Year 2 of the Quality Payment Program: MIPS and APMs

April 5, 2018
Aaron Elias
Senior Consultant - PYA
QUALITY PAYMENT PROGRAM
Year 2 of the Quality Payment Program:
MIPS and APMs

Texas MGMA 2018 Annual Meeting Page 2
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 

Years 1 and 2 Years 3+
Physicians (MD/DO, DPM, OD, DC, DMD/DDS)
PAs, APRNs, CNSs, CRNAs
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

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%

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
*Does not include Part B drug expenditures

Bipartisan Budget Act
1 Post-transition period begins in 2022, not 2019; CMS
has flexibility to adjust performance threshold and cost
component
2 Starting in 2018, MIPS payment adjustments only
apply to covered professional services
3 Starting in 2018, low-volume threshold only
based on covered professional services
Translation: more physicians excluded

Growth of APMs
Health Care Payment,
Learning, & Action
Network (HCPLAN)
Updated APM Framework
(July 2017)

Growth of APMs
One-quarter of commercial plan payments now
flow through Category 3/4 APMs*
*Health Care Payment Learning & Action Network 2016 Commercial Payer Survey (respondents represent over 128 million
covered lives, or nearly 44% of the combined commercial, Medicare Advantage, and Medicaid markets)

Key Terms
 MACRA Definition of “Advanced APM”
1. Use of CEHRT
2. Quality measures
3. At least 8% of revenues at risk for participating APMs
4. 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

Medicare Advanced APMs for 2018
Medicare Shared Savings Program
(Tracks 1+, 2, & 3)
Next Generation ACO Model
Bundled Payments for Care Improvement Advanced 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)

Required Thresholds Per Payment Year
Payment Year 2019 2020 2021 2022 2023 2024+
Threshold 25% 25% 50% 50% 75% 75%
Payment Year 2019 2020 2021 2022 2023 2024+
Threshold 20% 20% 35% 35% 50% 50%
Payment Amount Threshold
Patient Amount Threshold

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

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)

Low-Volume Threshold
 For 2018, individual or group exempt from MIPS if:
 $90,000 or less in allowable Part B charges, excluding Part B drugs; 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.

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

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.

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

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)

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)

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

MIPS Components
2018 Reporting Requirements and Scoring Methodology

Quality Reporting
Manner of
Participation
Reporting Mechanism Measure Requirements Data Completeness
Individual Part B Claims
6 measures (at least 1
outcome measure) OR
specialty-specific
measure set
60% of Part B patients
Individual or Group
QCDR
Qualified Registry
EHR
6 measures (at least 1
outcome measure) OR
specialty-specific
measure set
60% of individual’s or
group’s patients who
meet measure
denominator
Group
CMS Web Interface
(registration deadline
06/30/18)
All measures included
CMS-selected sample
of Part B patients

Quality Scoring
 Measure No. 7: All-Cause Readmissions
 CMS calculates using claims data; minimum 200 cases
 Group or NPI/TIN based on participation election
 Quality measure benchmarks established prior to performance period
(benchmarks for 2018 based on 2016 PQRS performance)
 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
 Quality component score
 Total points on 7 measures + bonus points
 Adjusted based on measures with insufficient # of cases

Point Assignment Based on Deciles
Measure Name
Submission
Method
Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10
Topped
Out
Preventive Care
and Screening:
Influenza
Immunization
(#110)
Claims
22.64 -
31.75
31.76 -
43.13
43.14 -
54.68
54.69 -
66.38
66.39 -
77.47
77.48 -
92.03
92.04 -
99.99
100 No
EHR
11.22 -
18.57
18.58 -
24.99
25.00 -
31.84
31.85 -
38.92
38.93 -
47.86
47.87 -
59.99
60.00 -
79.01
>= 79.02 No
Registry/ QCDR
11.57 -
21.39
21.40 -
31.39
31.40 -
41.31
41.32 -
51.13
51.14 -
62.04
62.05 -
74.27
74.28 -
91.83
>= 91.84 No
Sample Benchmarks for 2018 MIPS Quality Reporting and Measurement
Source: 2017 MIPS benchmarks as provided by CMS through qpp.cms.gov
Example:
Provider A
Provider B
Claims
EHR
61%
61%
6 points
9 points
Submission Method Performance Points Earned

Cost Reporting & Scoring
 Measures
 Medicare Spending per Beneficiary (MSPB) and total capita per 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 2 measures
 If only 1 measure can be calculated, that measure’s score will be the
category score

Improvement Activities Reporting
100+ Improvement Activities (21 new in 2018) Across 9 Subcategories
Each Graded Medium (10 pts) or High (20 pts)
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety and Practice Assessment
Participation in an APM
Achieving Health Equity
Integrated Behavioral and Mental Health
Emergency Preparedness and Response

Improvement Activities Scoring
Improvement Activities Component Score (capped at 100) =
(# of Medium Activities * 10) + (# of High Activities * 20) / 40 possible points
Most Participants
Attest to completion of activities worth 40 points (up
to 4 activities) for minimum of 90 days
Groups (a) with fewer than 15
participants, (b) located in rural
area or HPSA
Attest to completion of activities worth 20 points (up
to 2 activities) for minimum of 90 days
Participants in certified PCMH or
comparable specialty practice
designation
Full credit
Participants in MIPS APM Full credit
Participants in other APMs Half credit

Advancing Care Information Measures
Base Score (Required) Measures
(Y/N or report numerator/ denominator)
Performance Score Measures
(0 to 10 points each based on level of performance)
Security Risk Analysis Patient-Specific Education
E-Prescribing View, Download, or Transmit
Provide Patient Electronic Access Provide Patient Electronic Access
Health Information Exchange Health Information Exchange
Medication Reconciliation
Secure Messaging
Immunization Registry Reporting (Y/N)
2018 Option 1: Clinicians with CEHRT 2014 or CEHRT 2015

ACI Measures
Base Score (Required) Measures
(Y/N or report numerator/ denominator)
Performance Score Measures
(0 to 10 points each based on level of performance)
Security Risk Analysis Patient-Specific Education
E-Prescribing View, Download, or Transmit
Provide Patient Electronic Access Provide Patient Electronic Access
Send a Summary of Care Send a Summary of Care
Request and Accept Summary of Care Request and Accept Summary of Care
Secure Messaging
Patient-Generated Health Data
Clinical Information Reconciliation
Immunization Registry Reporting (Y/N)
** To incentivize implementation of 2015 Edition CEHRT, CMS finalized a bonus of 10% in the ACI category for ECs and groups that exclusively
use 2015 Edition CEHRT to report the five ACI base measures. This bonus will not be awarded if 2015 Edition CEHRT is used to report the four
transitional base measures.
2018 Option 2: Clinicians with CEHRT 2015**

ACI Scoring
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.

Final Score Calculation
 Sum of each of the products of each component score and each
component’s assigned weight, multiplied by 100.
 0 Points = Nonparticipation; negative payment adjustment
 15 Points = Neutral payment adjustment
 16-69 Points = Positive adjustment (sliding scale)
 ≥ 70 Points = Positive adjustment + exceptional performance bonus (0.5%)
 Example:
 Quality = (55 points / 70 possible points) x 50%
 Advancing Care Information = (84 points / 100 possible points) x 25%
 Improvement Activities = (40 points / 40 possible points) x 15%
 Cost = ( ) x 10%
 FINAL SCORE = 83.14

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

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

MedPAC Recommendation

Key Questions to Ask
 MIPS or Advanced APM?
 Group or individual reporting?
 Impact of reporting mechanism?
 Cost
 Burden
 Measure selection

Avoid “Topped Out” Measures
21 Perioperative Care: Selection of Prophylactic Antibiotic-First or Second
Generation Cephalosporin
23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When
Indicated in ALL Patients)
52 Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy
224 Melanoma: Overutilization of Imaging Studies in Melanoma
262 Image Confirmation of Successful Excision of Image Localized Breast Lesion
359 Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized
Nomenclature for Computerized Tomography (CT) Imaging Description

Minimum Threshold Strategy
 Must report a minimum of 15 points. Options may include:
 Fully participate in one component:
 IA
 Partially participate in multiple components
 ACI
 Quality
 IA
 Partially participate in one component:
 ACI
 Quality

Strategize for 2018
Benefit of Going
“All-In”
Benefits of
Doing the
Minimum

Action Items
 Gather your team
 Make key reporting and program decisions
 Review prior performance (QRUR and MIPS feedback)
 Define baselines
 Continue educating providers
 Frequently monitor dashboards
 Evaluate APM opportunities

PYA, P.C.
800.270.9629 | www.pyapc.com
Aaron M. Elias
Consulting Senior
aelias@pyapc.com

Year 2 of the Quality Payment Program: MIPS and APMs

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