Transforming Healthcare through Data-Driven Solutions. Pay for Performance Solutions
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1 Transforming Healthcare through Data-Driven Solutions Pay for Performance Solutions
2 Medicare Access and CHIP Reauthorization Act of 2015 MACRA Enacted April 15, /14/2015 Copyright Mingle Analytics 2
3 Agenda What do we already know about MIPS? What can/should we assume? What questions is Medicare asking us about MIPS? What do we want? How should it be set up? Post-Presentation your questions and comments to We will post answers and commentary on our 10/14/2015 Copyright Mingle Analytics 3
4 The Future of PQRS A System in Evolution 2016 (2018) is the Final Year in their current form: Physician Quality Reporting System (PQRS) Value Based Modifier (VBM) Quality Tiering Meaningful Use Merit-Based Incentive Payment System (MIPS) ((Quality Tiering + PQRS + VBM + EHR) + a b) x N Competition on a 100 point scale 30 quality points 30 resource use points 25 meaningful use points 15 practice improvement points Increasing Adjustments ±4% 2017 (2019) ±9% 2020 (2022) 10/14/ Mingle Analytics 4
5 MACRA, Section 101 Replaces the annual Medicare sustainable growth rate (SGR) adjustments to the Physician Fee Schedule With a new Merit-based Incentive Payment System (MIPS) Sunsets payment adjustments under Physician Quality Reporting System (PQRS) Value-Based Payment Modifier (VM) Electronic Health Records (EHR) Incentive Program Consolidates aspects of PQRS, VM, and EHR Incentive Program into the new MIPS Promotes the development of: Alternative Payment Models (APMs) Physician- focused payment models (PFPMs) 10/14/2015 Copyright Mingle Analytics 5
6 Published in the Federal Register 10/01/ CFR Part 414 [CMS-3321-NC] Request for Information Regarding Implementation of the Merit-based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models 10/14/2015 Copyright Mingle Analytics 6
7 Comment on the Implementation of MIPS Search for: Request Merit 10/14/2015 Copyright Mingle Analytics 7
8 The Merit-Based Incentive Payment System MIPS 10/14/2015 Copyright Mingle Analytics 8
9 1848(q) of the Act requires: MIPS applies to Medicare Part B payments starting January 1, 2019 Based on the 2017 Service and reporting year Assess annual composite performance of each MIPS EP annual composite performance score MIPS adjustment factor additional MIPS adjustment factor if indicated performance score a composite of: Quality resource use clinical practice improvement activities meaningful use of certified EHR technology 10/14/2015 Copyright Mingle Analytics 9
10 The Act requires the Secretary to consult with stakeholders identification of measures and activities for each of the four performance categories methodology to assess each MIPS Eligible Professional s Composite performance score This RFI Over 200 questions Nearly 30 topics 10/14/2015 Copyright Mingle Analytics 10
11 A Healthcare System in Transition - Programs in Evolution Fee For Service 10/14/ Mingle Analytics 11
12 Reasonable Assumptions The national goal is to push healthcare to higher value Sustainable Growth Rate adjustments were discontinued because they Did Not Work MIPS and related programs are proposed as more likely to work MIPS is designed to deliver equal amounts of reward and penalty We will be graded on a curve under MIPS 10/14/2015 Copyright Mingle Analytics 12
13 1. MIPS EP Identifier and Exclusions MIPS EP for the first 2 years Physician (doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, optometry, and chiropracty) Physician Assistant (PA) Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) Certified Registered Nurse Anesthetist (CRNA) MIPS Groups Any group that includes above professionals Virtual Groups: Small practices of 1-10 EPs band together Secretary has discretion to specify additional EPs starting in year 3 which may include Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician or Nutrition Professional Physical or Occupational Therapist Speech-Language Pathologist Audiologist 10/14/2015 Copyright Mingle Analytics 13
14 Current Identifiers Program PQRS for Individual Reporting PQRS for Group Practice Reporting EHR Incentive Program VBM Pioneer ACO Identifier TIN - NPI TIN NPI TIN ACO-ID 10/14/2015 Copyright Mingle Analytics 14
15 Identifiers My thoughts The operative unit of delivery is the Practice PQRS has been working well with TIN and TIN-NPI Meaningful Use, at the NPI level is excessively complicated Special identifiers required for APM Virtual Groups 10/14/2015 Copyright Mingle Analytics 15
16 The Split TIN When some providers in a TIN are exempt from MIPS due to being part of a qualifying APM what safeguards should be in place to ensure that we are appropriately assessing MIPS EPs and exempting only those EPs that are not eligible for MIPS? 10/14/2015 Copyright Mingle Analytics 16
17 Virtual Groups Small Practices (1-10 EPs) to be able to elect to report as a Virtual Group elect for a performance period for a year allows a group's performance to be tied together 10/14/2015 Copyright Mingle Analytics 17
18 Virtual Groups My Thoughts Ask: What is the potential advantage to the group? What is the potential advantage to the Patients of the Group? What is the potential advantage to the Payer? 10/14/2015 Copyright Mingle Analytics 18
19 7 available mechanisms to report 1. Claims-based reporting 2. Qualified Registry reporting 3. Qualified Clinical Data Registry reporting 4. Direct EHR products 5. EHR Data Submission Vendor products 6. Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS 7. GPRO Web Interface 10/14/2015 Copyright Mingle Analytics 19
20 Mechanisms My Thoughts We have 8 years of development and evolution behind the current 7 mechanisms Hold back from dramatic change for 2 years while we adjust to MIPS All 7 should continue to evolve/improve All mechanisms should apply to all entities Measure Group type of sampling methodology available to groups Web Interface could be that methodology but is not as applicable beyond primary care / general medicine 10/14/2015 Copyright Mingle Analytics 20
21 Data Accuracy My Thoughts The SEVT Tool works reasonably well Enhance it with available known data sets Expect periodic testing against known standards 10/14/2015 Copyright Mingle Analytics 21
22 CEHRT My Thoughts Keep our eyes on the prize Goal is High Quality and Low Cost We don t want to stifle innovation Use of CEHRT is desirable Other tools should not be precluded EHRT that is not certified Paper based charting Meaningful use can have reduced emphasis Low benchmarks Let competition and innovation drive and define Meaningful Use 10/14/2015 Copyright Mingle Analytics 22
23 Resource Use My Thoughts Good foundation Alignment with Measures is desirable Episode measures Episode costs Topic specific measures (ie: CABG, Sinusitis) Topical Costs Cost of Drugs is a potent driver of overall costs and should be included 10/14/2015 Copyright Mingle Analytics 23
24 CLINICAL PRACTICE IMPROVEMENT ACTIVITIES Promoting Health Equity and Continuity Social and Community Involvement Achieving Health Equity, high quality for underserved populations, emergency preparedness and response integration of primary care and behavioral health 10/14/2015 Copyright Mingle Analytics 24
25 Clinical Practice Improvement Activities My Keep our eyes on the prize Goal is High Quality and Low Cost But we don t want to stifle Community Service Efforts to Achieve equity It can be difficult and unprofitable to a serve People with Multiple or severe diseases Cultural barriers or incompatibilities Inability to Pay Thoughts Permanent recurring credits Rural, underserved, or HPSA service Annual recurring efforts Maintenance of Certification Open to new Medicare / Medicaid / Uninsured patients Does practice profile match Census for underserved populations? Select Cost and Quality metrics stratified by race, ethnic, other Special improvement projects Standard selections Special projects by application 10/14/2015 Copyright Mingle Analytics 25
26 MEANINGFUL USE OF CERTIFIED EHR TECHNOLOGY 25 percent of the composite performance score under the MIPS based on performance in the meaningful use of certified EHR technology performance category Secretary has discretion to reduce the percentage weight not below 15 percent When estimate that the proportion of EPs who are meaningful EHR users is 75 percent or greater 10/14/2015 Copyright Mingle Analytics 26
27 Meaningful Use My Thoughts Keep our eyes on the prize Goal is High Quality and Low Cost We don t want to stifle innovation Meaningful use can have reduced emphasis Low benchmarks Let competition and innovation drive and define Meaningful Use Change Unit of Analysis from NPI to choice of TIN TIN - NPI 10/14/2015 Copyright Mingle Analytics 27
28 Other Measures The Secretary may choose to use measures that are used for a payment system other than the PFS 10/14/2015 Copyright Mingle Analytics 28
29 Other Measures My Thoughts Standardize and disseminate across programs measures that are meaningful and working 10/14/2015 Copyright Mingle Analytics 29
30 Performance Standards Secretary must consider when establishing performance standards Historical performance standards Improvement Opportunity for continued improvement. if there are not sufficient measures and activities applicable and available to each type of EP, assign different scoring weights (including a weight of zero) from those that apply generally under the MIPS. 10/14/2015 Copyright Mingle Analytics 30
31 Performance Standards - My Thoughts At the heart of the mission is to promote more cost effective care. Cost effectiveness is the comparative analysis of the cost per unit of quality. Cost Quality Comparison Valid comparisons (in decreasing order of priority) include: 1. Compare against nationwide benchmarks. 2. Compare in my community. What is community? Geographical (suitable for primary care and general medicine) Primary Care service area Hospital Service Area Tertiary Care Service Area Specialty Regional or National 3. Compare to self. Am I improving year to year? 10/14/2015 Copyright Mingle Analytics 31
32 Weighing Performance - My Thoughts 9 measures in 3 domains is a good Foundation Goal BUT We improve what we measure Watch for bias (distraction) introduced by measuring what is measurable Obeisance to arbitrary goals Every specialty, theoretically, has an ideal set of measures that defines what we want from the specialty Priorities can evolve over time 10/14/2015 Copyright Mingle Analytics 32
33 MIPS COMPOSITE PERFORMANCE SCORE AND PERFORMANCE THRESHOLD Secretary must assess the total performance of each MIPS EP based on performance standards in each of four performance categories scoring scale of 0 to 100 applicable to each performance year 10/14/2015 Copyright Mingle Analytics 33
34 Questions re Public Reporting Should we continue to use a minimum 20 patient threshold for public reporting through Physician Compare of quality measures in addition to assessing the reliability, validity and accuracy of the measures. Should we use, instead, a minimum reliability threshold. Should CMS include individual EP and group practice-level quality measure data stratified by race, ethnicity and gender in public reporting? 10/14/2015 Copyright Mingle Analytics 34
35 Public Reporting My Thoughts A reliability threshold seems to be what we want Stratification by race, ethnicity and gender will Increase complexity and cost of reporting Generate smaller, less significant measurements Introduce new errors and unreliability We should address Race, Ethnicity, Gender, and other types of equitable distribution of care with specific focused measures 10/14/2015 Copyright Mingle Analytics 35
36 Feedback Reports My Thoughts Routinely available to the vendor submitting the data for the year of submission Others by action / permission of the Practice Authorized Representative Cost and Quality contributions to attributable patients from other entities Equitable distribution measurement 10/14/2015 Copyright Mingle Analytics 36
37 Alternative Payment Models establishes incentive payments for EPs who are Qualified Providers (QPs) with respect to a year. a specified percent of an EP's payments must be attributable to an eligible alternative payment entity Models under section 1115A of the Act Not health care innovation awards Shared Savings Program demonstrations under the Health Care Quality Demonstration Program demonstrations required by federal law 10/14/2015 Copyright Mingle Analytics 37
38 An APM requires participants to use certified EHR technology provides for payment based on quality measures comparable to the MIPS quality measures Either bears financial risk for monetary losses under the APM that are in excess of a nominal amount Or is a medical home 10/14/2015 Copyright Mingle Analytics 38
39 On QP, Qualification, Incentive, Adjustment Bulk Sum Incentive Payments in years For any year as a QP 5% of prior year aggregate part B payments Partial QP Not Incentive Eligible Choose MIPS +/- Adjustment eligible if submitting Secretary can choose qualification by patient count rather than payment Year MC QP Qualification Thresholds (APM as % of Total Payments) All Payer QP MC Com Ins MC PQP % 20% % 20% Partial QP All Payer PQP MC Com Ins % 25% 50% 40% 20% 40% % 25% 50% 40% 20% 40% % 50% 75% 50% 20% 50% 10/14/2015 Copyright Mingle Analytics 39
40 Questions re APM Entities Should patient count or Charges be used to define thresholds? What does Nominal Risk mean? What does substantial Risk mean? What entities should/could be considered EAPM entities? What Quality Measures should apply to APM entities What should define CEHRT use for an APM 10/14/2015 Copyright Mingle Analytics 40
41 APM My thoughts There should be coordination of measures and mechanisms for all entities CEHRT should be encouraged but not demanded Let competition and innovation drive the model Health Information Exchange should be encouraged but not demanded Let competition and innovation drive the model 10/14/2015 Copyright Mingle Analytics 41
42 On Physician Focused Payment Models Increase the Transparency of Physician-Focused Payment Models Physician-focused Payment Model Technical Advisory Committee The Committee will review and provide comments and recommendations to the Secretary on PFPMs submitted by stakeholders 10/14/2015 Copyright Mingle Analytics 42
43 On Technical Assistance to Practices beginning in Fiscal Year 2016, Secretary required to engage entities such as quality improvement organizations regional extension centers regional health collaboratives to offer guidance and assistance to MIPS EPs in practices of 15 or fewer professionals. Priority is to be given to small practices located in rural areas, HPSAs, medically underserved areas, practices with low composite scores. focus on performance categories under MIPS how to transition to implementation of and participation in an APM. 10/14/2015 Copyright Mingle Analytics 43
44 Questions and Discussion Contact Information (866) /14/ Mingle Analytics 44
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