macra: penalties and timelines - ncc.expoplanner.com · macra’s two pathways: mips and apm...

MACRA: Penalties and Timelines

Michael D. Flora, MBA, M.A.Ed., LCPCSenior Operations and Management ConsultantMTM Services

David R. Swann, MA, LCAS, CCS, LPC, NCCSenior Healthcare Integration ConsultantMTM Services

Why are you here?

• 2017 is now the "Transition Year" for The

Medicare Access and CHIP Reauthorization

Act (MACRA) with a two-year gap where both

financial penalties and rewards will be

provided. MACRA intersects payment and

quality.

1

Why are you here?

• In 2019, the Sustainable Growth Rate will be

discontinued for the Medicare Physician Fee

Schedule. Behavioral Health providers can

have Significant financial risk for non-

compliance with MACRA which includes

"doing nothing". This session will explain the

timelines and penalties to behavioral health

providers to enable successful rewards so

that Medicare enrollees have good access to

behavioral healthcare.

2

Learning Objectives

• Participants will understand the MACRA/MIPS

timeframes for penalties and rewards in a

performance based payment system

• Participants will understand the initial steps

needed to report on MACRA in 2017

• Participants will review some of the quality

metrics that are options to report in 2017

3

MACRA: Quality Measurement and Pay for Value Roots

• MIPPA-Medicare Improvements for Patients and Providers

Act – 2008 (eRX and Quality Resource Use Reporting)

• TRHCA – Tax Relief and Healthcare Act of 2006 (created

PQRS)

• AARA-American Recovery and Reinvestment Act – 2009

enacted by 111th US Congress (created the HITECH – Health

Info. Technology for Economic and Clinical Health) –

Meaningful use and $19B investment.

• PPACA – Patient Protection and Affordable Care Act – 2010

– (purchasing value, paying for value, measuring value)

• MACRA – Medicare Access and CHIP Reauthorization Act–

2015 (Quality Payment Program (QPP))

4

MACRA Impact and Timeline

• An Act to Measure:

– Lower Cost

– Better Care

– Better Health Status for Population

• Claims data collected and analyzed by Medicare

• Medicare Fee Schedule Freezes (end of sustainable

growth rate) January 1, 2019 for traditional Medicare

• 2017 Transition Year

• Two-year gap for financial impact (e.g. 2019 impact)

• In 2019, financial penalties and rewards begin

5

MACRA’s Two Pathways: MIPS and APM

• MIPS-Merit-Based Incentive Payment System –

four performance categories1. Quality metrics reporting from Mental/Behavioral Health Specialty

Set

2. Advancing Care Information – using CEHRT to report on a

customizable set of measures

3. Cost – compares cost of care among diagnostic groups – using

ICD-10 – value based payment modifier

4. Improvement Activities – e.g. integrated care, clinical pathways,

and care coordination

*A minimum of 90 consecutive days of data must be submitted from

January 1, 2017 through October 2, 2017 by March 1, 2018

6

MACRA’s Two Pathways: MIPS and APM

• APM-Advanced Alternative Payment

Models-not common among BH providers• Care models that CMS qualifies for APM incentive

payments. The 2017 models include:– Comprehensive End-Stage Renal Disease Model

– Comprehensive Primary Care Plus

– Next Generation ACO Model

– Shared Savings Program Track 2

– Shared Savings Program Track 3

– Oncology Care Model – Two-sided Risk

– Comp care for Joint Replacement

– Vermont Medicare ACO initiative

7

Preparing for MIPS

• Organizations will need the people, processes

and technology in place to accurately collect

and report data on the MIPS measures.

• Helping clinicians to perform well on the

measures leading to increased payments and

avoidance of penalties.

• Medicare revenue is at stake for BH

organizations that employ clinicians paid

through the Medicare Physician Fee Schedule

8

MIPS Eligible Behavioral Health Clinicians

• Applies to the following in 2017:

– Physicians

– Physicians Assistants

– Nurse Practitioners

– Clinical Nurse Specialists

• Beginning in 2019 the following may become eligible:

– Clinical Social Workers

– Clinical Psychologists

– Physical/Occupational Therapists

– Speech and Language Pathologists

9

Who’s Not Participating in MIPS?

• Hospitals

• Clinician in first year of Medicare Part B

Participation

• Below the “Low Patient Volume” Threshold -

$10,000 or less in charges for 100 or fewer

Medicare patients in one year.

10

CMS Awards MACRA Support to Solo and Small Group Practices

• $20 Million Awarded to Help Solo, Small Practices

Succeed Under MACRA

• Eleven organizations have been awarded $20 million for

the first year of a 5-year program to provide training and

education about MACRA’s Quality Payment Program—

which includes the Merit-based Incentive Payment

System (MIPS) and Advanced Alternative Payment

Models (APMs). - See more at:

http://www.ajmc.com/newsroom/20-million-awarded-to-

help-solo-small-practices-succeed-under-

macra#sthash.sJ2IdE1I.dpuf

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http://www.ajmc.com/newsroom/20-million-awarded-to-help-solo-small-practices-succeed-under-macra#sthash.sJ2IdE1I.dpuf

Select One of the Four Participation Options in 2017 to Comply

1. Submit minimum amount of Medicare data

to avoid the penalty. 90 consecutive days of

data on one quality measure between Jan 1,

and October 2, 2017.

2. Submit 90 consecutive days of Medicare

data between Jan 1, and October 2, 2017 for

more than one quality measure, more than

one clinical practice improvement activity, or

more than five advancing care information

measures.

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Select One of the Four Participation Options in 2017 to Comply

3. Submit a full year of 2017 data including

quality measures, clinical practice

improvement activities or advancing care

information measures.

4. Advanced Alternative Payment Model (APM)

Participation: Applies to providers who

receive 25% of their Medicare payments or

see 20% of their Medicare patients through

an Advanced APM in 2017.

13

Behavioral Health Related Quality Measures

• Antidepressant Medication

Management

• Preventative Care and

Screening: Screening for

Depression and follow-up plan

• Elder Maltreatment Screen and

follow up

• Adult Major Depressive

Disorder: coordination of care

of patients with specific

comorbid conditions.

• Adherence to antipsychotic

meds for persons with

Schizophrenia

• Follow up after hospitalization

for mental illness

• Dementia: cognitive

assessment

• Dementia: Functional status

assessment

• Dementia: management of

neuropsychiatric symptoms

• Dementia: counseling

regarding safety concerns

• Dementia: caregiver education

and support

14

MACRA: Are You Being Measured?

• Legislation is short compared to other healthcare legislation.

Still the Act contains these words:

– 27 times- EHR or Technology to manage, measure, and

report

– 18 times – Risk

– 31 times – Reasonable cost reimbursement

– 8 times – Meaningful use

– 38 times – Quality Measures

– 19 times – Resource use or Efficiency

– 171 times – Measures or Measurement

15

MACRA Adjustments (Penalties and Increases)

• Penalties (adjustments) begin in 2019 for

absence of or data sent in 2017.

• 4 percent reduction in Medicare fee schedule in

2019

• Adjustment grows by 1 percent in 2020.

• Adjustment grows by 2 percent in 2021, 2022 up

to a maximum of + or – 9 percent.

• A 10 percent bonus is available for clinicians who

provide exceptional quality between 2019 and

2024.

16

• In the new environment ongoing monitoring

and evaluation are necessary

• CBHOs need objective indicators of

performance.

– Develop ongoing monitoring and

performance measurement against required

metrics

– Develop KPIs and work flows for performance

metrics and quality measures

17

Implementing and Sustaining Performance

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Developing your CQI Plan

Incorporating the MACRA/MIPs Data

and Quality Measures

18

19

Defining the New Paradigm

CBHO• Non-Four Walls

• Trauma-Informed Care Model

• PPS Rate Setting Support

Requirements

• PPS-2--Another Level of

Complication

• CBHO Service Delivery

Operational Requirements

• Compliance with CBHO

Certification Requirements

Current

Business

Practices

• Current CQI

Measures and Plan

• Current Monitoring

and Evaluation

• Credentialing

• UM/UR

• Corporate

Compliance

• Current PI Projects a

Combined Areas

of Focus• Know the State Medicaid

Rules

• Understand How Your

Relationships Translate into

Costs

• Quality Measures

• DCO Management

• Getting Technology Right

• Fee Scale

• Telemedicine

• Clinical Quality Assurance

• Corporate Practice of

Medicine

• Decision-Making and

Change Management

Support Assessment

Follow-Up After Hospitalization for Mental Illness (FUH):

• The percentage of discharges for patients 6 years of age

and older who were hospitalized for treatment of

selected mental illness diagnoses and who had an

outpatient visit, an intensive outpatient encounter or

partial hospitalization with a mental health practitioner.

Two rates are reported:

• The percentage of discharges for which the patient

received follow-up within 30 days of discharge.

• The percentage of discharges for which the patient

received follow-up within 7 days of discharge.

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Questions you should be asking…

• Is this Data Element Currently Being Collected?

• Is this a Data Element in your E.H.R. ( Can the

CBHO collect this information)?

• What Work Flow or Work Force issues does the

CBHO anticipate with this data element

collection?

• What infrastructure changes are needed to

accommodate the measure ?

• How is your organization operationalizing this

measure?

21

Incorporating your Measures in to your CQI Plan

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• A CQI plan is a detailed, and overarching organizational work plan for a CBHO’s clinical and service quality improvement activities.

• It includes essential information on how your organization will manage, deploy, and review quality throughout the organization.

• A CQI plan is generally developed by executive and clinical leadership and, in many organizations, must be approved by the organizations governing body such as a Board of Directors.

• The CQI plan will outline the specific clinical focus and Quality Data Elements for the demonstration years.

23

Understanding a CQI Plan?

Source: US Department of Human Services HRSA

• Description of the organizations, mission, program goals and objectives

• Definition of key terms/concepts (Include Quality Measures and MIPs Terms)

• Description of how the CQI elements were selected ( Data and Quality Measures)

• Description of the training and support for staff involved in the CQI process

• Description of your quality methodology (PDSA) and quality tools and techniques to be utilized by the CBHO

24

Elements of an Effective CQI Plan


• Description of the communication plan of planned CQI activities and processes and how updates will be communicated to the management and staff

• Description of measurement and analysis, and how it will help define future MACRA/MIPS CQI activities

• Description of evaluation/quality assurances activities that will be utilized to determine the effectiveness of the CQI plans implementation

25



Purpose

• Describe the purpose of the CQI plan, including the organization’s mission and vision, policy statement, the types of services provided, etc.

Definitions

• Define the key concepts and quality terms used in the CQI program/project so that there is a consistent language throughout the organization regarding quality terms.

• Quality Improvement (CQI) refers to activities aimed at improving performance and is an approach to the continuous study and improvement of the processes of providing services to meet the needs of the individual and others.

• Continuous Quality Improvement (CQI) refers to an ongoing effort to increase an agency’s approach to manage performance, motivate improvement, and capture lessons learned in areas that may or may not be measured as part of accreditation. It is an ongoing effort to improve the efficiency, effectiveness, quality, or performance of services, processes, capacities, and outcomes.

• Quality Assurance (QA) refers to a broad spectrum of evaluation activities aimed at ensuring compliance with minimum quality standards. The primary aim of quality assurance is to demonstrate that a service or product fulfills or meets a set of requirements or criteria. QA is identified as focusing on “outcomes,” and CQI identified as focusing on “processes” as well as “outcomes.”

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• Describe the organizational structure, roles and responsibilities, timeline for reporting findings and improvement strategies, Dashboards, and training/support provided for project staffs.

• Describe how leadership provides support to CQI activities:

• Organizational structure is a formal, guided process for integrating the people, information, and technology of an organization, and serves as a key structural element that allows organizations to maximize value by matching their mission and vision to their overall strategy in quality improvement. Implementing a CQI plan requires a clear delineation of oversight roles and responsibilities, and accountability. The CQI plan should clearly identify who is accountable for CQI processes, such as evaluation, data collection, analysis education and improvement planning.

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Organizational System


• Organizational structure is a formal, guided process for integrating the people, information, data elements and technology of an organization, and serves as a key structural element that allows organizations to maximize value by matching their mission and vision to their overall strategy in quality improvement.

• Implementing a CQI plan requires a clear delineation of oversight roles and responsibilities, and accountability.

• You will need specific Job Descriptions for the CQI Program. The CQI plan should clearly identify who is accountable for CQI processes, such as evaluation, data collection, analysis education and improvement planning.

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• You can build upon your current CQI/QA Plan. The specific organizational structure for implementing a CQI plan can vary greatly from one organization to another.

• Generally, responsibility for Quality begins with Board that authorizes the CEO/Executive Director to provide resources to support quality program and assigns responsibility for CQI program to lead clinical and CQI staff (e.g., the Medical Director if your organization has one).

• A Quality Coordinator is assigned to support the medical director/chair of the committee and for day-to-day activities.

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• Depending on the size of the organization, who participates in CQI activities may vary.

• For example, in small clinics with a primary care provider, nurse, and support staff, most of the staff members are involved in all aspects of CQI work.

• In larger organizations such as a hospital, usually a Quality Committee is established that includes senior management, designated CQI staff if there are any, and other key players in the organization with the expertise and authority to determine program priorities, support change, and if possible, allocate resources.

• The main role of this group is to develop an organizational CQI plan, charter team, establish CQI priorities and activities, monitor progress towards goal attainment, assess quality programs and conduct annual program evaluation.

30



List and prioritize CQI projects:

• Areas for improvement can be identified by routinely and systematically assessing quality of care. CQI projects may be identified from self-assessment, customer satisfaction surveys, or formal organizational review that identifies gaps in services.

• Staff from all levels should be included to brainstorm and develop a list of changes that they think will improve the process.

• Consumer input on the experience of care delivery is extremely important to identify areas that need improvement. The CQI projects that are selected and prioritized should show alignment with the organization’s mission.

31

Identify Areas for Improvement


Operationalizing your Measures

32

• By June 30, 2018 (time bound), decrease the percentage of discharges for patients who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. CQI concepts and tools” (specific & relevant) by 25% (measurable & achievable).

• The CQI Committee will need to identify and define goals and specific objectives to be accomplished surrounding the each MACRA/MIPs quality and data measures

Two rates are reported:

• The percentage of discharges for which the patient received follow-up within 30 days of discharge.

• The percentage of discharges for which the patient received follow-up within 7 days of discharge.

33

For example, PQRS 391 NQF#0576

Performance Improvement and Change Management

36

Performance Improvement

• Performance Improvement is the process of designing or

selecting interventions which may include training directed toward

a change in behavior, typically on the job.

• PI is a systematic process of discovering and analyzing human

performance gaps, planning for future improvements in human

performance, designing and developing cost-effective and

ethically-justifiable interventions to close performance gaps,

implementing the interventions, and evaluating the financial and

non-financial results.


37

• Describe how the Quality program is measured, data is collected, monitored and analyzed

• Performance Improvement is used to monitor important aspects of an organization’s CBHO programs, systems, and processes; compare its current performance with the previous year’s performance, as well as HEDIS or other quality benchmarks and theoretical test performance measures, and identify opportunities for improvement in management, clinical care, and support services.

• Incorporate each of the QMs Requirements into your CQI plan

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Performance Improvement


39

Implementation Bridge

Current Operations and

Practices

Change in Operations and

Practices

Increases in Outcomes and Performance

Communicating clear expectationsBuilding capacity

Monitoring and reviewing

Giant Leap

Adapted from Hall, G. E., & Hord, S. M. (2006). Implementing change: Patterns, principles, and potholes. Boston: Pearson.

Changing Structures to Make MACRA Quality

Reporting Possible!

41

Creating the Structure:Six Steps Reporting Process

Participate in MACRA

Measurement

1. Study the Final

Regulations

2. Select Measures to

Report

3. Determine the Reporting

Vehicle

4. Develop an Internal

Reporting System

5. Identify a Standing Group to Analyze the

Data

6. Design and Implement Rapid

Cycle Improvements

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• Identify the CQI methodology and quality

tools/techniques to be utilized throughout the

organization. Describe the process:

• The purpose of a CQI initiative is to improve

the performance of existing services or to

plan new ones. Strategies for improvement in

the existing process can be identified by

using CQI tools such as benchmarking,

fishbone diagram, root-cause analysis, etc.

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CQI Initiative


“If you come to a fork in the road…take it”

Yogi Berra

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• HRSA Quality Tool Box :

http://www.hrsa.gov/quality/toolbox/methodology/

developingandimplementingaCQIplan/

• HRSA QM Manual

• NY State Office of Mental Health CQI Plan

Template

• GOA Performance Measurement and Evaluation

• Spokane Regional Health Department 2010 QI

Plan

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Resources

http://www.hrsa.gov/quality/toolbox/methodology/developingandimplementingaCQIplan/

macra: penalties and timelines - ncc.expoplanner.com · macra’s two pathways: mips and apm...

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