Webinar - July 19, 2017

1. Quality Payment Program
2018 Proposed Rule
MACRA Implementation in Year 2
Sean Timmons, Raleigh, NC
Cybil Roehrenbeck, Washington, DC
Neal Shah, Chicago, IL

2. Agenda
Quick MACRA Overview
Major Issues in
Proposed Rule
– MIPS
– APMs
Q&A

3. Polsinelli MACRA Resources
Available at: http://www.polsinelli.com/intelligence/ealert-new-cms-proposed-
rule-refine-macra

4. Quality Payment Program
(QPP) Overview
Medicare & CHIP Reauthorization Act (MACRA)
• Passed in 2015 to replace the Sustainable Growth Rate (SGR)
as method to set professional Part B payments
• Major rulemaking November 2016
Elements of QPP under MACRA
• Merit-Based Incentive Payment System (MIPS)
• Modified fee-for-service based on quality and cost metrics
• Alternative Payment Models (APMs)
• Most qualify for special treatment under MIPS
• “Advanced” APMs qualify for automatic 5% bonus

5. Impact on Reimbursement
Post-SGR rules: MPFS payment changes depend on
MIPS and APM performance.
“Baseline” MIPS rules automatically apply
unless:
– An exclusion is met; or
– Clinician or group participates in an APM.
MIPS applies to some APMs, using special
“MIPS APM” rules.
AAPMs can earn automatic bonuses.

6. Changes to MIPS
Summary:
Most 2017
“transition year”
policies remain;
Broad new program
exclusions
New policies that
support higher scores
/ more flexibility

7. MIPS Year 1 (2017)
MIPS Transition Year
• Performance in 2017 used
to calculate payment
adjustments of up to +/- 4%
in 2019
• Basic rule: budget-neutral
positive and negative
adjustments, plus $500M
for “exceptional
performers”
2017 Flexibilities
• Three “Pick Your Pace”
tracks allowing neutral or
slightly positive payments
with limited data
• Continued used of 2014
CEHRT optional

8. MIPS in Practice
Payment adjustments based on “composite score” or “overall
score”
Score based on four components (2017 weighting):
– Quality (60%; up to 85% for some ECs)
– Cost (0% in 2017)
– Advancing Care Information (ACI) (25% in 2017)
• If clinicians meet an exclusion, weight distributed to Quality
– Improvement Activities (IA) (15% in 2017)
Report data as individual, group, or (in 2018) virtual group

9. MIPS Scoring
Composite score compared to CMS-defined threshold
– If < threshold, negative adjustment
– If = threshold, neutral adjustment
– If > threshold, possible positive adjustment
– For 2017, threshold = 3 points
Above certain CMS-defined score, may earn bonus
“exceptional performer” bonus
All clinicians in an MIPS APM evaluated collectively in an
“APM Group”
– MIPS APMs use different scoring standard

10. QPP Program Year 2 (2018)
Proposed Rule
Published on 6/30/2017
Comments due August 21,
2017
CMS 5522-P; 42 CFR 414
Available at:
https://www.federalregister.gov/d
ocuments/2017/06/30/2017-
13010/medicare-program-cy-
2018-updates-to-the-quality-
payment-program

11. Significant Year 2 MIPS
Proposals
Per statute, now +/- 5% payment adjustments
Maintains most “transition year” flexibilities
“Low-volume MIPS exclusion” covering many more clinicians
Virtual Group proposals add options for small practices
More flexibility to report data
Partial participation still possible; higher threshold
Greater alignment of ACI and IA standards
New ACI exemptions
Proposals to end “topped out” rules

12. Major Practical Implications
Many more exclusions – more concentrated
application of MIPS
– < 40% of ECs covered under MIPS;
– Account for 65% of Part B professional payments
Large penalties, small bonuses for MIPS
– $173M must be budget-neutral
• 96.1% neutral or bonuses vs. 3.9% to receive penalties
– 77% of ECs to tap into $500M “exceptional” pool.
Possibly sharp out-year changes
– “Cost” category to go from 0% to 30% of score.

13. Implications for MIPS

14. Implications for MIPS (cont)

15. Low-Volume Threshold
ECs under low-volume threshold excluded from MIPS
– If they report as a group, the whole group must meet the threshold to
be excluded.
Current:
– < 100 patients/$30,000 in Part B reimbursement;
Proposed:
– < 200 patients/$90,000
Major change:
– Excludes nearly 600K of estimated 1.2M ECs
CMS solicits comments on approach & voluntary
reporting for otherwise-excluded

16. New Options to Participate
Partial reporting
– Generally can’t split reporting of a TIN
– Proposed exception where part of TIN in an APM
Facility-based Scoring
– Professionals who see >75% of patients in hospital
inpatient or ED scored under Hospital VBM score
– Could still voluntarily submit; CMS would use
highest score

17. Virtual Groups
New options for solos & groups of <
10 ECs
Must include at least 2 entities (e.g.,
two groups, two solos, a solo &
group).
Group cannot fall under a MIPS exclusion,
although individual clinicians may.
Eligibility:
Voluntary determination early in year;
Mandatory CMS determination + participant agreement
Application of MIPS generally same as groups, except:
Non-patient facing: >75% of NPIs
Small practice: <16 NPIs
Rural/HPSA: >75% of all TINs’ sites

18. Quality Component
Data completeness:
– Proposes to maintain rule that (if submitting via
QCDRs/QR/EHR) EC must submit data on at least 50% of
qualifying patients/encounters.
– If < 50%, will receive 1 point for measure.
Maintain 3-point floor for measures meeting data completeness &
case minimum.
Data submission options:
– Can now submit data using multiple sources in same category.
– May create requirement to submit data using multiple sources if
practice is unable to submit at least 6 measures.
Part-year scoring for measures affected by ICD-10 changes

19. Quality Scoring Bonuses
Most ECs can earn up to 60/70 points in Quality
– Max 10 points / measure, plus bonuses for each additional
high-priority/outcome measure
New improvement bonus:
– Up to 10 additional points based on size of improvement
over prior year.

20. Topped Out Measures
What is “topped out”?:
– Quality measure where most reporters achieve similar
score. CMS artificially limits range of scores.
– Very common – majority of claims measures & nearly half
of registry & QCDR measures topped out.
Proposed rule:
– CMS will begin phasing out topped out measures
– Cap on scores for certain topped out measures (starting
with 6 proposed in rule).

21. Advancing Care Information
(ACI)
Many IA measures now also count towards ACI bonus
calculation.
Bonus points for reporting to immunization registries may
now be earned by reporting to other public health registries.
May continue using 2014 CEHRT, but use of 2015 edition will
receive bonus to final score.
New exclusions
– ECs excepted from e-prescribing & Health Information Exchange if
they have low volume for relevant factors.
– Hardship exception for small practices (< 15 ECs) & ECs whose EHR
was decertified.
– Reweighted to 0% for ASC-based physicians.

22. Improvement Activities (IA)
Several new IA measures; more IA
measures also provide ACI credit.
Participation in CPC+ Model
would provide full score for IA.
– For group, 50% of sites must qualify
as PCMHs.

23. Final MIPS Score
New bonuses:
– Small practices:
• Automatic bonus of 5 points;
• Must have < 15 ECs.
– Patient complexity
• Uses average risk score of patients seen by a clinician
(HCC model used in MA & insurance programs)
• Bonus of up to 3 points
– 2015 CEHRT
• 10 point bonus for “end-to-end”.

24. Proposed Changes to APMs
MIPS APMs in 2018:
– Same scoring standard for all MIPS APMs;
– New “snapshot” date of 12/31/18.
AAPMs in 2018:
– Maintains standard for determining when an
entity is an AAPM;
– Keeps 2017 medical home AAPM standards in
place:
– Proposals for All-Payer Combination Option

25. APM Basics
APMs are formal value-based programs
– ACOs, BPCI, Medical Homes, etc…
CMS designates some models to be AAPMs &
publishes list each year
– Nearly all ECs in AAPMs are excluded from MIPS.
– Starting 2019, ECs can qualify based on non-
governmental payers too.
Most APM participants are not in AAPMs
– “APM Scoring Standard” under MIPS applies here

26. MIPS APM Changes
Scoring standard:
– CMS proposes a single standard for all APMs:
• Quality: 50%
• Cost: 0%
• IA: 20%
• ACI: 30%
Additional eligibility date
– Scores apply across “APM Entity group” of all ECs
participating in an APM; based on data during “snapshots”.
– Proposes to add a new date on 12/31 to capture last
quarter of performance.

27. AAPM Changes
Maintains many 2017 “Transition Year” Rules:
– Same risk standards used to determine when a
model is an AAPM
– Smaller medical homes may still qualify as AAPMs
– Medical home risk standards will not increase
New detail on All-Payer Combination Option
– Available in 2019
– Must meet standards similar to Medicare AAPMs
– Payers, APMs, and ECs may submit information on
their commercial arrangements for CMS approval

28. Contact Info
Sean Timmons
Raleigh, NC
919-832-1721
stimmons@polsinelli.com
Cybil Roehrenbeck
Washington, DC
202-777-8931
croehrenbeck@polsinelli.com
Neal Shah
Chicago, IL
312-463-6233
nshah@polsinelli.com

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