Providing an overview of QPP’s second performance year finalized in the 2018 Centers for Medicare & Medicaid Services’ QPP and Medicare Physician Fee Schedule, this presentation highlights changes from last year’s program requirements, identifies key areas of immediate focus relevant to financial risks and outcomes, and provides insights into 2019 planning.

1. The Georgia Society of CPAs Health Care Conference
FEBRUARY 23, 2018
Lori Foley
Principal
David McMillan
Principal
MACRA, MIPS, & APMs:
Considerations for 2018 and Beyond

2. MACRA and the QPP

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Program Overview
Merit-Based Incentive
Payment System (MIPS)
Advanced Alternative
Payment Models
Quality Payment Program
(QPP)
Medicare Access and CHIP Reauthorization Act of 2015
CMS Goal: APMs Incorporating FFS Payments CMS Goal: Adjusted FFS Payments 

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Years 1 and 2 Years 3+
Physicians (MD/DO, DPM, OD, DC, DMD/DDS)
PAs, APRNs, CNSs, CRNA
Physical or occupational therapists, speech-
language pathologists, audiologists, nurse
midwives, clinical social workers, clinical
psychologists, dieticians/nutritional
professionals
Eligible Clinicians
RHC/FQHC physicians and non-physicians
subject to QPP if any Part B services billed under his/her NPI

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QPP by the Numbers – 2018
Quality Payment Program Participation Reduction Remaining
All Medicare Clinicians (Billing Part B) 1,548,022
Qualifying Clinician Types (Physicians +) -233,289 1,314,733
Newly Enrolled Clinicians -81,954 1,232,779
Low-Volume Clinicians -540,347 692,432
Qualifying APM Participants (QPs) -70,732 621,700
Total Remaining Clinicians after Exclusions 621,700
% of All Medicare Clinicians Billing Part B 40%

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Key Program Changes
Participation options through individual
or group
Added virtual groups as an additional
participation option
APM track  exempt from MIPS Additional APMs added to the list
Low-volume threshold (<$30,000 in Part
B OR <100 Part B beneficiaries)
Low-volume threshold (<$90,000 in Part B
OR <200 Part B beneficiaries)
Performance score categories: Quality
60%, Improvement Activities 15%, and
Advancing Care Information 25%
Performance score categories: Quality 50%,
Improvement Activities 15%, Advancing
Care Information 25%, and Cost 10%
Minimum 90-day performance period
for Quality, Improvement Activities, and
Advancing Care Information
Minimum 12-month performance period
for Quality (90-day for Cost, Improvement
Activities, and Advancing Care Information)
2017 2018

7. Advanced APMs

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APM Pathway
 MACRA definition of “Advanced APM”
 Use of CEHRT
 Quality measures
 At least 8% of revenues at-risk for participating APMs
 Maximum possible loss must be at least 3% of expected
expenditures
 Qualifying Participant in Advanced APM
 Not subject to MIPS
 Automatic 5% bonus on all MPFS payments

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Medicare Advanced APMs for 2018
Medicare Shared Savings Program
(Tracks 1+, 2, & 3)
Next Generation ACO Model
Comprehensive ESRD Care
(Two-Sided Risk)
Comprehensive Primary Care Plus
(unless participating in MSSP, or starting in 2018 parent organization has more
than 50 MIPS-Eligible Clinicians)
Oncology Care Model
(Two-Sided Risk)
Vermont All-Payer ACO Model
Comprehensive Care for Joint Replacement Payment Model
(CEHRT Track)

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Medicare Advanced APMs for 2018
This just in….

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All-Payer/Other Payer Advanced APMs
 Medicare Advantage, Medicaid, and commercial payer APMs
eligible for consideration beginning 2019 performance year
 Requires CMS’ prior approval based on whether APM meets three
“advanced” criteria (or Medicaid Medical Home)
 ≥ 50% of clinicians in each APM Entity uses certified EHR
 Base payments on quality measures that are evidence-based, reliable,
and valid; at least one outcome measure
 Involves financial risk, i.e., withholds payment, reduces payment rates,
or requires repayment if actual aggregate expenditures exceed
benchmark
 Revenue-based standard of at least 8%
 Marginal risk of at least 30%
 MLR of no more than 4%
 Total potential risk of ≥ 3% of benchmark

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APM Scoring Standard
 Applies to those eligible clinicians identified on MIPS APM
participant list
 MIPS APM
 Advanced APMs
 Track 1 MSSP ACO
 Oncology Care Model (one-sided model)
 Added fourth snapshot date to identify eligible clinicians in
APM Entity Groups
 Included on participant list as of March 31, June 30, August 31,
or December 31 of performance year

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Applying the APM Scoring Standard
 50% Quality
 Based on APM performance measures
 20% Improvement Activities
 Full Credit
 30% Advancing Care Information
 Weighted mean average of APM participants’ reported scores
 APM Entity Group reporting
 0% Cost

14. MIPS Program

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MIPS Participation Election
 Final Score assigned to each NPI/TIN/Group
 Group reporting must include all NPIs who reassign to TIN;
cannot pick and choose
 NPI who reassigns to TIN reporting as a group may also
report individually (well, maybe…)
Virtual Group (2 TINs+)Group (TIN)Individual (NPI)

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Low-Volume Threshold
 For 2018, individual or group exempt from MIPS if:
 $90,000 or less in allowable Part B charges; or
 Bill for 200 or fewer traditional Medicare beneficiaries
 If elect group reporting, NPIs who would be exempt if
reporting individually are NOT exempt (unless group
collectively falls below threshold)
 Two determination periods (both with 30-day claims run-out)
 September 1, 2016, to August 31, 2017
 September 1, 2017, to August 31, 2018
Tip: Use the CMS Lookup tool to determine whether providers are excluded from MIPS; note that results for
multiple TIN/NPI combinations are reported if the provider bills under more than one TIN.

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Performance-To-Adjustment Cycle
Perform
CY 2018
Period of time for
which performance
will be evaluated
(now covers all 365
days of 2018)
CY 2020
Positive or negative
MPFS payment
adjustments based on
2018 Final Score
Adjust
Q3 2019
CMS reports on prior
year performance,
including calculation of
Final Score and
payment adjustment
for upcoming year
Feedback
March 31, 2019
Deadline for
individual/group to
report on required
measures
Submit

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Reporting Requirements
MIPS Component Reporting Policy
Quality 12 months of quality measure data
Advancing Care Information Minimum of 90 consecutive days of data
Improvement Activities Minimum of 90 consecutive days of data
Cost Performance
No reporting requirements; CMS will calculate cost
measures using Medicare claims data
Note: A minimum of 15 points required to avoid penalty, making 2018 another transition year.
Significantly higher points will be required in 2019 to avoid a financial penalty.

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Cost Reporting & Scoring
 Measures
 Medicare Spending Per Beneficiary (MSPB) and total per capita
cost measures
 Developing new episode-based measures release fall 2018
 Reporting
 CMS will calculate using administrative claims
 CMS will compare with other MIPS-eligible clinicians to set
benchmarks
 Scoring
 Same methodology as quality scoring
 Performance category score is the average of the two measures
 If only one measure can be calculated, that measure’s score will
be the category score

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MIPS Final Score Components
Quality Cost Performance
Improvement
Activities
Advancing Care
Information
50%
10%
15%
25%
30%
30%
15%
25%
30%
30%
15%
25%
2018 Performance Year 2019 Performance Year 2020 Performance Year
Impacts 2020 Payments Impacts 2021 Payments Impacts 2022 Payments

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2018 Final Score Calculation
Quality
Component Score
Cost Performance
Component Score
Improvement
Activities
Component Score
Advancing Care
Information
Component Score
Multiply Each By
Component Weight
Final
Score
(1-100)

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MIPS Payment Adjustments
2019 2022+2020 2021
+4%
-4%
+5%
-5%
+7%
-7%
+9%
-9%
Up to 12% Scaling Factor
Up to 15%
Scaling Factor
Up to 21%
Scaling Factor
Up to 27%
Scaling Factor
Performance
Threshold
Top performers share in $500 million bonus pool (not to exceed 10% of allowed charges)

23. QPP: Strategic Considerations

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MIPS or Advanced APM?
 Developed infrastructure to support value-based care?
 Engaged physicians
 Care management/coordination
 Strong post-acute-care network/relationships
 Ability (stomach) to accept financial risk?
 Understanding of cost of care (or desire to build
understanding) at patient, disease, episode-of-care level?
 Desire and ability to accept, analyze, use large data sets?

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Market Considerations
 MSSP affords waivers to Stark & Anti-Kickback Statutes
 BPCI-A is expected to afford the same
 Further (different?) alignment of providers with ACOs, health
systems, conveners
 CMS’ approach to future value-based care initiatives
 Rollback of comprehensive joint replacement, cardiac
rehabilitation, and episode payment models
 MEDPAC/MIPS

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MIPS – Minimum or “All In” for 2018?
Benefit of Going
All In
Benefits of
Doing the
Minimum

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Public Reporting
 Individual profile pages
 Participation in APM
 Final score
 Component scores
 Aggregate data
 Range of final scores and component scores

28. 800.270.9629 | www.pyapc.com
Lori Foley
CMA, PHR, SHRM-CP, CMM
Consulting Principal
lfoley@pyapc.com
David McMillan
CPA
Consulting Principal
dmcmillan@pyapc.com