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The Merit Health

Network

MACRA Overview –

July 2016

Background

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MACRA permanently eliminates the SGR (and annual rate cuts)

Consolidates Medicare PQRS, MU, VBM reporting programs

Establishes a path to predominant Value-Based payment methodologies

Passed in Senate 92-8; Passed in House 392-37

Fears

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Medicare projects 70% of rural practices with 2-9 docs will be penalized via MIPS

50% of non-pediatric physicians have never heard of MACRA

MIPS program is budget neutral; penalized providers will pay rewards for other providers

It is widely reported MACRA will force further consolidation

MIPS: National Financial Impact

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• MIPS is Budget Neutral

• Government expects $833 million will be redistributed

• Additional $500 million in bonuses for top performers

MACRA Progression

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Today vs. Tomorrow

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Currently: QRUR MU PQRS/VBMNon-

Existent

QPP: MIPS? APM? Both….

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Merit Incentive Based Payment

System (MIPS)

Default Program (≈90% of Medicare

Providers): A portion of Medicare

Revenue at the TIN/Individual Provider

Level is at risk based on the following

performance categories:

Alternative Payment Models (APMs)

Generic term for providers who receive

significant revenue through 2-sided risk-

based contracts.

Currently Proposed Options:

• Medicare Shared Savings Program

(MSSP) Tracks 2 & 3

• Next Generation ACO

• Oncology Care Model Two-sided Risk

Arrangement (Available 2018)

• Comprehensive End-Stage Renal Disease

Care (CEC) Model

Ultimate Goal: APM’s

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• Requires:• “More than nominal” Risk• Quality measurement• Very advanced Value-

Based Design (Technology, Analytics, Workflow, Contracts, etc.)

• Provides:• Prospective 5% Lump-

Sum annual bonus in 2019-2024

• Exemption from MIPS requirements

2019

–

2020

2021–

2022

25% N/A

50%

N/A 25%

50%

OROption 1 Option 2

Required for All

Providers

2023

and

on

75%

N/A 25%

75%

Required Percentage of Revenue

Under Risk-Based Payment Models

Option 1

Medicare Only

Option 2

Medicare +

Commercial

Contracts

Current Focus: MIPS

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• MIPS is the Default Program; AKA New Medicare FS• CMS anticipates 90% of all

physicians will be paid via MIPS in 1st year of the Quality Payment Program (QPP)

• Adjusts Medicare payments based on performance on a single budget-neutral payment beginning in 2019 (2-year Look-Back)

• Applies to physicians, NPs, clinical nurse specialists, physician assistants, and certified RN anesthetists

MIPS: Composite Performance Scores

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4 Categories = 100%

1. Quality = 50%

2. Advancing Care Information = 25%

3. Clinical Practice Information Activities = 15%

4. Cost = 10%

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Components of the MIPS Score

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MIPS Category: Quality (50% Yr 1 MIPS Score)

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From 9 PQRS Measures to 6 total Measures

During Open Comment period, many pushed towards specialty and

practice-specific measures

Final Rule to show many changes

Focus today on ability to incorporate 6 measures into workflow

MIPS Category: ACI (25% Yr 1 MIPS Score)

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Key Takeaways:

High, historical MU compliance does not guarantee a high ACI score.

Unlike Historical MU, ACI Scoring is a CONTINUOUS scale, Not All-Or-Nothing

• Replaces Meaningful Use

• Potential to Participate as a group (If Final Rule allows)

• Advanced Practice Providers – exempt (Midlevels, NPs, PAs, etc.)

• Split Into Base Score & Performance Score

• Proposed Rule = Complicated Scoring (130 total points, only 100

needed to earn full score in ACI category)

ACI Base Score (50 Points)

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6 Objective and Measure Categories

1. Protect Patient Health Information - Y/N (Required)

2. Patient Electronic Access - N/D

3. Coordination of Care & Patient Education - N/D

4. Electronic Prescribing - N/D

5. Health Information Exchange – N/D

6. Public Health/Registry Reporting – Y/N

*N/D = Numerator/Denominator

ACI Performance Score (80 Points)

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3 Objective and Measure Categories

1. Patient Electronic Access - N/D

2. Coordination of Care & Patient Education – N/D

3. Health Information Exchange – N/D

** Immunization Registry – Mandatory

** Bonus Point – Pub Health reporting beyond immunizations

* N/D = Numerator/Denominator

MIPS Category: Clinical Practice

Improvement Activities (15% of MIPS Score)

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* Max Score = 60

* PCMH Participation Guarantees 100%

CPIA Score

* Largely Undefined Currently

* Secretary shall give consideration to

practices <15 Eps, rural practices, and Eps

in underserved areas

90 Proposed activities – 9 Categories1. Expanded Practice Access

A. After hours hotline

B. Same-day appointments

2. Beneficiary Engagement A. Care Plans

B. Self-assessment training

C. shared decision-making, etc.)

3. Achieving Health Equity

4. Population Health Management 1. Qualified clinical data registry

2. Monitoring conditions

5. Patient Safety & Assessment1. Use of Surgical Checklists

2. Assessments related to maintaining Certifications

6. Emergency Preparedness & Response

7. Care Coordination

8. Participation in Advanced APM or Medical HomeModel

9. Integrated Behavioral Health

MIPS Category: Cost (10% 1st Yr MIPS Score)

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1. Replaces cost component / resource use of VBMP.

2. Scored on Medicare claims = NO REPORTING.

3. 40 specific episode measures – among specialists.

4. Must see at least 20 patients in respective category.

5. Each cost measure max out at 10 points.

Score Summary Recap

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Key Questions & Suggestions

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Key Questions

1. Do you use CEHRT (Certified EHR Technology)?

2. Do you feel comfortable with your reporting process? (Proposed Full-year

reporting)

3. Do you know the measures your EHR is capable of reporting? (These metrics will

become public under MACRA) http://oncchpl.force.com/ehrcert

Key Suggestions

1. Stay familiar with CMS’ Core Measures as CMS & AHIP agree to harmonize

metrics

2. Improving your PQRS reporting process will pay dividends

3. 2017 Reporting Year will be 50 % PQRS & 25% ACI (Formerly Meaningful Use)

4. Download QRUR

5. Prepare to adjust workflows

6. Focus resources on specific PQRS measures. Identify workflow adjustments

7. Assess EHR/technological capability to comply

Strategic Plan

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1. Short-run: Focus on Coding, PQRS Workflow, Care-Coordination

(CCM 99490), Chronic Care management, CPC+*, analytics

2. Long-Term: Learn via MIPS; Prepare APM contracts by expanding

to MA plans, then commercial FFV arrangements

3. Educate staff on initiatives

A. Many metrics involve strong communication & non-physician

reporting processes

B. Cultural change management in pursuit of Triple Aim

4. Establishing a CIN provides the architecture to strategically step

towards value-based payments to shift from MIPS to APMs & receive

further incentive-rewards

* CPC+ (Comprehensive Primary Care Plus) Regions are to be announced August 1, 2016

Sample Roadmap

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Acronyms Reference Guide

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• ACO – Accountable Care

Organization

• APM – Advanced Alternative

Payment Model

• CMS – Centers for Medicare &

Medicaid Services

• CPC+ – Comprehensive

Primary Care Plus

• EHR – Electronic Health

Record

• EP – Eligible Professional

• HHS – U.S. Department of

Health & Human Services

• MACRA – The Medicare Access

and CHIP Reauthorization Act of

2015

• MIPS – Merit-Based Incentive

Payment System

• MSSP – Medicare Shared

Savings Program

• PQRS – Physician Quality

Reporting System

• QPP – Quality Payment Program

• QRUR – Quality and Resource

Use Report

• VBPM – Value-Based Payment

Modifier

Summary: Merit Health QPP Plan

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1. More education for members

2. Continue CIN objectives

3. Analytics implementation

4. More clinical workgroups

5. Analytics support

6. Partnership

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