become
QPs for the
payment year.
Threshold Scores
above the QP
threshold = QP
status
Advanced APM Entities
Eligible Clinicians
Threshold Scores below the
QP threshold = no QPs
51
Quality Payment Program
What is the Performance Period for QPs?
•
The QP Performance Period is the period during which CMS will assess eligible
clinicians’ participation in Advanced APMs to determine if they will be QPs for the
payment year.
•
The QP Performance Period for each payment year will be from January 1 – August
31st of the calendar year that is two years prior to the payment year.
Performance Period:
Incentive Determination:
Payment:
QP status based on Advanced APM
participation
Add up payments for Part B
professional services furnished
by QP
+5% lump sum
payment made
(excluded from MIPS
adjustment)
52
Quality Payment Program
What are the three “Snapshots” for QPs during
the Performance Period?
•
During the QP Performance Period (January – August), CMS will take three
“snapshots” (March 31, June 30, August 31) to determine which eligible
clinicians are participating in an Advanced APM and whether they meet the
thresholds to become Qualifying APM Participants.
MAR
JUN
AUG
31
30
31
53
Quality Payment Program
How are QPs determined during the Performance
Period?
•
For each of the three QP determinations, CMS will use claims data from period “A” for
the APM Entity participants captured in the snapshot at point “B.” CMS then allows for
claims run-out during period “C” and finalizes QP determinations at point “D.”
•
If an APM Entity meets the QP threshold, subsequent eligible clinician additions to the
Participation List do not automatically confer QP status to those eligible clinicians. If
the group meets the QP threshold for a subsequent QP determination, then the new
additions become QPs.
Jan 2017
Feb 2017
A
Mar 2017
May
2017
Apr 2017
B
Jun 2017
Jul 2017
C
Aug 2017
Sep 2017
Oct 2017
Nov 2017
Dec 2017
D
#1
B
A
C
D
B
C
#2
A
D
#3
54
Quality Payment Program
When Will Clinicians Learn their QP Status?
•
•
Reaching the QP threshold at any one of the three QP
determinations will result in QP status for the eligible clinicians
in the Advanced APM Entity
Eligible clinicians will be notified of their QP status after each
QP determination is complete (point D).
Jan 2017
Feb 2017
A
Mar 2017
May
2017
Apr 2017
B
Jun 2017
Jul 2017
C
Aug 2017
Sep 2017
Oct 2017
Nov 2017
Dec 2017
D
#1
B
A
C
D
B
C
#2
A
D
#3
55
Quality Payment Program
What if Clinicians do not Meet the QP Payment or
Patient Thresholds?
•
Clinicians who participate in Advanced APMs, but do not meet
the QP threshold, may become “Partial” Qualifying APM
Participants (Partial QPs).
•
Partial QPs choose whether to participate in MIPS.
Medicare-Only Partial QP Thresholds in Advanced APMs
Payment
Year
2019
2020
2021
2022
2023
2024 and
later
Percentage
of
Payments
Percentage
of Patients
56
Quality Payment Program
Other Payer Advanced APMs
57
Quality Payment Program
Do payments from other payers apply to QP
determination?
•
Starting in the 2019 QP Performance Period, participation in
payment arrangements with other, non-Medicare payers can
contribute to meeting the QP threshold.
•
The “All-Payer Combination Option” will be based on a combination
of Advanced APM participation and participation in “Other Payer
Advanced APMs.”
-
•
To be considered under the All-Payer Combination Option, eligible clinicians
must also participate in an Advanced APM but not meet the QP threshold
under the Medicare Option.
Other Payer Advanced APMs must meet criteria similar to those for
Advanced APMs.
58
Quality Payment Program
What is the Performance Period for QPs?
•
The QP Performance Period is the period during which CMS will assess eligible
clinicians’ participation in Advanced APMs to determine if they will be QPs for the
payment year.
•
The QP Performance Period for each payment year will be from January 1 – August
31st of the calendar year that is two years prior to the payment year.
Performance Period:
Incentive Determination:
Payment:
QP status based on Advanced APM
participation
Add up payments for Part B
professional services furnished
by QP
+5% lump sum
payment made
(excluded from MIPS
adjustment)
59
Quality Payment Program
All-Payer Combination Option
How do Eligible Clinicians become Qualifying
APM Participants? – Step 1
 Qualifying APM Participant determinations are made at the
Advanced APM Entity level, with certain exceptions:
 individuals participating in multiple Advanced APM Entities,
none of which meet the QP threshold as a group, and
 eligible clinicians on an Affiliated Practitioner List when that
list is used for the QP determination because there are no
eligible clinicians on a Participation List for the Advanced APM
Entity. For example, gain sharers in the Comprehensive Care
for Joint Replacement Model will be assessed individually.
60
Quality Payment Program
All-Payer Combination Option
How do you calculate Threshold Scores? – Step 2
 CMS will calculate a percentage “Threshold Score” for each Advanced APM
Entity using two methods (payment amount and patient count).
 Methods are based on payments from and patient furnished services
through agreements with all payers, with certain exceptions.
 CMS will use the method that results in a more favorable QP determination
for each Advanced APM Entity.
These definitions
are used for
calculating
Threshold Scores
under both
methods.
The aggregate of all payments (or all patients given
services) under the terms of the payment arrangement
The aggregate of all payments (or all patients given
services) from the payer
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Quality Payment Program
All-Payer Combination Option
How do you calculate Threshold Scores? – Step 2
 Calculate the Threshold Score under the All-Payer
Combination Option.
PAYMENT AMOUNT METHOD
$$$ the terms of Advances APMs and Other
Payer Advanced APMs
=
$$$ from all payers
PATIENT COUNT METHOD
# of patients given services under Advanced
APMs and Other Payer Advanced APMs
Threshold
Score %
# of patients given services under
all payers
=
Threshold
Score %
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Quality Payment Program
All Payer Combination Option
How do you calculate Threshold Scores? – Step 2
Payments from the following sources are excluded from the calculation
under the All-Payer Combination Option:
 Department of Defense Health Care Programs
 Department of Veterans Affairs Health Care Programs
 Title XIX in a state with no Medicaid Medical Home Model or APM. In
order not to adversely impact physicians who have no opportunity to
participate, Title XIX payments or patients would be excluded unless:
 a state had at least one Medicaid Medical Home Model or APM in
operation that is determined to be an Other Payer Advanced APM;
and
 the relevant Advanced APM Entity is eligible to participate in at
least one such Other Payer Advanced APM, regardless of whether
the Advanced APM Entity actually participates in such Other Payer
Advanced APMs.
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Quality Payment Program
How do Eligible Clinicians become Qualifying
APM Participants? – Step 3
 The Threshold Score for each method is compared to the
corresponding QP threshold table and CMS takes the better
result.
All-Payer Combination Option
Payment
Year
QP Payment
Amount
Threshold
QP Patient
Count
Threshold
2019
2020
N/A
N/A
N/A
N/A
2021
2022
2023
2024 and
later
Medicare
Total
Medicare
Total
Medicare
Total
Medicare
Total
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Quality Payment Program
QP Determination Tree
Payment Years 2021 - 2022
QP
QP
YES
YES
Is All-Payer Threshold Score
PARTIAL QP
> 50%
Is Medicare Threshold Score
> 50%
NO
YES
NO
YES
Is All-Payer Threshold Score
Is Medicare Threshold Score
> 40% OR is
> 25%
Medicare Threshold Score > 40%?
NO
YES
NO
Is Medicare Threshold Score
MIPS Eligible Clinician
> 20%
NO
MIPS Eligible Clinician
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Quality Payment Program
How do Eligible Clinicians become Qualifying
APM Participants? – Step 4
OTHER PAYER
ADVANCED APM
ADVANCED APM
 All the eligible clinicians in
the Advanced APM Entity
become QPs for the
payment year.
ADVANCED APM ENTITY
ELIGIBLE CLINICIANS
OR
Entity-level Threshold
Score below the QP
threshold = no QPs
Entity-level Threshold
Score above the QP
threshold = QPs
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Quality Payment Program
APM Scoring Standard
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Quality Payment Program
What are MIPS APMs?
Goals
MIPS APMs are a Subset of APMs
• Reduce eligible clinician reporting
burden.
APMs
• Maintain focus on the goals and
objectives of APMs.
How does it work?
• Streamlined MIPS reporting and scoring
for eligible clinicians in certain APMs.
MIPS
• Aggregates eligible clinician MIPS scores
APMs
to the APM Entity level.
• All eligible clinicians in an APM Entity
receive the same MIPS final score.
• Uses APM-related performance to the
extent practicable.
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Quality Payment Program
What are the Requirements to be Considered a MIPS
APM?
The APM scoring standard applies to APMs that meet these criteria:

APM Entities participate in the APM under an agreement with CMS;

APM Entities include one or more MIPS eligible clinicians on a
Participation List; and

APM bases payment incentives on performance (either at the APM Entity
or eligible clinician level) on cost/utilization and quality.
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Quality Payment Program
What are key dates for the APM scoring standard?
•
To be considered part of the APM Entity for the APM scoring standard, an
eligible clinician must be on an APM Participation List on at least one of the
following three snapshot dates (March 31, June 30 or August 31) of the
performance period.
•
Otherwise an eligible clinician must report to MIPS under the standard MIPS
methods.
MAR
JUN
AUG
31
30
31
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Quality Payment Program
To which APMs does the APM Scoring Standard
apply in 2017?
For the 2017 performance year, the following models are considered MIPS APMs:
Comprehensive ESRD Care (CEC) Model
(All Arrangements)
Comprehensive Primary Care Plus
(CPC+) Model
Shared Savings Program Tracks 1, 2, and 3
Next Generation ACO Model
Oncology Care Model (OCM)
(All Arrangements)
The list of MIPS APMs is posted at QPP.CMS.GOV and will be updated on an ad
hoc basis.
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Quality Payment Program
Shared Savings Program (All Tracks) under the APM
Scoring Standard
REPORTING REQUIREMENT
Quality
PERFORMANCE SCORE
 ACOs submit quality measures to the
CMS Web Interface on behalf of their
participating MIPS eligible clinicians.
 The MIPS quality performance category requirements and
benchmarks will be used to score quality at the ACO level.
 MIPS eligible clinicians will not be
assessed on cost.
 N/A
 No additional reporting necessary.
 CMS will assign the same improvement activities score to
each APM Entity group based on the activities required of
participants in the Shared Savings Program.
WEIGHT
Cost
Improvement
Activities
 All ACO participant TINs in the ACO
 All of the ACO participant TIN scores will be aggregated as
submit under this category according to
a weighted average based on the number of MIPS eligible
the MIPS group reporting requirements.
clinicians in each TIN to yield one APM Entity group score.
Advancing Care
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Quality Payment Program
Next Generation ACO Model under the APM Scoring
Standard
REPORTING REQUIREMENT
Quality
PERFORMANCE SCORE
 ACOs submit quality measures to
the CMS Web Interface on behalf
of their participating MIPS eligible
clinicians.
 The MIPS quality performance category requirements and
benchmarks will be used to score quality at the ACO level.
 MIPS eligible clinicians will not
assessed on cost.
 N/A
WEIGHT
Cost
 No additional reporting necessary.  CMS will assign the same improvement activities score to each APM
Entity group based on the activities required of participants in the
Next Generation ACO Model.
Improvement
Activities
Advancing Care
 Each MIPS eligible clinician in the
APM Entity group reports
advancing care information to
MIPS through either group
reporting at the TIN level or
individual reporting.
 CMS will attribute one score to each MIPS eligible clinician in the
APM Entity group. This score will be the highest score attributable to
the TIN/NPI combination of each MIPS eligible clinician, which may
be derived from either group or individual reporting. The scores
attributed to each MIPS eligible clinicians will be averaged to yield a
single APM Entity group score.
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Quality Payment Program
All Other APMs under the APM Scoring Standard
REPORTING REQUIREMENT
Quality
PERFORMANCE SCORE
 The APM Entity group will not be
assessed on quality under MIPS in the
first performance period.
 N/A
 MIPS eligible clinicians will not be
assessed on cost.
 N/A
 No additional reporting necessary.
 CMS will assign the same improvement activities score to each
APM Entity group based on the activities required of
participants in the MIPS APM.
 Each MIPS eligible clinician in the APM
Entity group reports advancing care
information to MIPS through either
group reporting at the TIN level or
individual reporting.
 CMS will attribute one score to each MIPS eligible clinician in
the APM Entity group. This score will be the highest score
attributable to the TIN/NPI combination of each MIPS eligible
clinician, which may be derived from either group or individual
reporting. The scores attributed to each MIPS eligible clinician
will be averaged to yield a single APM Entity group score.
WEIGHT
Cost
Improvement
Activities
Advancing Care
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Quality Payment Program
Physician-Focused Payment Model
Technical Advisory Committee
75
Quality Payment Program
Physician-Focused Payment Model Technical
Advisory Committee
•
MACRA established the Physician-Focused Payment Model Technical
Advisory Committee (PTAC) to review and assess Physician-Focused
Payment Models based on proposals submitted by stakeholders to
the committee.
•
The PTAC is a federal advisory committee that provides independent
advice to the Secretary. The PTAC is supported by HHS Office of the
Assistant Secretary for Planning and Evaluation.
•
This committee provides a unique opportunity for stakeholders to
participate in the development of new models and to help determine
priorities for the physician community
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Quality Payment Program
PFPM Technical Advisory Committee (PTAC)
PFPM =
Physician-Focused Payment Model
Goal to encourage new APM options for Medicare
clinicians
Submission of
model proposals
by Stakeholders
Technical
Advisory
Committee
11 appointed care delivery
experts that review
proposals, submit
recommendations to HHS
Secretary
Secretary
comments on
CMS website,
CMS considers
testing
proposed
models
Models with
favorable
response go to
CMS Innovation
Center
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Quality Payment Program
How Does the PTAC Work?
Proposed model is submitted to the PTAC.
PTAC reviews and provides comments and recommendations on proposals to the
Secretary.
Secretary of the Department of Health and Human Services reviews the
recommendations of PTAC and posts a detailed response on the CMS website.
Models that receive a favorable response will go to the CMS Innovation Center.
Models that are implemented will go through the CMS developmental process for
APMs.
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Quality Payment Program
Where can I go to learn more?
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Quality Payment Program
Help Is Available
qpp.cms.gov
CMS has organizations on the ground to provide help to clinicians who are eligible for the Quality Payment Program:
Transforming Clinical Practice Initiative (TCPI): TCPI is designed to support more
than 140,000 clinician practices over the next 4 years in sharing, adapting, and further
developing their comprehensive quality improvement strategies. Clinicians participating in
TCPI will have the advantage of learning about MIPS and how to move toward participating
in Advanced APMs. Click here to find help in your area.
Quality Innovation Network (QIN)-Quality Improvement Organizations (QIOs): The
QIO Program’s 14 QIN-QIOs bring Medicare beneficiaries, providers, and communities
together in data-driven initiatives that increase patient safety, make communities healthier,
better coordinate post-hospital care, and improve clinical quality. More information about
QIN-QIOs can be found here.
If you’re in an APM: The Innovation Center’s Learning Systems can help you find
specialized information about what you need to do to be successful in the Advanced APM
track. If you’re in an APM that is not an Advanced APM, then the Learning Systems can
help you understand the special benefits you have through your APM that will help you be
successful in MIPS. More information about the Learning Systems is available through your
model’s support inbox.
Quality Payment Program
Quality Payment Program
When and where do I submit comments?
•
•
•
The final rule with comment includes changes not reviewed in this presentation.
We will not consider feedback during the call as formal comments on the
rule. See the proposed rule for information on submitting these comments by the
close of the 60-day comment period on December 19, 2016. When commenting
refer to file code CMS-5517-F.
Instructions for submitting comments can be found in the proposed rule; FAX
transmissions will not be accepted. You must officially submit your comments in
one of the following ways: electronically through
-
Regulations.gov
-
by regular mail
-
by express or overnight mail
-
by hand or courier
For additional information, please go to: QPP.CMS.GOV
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