MACRA MIPS and CME Working Group 3/17/16
MACRA, MIPS and CME • Enacted in April 2015 • Eliminates SGR; Requires EHR interoperability by 2018 • Creates Two New Payment Paths for Medicare Eligible Provider Reimbursement • Path 1: Alternative Payment Model (APM’s) • Path 2: Merit Based Incentive Payment System (MIPS) • MIPS 2017 performance measures determines 2019 Payments • APM selection is necessary before 2019
Healthcare Reform and Transformation • Legislation and Healthcare Change • 1985 e Claims and e Remits Available – Limited Use • 1996 – HIPAA Enacted (Kennedy-Kassebaum Act) ▪ Standardization of Electronic Admin. and Financial Data ▪ Unique Health Identifiers ▪ Security and Privacy • Today, ‘Care/’Caid and Commercial nearly 100% Electronic • 2008 – MIPPA – e Prescribing ▪ 4% of Physicians used eRx in 2004 ▪ Today, 73% Physicians use eRx; 58% of ALL Prescriptions! • 2009 – ARRA/HITECH – Certified EHR Technology … • 30% of physicians used EHR in 2009 • Today 78% Use EHR
In the HIMSS analysis of results, only 3 percent of respondents said they believe their organization is highly prepared to make the transition to pay for value from the current reimbursement approach of fee-for- service. http://s3.amazonaws.com/rdcms-himss/files/production/public/FileDownloads/2016-cost%20-accounting- survey-executive-summary.pdf
Payment Evolution Today – MACRA → Two Payment Paths Alternative Payment Model Differential FFS based on measured performance (MIPS)
Path 1: Alternative Payment Models (APMs) • 2019-24 → 5% Medicare Bonus • Under MACRA, APM includes the following for Medicare patients: − PCMHs − CMMI Models (except grant awards), including: ▪ Bundled Payments ▪ Primary Care Transformation − ACOs under Medicare Shared-Savings Program (MSSP) − Select Medicare demonstrations − Other demonstrations required by law • APM must accept more than nominal risk • All Programs are Data Capture and Reporting
Path 2: Merit Based Incentive Payment System (MIPS) • Incorporates three existing programs into one program • Meaningful Use (Started in 2011) • Physician Quality Reporting System (Started in 2007) • Value Based Modifier (First applied in 2015) • Adds an additional category “Clinical Practice Improvement Activities” (CPIA) • MIPS Scores will • Drive reimbursement levels, and • Posted publicly on Physicians Compare Website
Eligible Professionals in MIPS • Eligible professionals (EPs) for 2017 and 2018 include: • Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists. • In 2019, more professionals become eligible for MIPS, including: • Physical or occupational therapists, speech language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dieticians or nutrition professionals.
Some Providers Exempt from MIPS • Providers who do not meet the "low volume threshold" • Medicare Shared Savings Program Accountable Care Organization providers and other participants in alternative payment models and • First Year Medicare providers • The aforementioned "low volume threshold" can be one of three things: • The minimum number of individuals enrolled under Medicare who are treated by the EP for the performance period; • The minimum number of items and services furnished to individuals enrolled under Medicare by the EP for the performance period or; • The minimum amount of allowed charges billed by the EP under Medicare for the performance period.
MIPS Consolidation of Current CMS Programs Year Meaningful Quality – Resource Clinical Total Use PQRS Use - VBM Practice Points Improvemen t 2017 25 Pts 50 Pts 10 Pts 15 Pts 100 Pts Reporting 2019 Payments 2018 25 Pts 45 Pts 15 Pts 15 Pts 100 Pts Reporting 2020 Payments 2019 25 Pts 30 Pts 30 Pts 15 Pts 100 Pts Reporting
MIPS Payment Adjustments 30% 27% 27% 21% 23% 15% 15% 12% 8% 0% -4% -5% -8% -7% -9% -9% -15% Positive Adjustment Negitive Adjustment Negative Adjustment • • 2019 2020 2021 2022 2023 and Beyond
Physician Quality Reporting System (PQRS) • Standardized federal reporting on Medicare Quality Measures • Combining Several Sources of Measures for MIPS • Several Methods of Reporting o Electronic Health Record (EHR Direct) o Qualified Clinical Data Registry (QCDR) o Group Practice Reporting Option (GPRO) o CMS-Certified Survey Vendor • Important that Physicians Understand which Quality Measures are More Important than others and evidence behind them, • CE Education Is Important for learning the basics of reporting quality measures and providing context to the MIPS program
https://www.facs.org/~/media/files/advocacy/regulatory/ 2013_pqrserx_experience_report.ashx
Meaningful Use • Medicare EHR Incentive Program • Based on usage of EHR System and How it is implemented • Core Objectives • Patient Access to Medical Records • Interoperability of Data • Training is provided by the EHR Companies but Often Missing Clinical Context • Need for Education on How EHR and other health IT can help improve patient outcomes
Low Number of EP’s Attested to Meaningful Use • Eligible Providers • Approx. 1,000,000 Total EPs • 303,801 EPs had attested in 2014 - 30% of EP’s • 303,588 Successfully • 213 Unsuccessfully • 59,605 for Stage 2 - 6.0% of EP’s • Hospitals • 5,414 Total Hospitals • 4,444 Hospital had attested • All successfully for Stage 1 • 1,835 for Stage 2 Source https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ HITPC_January2016_Fulldeck.pdf
Value Based Payment Modifier (VM) • Based on Quality and Efficiency Tiering • Some Credit for Participating in Data Registry • Quality and Efficiency Tiers based on Peer Performance Data • IOM’s → 6 Areas of Quality Measurement (2001) – “Crossing the Quality Chasm” • Per Capita Costs for All Attributed Beneficiaries and Per Capita Costs for Beneficiaries with Specific Conditions measures • The four condition-specific per capita cost measures include the costs of beneficiaries with diabetes, chronic obstructive pulmonary disease, coronary artery disease, and heart failure. • Claims Data • Consumer Assessment of Healthcare Providers & Systems (CAHPS) and Physician Quality Reporting System (PQRS) measures • Little Knowledge of this System, High Failures to Capture Data Consistently and Accurately; and, Report Correctly
Performance on VBM 2016 Physician Fee Schedule 13,813 Physician groups with 10+ eligible professionals (EPs) were subject to the VM 588,167 Physician/TIN combinations impacted 30.9 Billion dollars in 2014 payments reviewed 128 Groups exceed quality and efficiency benchmarks against national mean = eligible for an upward payment adjustment (factor +15.92% or +31.48%) .9% of Eligible Groups received bonus, representing 4,273 physicians 59 Groups in the lower quality/efficiency performance quadrant and subject to a negative payment adjustment (-1.0% to -2.0%) 5,418 Groups were unsuccessful in minimum reporting requirements compliance (PQRS) = decrease in 2016 Medicare payments (-2.0%) – outside budget neutral calculations 39% failed in submission of paperwork. – Penalties represented 141,382 Physicians 8,208 Groups met minimum reporting requirements for unchanged 2016 reimbursement 59% saw no changes in reimbursement Failure to report (technology/compliance issue) or measure strong performance in relation to quality and efficiency measures impacts reimbursement. Note: Physicians participating in a CMS ACO are not subject to the ACA VM https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-VM-Overview-PDF-Memo.pdf
Total Incentive Performance Program Participation Incentive No Difference Penalties Payment PQRS 51% 39% 12% 49% Meaningful 48% 48% Stage 1 52% Use 6% Stage 2 Value Based 61% 01% 60% 39% Modifier
Clinical Practice Improvement Activity (CPIA) • Brand New Measurement Category • Definition: The term "Clinical Practice Improvement Activity" is defined as an activity that relevant eligible professional organizations and other stakeholders identify as one that improves clinical practice or care delivery and that the Secretary determines is likely to result in improved outcomes. • Desired Results: The CPIA will assess healthcare professionals on their effort to engage in continuing education and working to improve their practices and facilitate future participation in APMs.
CME
Reasons To Have CME Recognized In MIPS • CME has long been recognized as a means by which physicians (aka Eligible Providers) demonstrate that they are engaging in Continuing Professional Development (CPD) to maintain the knowledge, skills, and practice performance that lead to optimal patient outcomes. • Lifelong learning, assessment and improvement are integrally related. Learning is a necessary component of the change process that results in meaningful, sustained Clinical Performance Improvement. • Without learning, assessment and professional development, the measurement of adherence to quality metrics, and health information technology usage on their own are insufficient to produce clinical performance improvement.
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