Rural Quality Advisory Council Rural Quality Improvement Technical Assistance (RQITA) Program January 4, 2018
Agenda • Welcome • 2018 Final MIPS Rule: Implications for Rural • NQF MAP Rural Health Workgroup Update • From the Field • RQITA Overview • Wrap-Up 1
Rural Quality Advisory Council • Convened by RQITA team on behalf of FORHP • Purpose: – Offer advice and counsel on development of rural-relevant quality improvement goals and metrics, and integration into new and existing FORHP funded programs. – Provide feedback, guidance, and insight on the development, implementation, and evaluation of the Rural QI TA strategies, tools, and resources. 2
Council Structure • 11 members and 7 key partners, plus RQITA and FORHP staff – Representation across FORHP programs, different types of rural providers, geography • Membership Terms – Key Partners (ongoing) – Rural In-the-Field Leaders (2-year terms) – Subject Matter Experts (2-year terms) 3
Welcome to the 2018 Council • Review of Council background and purpose • Introduction of Council members: a round robin with each Council member introducing themselves and responding briefly to the question, – “ What is the most pressing rural health quality issue or opportunity in 2018 from your perspective?” 4
2018 Final MIPS Rule: Implications for Rural • A re-cap of the 2018 final MIPS rule focused on key features relevant to rural providers, including measure changes and virtual group reporting. • Link to final rule: https://www.cms.gov/Medicare/Quality- Payment-Program/Resource- Library/Resource-library.html 5
2018 QUALITY PAYMENT PROGRAM FINAL RULE Rural Quality Advisory Council Meeting January 4, 2018 6
QUALITY PAYMENT PROGRAM BACKGROUND 7
QPP: WHERE ARE WE GOING IN 2018? Final rule with comment for QPP participation in CY18 published November 2017, comments due January 2 Considerations for Latest QPP Updates Improve beneficiary outcomes Reduce burden on clinicians Increase adoption of Advanced APMs Maximize participation Improve data and information sharing Ensure operational excellence in program implementation Deliver IT systems capabilities that meet the needs of users 8
MIPS YEAR 2 PARTICIPATION ESTIMATES MIPS Eligibility by Practice Size >600,000 clinicians are estimated to (2018 Estimate) be MIPS-eligible in year 2 These clinicians represent 40% of TIN/NPIs and 66% of Medicare Part 19% B allowed charges Approx. 540,000 clinicians excluded due to low-volume threshold 185,000-250,000 clinicians expected to be qualifying participants (QPs) in APMs 1-15 Clinicians 16-24 Clinicians 25-99 Clinicians 100 or More Clinicians 9
QUALITY PAYMENT PROGRAM FINAL RULE FOR CY 2018 MIPS Policies of Interest to Rural Providers: • Increasing the low-volume threshold • Increasing the performance threshold and payment adjustment • Adding cost as a component of the MIPS score • Addressing policies for “topped out” measures • Allowing for bonus points to be added to the MIPS score • Giving solo practitioners and small practices the choice to form Virtual Groups • Clarifying rural and HPSA practice designations • Delaying facility-based measurement until year 3 10
LOW VOLUME THRESHOLD IN YEAR 2 11
PERFORMANCE THRESHOLD AND PAYMENT ADJUSTMENT IN YEAR 2 Year 2: Performance in 2018 that applies to payments in 2020 Performance Threshold: 15 point MIPS Performance Score for neutral or positive payment adjustment in year 2 Increases from 3 point threshold in year 1 Exceptional performance remains set at 70 points Payment Adjustment: Maximum payment adjustment of ± 5% in year 2 Increasing from ± 4% in year 1 Fee Schedule Adjustment: 0% for 2020 payments Decreases from +0.5% for 2019 payments Remains at 0 until 2026 0.75% qualifying APM conversion factor 12 0.25% non-qualifying APM conversion factor
MIPS YEAR 2 SCORING Performance Period in Year 2 • Quality and Cost: 12 months • IA and ACI: 90 Days 13
COST YEAR 2 SCORING Change: 10% Counted toward Final Score in 2018 Medicare Spending per Beneficiary (MSPB) and total per capita cost measures are included in calculating Cost performance category score for the 2018 MIPS performance period. These measures were used in the Value Modifier and in the MIPS transition year CMS is developing new episode-based measures with significant clinician input to propose in future rulemaking 14
QUALITY YEAR 2 SCORING 15
QUALITY: TOPPED OUT MEASURES 16
QUALITY: TOPPED OUT MEASURES 17
QUALITY: NEW MEASURES FOR 2018 Q459: Average Change in Back Pain following Lumbar 1. Discectomy / Laminotomy Q460: Average Change in Back Pain following Lumbar Fusion 2. Q461: Average Change in Leg Pain following Lumbar 3. Discectomy / Laminotomy Q462: Bone Density Evaluation for Patients with Prostate Cancer 4. and Receiving Androgen Deprivation Therapy Q463: Prevention of Post-Operative Vomiting (POV) - 5. Combination Therapy (Pediatrics) Q464: Otitis Media with Effusion (OME): Systemic Antimicrobials - 6. Avoidance of Inappropriate Use Q465: Uterine Artery Embolization Technique: Documentation of 7. Angiographic Endpoints and Interrogation of Ovarian Arteries Q467: Developmental Screening in the First Three Years of Life 8. 18
QUALITY AND COST: IMPROVEMENT SCORING 19
SPECIAL MIPS SCORING PROVISIONS FOR SMALL AND RURAL PROVIDERS IN 2018 Category Scores Quality: Small practices receive 3 points for measures not meeting data completeness requirements ACI: Hardship exemptions available for small and rural providers IA: Report on no more than 2 medium or 1 high- weighted activity to reach the highest score Final Score Bonuses Small Practice Bonus: 5 bonus points to final score for practices of 15 or fewer clinicians No Rural Bonus Complex Patient Bonus (not specific to small or rural providers): Up to 5 bonus points 20
MIPS DATA SUBMISSION 21
VIRTUAL GROUPS IN CY 2018 Eligibility: A solo practitioner or a group of 10 or fewer eligible clinicians May join one virtual group for a performance period Election to join applies to all MIPS-eligible clinicians in the group Solo practitioners or group must be MIPS-eligible Election Deadline: December 31, 2017 for 2018 participation Election Process: A two-stage virtual group election process for 2018 and 2019 Stage 1 (optional): Virtual group eligibility determination Stage 2: Virtual group formation Agreement: Virtual groups must execute a written formal and contractual agreement between each member of a virtual group meeting specified criteria Reporting Requirements: Assessed at the virtual group level across all four MIPS performance categories CMS Estimate: 765 MIPS eligible clinicians will join 16 virtual groups in 2018 22
ALTERNATIVE PAYMENT MODELS Extends the revenue-based nominal amount standard for two additional years (through performance year 2020) Changes the nominal amount standard for Medical Home Models so that the minimum required amount of total risk increases more slowly Gives more detail about how the All-Payer Combination Option will be implemented Allows clinicians to become Qualifying APM Participants (QPs) through a combination of Medicare participation in Advanced APMs and participation in Other Payer Advanced APMs Available beginning in performance year 2019 23
BUDGET ESTIMATES MIPS CMS estimates 96.8% of MIPS eligible clinicians will report in 2018 97.1% to receive positive or neutral payment adjustments 74.4% to receive “exceptional payment adjustment” CMS estimates that small practices are somewhat less likely to reportin 2018 and avoid negative payment adjustments 90.0% of MIPS eligible clinicians in small practices expected to report 90.9% to receive positive or neutral payment adjustments 61.3% to receive “exceptional payment adjustment” CMS hopes to achieve budget neutrality with equally distributed negative and positive payment adjustments (both $118 million) With approximately $500 million in exceptional performance payments Advanced APMs CMS estimates between $675 million and $900 million APM incentive payments in 2020 24
RESOURCES QPP Website QPP CY 2018 Final Rule QPP CY 2018 Executive Summary QPP Year 2 Overview Fact Sheet 25
DISCUSSION QUESTIONS What are your thoughts on CMS increasing the low volume threshold? What expectations do you have for rural participation in MIPS and virtual groups? What approaches could help simplify the scoring approach? What considerations exist for the addition of the cost category and rural providers for year 2? Are there changes that could encourage greater rural participation in APMs? 26
NQF MAP Rural Health Workgroup Update • Newly launched MAP Rural Health Workgroup was formed to provide recommendations on issues related to measurement challenges in the rural population. • Additionally, the Workgroup will identify a core set of the best available (i.e., “rural relevant”) measures and identify rural - relevant gaps in measurement. 27
NQF MAP Rural Health Workgroup (cont.) • The workgroup meets approximately monthly November 2017 – August 2018, and will have met twice prior to the January 4th Council call. • http://www.qualityforum.org/MAP_Rural_Heal th_Workgroup.aspx 28
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