This document provides an overview of the Merit-based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act (MACRA). MIPS replaces previous quality reporting programs and includes four components that determine a Composite Performance Score: Quality, Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information. Scores will determine payment adjustments beginning in 2019, with the potential for bonuses or penalties up to 9% by 2022 based on performance compared to benchmarks and thresholds. The document reviews the scoring methodology and reporting requirements for each MIPS component.

1. Presented by Aaron Elias
TMA CME Road Show
Dollars and Sense
CONTINUED SHIFT FROM VOLUME TO VALUE
MACRA and the Merit-Based Incentive
Payment System (MIPS)

2. TMA: CME Summer Road Show Dollars and Sense Page 1
Fact of the Day
50% Of polled non-pediatric physicians
have never heard of MACRA.
Source: 2016 MACRA survey by Deloitte

3. TMA: CME Summer Road Show Dollars and Sense Page 2
Topics
1
2
3
4
Introduction to MACRA
Provider Considerations Under MACRA
MIPS Components and Scoring
Additional Considerations

4. Introduction to MACRA

5. TMA: CME Summer Road Show Dollars and Sense Page 4
CMS Payment Goals
30% of traditional Medicare
payments through APMs
50% of traditional Medicare
payments through APMs
85% of Medicare fee-for-
service payments tied to scores
on quality and efficiency measures.
90% of Medicare fee-for-
service payments tied to scores
on quality and efficiency measures.
03/03/2016 - Mission Accomplished
By December 31, 2016: By December 31, 2018:

6. TMA: CME Summer Road Show Dollars and Sense Page 5
VBR Framework
FEE-FOR-SERVICE
(FFS) PAYMENTS
POPULATION-BASED
APMs
ADJUSTED FFS
PAYMENTS
APMs INCORPORATING
FFS PAYMENTS
$
$
Bank
A Pay For
Reporting
B Pay For
Performance
C Pay/Penalty
For
Performance
A Total Cost of
Care Shared
Savings
B Total Cost of
Care Shared
Risk
C Retrospective
Bundled
Payment
D Prospective
Bundled
Payment
A Condition-Specific
Population-
Based
Payments
B Primary Care
Population-
Based
Payments
C Comprehensive
Population-
Based
Payments
A Traditional FFS
B Infrastructure
Incentives
C Care
Management
Payments

7. TMA: CME Summer Road Show Dollars and Sense Page 6
Medicare Access and CHIP Reauthorization Act of 2015
(MACRA)
FFS payment adjustments based on individual composite performance score
Quality
Efficiency and Resource Use
Advancing Care Information (Meaningful Use)
Clinical Practice Improvement Activities
Exception for qualifying APM participants!
MACRA

8. TMA: CME Summer Road Show Dollars and Sense Page 7
Transition to MIPS
Through
December 31, 2018
• 0.5% annual MPFS update (2016-
2019)
• Payment adjustments
• 2% PQRS reporting penalty
• 3% EHR meaningful use penalty
• +/- 4% Value-Based Modifier
bonus/penalty
Starting
January 1, 2019
• Annual MPFS update
• 0% in 2020 - 2025
• 0.25% thereafter (0.75% for
participants in qualifying APMs)
• Single payment adjustment based on
composite performance score (CPS)
• Incentives for participation in APMs

9. TMA: CME Summer Road Show Dollars and Sense Page 8
MIPS Regulation – As It Stands
Payment adjustments commence January 1, 2019
First performance year commences January 1, 2017
Final rule to be published prior to November 1, 2016
Comments due to CMS by June 27, 2016
Proposed Rule published April 26, 2016 (Quality Payment Program)
CMS “Listening Tour”

10. Provider Considerations Under MACRA
MIPS and Advanced APM Eligibility

11. TMA: CME Summer Road Show Dollars and Sense Page 10
*Clinicians ineligible the first two years may voluntarily
report to gain experience in the MIPS program, though these
clinicians will not receive a MIPS adjustment during the
period.
Years 1 and 2 Years 3+*
Physicians (MD/DO & DMD/DDS),
PAs, NPs, CNSs, CRNA
Physical or occupational therapists, speech-
language pathologists, audiologists, nurse
midwives, clinical social workers, clinical
psychologists, dieticians/nutritional
professionals
MIPS Eligible Clinicians (MECs)

12. TMA: CME Summer Road Show Dollars and Sense Page 11
Non-MECs
1. First year of Medicare Part B participation
2. Below low volume threshold
 Medicare billed charges of $10,000 or less; and
 Provide care for 100 or fewer Medicare beneficiaries
3. Qualifying Participants (QPs) in Advanced APMs
Note: MIPS does not apply to Part A providers (including hospitals, rural
health clinics, federally qualified health centers)

13. TMA: CME Summer Road Show Dollars and Sense Page 12
Advanced APMs
Qualifying Advanced APMs
Medicare Shared Savings Program (Tracks 2 & 3 Only)
Next Generation ACO Model
Comprehensive ESRD Care
Comprehensive Primary Care Plus (CPC+)
Oncology Care Model (OCM) – two-sided risk track only, available in 2018

14. TMA: CME Summer Road Show Dollars and Sense Page 13
Be excluded from MIPS
Minimum % of patients/ payments through
Advanced APM
Receive 5% lump sum bonus
Bonus applies in 2019-2024; QPs
receive higher MPFS updates
starting in 2026
QPs
will:
QPAdvanced APM
Lower threshold
for Partial QPs
Partial QPs not eligible for bonus,
but can opt out of MIPS payment
adjustments
QPs and Partial QPs

15. TMA: CME Summer Road Show Dollars and Sense Page 14
MIPS Decision Tree
Are you a physician or eligible
non-physician practitioner?Q:
NO
YES
Will you be newly enrolled in Medicare
in 2017?
Will you have less than $10,000 in
charges or see less than 100 Medicare
patients in 2017?
Are you a participant in an Alternative
Payment Model?
MIPS Participation Choice
Is your APM on the list of Advanced
APMs for 2017?
GROUP
MIPS Reporting
INDIVIDUAL
MIPS Reporting
Determined to be a Qualified
Participant (QP)*?
APM ENTITY
MIPS Reporting
EXEMPT
from MIPS
* Or partial qualifying APM Participant (Partial QP) and elects not to be subject to MIPS
NO
YES NO
YES
YES
YES
NO
NO
NO
YES

16. • Quality
• Resource Use
• Clinical Practice Improvement Activities
• Advancing Care Information
MIPS Components

17. TMA: CME Summer Road Show Dollars and Sense Page 16
Composite Score Components
50% 45%
30%
10% 15%
30%
15% 15% 15%
25% 25% 25%
2019 2020 2021
(and beyond)
Quality
Resource Use
($)
Clinical Practice
Improvement Activities
(CPIA)
Advancing Care
Information (ACI)

18. TMA: CME Summer Road Show Dollars and Sense Page 17
Quality Measure Component
 Closely related to historic PQRS
 Reporting requirements less strict; various reporting mechanisms
available
 Specialty-specific measures groups or individual measures
 Plus 3 population-based measures (no reporting necessary)
Measure Type Reporting Mechanism Criteria Data Completeness
Individual MIPS Eligible
Clinicians (ECs)
Part B Claims
6+ measures
Including: one cross-cutting
and one outcome**
80% of MIPS eligible clinicians’
patients
Individuals MIPS Eligible
Clinicians (ECs) or Groups
QCDR
Qualified Registry
EHR
6+ measures
Including: one cross-cutting
and one outcome**
90% of MIPS eligible clinicians’
or groups’ patients*
Groups CMS Web Interface
Report on all measures
included
Sampling requirements for
Medicare Part B patients
Groups CAHPS for MIPS Survey
CMS-approved survey vendor
paired with other mechanism,
counts as one measure
Sampling requirements for
Medicare Part B patients
* This includes all patients, not just Medicare patients, which is a major change for some groups who have historically participated in PQRS.
** If less than 6 measures apply, then report on each measure that is applicable. Choice between individual measures or specialty-specific measures.

19. TMA: CME Summer Road Show Dollars and Sense Page 18
Quality Measure Component
 Quality measure benchmarks established prior to
performance period (benchmarks for 2017 based on 2015)
 Points given for actual performance, split into deciles
 Decile 1 = 1 point (lowest possible)
 Decile 10 = 10 points (highest possible)
 Bonus points for:
 Reporting high-priority measures (1-2 bonus points per measure)
 Using QCDR or CEHRT for reporting (1 bonus point)
 If you report more than the minimum, CMS will select your
best measures
Scoring Methodology

20. TMA: CME Summer Road Show Dollars and Sense Page 19
Resource Use Component
 Incorporate current VBM total cost of care measures
 No reporting requirements – CMS automatically calculates
based on administrative claims
 Still using a beneficiary attribution process
 Change from VBM: over 40 episode-specific measures to
account for differences among specialties
 Greater than 20-patient sample
 Score based on total score divided by highest possible score

21. TMA: CME Summer Road Show Dollars and Sense Page 20
Resource Use Component
 Resource use benchmarks set during the actual performance
year (benchmarks for 2017 based on 2017 actual)
 Points given for actual performance, split into deciles:
 Decile 1 (highest cost) = 1 point
 Decile 10 (lowest cost) = 10 points
 Average of points for all applicable resource measures
Scoring Methodology

22. TMA: CME Summer Road Show Dollars and Sense Page 21
Resource Use Component
 Measures development (for future years)
 CMS to develop new classification codes in 2016-17
 Care episode groups
 Patient condition groups
 Patient relationship categories
 Beginning January 1, 2018, claims must include new codes as
appropriate

23. TMA: CME Summer Road Show Dollars and Sense Page 22
CPIA Component
 Clinical Practice Improvement Activities
 Activities weighted as either “high” or “medium”
 Eight different subcategories of activities, plus participation in an APM
•Same day appointments
•After-hours access to
clinician advice
•Use of tele-health services
•Collect patient experience
and satisfaction data
Expanded Practice
Access
•Monitoring health
conditions
•Participation in qualified
data registries
•Participate in Million Hearts
•Participate in research for
targeted patient populations
Population
Management
•Timely communication of
test results
•Implement regular care
coordination training
•Develop care plans for at-
risk patients
Care Coordination
•Establishment of care plans
•Use of shared decision-
making mechanisms
•Use group visits for common
chronic conditions
Beneficiary
Engagement
•Use of clinical and surgical
checklists
•Practice assessments
•Use decision support and
protocols
Patient Safety
Practice Assessment
•See new and follow-up
Medicaid patients in a
timely manner
•Use QCDR to screen for
social determinants of
health
Achieving Health
Equity
•Participate in humanitarian
volunteer work
•Participate in Disaster
Medical Assistance Teams
Emergency
Response and
Preparedness
•Engage patients with
behavioral health conditions
•Offer behavioral health
services
Integrated
Behavioral and
Mental Health

24. TMA: CME Summer Road Show Dollars and Sense Page 23
CPIA Component
 Maximum score = 60 points
 Medium weight = 10 points
 High weight = 20 points
 Exceptions:
 Small groups (<=15 professionals), HPSA, etc., must only report on two
activities (30 points given for any activity)
 APM participants start with 30 points
 Patient-Centered Medical Homes automatically receive 60 point max
Scoring Methodology

25. TMA: CME Summer Road Show Dollars and Sense Page 24
Advancing Care Information (ACI)
 Formerly known as Meaningful Use (MU)
 Component is split into two parts: base score and performance score
 Performance measures correlate to MU Stage 3 or modified Stage 2
**must attest to a “yes” response to protection of patient health information to receive a non-zero base score
 Points for submitting numerators and
denominators:
 Protection of patient health information**
 Electronic prescribing
 Patient electronic access
 Coordination of care through patient
engagement
 Health information exchange
 Public health and clinical data registry
reporting
 Based on reported results for base score
measures
 Patient electronic access
 Coordination of care
 Health information exchange
 Bonus percentage point for public health
registry
Performance ScoreBase Score

26. TMA: CME Summer Road Show Dollars and Sense Page 25
ACI Component
Scoring Methodology
Base Score
50 Points
Performance Score
80 Points
Composite ACI Score
100 Points (Maximum)
**Opportunity for 1 bonus point for public
health registry participation
Note:
Potential to score more than 100 points based on performance
score; however, score will be capped at 100.

27. TMA: CME Summer Road Show Dollars and Sense Page 26
Differences for APM Entities
Shared Savings Program
Participants
Next-Gen ACO
Participants
Other APM Entity
Participants
Quality Group reporting via Web
Interface on MSSP standard
measures (50%)
Group reporting via Web
Interface on Next-Gen ACO
standard measures (50%)
No quality consideration in
Year 1 (0%)
Resource Use Not Applicable (0%) Not Applicable (0%) No resource use
consideration in Year 1 (0%)
Clinical
Practice
Improvement
Activities
Receive a minimum of half
of the total points;
participant TIN scores will
be aggregated (20%)
Receive a minimum of half
of the total points;
participant TIN scores will
be aggregated (20%)
Receive a minimum of half
of the total points; other
APM Entity group eligible
clinician scores aggregated
(25%)
Advancing
Care
Information
Participant TIN scores
aggregated (30%)
Participant TIN scores
aggregated (30%)
APM Entity group eligible
clinician scores aggregated
and averaged (75%)
Goal:
Allow APM entities to focus on the goals and objectives of their respective APMs while lowering costs and
improving quality. CMS also desires to avoid duplicative reporting requirements for these entities.

28. MIPS Composite Performance Score
Calculation of CPS and Other Factors

29. TMA: CME Summer Road Show Dollars and Sense Page 28
Composite Performance Score
 Composite Performance Score = CPS
 Assigned lowest potential score for a category if failure to
report required information
 Multiple reporting methods; option to be assessed as a group,
as an individual, or with your APM entity
 Score will ultimately be tied to a TIN/NPI combination number
 CPS will follow the individual, regardless of reporting mechanism
 Starting in 2020, formula to reward year-to-year score
improvement

30. TMA: CME Summer Road Show Dollars and Sense Page 29
Composite Performance Score
 CMS to provide Eligible Clinicians (ECs) with regular
performance feedback reports
 Beginning 07/01/17, ECs to receive confidential feedback on quality
and resource use measures
 Beginning 07/01/18, ECs to receive patient claims data
 CMS to establish informal review process; limits on
administrative and judicial review
 CMS to calculate CPS of 1 to 100 for each EP at conclusion of
performance period

31. TMA: CME Summer Road Show Dollars and Sense Page 30
Composite Performance Score
Quality
Score
Resource Use
Score
CPIA
Score
Advancing Care
Information
Score
Component
Weight
Component
Weight
Component
Weight
Component
Weight
ACI Points
CPIA Points
Resource Use Points
Quality Points
COMPOSITE
PERFORMANCE SCORE
(CPS), 1 – 100

32. TMA: CME Summer Road Show Dollars and Sense Page 31
Performance Threshold
Threshold Value
• Must be the mean or
median of composite
performance score for all
EPs
• 2019 threshold will be
modeled based on 2014
and 2015
• CMS will aim to set the
threshold such that 50% of
ECs will fall above/below
• By Year 3, CPS must be at or
above prior year values
Impact on Eligible Clinicians
• Score below threshold =
penalty
• Score above threshold =
bonus
• Must remain a budget-
neutral program
• Scaling factor, like VM, for
additional upward
potential

33. TMA: CME Summer Road Show Dollars and Sense Page 32
MIPS Payment Adjustments
2019 2022
(and beyond)
2020 2021
+4%
-4%
+5%
-5%
+7%
-7%
+9%
-9%
Plus: Scaling Factor
Plus: Scaling Factor
Plus: Scaling Factor
Plus: Scaling Factor
Composite Performance Score
Impact on Medicare Part B Payments:
Performance
Threshold

34. Additional Considerations
Moving Forward Under MACRA

35. TMA: CME Summer Road Show Dollars and Sense Page 34
Physician Compare
For each eligible clinician, MIPS composite
score and performance category scores
For each EC in a qualifying APM, name and
performance of APM (when feasible)
Periodically, aggregate information on the
MIPS
(range of scores for all eligible clinicians)

36. TMA: CME Summer Road Show Dollars and Sense Page 35
Timing
2018 2019
No change in payments; eligible clinicians report on
2017 performance
MECs receive payments based on 2019 adjustment
factor (+ exceptional performance incentives); MECs
report on 2018 performance
CMS calculates MIPS composite performance score
for each MEC based on 2017 performance
CMS calculates MIPS composite performance score for
each MEC based on 2018 performance
CMS calculates and announces mean/median
composite performance score
CMS calculates and announces mean/median
composite performance score
CMS calculates and announces each MEC’s 2019
adjustment factor (based on 2017 performance
compared to mean/median composite performance
score)
CMS calculates and announces each MECs 2020
adjustment factor (based on 2018 performance
compared to mean/median composite performance
score)
CMS calculates and announces 2019 exceptional
performance incentive payments
CMS calculates and announces 2020 exceptional
performance incentive payments

37. TMA: CME Summer Road Show Dollars and Sense Page 36
Possible Delay
 Significant concerns from legislators and physician advocacy
groups about implementation of MACRA
 Recent indications from CMS that MACRA could be delayed
 July 1, 2017?
Bottom Line:
Must prepare for MACRA implementation by
January 1, 2017… until told otherwise.

38. Information in this presentation was
from the Notice for Proposed
Rulemaking (NPRM) on MIPS and
APMs published on April 26, 2016. The
final rule is expected to be released
Fall 2016.
Thank You
Note:

39. PERSHING YOAKLEY & ASSOCIATES, P.C.
800.270.9629 | www.pyapc.com
AARON ELIAS, MSHA
Consulting Senior
aelias@pyapc.com
(404) 266-9876
‐ “Simple is better”
‐ Advisory practice focused on value transformation and strategy
‐ Analytic focus