MACRA, MIPS, and APMs – What to Expect from all these Acronyms?!

Shari M. Erickson, MPHVice President, Governmental Affairs & Medical Practice

ACP Pennsylvania Council Meeting

Saturday, December 5, 2015

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What a long, strange trip it’s been

After 12 years of lobbying Congress to repeal the SGR, we finally wore them down!

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So, what did we get instead?

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Congressional Intent of MACRA, beyond SGR repeal:• Improve care for Medicare beneficiaries• Change our physician payment system from one

focused on volume to one focused on value

MACRA is part of a broader push towards value and quality

In January 2015, the Department of Health and Human Services announcednew goals for value-based payments and APMs in Medicare

4Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

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MACRA Overview/Acronym Definitions…

The Medicare Access and CHIP Reauthorization Act of

2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015

Merit-Based Incentive Payment System (MIPS)

Alternative Payment Models (APMs)

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Merit-based Incentive Payment System

Alternative Payment Model

Starting in 2019*, physicians will choose from or land in one of two paths: MIPS or APMs?

* This decision will actually need to be made sooner than 2019. The initial performance period for MIPS in MACRA is 2017.

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Two pathways: MIPS versus APMs (2019)

MIPS• MIPS adjusts traditional fee-for-

service payments upward or downward based on new reporting program, integrating PQRS, Meaningful Use, and Value-Based Modifier

• Measurement categories (composite score of 0-100):• Clinical quality (30%)• Meaningful use (25%)• Resource Use (30%)• Practice improvement (15%)

APMs• Supported by their own payment

rules, plus• 5% annual bonus FFS payments for

physicians who get substantial revenue from alternative payment models that• Involve upside and downside

financial risk, e.g. ACOs or bundled payments

• OR• PCMHs, if ↑ quality with ↓ or ↔

cost; ↓ cost with ↑ or ↔ quality (e.g., CPCI)

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Merit-Based Incentive Payment

System (MIPS)

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MIPS changes how Medicare links performance to payment

MACRA streamlines those programs into MIPS:

Merit-Based Incentive Payment System(MIPS)

Physician Quality Reporting

Program (PQRS)

Value-Based Payment Modifier

Medicare EHR Incentive Program

There are currently multiple individual quality and value programs for Medicare physicians and practitioners:

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

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What MIPS means for Medicare’s PQRS, Value-based Payment Modifier Program, and Meaningful Use…

PQRS, VBM, and MU no longer exist as stand-

alone programs starting in

2019.

In fact… 2016 is the

FINAL reporting

period for all of these

programs as stand alones!

However, the infrastructure

for these programs is expected to be used for

MIPS beginning in

2017.

This is an opportunity to improve them all!

A single MIPS composite performance score will factor in performance in 4 weighted performance categories:

MIPSComposite

Performance Score

Quality Resource use

Clinical practice

improvement activities

Meaningful

use of certified EHR technology

How will physicians and practitioners be scored under MIPS?

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30% 30%

15% 25%

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

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* NEW* Clinical Practice Improvement Activities

The subcategories shall include at least the following: • Expanded practice access• Population management• Care coordination• Beneficiary engagement• Patient safety and practice assessment• Participation in an APM

Must be established in collaboration with professionals The Secretary must consider if they are attainable for small

practices those in rural and underserved areas. Key Question: How will these need to be reported/tracked?

Need to ensure minimal burden but still push toward value.

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Clinical Practice Improvement Activities –PCMH and PCMH Specialty Practices

“Certified” PCMH and PCMH specialty practices receive highest potential score

Key questions (to be answered via rulemaking):• What will be the role of existing PCMH and PCMH

specialty practice accreditation and recognition programs?

• Will CMS consider PCMH programs that are led by other payers, states, etc.?

How much can MIPS adjust payments?

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• Based on the MIPS composite performance score, physicians and practitioners will receive positive, negative, or neutral adjustments up to the percentages below.

• MIPS adjustments are budget neutral. A scaling factor may be applied to upward adjustments to make total upward and downward adjustments equal.

MAXIMUM AdjustmentsAdjustment to provider’s base rate of

Medicare Part B

payment

Merit-Based Incentive Payment System(MIPS)

4%5% 7%9%

-9%2019 2020 2021 2022 onward

-7%-5%-4%

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

Are there any exceptions to MIPS adjustments?

There are 3 groups of physicians and practitioners who will NOT be subject to MIPS:

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FIRST year of Medicare participation

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Participants in eligible Alternative Payment

Models who qualify for the bonus payment

Below low volume threshold

Note: MIPS does not apply to hospitals or facilities

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

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Alternative Payment Models (APMs)

Alternative Payment Models (APMs)

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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

According to MACRAlaw, APMsinclude:

APMs are new approaches to paying for medical care through Medicare thatincentivize quality and value.

• MACRA does not change how any particular APM rewards value.• APM participants who are not “Qualified Participants” will receive

favorable scoring under MIPS.• Only some of these APMs will be eligible APMs.• Over time, more APM options will become available…

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

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Two basic “screens” for APMs

Eligible APM:• The most advanced APMs that meet the following

criteria according to the MACRA law:• Base payment on quality measures comparable to those in MIPS• Require use of certified EHR technology• Either (1) bear more than nominal financial risk for monetary losses OR

(2) be a medical home model expanded under CMMI authority

Qualifying APM participants (i.e., qualifying participants or QPs):• Physicians and other clinicians who have a certain % of

their patients or payments through an eligible APM

How does MACRA provide additional rewards for participation in APMs?

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APMparticipants

QPs

Those who participate in the most advanced APMs may be determined to be qualifying APM participants (“QPs”). As a result, QPs:1. Are not subject to MIPS2. Receive 5% lump sum bonus payments for years

2019-20243. Receive a higher fee schedule update for 2026 and

onward

Most physicians and practitioners who participate in APMs will be subject to MIPS and will receive favorable scoring under the MIPS clinical practice improvement activities performance category.

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

Independent PFPM Technical Advisory Committee

PFPM = Physician-Focused Payment Model

Encourage new APM options for Medicare physicians and practitioners.

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Technical Advisory

Committee (11 appointed care delivery

experts)

Submission of

model proposals

Review proposals, submit recommendations to

HHS Secretary

Secretary comments on CMS website, CMS

considers testing proposed model

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

Source: https://www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

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PCMH as an Alternative Payment Model in MACRA

Strict definition initially: PCMH as expanded under the CMS Innovation Center

can be an eligible APM without taking on financial risk• i.e., the Comprehensive Primary Care (CPC) Initiative

But… There are lots of other PCMH programs across the

country• Initially, they will fall under MIPS (but will score well there!)• However, over time this is expected to change

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PCMH as an APM in the future

Beginning in 2021, the threshold % (of payments or patients) to be an eligible APM (and a QP) may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid.

The physician-focused payment model pathway is intended to allow for more APMs to be counted.

Bottom line… If you are in primary care, becoming a PCMH is the answer!

For subspecialists, becoming a PCMH neighbor/specialty practice will be a huge benefit!

Prepared by the American College of Physicians, Division of Governmental Affairs and Public PolicyUnder MACRA, what’s the range of possible FFS updates and incentive payments per year? (Physicians can participate in either MIPS or APM, not both)

Date Baseline MIPS (incentiveadjustments), without exceptional performance adjustment*

Baseline, plus/minus MIPS, without exceptional performance adjustment*

MIPS maximum,withexceptional performance adjustment*

APM (FFS bonus only, does not include incentives from own APM pay structure)

4-1-2015 0% instead of21% SGR

cut

N/A N/A N/A N/A

7-1-2015 thru 12-31-2018

0.5% N/A N/A N/A N/A

2019 0.5% +/-

4.0%** = -3.5% to +4.5%** 14.5% FFS bonus: +5%

2020 0% +/-

5.0%** = -5.0% to +5.0%** 15% FFS bonus: +5%

2021 0% +/-

7.0%** = -7.0% to +7.0%** 17% FFS bonus: +5%

2022, 2023 and 2024

0% +/-

9.0%** = -9.0% to + 9.0%** 19% FFS bonus +5%

2025 0% +/-

9.0%** = -9.0-% to plus 9.0%** N/A 0%

2026 and subsequentyears

0.25% (for non-APM physicians only)

+/-

9.0%** = -8.75% to plus 9.25% ** N/A 0.75%

*Exceptional performance adjustment for those with the highest composite scores, limited to additional adjustment of 10% per year.**HHS can increase the maximum MIPS positive adjustment (not counting the exceptional performance adjustment) to no more than 3x maximum MIPS incentive adjustment for that calendar year, if there are sufficient funds available. HHS cannot increase the maximum negative MIPS adjustment by more than the amount specified.

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MACRA Implementation

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MACRA Implementation Timeline

October 20152016 Medicare Physician Fee Schedule – Final Rule ReleasedTwo Meaningful Use final rules released.

• New 60-day comment period on Stage 3

A Request for Information (RFI) released from CMS on both MIPS and APM pathway implementation

Spring 2016MU Stage 3 Final RuleMACRA Proposed RuleMACRA Measure Development Plan

Summer 20162017 Physician Fee Schedule Proposed Rule

Fall 20162017 Physician Fee Schedule Proposed RuleMACRA Final Rule (for the 2017 performance period; 2019 MIPS payment adjustment period)Annual list of MIPS quality measures (by Nov. 1 for 2017 performance period)

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Relevant 2016 Physician Fee Schedule Changes

PQRS Changes for 2016 – Minimal!• Are now allowing group reporting via QCDRs• Did not finalize a proposal that group practices with 25+

EPs report on CAHPS for PQRS survey measures – Only groups of 100+ EPs will need to report on CAHPS in 2016

Value-Based Payment Modifier Changes for 2016 – also Minimal!• Maintain the 2015 amount at risk of 4.0% for groups of 10

or more EPs• Solo EPs and small group practices (2-9 EPs) are no longer

held harmless (can face a -2% adjustment)

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Changes to Quality Measures for PQRS

4 new cross-cutting measures (bringing total to 23) 37 new individual quality measures (8 proposed

measures not finalized) 281 total measures in the PQRS measure set and 18

measures in the GPRO web interface for 2016 3 new measures groups:

• Cardiovascular Prevention• Diabetic Retinopathy• Multiple Chronic Conditions

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Summary of CY 2018 Payment Adjustments

Based on reporting in performance year 2016• PQRS: -2.0 percent for failing to satisfactorily

report• Meaningful Use of EHRs: -3.0 percent for failing

to attest to MU• Value-based Payment Modifier maximum

downward adjustments: • -4.0 percent for groups of 10 or more EPs• -2.0 percent for solo and groups of 2 – 9 EPs

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MACRA Request for Information – Comments Submitted November 17th*

MIPS Topics (97 questions) include:

• MIPS Participation determination and options• Measurement Categories• Composite Performance Score and Threshold, including Flexibility in Weighting • Public Reporting on Physician Compare• Feedback Reports• Technical Assistance for Small and Rural Practices

APM Topics (50 questions) include:

• Eligible APM Entity Requirements• Qualifying and Partial Qualifying APM Participants• Payment Incentive for APM Participation• Patient Attribution• Nominal Financial Risk definition• Medicaid: Medical Homes and Other State APMs• Physician-Focused Payment Models

* https://www.acponline.org/acp_policy/letters/acp_comment_letter_macra_rfi_2015.pdf

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Highlights of ACP Comments on MACRA RFI

Called on CMS to use the opportunity provided through the new MACRA law to build a learning health and healthcare system.

Recommended that CMS work to ensure that patients, families, and the relationship of patients and families with their physicians are at the forefront of the Agency’s thinking.

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ACP’s RFI Comments: Key Principles for MACRA Implementation

Support delivery system improvements. Avoid administrative and cost burdens for patients. Reduce administrative burdens for physicians. Improve current quality and reporting systems. Recognize patient diversity. Provide choice of payment models. Be equitable. Be relevant and actionable. Provide stability and resources. Be transparent.

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Meaningful Use Rules Summary

1) Final 2015 Certification2) Stage 3 MU & Final Stage 2 MU

Modifications

Proposed Stage 2 MU modifications

Proposed Stage 3

Certification

Proposed Stage 3 MU

What is final…• Stage 2 modifications for 2015-2017• 2015 Certification Requirements

So, what about Stage 3…• Now that MACRA has passed, CMS wants

to take more time to finalize these rules.• Therefore, Stage 3 MU will not be

finalized until 2016. This is exactly what ACP had asked

for – a brief pause in rollout to make some changes!!!

• Stage 3 is optional for 2017, required in 2018.

• 2017 MU will be the first reporting period for MIPS.

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Stage 2 Modifications – finally final, but not ideal in terms of timing…

90-Day Reporting Period for 2015 DONE!

But, it came too late and we now need to work on this change for 2016 (when full year reporting is

required).

Stage 2 Objective for Patient Electronic

Access, measure #2 –change threshold from

5% to “equal or greater than 1”

DONE!This change applies to

2015 and 2016! Need to work on fixing

it for 2017.

Stage 2 Objective for Secure Electronic Messaging – the

threshold changed from % of patients to be a yes/no response

DONE!Fixed for 2015, but changes to at least 1 patient in 2016 & 5% in 2017. Not ideal.

Key ACP asks… What happened, and next steps…

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ACP’s Stage 3 (draft) Comments… it needs to be a bold new world!

We believe that CMS has a golden opportunity for a MU “do-over”• MU should aim to fill in key gaps and/or strive to incent optimization

of value from health IT (based on specialty and setting of care). • MU measures should not be burdensome, and should be built into

existing or emerging workflows, such that as care is provided, process or activity measurements can be auto-generated.

• No measure thresholds!!!!• We can learn from all the data submitted.

In fact, MU must permit and even encourage flexibility and innovation! CMS and ONC must collaborate with physicians to determine the key

tasks that physicians and staff will need to perform better to improve care—and help facilitate health IT education.

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How Can ACP Help You to Succeed?

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MIPS or APM? ACP plans to help members choose the right path

1. Advocacy so that whatever path they choose, it gets them to a destination of higher quality, more cost-effective care, without unnecessary obstacles, barriers, potholes, and detours along the way!

2. Education & Resources to help them succeed (e.g. Practice Advisor, Genesis Registry, PQRS Wizard, Timeline)

3. Decision tool (?) to guide them on which path to take, MIPS or APMs

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Critical First Steps – Information Gathering and Education (ACP Plans/Activities To Date)

Seeking out feedback on the needs/wants of our members:• Member panel survey• ACP Committee and Council meetings (including the Council of

Subspecialty Societies (CSS))• Outreach to other societies and stakeholders

Webinars (live and recorded) Slides/speaker notes for use by our Governors and members

– on MACRA overall and tools/services to help FAQ documents and fact sheets Articles in ACP publications Intent to serve as a warehouse of resources

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Current and Evolving Products

ACP online Running a Practice (https://www.acponline.org/running_practice/)

Physician & Practice Timeline (text alerts – acptimeline to 313131) (https://www.acponline.org/running_practice/physician_practice_timeline/)

ACP Practice Advisor® (https://www.practiceadvisor.org/) – will be growing through ACP’s CMS Innovation Center Support & Alignment Network (SAN) grant

AmericanEHR (http://www.americanehr.com/) – data from physicians for physicians on EHR selection and usability, including MU cert.

PQRS Wizard (https://www.pqrswizard.com/) Genesis Registry (for PQRS, MU, etc.) - QCDR

(https://www.medconcert.com/content/medconcert/Genesis/)

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Potential MACRA Navigator (MIPS vs. APMs) –Potential Product Description

Base – electronic algorithm – practice characteristics, quality measurement experience, quality improvement activities, and readiness

Algorithm does NOT result in a single answer – but rather analyzes the challenges and opportunities with each option – and identifies gap areas (e.g., are you doing care coordination, population management, etc.)

The user identifies their pathway – and is then directed to tailored resources to help them succeed. ACP resources such as Practice Advisor® and Running a Practice

Several options for data usage – for small practices, integrated groups, consultants, and researchers

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ACP’s CMMI Support & Alignment Network (SAN) Grant – New Opportunities

Transforming Clinical Practice Initiative (TCPI) -Announced by the U.S. Department of Health and Human Services 9/29/2015• Practice Transformation Networks (PTN) 29• Support & Alignment Network (SAN) 10 – ACP is one of

these!!!

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-29.html

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ACP- TCPI SAN

Title - Transforming Clinical Practice: Educating Clinicians, Engaging Patients, Reducing Cost, and Improving Outcomes Timing: 4 Years (re-application each year)Amount: $840,707 year one; if awarded, a total of $2,825,984 over 4 years.Lead Staff: Daisy Smith, Program Manager, and Kelly Pearson Objectives:

• Broad dissemination and provision of evidence-based practice transformation tools and information

• Development and dissemination of Transforming Clinical Practice Initiative (TCPI)-aligned modules on the ACP Practice Advisor®

• Evaluation of practice transformation tools and impact

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Additional ideas for ACP’s role, particularly re: IM subspecialties, have included…

MIPS: Play a role in helping ensure the development/ testing/ implementation of guidelines, measures, and clinical practice improvement activities relevant for subspecialties.

APMs: Serve as a means of sharing what IM societies are doing to develop APMs, help facilitate opportunities for collaboration/ partnering; potentially create basic tools for APM development.

Both MIPS & APMs: Convening of cross-discipline groups to facilitate the development/ implementation of educational opportunities, QI projects, tools and resources to help, etc. in a collaborative way

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Other ideas for how ACP can help are welcome!!

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Questions?serickson@acponline.org