© 2016, Telligen, Inc.

Michelle Brunsen & Sandy Swallow

June 22, 2017

MIPS Sur v ive and Thr ive:

Improvement Act iv i t ies and Cost

Categor ies

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Calendar Year 2018 Updates to the QPP▪ Fact Sheet: CY 2018 Updates to QPP PROPOSED RULE

▪ CY 2018 Updates to QPP PROPOSED RULE (CMS-5522-P)

▪ Comments on the rule are due by 5:00 pm ET on 8/21/17 (instructions p. 2 of Proposed Rule using link above)

▪ If submitting comments electronically:– https://www.regulations.gov/

– Type in Search field: CMS-2017-0082

– Click on the one option: Medicare Program; CY 2018 Updates to the QPP

– Click on “Comment Now!”

PROPOSED RULE RELEASED 6/20/17

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▪ Quality Payment Program Categories and Weights

▪ Improvement Activity Category– Basics

– Scoring examples

– Tips

▪ Cost Category– Focus on the requirements

– Patient attribution

– Proposed episodes of care

– Scoring basics

▪ Connect the Final Score to the MIPS payment adjustment

Objectives

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Performance Categories and Weights

Quality Payment Program

Quality 60% MIPS

50% MIPS-APMs

Advancing Care Information

25% MIPS30% MIPS-APMs

Improvement Activities 15% MIPS

20% MIPS-APMs

Cost 0%

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Quality Payment Program

Improvement Activities Category

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▪ 15% of Final Score in Transition Year (20% for MIPS-APMs)

▪ Assesses participation in activities that improve your clinical practice

▪ Patient centric

▪ 92 activities

▪ Encourages participation in certified patient-centered medical homes (PCMH) and Advanced Alternative Payment Models (APMs)

▪ Medium- or High-Weighted Activities– Medium = 10 points

– High= 20 points

▪ Need 40 points for maximum score

Improvement Activities Basics

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Subcategories

Improvement Activities Basics

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▪ Maximum Points = 40 Points– High-weighted activities = 20 points

– Medium-weighted activities = 10 points

▪ Participation Thresholds– 90-day minimum required

▪ Reporting Options: – Attestation

– Qualified Registry

– EHR direct

– Qualified Clinical Data Registry (QCDR)

– CMS Web Interface (for groups 25 clinicians or more)

▪ No submission of evidence required – May be audited; keep documentation for a minimum of 6 years!

Improvement Activities Basics

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Special Scoring Considerations▪ Participant in PCMH = Maximum Possible Points (40)

– Certification from a nationally recognized certifying agency

▪ Participant in APM Designated as a Medical Home Model – 50-100% of maximum possible points at CMS’ discretion

▪ Special Populations –> Alternate Activity Weights– Practices with <= 15 clinicians

– Rural

– Health Professional Shortage Area (HPSA) practices

– Non-patient facing MIPS Eligible Clinicians

– Medium-weight activity = 20 points

– High-weight activity = 40 points

Improvement Activities Basics

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▪ Full credit for APM Entity Group by virtue of participation

▪ No additional reporting necessary

▪ APMs hold their participants accountable for cost and quality of care provided to Medicare Beneficiaries (MIPS APM)

▪ In future years, credit can drop as low as 50% for APM participation

▪ List of Improvement Activity and Subcategory with weighting for each model on Resources slide

APM Scoring Standard Basics

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▪ Medicare Shared Savings Program ACOs (Tracks 1, 2 and 3)

▪ Next Generation ACO Model

▪ Oncology Care Model (one- or two-sided risk arrangement)

▪ Comprehensive Primary Care Plus Model (CPC+)

▪ Comprehensive ESRD Care Model (CEC) Large Dialysis Organization (LDO) Arrangement

Non-LDO Arrangement – one-sided risk

Non-LDO Arrangement – two-sided risk

MIPS APMs for 2017 Performance Period

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Receive 0 Points

▪ Do not select any activities

▪ Do not implement for at least 90 days

▪ Not participating in an APM

▪ Not participating in a certified patient-centered medical home or comparable specialty practice

Improvement Activities Basics

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CMS’ QPP site: https://qpp.cms.gov

Choosing Improvement Activities

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CMS QPP Site – Choosing Activities

Improvement Activities Basics

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✓ Annual registration in the Prescription Drug Monitoring Program

✓ Consultation of the Prescription Drug Monitoring Program *

✓ Engagement of new Medicaid patients and follow-up *

✓ TCPI participation *

✓ Implementation of improvements that contribute to more timely communication of test results

✓ Provide 24/7 access to care for advice about urgent and emergent care *

* High-weighted activities

Improvement Activities Examples

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2017 IA Scoring Example for Practice >15 ECs

Activity Measure Weight Points Total Possible Points

1 Improvements for timely communication of test results

Medium 10

2 Engagement of new Medicaid patients

High 20

3 24/7 Access to care High 20

50 40

50 points/40 possible category points = 125%

100% Cap of 40 points

X 15 Possible Composite Category points

15 Composite Category Points Earned

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2017 IA Scoring Example for Practice <15 ECs

Activity Measure Weight Points Total Possible Points

1 Annual Registration Prescription Drug Monitoring Program

Medium 20

2 TCPI Participation High 40

60 40

60 points/40 possible category points = 150%

100% Cap of 40 pointsX 15 Possible Composite Category points15 Composite Category Points Earned

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Category Reporting Requirements

Category Scoring Category Weight

Improvement Activities

No additional reporting necessary

• Full credit for the APM Entity Group through MSSP participation.

• In future years, credit could drop as low as 50% for MSSP participation, allowing additional reporting by ACO participant TINs to achieve full credit in this performance category.

20%

Special IA Scoring Standards for MIPS-APMs

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▪ 14 high-weighted activities – START HERE – 1 needed for practice with 15 or fewer clinicians

– 2 needed for practice 16 or more clinicians

▪ 13 activities include Qualified Clinical Data Registries (QCDRs)

▪ For group reporting, only 1 MIPS EC in a TIN must perform the Improvement Activity for the TIN to get credit

▪ Avoid a -4% payment adjustment in 2019 – Test Pace– Select one Improvement Activity

– May have implemented an Improvement Activity already

– Use the CMS’ portal to attest for 2017 Transition Year at no cost

▪ List of activities for MIPS APMs

Improvement Activities Tips

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▪ Implement activities for at least 90 days – START NOW– Review activities in detail

– Ask for team input

– Discuss how to implement activities

– Decide how to document activities for proof, if audited

▪ Document steps taken to implement Improvement Activity– Differs depending on Improvement Activities chosen

▪ Documented Policy

▪ Brochure

▪ Agreement (TCPI, Prescription Drug Monitoring Program) and annual updates

– Keep for minimum 6 years electronically and on paper

▪ Receive 10% bonus points in Advancing Care Information Category by submitting using your CEHRT

Improvement Activities Tips

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Bonus Score Opportunities – 10% ACI Category

Report Improvement Activities Using CEHRT

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Quality Payment Program

Cost Category

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Replaces cost component of Value Modifier Program

▪ Cost scoring weight– 0% for 2017

– 10% for 2018

– 30% for 2019

▪ CMS will provide feedback report based on 2017 claims data– All measures are calculated on administrative claims collected for full

year

– Actionable

▪ No separate reporting is required

Focus on the Cost Performance Category

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Cost Changes

▪ Patients attribution– No longer attributed to TIN

– Attributed to TIN-NPI level of PCP with plurality of visits

▪ Specialist attribution if no PCP visits

– May change TIN cost performance metrics

▪ Cost comparison– Decile ranking instead of + standard deviation

Focus on the Cost Performance Category

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Risk Adjustments Apply

▪ Geographic Payment Rate– Location modifications in the fee schedule

▪ Hierarchy Condition Codes (HCC)▪ Beneficiary risk – complexity

▪ Specialty adjustment applied only to Total per Capita Costs Measures

Focus on the Cost Performance Category

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Cost Measures

▪ Total per capita costs (Parts A and B) for all attributed beneficiaries– Annual costs per beneficiary from all sources

– Attributed to one PCP (group)

▪ Medicare spending per beneficiary (MSPB)– Charges attributed to inpatient stays

– Attributed to provider (group) with plurality of charges

– Case minimum dropped from 125 to 35

▪ Episode-based measures– 10 anticipated in 2018

– 40 being tracked

Focus on the Cost Performance Category

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Plans to Develop▪ MACRA requires the establishment and use of classification

code sets– Additional Care Episodes Measures

– Additional Patient Condition Groups and codes

▪ Diabetes

▪ COPD

– Patient Relationship Categories and codes

▪ 5 “Proposed” in the works

▪ Risk adjustments on socio-economic status

▪ Include Part D costs

Focus on the Cost Performance Category

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Focus on the Cost Performance Category

*Current Episodes of Care– Aortic/mitral valve surgery

– CABG

– Hip/Femur Fracture or Dislocation Treatment

– Cholecystectomy and common duct exploration

– Colonoscopy and biopsy

– TURP for BPH

– Lens and cataract procedures

– Hip replacement or repair

– Knee arthroplasty

– Mastectomy

Proposed Episodes of Care– Ischemic Heart Disease, Chronic

– Ischemic Stroke

– Cholecystitis

– Prostatectomy for Prostate Cancer

– Kidney and Urinary Tract Infection

– Osteoporosis

– Parkinson Disease

– Rheumatoid Arthritis

– Asthma/COPD, Acute Exacerbation

– Asthma/COPD, Chronic

– URI, Acute, Simple

– Deep Vein Thrombosis of Extremity

*CMS will still provide feedback on performance in these categories in 2017, but it will not affect your 2019 payments

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▪ Score each measure on a 10 point scale based on decile rank

▪ Compare to measure-specific performance period benchmarks

▪ Consider Improvement Scoring after the first year

▪ 20 case minimum to be included in benchmark

▪ Composite Score is a straight average of all calculated standardized components that have a 20 case minimum

Cost Category Scoring Basics

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Hypothetical Cost Scoring Example

4 Cost Measures Scored

Total Possible Points = 40

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Hypothetical Cost Scoring Example

Actual Total Score = 22.3

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Hypothetical Cost Scoring Example

22.3 Actual Points

40 Total Points= 55.8%

Max. Cost Score for 2018 = 10

55.8% of 10 = 5.6

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Special Cost Scoring Standards for MIPS APMs

Category Reporting Requirements

Category Scoring

CategoryWeight

Cost (VM) • MIPS eligible clinicians participating in the MSSP will not be assessed on cost. No reporting necessary.

• N/A 0%

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2017 Feedback Report Can Tell You

Focus on the Cost Performance Category

▪ Care coordination efforts

▪ Areas where your care is more costly than your peers

▪ Referral patterns

▪ Care you manage outside your office

▪ Post acute care partners

▪ Communicate to patients about where they chose their care

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Quality Payment Program

Connect the Final Score to Payment Adjustment

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How Are Payments Adjusted Under MIPS?

MIPS Financial Impact on Clinicians

▪ Calculate the final score by sum of performance categories

▪ Positive, negative, neutral adjustments based on CMS-established threshold

– Budget neutral program

▪ Clinicians at or above performance threshold will receive a neutral or positive adjustment factor based on a linear sliding scale

▪ Adjustments applied to a clinician’s Medicare Part B claims

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2017 Final Score Need to Know

Connecting the Final Score to Payment Adjustment

3+ points avoid the negative payment adjustment

70+ points gain access to $500 million bonus pool for exceptional performers

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You can earn the 3 point minimum by:

Connecting the Final Score to Payment Adjustment

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Reasons to go for full participation:

▪ 2017 is the easiest year to access $500M bonus pool

▪ Public reporting

▪ Setting up for future success

Connecting the Final Score to Payment Adjustment

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Bringing it all together

Connecting the MIPS Final Score to Payment Adjustment

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2017 Performance Score Thresholds

Final Score Points

Payment Adjustment

> 70 points • Positive adjustment• Eligible for exceptional

performance bonus –minimum of additional 0.5%

4-69 points • Positive adjustment• Not eligible for

exceptional performance bonus

3 points • Neutral payment adjustment

0 points • Negative payment adjustment of -4%

• 0 points = does not participate

Bringing it all together!

Hypothetical MIPS Scoring Example

Quality + ACI + IA + Cost = Final Score

49.9 20 15 0 84.9

Payment Adjustments in CY 2019

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•3+ points to avoid negative payment adjustment

•70+ points to access $500M bonus poolFinal Score

•No longer all-or-nothing

•Ample opportunities for bonusesQuality

•Attest to 2-4 activities out of 92

•No evidence needs to be reported; but should be on recordIA

•All base measures required to get any points

•Need 100 out of 155 possible for max scoreACI

•Goal is to align cost measures with quality of care assessment so that patient outcomes and smarter spending can be pursuedCost

Take-Aways!

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Full Service QPP Technical Assistance

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▪ CMS QPP Website– Improvement Activities Fact Sheet

– Scores for Improvement Activities in MIPS APMs for 2017

– MACRA Quality Payment Program Overview – Recording

– Merit-based Incentive Payment System (MIPS) Overview – Recording

– Getting Started with the QPP: An Overview of MIPS for Small, Rural and Underserved Practices - Recording

Resources

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Thank you for joining us!

Sandy Swallow

515-223-2105

Sandy.swallow@area-D.hcqis.org

www.telligenqinqio.com

Michelle Brunsen

515-453-8180

mbrunsen@telligen.com

www.telligenqpp.com

This material was prepared by Telligen, the Quality Payment Program Small, Underserved and Rural Support contractor for Iowa, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy