MACRA - Robert Hall
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State Legislative Conference 2016
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MACRA - Robert Hall
- 5. MACRA Timeline • MACRA enacted: April 16, 2015 • Request For Information: October 2015 • Proposed Rule released: April 27, 2016 – 60-day comment period • Final Rule released: October 14, 2016 *Medicare physician fee schedule published separately 5 Materials herein reflect public law 114-10 dated April 16, 2015
- 6. MACRA Timeline 2017 2018 2019 2020 2021 2022-2024 2025 2026 Medicare Part B Baseline Payment Updates +0.5% +0.5% +0.5% 0% 0% 0% +0.25%* +0.75%** *Non-qualifying APM Conversion Factor **Qualifying APM Conversion Factor Merit-Based Incentive Payment System (MIPS) PQRS, Value-based Modifier, & Meaningful Use Quality, Cost, Advancing Care Information, & Improvement Activities -9% -9%? 0 or +/-4%* “Pick Your Pace” +/-5% +/-7% Qualifying APM Participant 5% Incentive payment Excluded from MIPS +0% +/-9% 6
- 7. Medicare Physician Payments 2017 to 2020 2015 Performance Year – PQRS, VBM, MU • 2017 Payment Year [-9%] 2016 Performance Year – PQRS, VBM, MU • 2018 Payment Year [-9%] 2017 Performance Year – MACRA Pick Your Pace • 2019 Payment Year [0 to +4%] 2018 Performance Year – MACRA QPP • 2020 Payment Year [+/- 5%]
- 8. MACRA Quality Payment Program Payment Pathways Merit-Based Incentive Payment System (MIPS) Advanced Alternative Payment Models (AAPM) 8
- 10. Who May/Must Participate Physicians (MD/DO) Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist MACRA defines eligible clinicians as: *You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as established by the law.
- 11. Merit-Based Incentive Payment System (MIPS)
- 12. Consolidates Quality & Value Programs 12 • Physician Quality Reporting System • Value Based Payment Modifier • Meaningful Use MIPS MU VBPM PQRS
- 13. Establish Final Score 13 Quality Cost Improvement Activities Advancing Care Information
- 14. Weighting by Category - 2017 Quality, 60% Cost, 0% Improvement Activities1, 15% Advancing Care Information, 25% 1 - “Certified” PCMH receives the full 15 points for CPIA; APM Participants receive half credit 14
- 15. MACRA Timeline 2017 2018 2019 2020 2021 2022-2024 2025 2026 Medicare Part B Baseline Payment Updates +0.5% +0.5% +0.5% 0% 0% 0% +0.25%* +0.75%** *Non-qualifying APM Conversion Factor **Qualifying APM Conversion Factor Merit-Based Incentive Payment System (MIPS) PQRS, Value-based Modifier, & Meaningful Use Quality, Cost, Advancing Care Information, & Improvement Activities -9% -9%? 0 or +/-4%* “Pick Your Pace” +/-5% +/-7% Qualifying APM Participant 5% Incentive payment Excluded from MIPS +0% +/-9% 15
- 16. ‘Pick your Pace’ Options for 2017 Test • Submit some data to QPP • No adjustment Partial Participation • Report part of the year • Small positive adjustment Full Participation • Report full year • Modest positive adjustment Advanced APM • Qualifying Program & Eligible Clinician • 5% incentive payment NO NEGATIVE PAYMENT ADJUSTMENTS
- 17. Data Submission • Physicians participating in the MIPS pathway must submit quality, advancing care, and clinical practice improvement activity data to CMS by March 31, 2018. Physicians participating in an Advanced Alternative Payment Model also must submit data by March 31, 2018. • If you do not submit 2017 data by the March 31, 2018 deadline, you will receive a negative 4% payment adjustment in 2019. – Report as an individual – if you submit MIPS data as an individual, your payment adjustment will be based on your performance. An individual is defined as a single NPI tied to a single TIN. – Report as a group – if you submit MIPS data as a group, then the group will get one payment adjustment based on the group’s performance. A group is defined as a set of physicians and other clinicians, identified by their NPIs, sharing a common Tax Identification Number or TIN. 17
- 18. Exemptions 18 • Year 1 Medicare • Eligible Advanced Alternative Payment Model with Bonus • Below low volume threshold – Less than or equal to $30,000 Medicare payments; or less than or equal to 100 Medicare beneficiaries
- 20. Definitions Qualifying APM • Based on existing payment models Advanced APM • Based on criteria of the payment model Qualifying APM Participant • Based on individual physician payment or patient volume 20
- 21. Advanced APMs • Shared Savings Program (Tracks 2 & 3) • Next Generation ACO Model • Comprehensive Primary Care Plus (CPC+) • Comprehensive ESRD Care (CEC) (large dialysis organization arrangement) • Oncology Care Model (OCM) • All other APMs that meet criteria for the APM scoring standard 21
- 22. Additional Rewards for Qualifying Participants 22 • Not subject to MIPS • 5% bonus 2019-2024 • Higher fee schedule update 2026 QPAdvanced APM
- 23. Medical Home Materials herein reflect public law 114-10 dated April 16, 2015
- 24. Medical Home Criteria • A Medical Home Model as an APM entity is required to have the following elements: • A primary care focus consisting of primary care or multispecialty practices with primary care physicians and practitioners that offer primary care services. • Empanelment of each patient to a primary clinician. 24
- 25. Medical Home Criteria • A Medical Home Model also must have at least four of the following additional elements: • Planned coordination of chronic and preventive care • Patient access and continuity of care • Risk-stratified care management • Coordination of care across the medical neighborhood • Patient and caregiver engagement • Shared decision-making • Payment arrangements, in addition to, or substituting for fee-for-service payments (for example, shared savings, population-based payments) 25
- 26. Medical Home Recognition • Recognized certification organizations expanded to include state-based, regional or state programs, private payers, or entities that administer patient- centered medical home accreditation to at least 500 practices. • If one practice under the TIN has PCMH recognition, then the entire TIN will qualify for full points within the improvement activities category. 26
- 27. Impact on Solo/Small Practices • CMS estimates that at least 80% of physicians in small and solo practices with one to nine physicians will receive a positive or neutral MIPS payment adjustment in 2019. 27
- 28. What Can I Do Right Now? 28 Test • Report something Partial Participation • Report 90 days Full Participation • Report Full Year Advanced APM • MSSP (Tracks 2 & 3) • Next Gen ACO • CPC+ ‘Pick Your Pace’
- 29. There is Help Available • Find a PTN – Go to aafp.org/tcpi – Click “Find a PTN” to find a practice transformation network in your area – Email tcpi@aafp.org with any questions. 29
Editor's Notes
- Welcome and thank you for being here today to hear about the Medicare Access and CHIP Reauthorization Act, also known as MACRA. After this lecture you will have a better understanding of what these letters stand for and how they will affect your practice moving forward. So, let’s get started.
- Comment reviews – watch for additional deadlines
- And finally, the full timeline. The timeline illustrates the payment updates, and the penalties and/or benefits by year for both MIPS and Qualifying APM Participants. This timeline is available on the AAFP website
- As we move forward, we will discuss each of the new payment models in more detail. We anticipate many of our members will move through MIPS into the alternative payment model so it’s important to understand both programs.
- ADD SPEAKER NOTES ON ELIGIBLE CLINICANS: *You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as established by the law.
- Lets start by take a deeper dive into MIPS
- The programs to be consolidated include the physician quality and reporting system, value based payment modifier, and meaningful use. The logistics of how these programs are going to be consolidated has yet to be determined.
- In addition to the existing programs that will be consolidated, a new category of clinical practice improvement activities has been introduced. Physicians will be assessed, and receive payment adjustments, based on a composite score comprised of these four categories. You will see that many primary care providers are already doing something (if not a lot) in each of these categories. Quality – Physicians will need to report on 6 measures of their choosing- one being cross-cutting and one being outcome Resource Use- There will be no data submitted by physicians. CMS will use claims data. Meaningful use- Now called Advancing Care Information.
- This is a breakdown of year 1 scoring. The four categories above contribute points, in a weighted fashion, to make up the performance score. The total number of points scored will range from 0-100, with each category weighted as established in statue. Quality 60% Cost 0% IA 15 ACI 25 This is a breakdown of year 1 scoring. The four categories above contribute points, in a weighted fashion, to make up the MIPS Composite Performance Score. The total number of points scored will range from 0-100, with each category weighted as established in statue. You will notice there is a footnote for CPIA. Specifically, a “Certified” patient centered medical home will receive the full 15 points for this category. Those in alternative payment models who do not qualify for the alternative payment model bonus, will get half the credit for the CPIA category. We will discuss this more in the alternative payment model section. “Certified” patient centered medical home is defined in the proposed rule as those recognized by NCQA, the Joint Commission, URAC, and AAAHC. The AAFP is advocating for state-based and payer programs to be included in this definition as well.
- And finally, the full timeline. The timeline illustrates the payment updates, and the penalties and/or benefits by year for both MIPS and Qualifying APM Participants. This timeline is available on the AAFP website
- There are 4 groups of physicians and practitioners who will not be subject to MIPS –Those who are in their first year of Medicare participation. Participants in eligible Alternative Payment Models who qualify for the bonus payment . Those who have a patient volume below the low volume threshold- this number has not been defined. And most likely, federally qualified health centers and Rural health clinics.
- As we’ve mentioned, most providers will move through MIPS as they prepare to enter the Alternative Payment Model track. At the highest level, MIPS is based on existing activities with few entry requirements or exceptions making it easy to become a participant. Conversely, in the APM track, you must meet specific qualification and eligibility criteria. Let’s talk about what each of these mean.
- The payment models listed here, are existing Advanced APM models as listed in the proposed rule. These models will not be subject to MIPS requirements.
- Qualifying APM participants are excluded from MIPS, and will receive an annual 5% bonus payment from 2019-2024. They will also receive a higher Medicare physician fee schedule update (of 0.75%) starting in 2026. Physicians and practitioners who participate in qualifying APMs that are not an eligible APM are not a “qualifying participant” and will be subject to MIPS. However, APM participation is a clinical practice improvement activity, as defined under MIPS. As a result, these APM participants will receive favorable scoring for this performance category.
- So, What Can You Do Right Now to take advantage of the payment opportunities? Evaluate your practice: If you are not submitting PQRS, it is time to start. Look for your individual or your group practices QRUR. If you are unfamiliar with QRUR, there is a recent article in Family Practice Management explaining how to retrieve and interpret your report. If you have questions, you can always “ask the expert” at aco@aafp.org.
- If you are not already participating in an Advanced APM, take advantage of the technical assistance provided through the Transforming Clinical Practices Initiative (TCPI) This project is focused on positioning practices to “thrive as a business via pay for value approaches” by providing practice coaches, resources from quality improvement networks and quality improvement offices and other organizations in practice transformation. For more information go the AAFP website dedicated to this project or email tcpi@aafp.org
- For more information, visit our MACRAReady landing page which will be updated as we learn more. FAQs Timeline MIPS/APM Comparison table Related articles Related links Check out Family Practice Management for up to date articles about MACRA, payment reform, and the practice transformation needed to get your practice ready for the new environment. FPM is a free resource online for members.