Under the MACRAscope:

Robert Tennant, MADirector, HIT Policy, MGMA Government Affairsrtennant@mgma.org

G08: Under the MACRAscope: MIPS and EHRs

Learning ObjectivesThis session will provide you with the knowledge to:

• Distinguish the requirements related to the ACI component of MIPS

• Understand how ACI is expected to impact your medical group

• Recognize the challenges associated with ACI and tactics to help overcome them

Abstract• The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

permanently eliminated the SGR’s annual threat of physician payment cuts and enacted significant reforms to Medicare EHR requirements.

• MACRA requires that a Merit-Based Incentive Payment System (MIPS) include an EHR usage component known as Advancing Care Information (ACI) to replace Meaningful Use.

• This session will outline ACI, worth 25% of the MIPS calculation, which is a complex set of requirements that involve eligible clinicians achieving both a “base” score and a “performance” score in order to achieve success.

• Session participants will receive an overview of the key regulatory provisions of ACI, an analysis of the challenges associated with this MIPS component, and a discussion of potential ACI implementation strategies.

Agenda• Changes to 2016 Meaningful Use• MACRA Overview:

– Legislation / Final Regulation (MIPS/APMs)

• ACI Specifics– Base Score / Performance Score / Bonus Points– EHR Certification– Exceptions

• Practice Action Steps• Appendix

• Q/A #UndertheMACRAscope

Key regulatory proposals impacting EP participation in 2016 Meaningful Use

Shorter Reporting Period. Any continuous 90-day reporting period for 2016.Clinical Quality Measurement. Any continuous

90 days for any EP who reports via attestation for 2016. Does not need to be same 90 days as the EHR reporting for measure and objectives.New Hardship Category for EPs Transitioning to

MIPS. For EPs who are new to the MU program and plan on transitioning to MIPS in 2017.

MACRA(Medicare Access and CHIP Reauthorization Act)

MACRA: How we got here

Historic, bipartisan legislation• 484 members of Congress

or 91% voted for MACRA• Supported by MGMA,

AMA, AHA, and many more physician stakeholders

• Signed into law April 2015

MACRA payment reform

Pre-MACRA

Annual update uncertainty resulting from SGR

Largely fee-for-service payment

Three fragmented quality reporting programs

Limited bonuses and up to 9% reporting penalties

Post-MACRA

Permanent repeal of SGR, stable payment updatesIncentivizes the transition to value-based paymentCombines quality reporting programs into oneIncreased bonuses and decreased risk at outset

“We are now in the process of ending Meaningful Use and moving to a new regime

culminating with the MACRA implementation….The Meaningful Use program

as it has existed, will now be effectively over and replaced with something better.”

- CMS Acting Administrator Andy Slavitt, Jan. 11, 2016

Andy Slavitt on “The Death of Meaningful Use”

Advancing Care InformationFinal Rule

Quality30%

Advancing Care Info (EHR Use)

25%Cost30%

MIPS performance category weights

2017 2018 2019…IA

15%

ACI25%

Quality60%

IA 15%

ACI25%

Quality50%

IA 15%

ACI25%

Cost30%

Quality30%

Over time, the cost category will gradually become larger and the quality category will become smaller

BASE SCORE + PERFORMANCE SCORE + BONUS POINTS = TOTAL ACI POINTS

Earning 100 (or more) ACI points will award you the full 25 MIPS composite score points*

• fBASE SCORE

50 POINTS

PERFORMANCE SCORE

90 POINTS

BONUS POINTS(VIA PUBLIC HEALTH OR

CLINICAL REGISTRY)

5 POINTS

BONUS POINTS(VIA CPIA)

10 POINTS

*90-day reporting in 2017-2018

Base Score 2017 (50 %)

• Base score comprised of 4 required objectives (down from 11 in the proposed rule):1. Performing a Security Risk Analysis2. E-Prescribing3. Providing Patient Access to their Data4. Health Information Exchange

Base Score 2018+ (50 %)• Base score comprised of 5 required

objectives:– Performing a Security Risk Analysis– E-Prescribing– Providing Patient Access to their Data– Sending Summary of Care via HIE– Requesting/Accepting Summary of Care

Base Score• Base Score numerators will be either one

patient (e-prescribing, providing patient access, HIE) or a yes/no (conducted a Security Risk Analysis) answer during attestation

• Failure by an EC to meet any of the base score requirements will result in a 0 for the Base Score and a 0 for the entire ACI category

1. Protect Patient Health Information• Objective: Protect ePHI created or maintained by the

CEHRT through the implementation of appropriate technical, administrative, and physical safeguards

• Measure: Conduct or review a security risk analysis in accordance with the requirements, including addressing the security (to include encryption) of ePHI data created or maintained by CEHRT in accordance with requirements, implement security updates as necessary, and correct identified security deficiencies as part of the ECs risk management process.

Note: RA-leading cause of failing MU audit!

Risk Analysis Tips• Don’t assume your RA will be conducted by your

EHR vendor (without additional cost)• Talk to colleagues-how did they conduct their RA?• Do assume that you will be audited• Review the available resources (i.e., MGMA, HHS)• Focus on highly vulnerable areas and consider

outside help (i.e., mobile tech, security for remote access to EHR)

• Document everything RA-related

t

2. Electronic Prescribing• Objective: Generate and transmit

permissible prescriptions electronically• Measure: At least one permissible

prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRTNote: ERX not in performance category

(topped out)

3. Patient Electronic Access (2017)• Objective: The EC provides patients (or patient-

authorized rep) with timely electronic access to their health information and patient-specific education

• Measure: At least one patient seen by the EC during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the EC’s discretion to withhold certain information

Note: HIPAA gives the EC the right to redact info that could be harmful to patient or someone else

4. Health Information Exchange • Objective: the EC provides a summary of care record

when transitioning or referring their patient to another setting of care, receives or retrieves a SOC record upon the receipt of a transition or referral or upon the first patient encounter with a new patient, and incorporates SOC information from other clinicians into their EHR using the functions of CEHRT

• Measure: the EC transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a SOC record; and (2) electronically transmits such summary to a receiving clinician for at least one transition of care or referral

Performance Score-2017• 7 “performance” options in 2017 (2 from base)• 10% each for 5 measures• 20% for base score patient access / HIE

measures• 90 total points possible• Achieving 90% in a given measure will earn 9

points (18 points if measure worth 20%). If you are between (such as an 85%), you would round to the nearest whole number—9 points.

2014 Edition Objectives(only available for use in 2017)

2014 Edition Objectives(only available for use in 2017)

Bonus Scoring• Up to 5% for reporting to one or more additional

public health or CDRs beyond Immunization registry reporting (active engagement)

• ECs can earn up to 10% in the performance score for reporting a designated improvement activity using CEHRT.

• Table 8 in final rule lists 18 IAs, Table H lists 19– Extra one is “Provide self-management materials at

an appropriate literacy level and in an appropriate language” and CMS now tells us it doesn’t count

ACI Improvement Activity Examples Engage patients, family and caregivers in developing a plan of

care and prioritizing their goals for action, documented in the CEHRT.

Use decision support and protocols to manage workflow in the team to meet patient needs.

Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).

Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: participate in a Health Information Exchange if available; and/or use structured referral notes

Complete list at mgma.org/MACTA

Sample 2017 EC ACI ScoreMeasure Action and Score

1 Base Score (50%) 50 ACI %

2 (Performance) PatientElectronic Access (20%)

You provided 45% of your patients access to their medical record (VDT) on your portal within 48 hrs of the visit = 10 ACI %.

3 (Performance) Health Information Exchange (20%)

You provided a summary of care via your EHR to 34% your patients during their transition/referral to other clinical sites = 6 ACI %.

4 (Performance) Secure Messaging (10%)

You had 37% of your patients send the practice a secure message = 4 ACI %.

5 (Bonus) Public Health and CDR Reporting (5%)

You were able to report to a state public health registry = 5 ACI %

6 (Bonus) ImprovementActivity (10%)

Used CEHRT decision support and protocols to manage workflow = 10 ACI %

7 Total ACI Percent (out of 100) 858 Total MIPS Composite

Score Points21.25 points(Out of a possible 25)

Data Blocking Attestation • ECs must attest to 3 statements:

1. EC did not limit or restrict the compatibility or interoperability of certified EHR technology.

2. EC implemented technologies, standards, policies, practices, and agreements

3. EC responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information

EC expected to “take reasonable steps but EC “will not be held accountable for factors that it cannot reasonably influence or control

Hardship Exceptions• Exceptions same as existing 2016 Meaningful

Use program:– Insufficient Internet Connectivity– Extreme and Uncontrollable Circumstances– Lack of Control over the Availability of CEHRT– Hospital-based (reduced from 90% to 75%,

POS 21, 22, or 23 )– If granted, ACI weighted to zero % for MIPS

final score

Rural Health Clinics/FQHCs

• Items and services furnished by an EC that are payable under the RHC or FQHC methodology 158 are not be subject to the MIPS payments adjustment

• These ECs have the option to voluntarily report on applicable measures and activities for MIPS

Level of EHR Certification Required• 2014 CEHRT or a combination of 2014 and

2015 CEHRT is acceptable for 2017• For 2018, only 2015 CEHRT will be

permitted– “While we understand the commenters’

concerns…(We) encourage MIPS eligible clinicians to work with their EHR vendors in the coming months to prepare for the transition to 2015 Edition in for the performance period in CY 2018.”

Have no EHR or Plan to Skip ACI in 2017?• Can you avoid the penalty and potential get a

bonus in 2019? YES!• 2017-Quality component of MIPS is worth 60

points, IA 15 points• Max these out (i.e., report 6 quality measures,

and implement sufficient IAs) and you could see a small bonus

• OR report at least one quality measure or one IA to avoid the 2019 penalty

ACI issues and challenges• Base Score (4-5 objectives make it easier, but

still “all or nothing”)• Performance Score

Many necessitate 3rd party actionsNo thresholds = uncertainty regarding practice

resource deployment

• 2015 CEHRT optional in 2017, required in 20182014 edition products certified = 4,2252015 edition products certified = 19 (12 EPICs)

Action steps for your practice

Steps to PrepareUnderstand that specifications could change

– Specifications (2018+) subject to change– CMS expected to release additional

information/guidance– Stay informed on all program updates via Washington

ConnectionAssess your practice’s performance under

current the Meaningful Use program– Are you/did you participate in MU? – Build on your existing templates/dashboards– Reporting quality data via EHR an option?

Steps to PrepareExplore technology-based clinical

practice improvement opportunities – Bonus points in the ACI category– Look to also meet your 15% IA category– Review IA alternatives and discuss internally

the best options (clinical relevance, technology capability, staff availability, cost)

– Are you doing one or more IAs already?– Leverage IAs in your marketing

Steps to PrepareReview your workflow processes related to patient

engagement– Determine the percentage of your patients who

engaged your clinicians through secure messaging or viewed, downloaded or transmitted their record via your web portal

– More challenging for certain specialties – What would you have to do to increase

numbers?• Assign FTEs, patient engagement campaigns,

waiting room patient education, kiosks/iPads, include in pre-registration process

Steps to PrepareReview your workflow processes related to

data exchange– Determine what percentage of your external

transitions of care involved data exchange via your EHR?

– Identify the care settings you interact with that can exchange summary of care documents

– Build those relationships for both sending and receiving SOC documents

– Evaluate your vendor and staff training needs in this area

Steps to PrepareEvaluate EHR and other tech vendor readiness

– Determine if your vendors are able to support the transition to MIPS/APMs

– Ask your vendor what IAs they can support– When does your EHR expect to recertify to ONC 2015

requirements? If not…– Review your vendor contracts– Identify potential new vendors – Combine with PM review– Network with your MGMA colleagues to help select– Determine and budget for anticipated upgrade or

replacement costs

Steps to PrepareVisit MGMA.org/MACRA for an member-benefit

summary of the final rule, a guide for small practices, and all the latest news about MIPS and APMs.

Join MGMA’s new interactive e-group, “MIPS/APMs Medicare Value-Based Payment Reform,” to interact with your peers and ask MGMA Government Affairs staff questions as the MIPS and APM programs unfold.

Read your Washington Connection eNewsletter-we will communicate to members all policy changes from the government and announce any new CMS or MGMA member-benefit resources.

Summary• ACI 25% of the total MIPS composite score• 155 available ACI points / 100 ACI points gets you your full 25%• Base Score is 50 points toward the ACI score and is “all or nothing”• For 2017, Performance Score is worth up to 90 points with 7

options• Bonus point opportunities (up to 15 points) by (i) PH/CDR

reporting or (ii) reporting an improvement activity• 2014 CEHRT in 2017, 2015 CEHRT starting in 2018• 90-day reporting (2017-2018)• ECs can skip ACI in 2017 and potentially STILL get small bonus

and/or avoid 2019 penalty• Look to MGMA for updates and resources!

Don’t miss out on the other timely Government Affairs sessions at

AC16! Today, don’t miss the continuation of our Under the “MACRAscope” session series:

• 2:45-3:35 p.m. Group Practice Perspectives on APMs

And on Wednesday, join GA for the culminating main stage session of AC16!

• 8:30-9:30 a.m. MGMA's View from Washington

Let Robert know what you thought!

Fill out the speaker evaluation emailed to you at the end of each day or immediately through the MGMA16 mobile app.

For Continuing Education

(ACMPE – 1 credit, CPE – 1.2 credits, CEU – 1 credit)

CPE credit requires a code to claim credit – use the code: AC16CPE1

Remember to get scanned into every session throughout the conference to qualify for CPE and CEU credit

Visit: mgma.org• MACRA Resource Center

– Resources to assist members navigate each of the MIPS components and APMs

–Meaningful Use Resource Center• Assistance in meeting the 2016

requirements

• HIPAA Resource Center– Assistance in conducting a risk analysis

Thank You!

Robert Tennantrtennant@mgma.org

202.293.3450

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Appendix

Quality30%

Advancing Care Info (EHR Use)

25%Cost30%

MIPS category weights for MIPS APMs

MSSP Track 1 and Next Gen ACOs

IA 20%

ACI30%

Quality50%

IA 25%

ACI75%

Other MIPS APMs

* Does NOT include cost * Does NOT include cost or quality

Patient-Facing Encounters

• CMS will publish the list of patient-facing encounters on the CMS Web site located at www.QualityPaymentProgram.cms.gov

Summary of Care Requirements• Summary of care must include the following

information, if the provider knows it: – Patient name / Demographic information (preferred language, sex, race,

ethnicity, date of birth) / Vital signs (height, weight, blood pressure, BMI) / Smoking status

– Referring or transitioning provider’s name and office contact information– Encounter diagnosis / Procedures– Laboratory test results / Immunizations– Functional status, including activities of daily living, cognitive and

disability status– Care plan field, including goals and instructions– Care team including the primary care provider of record and any

additional known care team members beyond the referring or transitioning provider and the receiving provider

– Reason for referral

2015 Edition Objectives(for use in 2018)

2015 Edition Objectives(for use in 2018)