mips roadmap series “changes in reimbursement for ... · changes in reimbursement for physicians...

Iowa SHIP Kickoff Webinar 6-20-17

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Presented by Michele Madison - Morris, Manning & Martin, LLP

MIPS ROADMAP SERIES“Changes in Reimbursement for

Physicians and Practices”

September 18, 2017

A PORTION OF THESE MATERIALS WERE PRODUCED PURSUANT TO THE Iowa Small Hospital Improvement

Program (SHIP) Grant FY 17, IA Contract #5888SH01 and the Georgia Small Hospital Improvement Grant FY 17.

WEBINAR ETIQUETTE

Hospital Transformation Consortium

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WEBINAR RESOURCES


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offer 0.1 CEUs for this program.

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Anyone that misses the webinar can view the recording online, posted on the program Dashboard, for CEUs.

CONTINUING EDUCATION



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CONTINUING EDUCATION


HTHU provides over 300 courses online, over 100 Webinars a year, and various live training conference and workshops. Accredited Education from the International Association for Continuing Education & Training (IACET). (Who accepts the IACET CEU? Full list at www.iacet.org)

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ACTION ITEM: GROUP PARTICIPATION


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Welcome & Introductions Susannah Cowart,

HomeTown Health, LLC

A MIPS Roadmap: Changes in

Reimbursement for Physicians and

Practices

Michele Madison,

Morris, Manning & Martin, LLP

Upcoming Events & Resources Susannah Cowart,

HomeTown Health, LLC

AGENDAA MIPS Roadmap

Program GoalsA MIPS Roadmap Series

The goal of the Hospital Transformation Consortium is to build a group of hospitals and

other stakeholders that work together to support hospital collaboration and a

community of shared best practices in transforming areas of Quality & Data

Reporting, Financial Processes, & Technology in order to improve the value for

the patient.

The objective of the MIPS Roadmap Series

includes enabling Hospitals and Providers to

understand…

• The Quality Scoring Standard under MIPS;

•The types of Quality Metrics that apply to the

provider;

•Practice operations that impact the Quality Metric;

and

•Quality Metric Impact on APMs.


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Trainer Biography

A MIPS Roadmap

Michele Madison, Partner


Michele Madison is a partner at Morris, Manning & Martin and serves in the firm’s

Healthcare Practice, where she provides general legal advice to health systems in

various regulatory and business matters. She also works with information

technology companies and advises clients on compliance with regulations and

industry standards. Michele has specific experience in negotiating contractual

agreements between healthcare providers and service providers, interpreting and

advising health systems on regulations applicable to the healthcare industry, and

providing regulatory advice with a focus on Stark, Anti-Kickback and HIPAA.

She also has key experience and expertise in Compliance programs providing

advice for compliance with state and federal regulations and regularly draws and

negotiates agreements with hospitals, physicians, managed care organizations and

ancillary service providers, as well as contractual agreements for vendors with an

emphasis on information technology, purchasing and lease agreements. Michele

also works with electronic medical record vendors and personal health record

providers. She is a graduate of Georgia State University and The University of

Georgia School of Law.

Disclosure of Proprietary Interest

A MIPS Roadmap

Morris Manning & Martin, LLP does not have any proprietary

interest in any product, instrument, device, service, or material

discussed during this learning event. This is an educational

session and does not provide legal advice.

The education offered by Morris, Manning & Martin, LLP in this

program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant.


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Presented by Michele Madison, Partner at Morris, Manning & Martin, LLP

A MIPS ROADMAP SERIESChanges in Reimbursement for

Physicians and Practices

Learning Outcome Standard: Based on guidelines for the Center for Medicare and Medicaid (CMS) Quality Payment Program for Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).

Changes in Reimbursement for Physicians and Practices

Purpose of Today

A MIPS Roadmap

Support Hospitals and Providers in

understanding and adjusting to the changing

Reimbursement models that will impact

Part B reimbursement commencing in 2019.

Discuss an overview of The Quality Metric

Component of the Reimbursement models:

Medicare Incentive Based Payment System

(“MIPS”) and Advanced Alternative Payment

Models


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Future Series TrainingA MIPS Roadmap

Focus on Clinical Practice Improvement

Activities & Advancing Care Information

Cost Metric


Learning Outcomes

A MIPS Roadmap

By the end of this presentation, you should be able to:

• Describe the Quality Metric percentage of the Composite

Score for each Provider;

• Describe the methods to report the Quality Metrics;

• Understand the types of Quality Metrics available; and

• Understand the impact of the Quality Metrics on MIPS and

APMs.


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Did your physicians report on Physician Quality Reporting System in the last year?

___ Yes

___ No

___ I do not know

Poll Question

MACRA and The Changing

Reimbursement Models


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MACRA Overview

Changing Reimbursement Models

Poll Question

Have you reviewed your QRUR reports for each provider?

____Yes

____NO

____ I do not know what a QRUR report is or how to review it

http://d.pr/11oyA


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Educate Providers on

MIPS and APMs

(1) support care improvement by focusing on better outcomes for patients, decreased provider burden, and preservation of independent clinical practice;

(2) promote adoption of alternative payment models that align incentives across healthcare stakeholders; and

(3) advance existing efforts of Delivery System Reform, including ensuring a smooth transition to a new system that promotes high-quality, efficient care through unification of CMS legacy programs.

Quality Payment Program


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(1) to improve beneficiary outcomes and engage patients through patient-centered Advanced APM and MIPS policies; (2) to enhance clinician experience through flexible and transparent program design and interactions with easy-to-use program tools; (3) to increase the availability and adoption of robust Advanced APMs; (4) to promote program understanding and maximize participation through customized communication, education, outreach and support that meet the needs of the diversity of physician practices and patients, especially the unique needs of small practices; (5) to improve data and information sharing to provide accurate, timely, and actionable feedback to clinicians; and (6) to ensure operational excellence in program implementation and development.

QPP Strategic Objectives

Value Based Reimbursement

• 30% based upon APM by 2016

• 50% based upon APM by 2018

• 85% of Payments based upon Quality by 2016

• 90% of Payments based upon Quality by 2018

Delivery System Reform


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Merit-based Incentive Payment System (MIPS)

• Providers are scored on 3 and then 4 metrics to create a Composite Score

• Providers Reimbursement will go up or down depending upon performance when compared with peers

Advanced Alternative Payment Model

• Must be a Qualified Provider

• Bonus Payment of 5%; and

• Not subject to MIPS

Two Payment Models=QPP

MIPS

Eligible Providers Excluded Providers

• Physicians

• Nurse Practitioners

• Clinical Nurse Specialists

• Certified Registered Nurse Anesthetists

• Groups of these providers

• $100M in Technical Assistance for small and rural groups

• New Physician enrolled in part B in last year

• Low Volume < $30K for Medicare OR <100 Medicare Patients

• Participate in Advanced APM

• Projected to Exclude 32.5% of Practitioners


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MIPS

Merit-Based Incentive Payment Model

Increase in Reimbursement based upon the Composite Performance Score (CPS)

Quality (60%)

Resource Use (10%)—Removed with the Final Rule

Clinical Practice Improvement Activities (15%)

Advancing Care Information (meaningful use) (25%)

EVALUATION PERIOD IS CALENDAR YEAR 2 YEARS PRIOR

(i.e. 2017 performance impacts

$199Million for 2019)

2019 1st Payment Period (-4% to +4%)

2020 2nd Payment Period (-5% to +5%)

2021 3rd Payment Period (-7% to +7%)

2022 4th Payment Period (-9% to +9%)

MIPS Payments


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Proposed Rule Changes for Year 2

1. Offering the Virtual Groups participation option. 2. Increasing the low-volume threshold so that more small practices and eligible

clinicians in rural and Health Professional Shortage Areas (HPSAs) are exempt from MIPS participation.

3. Continuing to allow the use of 2014 Edition CEHRT (Certified Electronic Health Record Technology), while encouraging the use of 2015 edition CEHRT.

4. Adding bonus points in the scoring methodology for: Caring for complex patients.

Using 2015 Edition CEHRT exclusively. 5. Incorporating MIPS performance improvement in scoring quality performance. 6. Incorporating the option to use facility-based scoring for facility-based clinicians.

More Proposed Changes

• CMS is also proposing more flexibilities for clinicians in small practices that would:

• Add a new hardship exception for clinicians in small practices under the Advancing Care Information performance category.

• Add bonus points to the Final Score of clinicians in small practices.

• Continue to award small practices 3 points for measures in the Quality performance category that don’t meet data completeness requirements.


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Quality Reporting

Quality Reporting

Qualitynet Reports


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QRUR Reports

• Used by CMS to determine “value modifiers” for physician payments

• Utilizes both components of the value equation where V = Q/C to determine adjustments to CMS physician payments

• Measures quality through PQRS measures – Billing codes that reflect compliance with quality process measures

– Mostly HEDIS measures developed by the NCQA

• Measures costs by comparing provider’s spending on Medicare patients and comparing to peer groups

Interpreting the QRUR

• Data reported by TIN – group or solo practitioner • 2 year lag • Key measures:

– Quality Composite Score Risk adjusted, composite score across six domains – 1. Effective Clinical Care 2. Person and Caregiver Centered Patient Care and Experience 3. Community Population Health 4. Patient Safety 5. Communication and Care Coordination 6. Efficiency and Cost Reduction

– Cost Composite Score

• Scoring was not done for all provider TINs (groups or individuals) who paid a penalty for not submitting PQRS data or were active in a Medicare ACO (MSSP) in 2015


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QRUR Reports

• Used by CMS to determine “value modifiers” for physician payments

• Utilizes both components of the value equation where V = Q/C to determine adjustments to CMS physician payments

• Measures quality through PQRS measures – Billing codes that reflect compliance with quality process measures

– Mostly HEDIS measures developed by the NCQA

• Measures costs by comparing provider’s spending on Medicare patients and comparing to peer groups

Interpreting the QRUR

• Data reported by TIN – group or solo practitioner • 2 year lag • Key measures:

– Quality Composite Score Risk adjusted, composite score across six domains – 1. Effective Clinical Care 2. Person and Caregiver Centered Patient Care and Experience 3. Community Population Health 4. Patient Safety 5. Communication and Care Coordination 6. Efficiency and Cost Reduction

– Cost Composite Score

• Scoring was not done for all provider TINs (groups or individuals) who paid a penalty for not submitting PQRS data or were active in a Medicare ACO (MSSP) in 2015


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Selection of 6 measures out of 284 Measures* 1 cross-cutting measure and 1 outcome measure, or

* High priority measure if outcome is unavailable

Select from individual measures or a specialty measure setPopulation measures automatically calculated

Key Changes from (PQRS):Reduced from 9 measures to 6 measures •Emphasis on outcome measurement•Year 1 Weight: 60%

Quality

• Clinical Care

• Safety

• Care Coordination

• Patient and Caregiver Experience

• Population Health and Prevention

See List of 284 Measures at

Qpp.cms.gov

Quality Domains


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Electronic Clinical Quality Measure (eCQM)

1. Sign up for a Unified Medical Language allow you to access the National Library of Medicine’s (NLM) Value Set Authority Center (VSAC) to view all codes included in eCQM value sets.

2. Sign up for a JIRA Account: allows you to submit issues regarding eCQM implementation and receive feedback. Key topic areas include the CQM Issue Tracker, Quality Data Model (QDM) Issue Tracker, Quality Reporting Document Architecture (QRDA) Issue Tracker, Bonnie Issue Tracker and Cypress Issue Tracker

eCQMs

3. Signing up for an eCQI Resource Center account and subscribing to the Eligible Professional/Eligible Clinician and/or Eligible Hospital pages will provide you with alert when the EP or EH page has been updated.4. Update codes to latest version:

Work with your coding department and health IT vendor to ensure your systems have been updated to the latest code versionsSome value sets contain “legacy codes.” These codes will be inactive in the current code system version but will be considered active in one of the prior code system versions noted in the file.

5. Work with your health IT vendor to ensure your systems are using updated technical standards and testing tools found in the

eCQM Pre-Publication document and Standards and Tool versions.

https://ecqi.healthit.gov/user/register

https://ecqi.healthit.gov/ep

https://ecqi.healthit.gov/eh

https://ecqi.healthit.gov/system/files/2017-ecqm-au-prepublication.pdf

https://ecqi.healthit.gov/ecqi-standards


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eCQMs

1. Eligible Professionals/Eligible Clinicians or Eligible Hospitals

Review the updated eCQMs used in CMS quality programs for the current reporting/performance period in the sortable table on the Eligible Hospital or Eligible Professional/Eligible Clinicianwebpages

2. Download the eCQM annual update zip files and corresponding artifacts on the Eligible Hospital or Eligible Professional/Eligible Clinician webpages

eCQMs

4. Secure Data on each Measure

Click into an eCQM on the online table to view detailed hhuman-readable information on the measure

Download and open zip files for the individual eCQM your organization uses

Open the Hyper Text Markup Language (HTML) document that contains the measure specification description

Review Health Quality Measure Format (HQMF) document (Include specific reading instruction)








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eCQMs

5. Download the corresponding annual update value sets from NLM’s VSAC using your UMLS license log in.

– eCQM value set files with their associated data types and attributes are available on the Download tab at the VSAC website under the CMS eCQM Value Sets section.

– Review the change files and retired code lists to confirm your patient record data is supported.

eCQMs Implementation

• Perform a Gap Analysis– Review updated value sets– Use the United States Health Information Knowledgebase (USHIK) comparison tool which

may be accessed directly from the measure tables located on the EP/Eligible Clinician and EH pages of the eCQI Resource Center. Select the most current version of the eCQMs and the version of the eCQM you are using. This side by side comparison provides a visual of all changes to a measure, identify the updates that require action on your part such as updating diagnosis codes and/or data fields available in your electronic health record (EHR) or an end user’s workflow.)

• Read the Technical Release Notes. The Technical Release Notes provide a list of all changes to a measure. Identify the updates that require action on your part such as updating diagnosis codes and/or data fields available in your EHR or an end user’s workflow.

https://vsac.nlm.nih.gov/


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eCQMs

• Read the Measure Logic Guidance. The Measure Logic Guidance provides general logic implementation guidance along with detailed information on topics such as measure versioning and time interval calculations.

• Define what system requirements are needed to implement update.• Consider potential workflow impacts, review the workflow section of the

eCQM 102 – How to Implement Quality Measure Updates presentation.• Compile list of system requirements across the measures the organization

will report, as well as overall workflow impacts.• Implement system changes to support data capture for the updated

measures.• Educate clinicians on changes to data entry or workflow, if any.

Quality Scoring

60% of total Composite Score

Report on at least 6 measures

Each measure is worth 3-10 points

Reporting on a Measure = 3 points

Can get more than 3 points if there is a Benchmark

https://www.cms.gov/eHealth/downloads/Webinar_eHealth_June4_eCQM.PDF


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Benchmarks for Scoring

a. Need at least 20 reporters that meet the following criteria

b. Meet or exceeds the minimum case volume (has enough data to reliably measured)

c. Meets or exceeds data completeness criteria

d. Has performance greater than 0 percent

Quality Bonus Points

• 2 bonus points for each additional outcome and patient experience measure

• 1 bonus point for each additional high-priority measure

• 1 bonus point for submitting electronically end-to-end


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Maximum Quality Score

CMS Web Interface Reporter total score 120 for groups with complete reporting and the readmission measure

110 for groups with complete reporting and no readmission measure

Other submission mechanisms total score 70 for 6 measures + 1 readmission measure 60 if readmission measure does not apply

Individual:

• Qualified Clinical Data Registry (QCDR)

• Qualified registry

• Electronic Health Record (EHR)

• Administrative claims

• Attestation

Data Submission


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Group Reporting

Group Reporting:• CMS Web Interface (only available to groups with 25 or more eligible

clinicians)• Qualified Clinical Data Registry (QCDR)• Qualified Registry• Electronic Health Record (EHR)• Administrative Claims• CAHPS for MIPS Survey (only available to groups with 2 or more

eligible clinicians)• Attestation

Reporting

• Must report by March 31, 2018

• Feedback provided

• Payment adjustment January 1, 2019


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Advanced Alternative

Payment Models

MACRA

Alternative Payment Models (“APM”)

1. CMS Innovation Center model

2. MSSP (Medicare Shared Savings Program)

3. Demonstration under the Health Care Quality Demonstration Program

4. Demonstration required by federal law

– FINAL RULE ACO 1+


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Advanced APMs

Qualifying Providers must:

1. Use a Certified Electronic Health Record

2. Perform under the Quality metrics used for MIPS

3. Financial Risk (similar to ACO) or Medical Home Model

• Final Rule creates a Physician-Focused Payment Model Technical Advisory Committee (PTAC) to provide recommendations on

• Physician Focused Payment Models (“PFPM”)

Alternative Payment Models


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Advanced Alternative Payment Model

Significantly

participating in

Advanced APMs

• Receive 25% of your

Medicare payments

OR

• See 20% of your Medicare

patients through an

Advanced APM

5% Increase

Action Items

1. Evaluate QRUR Reports

2. Evaluate Highest Priority Metrics

3. Determine if eCQMs are applicable

4. Confirm if CEHRT can be used to submit

5. Select 6 Measures from the 284 Measures

6. Select Bonus Measures

7. Confirm with EHR vendor the ability to report


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• Quality Payment Program:

– qpp.cms.gov; email:

– [email protected]; or

– dial 1-866-288-8292 (Monday-Friday 8AM-8PM ET). TTY users can call 1-877-715-6222.

Resources


Learning Outcomes

A MIPS Roadmap

By the end of this presentation, you should be able to:

• Describe the Quality Metric percentage of the Composite

Score for each Provider;

• Describe the methods to report the Quality Metrics;

• Understand the types of Quality Metrics available; and

• Understand the impact of the Quality Metrics on MIPS and

APMs.


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QUESTIONS?

If you have questions about this education, please contact:

Michele Madison, Partner


Phone: 404-504-7621

Email: [email protected]

Or you can contact [email protected]

UPCOMING EVENTS & RESOURCESHospital Transformation Consortium

http://d.pr/11oyA


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CONSORTIUM TRAINING

A MIPS Roadmap (Provider Alternative Payment Models/Merit Based Incentive Program)As Physicians become more central to quality and payment model reform, this series of training for hospital

providers and system physician offices will provide a solid foundation for the Merit-Based Incentive

Payments program and other Alternative Payment Models for physicians. Provided by healthcare attorney

Morris, Manning & Martin, learn about the penalties, bonus payments, improvement activities, and

requirements involved for physicians in the program. This MIPS Roadmap will help hospitals to ensure they

are prepared for the upcoming MIPS deadlines, and will include education on the following topics.

Webinar Series held at 12 pm CST / 1 pm EST

September 18, 2017: Focus on Quality Measures Webinar Training 0.1 CEUs

November 13, 2017: Focus on Clinical Practice Improvement Activities

& Advancing Care InformationWebinar Training 0.1 CEUs

February 12, 2018: Cost Metric & Closing Webinar Training 0.1 CEUs

CONSORTIUM SUPPORT

IOWA

WEBSITE DASHBOARD

www.hthu.net/iahtc

GEORGIA/FLORIDA

WEBSITE DASHBOARD

www.hthu.net/htc17


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Questions?

Questions about these resources or Upcoming Events?

Contact:

Susannah Cowart, Quality Program Lead

[email protected]

or

Jennie Price, SHIP Program Manager

[email protected]

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