The document provides an overview of MACRA and its implications for Medicare payment systems, highlighting the transition to value-based payment methodologies and the introduction of the Merit-Based Incentive Payment System (MIPS). It details the different performance categories under MIPS, the scoring system, and the potential penalties and rewards for providers. The focus is on the necessity for providers to adapt their reporting processes and workflows in response to these changes in order to optimize their performance and revenue under the new system.

1. 1
The Merit Health
Network
MACRA Overview –
July 2016

2. Background
2
MACRA permanently eliminates the
SGR (and annual rate cuts)
Consolidates Medicare PQRS, MU,
VBM reporting programs
Establishes a path to predominant
Value-Based payment methodologies
Passed in Senate 92-8; Passed
in House 392-37

3. Fears
3
Medicare projects 70% of rural practices
with 2-9 docs will be penalized via MIPS
50% of non-pediatric physicians have
never heard of MACRA
MIPS program is budget neutral;
penalized providers will pay rewards
for other providers
It is widely reported MACRA will force
further consolidation

4. MIPS: National Financial Impact
4
• MIPS is Budget Neutral
• Government expects $833 million will be redistributed
• Additional $500 million in bonuses for top performers

5. MACRA Progression
5

6. Today vs. Tomorrow
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Currently: QRUR MU PQRS/VBMNon-
Existent

7. QPP: MIPS? APM? Both….
7
Merit Incentive Based Payment
System (MIPS)
Default Program (≈90% of Medicare
Providers): A portion of Medicare
Revenue at the TIN/Individual Provider
Level is at risk based on the following
performance categories:
Alternative Payment Models (APMs)
Generic term for providers who receive
significant revenue through 2-sided risk-
based contracts.
Currently Proposed Options:
• Medicare Shared Savings Program
(MSSP) Tracks 2 & 3
• Next Generation ACO
• Oncology Care Model Two-sided Risk
Arrangement (Available 2018)
• Comprehensive End-Stage Renal Disease
Care (CEC) Model

8. Ultimate Goal: APM’s
8
• Requires:
• “More than nominal” Risk
• Quality measurement
• Very advanced Value-
Based Design
(Technology, Analytics,
Workflow, Contracts, etc.)
• Provides:
• Prospective 5% Lump-
Sum annual bonus in
2019-2024
• Exemption from MIPS
requirements
2019
–
2020
2021–
2022
25% N/A
50%
N/A 25%
50%
OROption 1 Option 2
Required for All
Providers
2023
and
on
75%
N/A 25%
75%
Required Percentage of Revenue
Under Risk-Based Payment Models
Option 1
Medicare Only
Option 2
Medicare +
Commercial
Contracts

9. Current Focus: MIPS
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• MIPS is the Default Program;
AKA New Medicare FS
• CMS anticipates 90% of all
physicians will be paid via MIPS
in 1st year of the Quality Payment
Program (QPP)
• Adjusts Medicare payments
based on performance on a
single budget-neutral payment
beginning in 2019 (2-year Look-
Back)
• Applies to physicians, NPs,
clinical nurse specialists,
physician assistants, and
certified RN anesthetists

10. MIPS: Composite Performance Scores
10
4 Categories = 100%
1. Quality = 50%
2. Advancing Care Information = 25%
3. Clinical Practice Information Activities = 15%
4. Cost = 10%

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12. Components of the MIPS Score
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13. MIPS Category: Quality (50% Yr 1 MIPS Score)
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 From 9 PQRS Measures to 6 total Measures
 During Open Comment period, many pushed towards specialty and
practice-specific measures
Final Rule to show many changes
Focus today on ability to incorporate 6 measures into workflow

14. MIPS Category: ACI (25% Yr 1 MIPS Score)
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Key Takeaways:
High, historical MU compliance does not guarantee a high ACI score.
Unlike Historical MU, ACI Scoring is a CONTINUOUS scale, Not All-Or-Nothing
• Replaces Meaningful Use
• Potential to Participate as a group (If Final Rule allows)
• Advanced Practice Providers – exempt (Midlevels, NPs, PAs, etc.)
• Split Into Base Score & Performance Score
• Proposed Rule = Complicated Scoring (130 total points, only 100
needed to earn full score in ACI category)

15. ACI Base Score (50 Points)
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6 Objective and Measure Categories
1. Protect Patient Health Information - Y/N (Required)
2. Patient Electronic Access - N/D
3. Coordination of Care & Patient Education - N/D
4. Electronic Prescribing - N/D
5. Health Information Exchange – N/D
6. Public Health/Registry Reporting – Y/N
*N/D = Numerator/Denominator

16. ACI Performance Score (80 Points)
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3 Objective and Measure Categories
1. Patient Electronic Access - N/D
2. Coordination of Care & Patient Education – N/D
3. Health Information Exchange – N/D
** Immunization Registry – Mandatory
** Bonus Point – Pub Health reporting beyond immunizations
* N/D = Numerator/Denominator

17. MIPS Category: Clinical Practice
Improvement Activities (15% of MIPS Score)
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* Max Score = 60
* PCMH Participation Guarantees 100%
CPIA Score
* Largely Undefined Currently
* Secretary shall give consideration to
practices <15 Eps, rural practices, and Eps
in underserved areas
90 Proposed activities – 9 Categories
1. Expanded Practice Access
A. After hours hotline
B. Same-day appointments
2. Beneficiary Engagement
A. Care Plans
B. Self-assessment training
C. shared decision-making, etc.)
3. Achieving Health Equity
4. Population Health Management
1. Qualified clinical data registry
2. Monitoring conditions
5. Patient Safety & Assessment
1. Use of Surgical Checklists
2. Assessments related to maintaining Certifications
6. Emergency Preparedness & Response
7. Care Coordination
8. Participation in Advanced APM or Medical HomeModel
9. Integrated Behavioral Health

18. MIPS Category: Cost (10% 1st Yr MIPS Score)
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1. Replaces cost component / resource use of VBMP.
2. Scored on Medicare claims = NO REPORTING.
3. 40 specific episode measures – among specialists.
4. Must see at least 20 patients in respective category.
5. Each cost measure max out at 10 points.

19. Score Summary Recap
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20. Key Questions & Suggestions
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Key Questions
1. Do you use CEHRT (Certified EHR Technology)?
2. Do you feel comfortable with your reporting process? (Proposed Full-year
reporting)
3. Do you know the measures your EHR is capable of reporting? (These metrics will
become public under MACRA) http://oncchpl.force.com/ehrcert
Key Suggestions
1. Stay familiar with CMS’ Core Measures as CMS & AHIP agree to harmonize
metrics
2. Improving your PQRS reporting process will pay dividends
3. 2017 Reporting Year will be 50 % PQRS & 25% ACI (Formerly Meaningful Use)
4. Download QRUR
5. Prepare to adjust workflows
6. Focus resources on specific PQRS measures. Identify workflow adjustments
7. Assess EHR/technological capability to comply

21. Strategic Plan
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1. Short-run: Focus on Coding, PQRS Workflow, Care-Coordination
(CCM 99490), Chronic Care management, CPC+*, analytics
2. Long-Term: Learn via MIPS; Prepare APM contracts by expanding
to MA plans, then commercial FFV arrangements
3. Educate staff on initiatives
A. Many metrics involve strong communication & non-physician
reporting processes
B. Cultural change management in pursuit of Triple Aim
4. Establishing a CIN provides the architecture to strategically step
towards value-based payments to shift from MIPS to APMs & receive
further incentive-rewards
* CPC+ (Comprehensive Primary Care Plus) Regions are to be announced August 1, 2016

22. Sample Roadmap
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23. Acronyms Reference Guide
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• ACO – Accountable Care
Organization
• APM – Advanced Alternative
Payment Model
• CMS – Centers for Medicare &
Medicaid Services
• CPC+ – Comprehensive
Primary Care Plus
• EHR – Electronic Health
Record
• EP – Eligible Professional
• HHS – U.S. Department of
Health & Human Services
• MACRA – The Medicare Access
and CHIP Reauthorization Act of
2015
• MIPS – Merit-Based Incentive
Payment System
• MSSP – Medicare Shared
Savings Program
• PQRS – Physician Quality
Reporting System
• QPP – Quality Payment Program
• QRUR – Quality and Resource
Use Report
• VBPM – Value-Based Payment
Modifier

24. Summary: Merit Health QPP Plan
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1. More education for members
2. Continue CIN objectives
3. Analytics implementation
4. More clinical workgroups
5. Analytics support
6. Partnership

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