MACRA, QPP, MIPS and APMs

Rules of the Game

Make effective use of the 2017 and 2018 Transition Years

 Mike E.C. Schmidt
Director of Certification and Client Success at Eye Care
Leaders
Mike leads the teams at Eye Care Leaders which focus on client success with
MIPS and the related ONC Health IT Certification program. He brings more
than 30 years of experience from the medical device software and
healthcare IT field, including general management, marketing, software

About Your management, and software development positions in the ophthalmology,

oncology and radiology fields, including at Carl Zeiss Meditec, Varian

Speaker
Associates, Siemens Medical Systems and Pacsgear. Mike also owned and
led SES, a turnkey software development company focusing on high-risk
applications.

With the increased regulation, Mike has focused on MACRA, MIPS,

Meaningful Use and other EHR related regulatory concerns. He has spoken
at national conferences including at the User Group Conferences for
Medflow, Integrity, Management Plus MD Office.

Mike received his bachelors degree in mathematics from the University of

California at Berkeley and his masters degree in mathematics from the
University of Washington at Seattle.

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 The MIPS Challenge
Regulatory Update on the 2018 MIPS Proposed
Rule
The MIPS 2017 & 2018 Transition Years

Agenda The MIPS Composite Performance Score

MIPS ACI Performance
MIPS Improvement Activities Performance
MIPS Quality Performance
MIPS APMs and Advanced APMs
Action Items and Summary

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 Merit-Based Incentive Payment System
1 of 2 tracks of the Quality Payment
Program (QPP)
Alternate Payment Models (APMs) represent
the other track
Created by MACRA, a law passed with bi-
What is partisan support in 2015, nothing to do with
the Affordable Care Act, and not going away
MIPS?
MIPS is the most widely recognized acronym
and is often misused to refer to the program as
a whole
MIPS and specifically APMs are intended to rein
in rising Medicare costs
MIPS represents a historic transition from the
classic Fee-For-Service model to a value-
based reimbursement model

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 Instead of the provider specifying the fee to be
paid
the payer will pay what they determine the
services are worth!
The payer measures several categories of provider
performance such as quality of care and cost of
care
MIPS shifts value-based reimbursement amounts are
power to calculated in terms of payment adjustments
relative to the FFS schedule, which will continue to
the payer exist
MACRA requires MIPS and its payment
adjustments to be budget neutral
Congressional hopes for containing Medicare
costs lie primarily with the APMs, which put
increasing financial risk on the health care delivery
organizations
Over time, Congress hopes to move increasing
numbers of physicians from MIPS to APMs

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 Adjustments by Practice Size
Practice Size Physicians with Physicians with Positive
Negative Payment Payment Adjustment
Adjustment
Solo 87% 12.9%
2-9 69.9% 29.8%
The 10-24 59.4% 40.3%

Challenge of 25-99
100+
44.9%
18.3%
54.5%
81.3%
MIPS Proposed Rule Table 64, CMS estimatees based on 2014 data

Small practices lack economy of scale to

manage MIPS performance effectively
MIPS has disproportional effects on ambulatory
specialties such as ophthalmology

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 90-day reporting for 2018 MIPS EHR and
Improvement Activities
But keeps 2018 MIPS Quality reporting period at
the full calendar year
Regulatory Allows old 2014 Edition CEHRT for one more
Update: year
CMS But awards 10 MIPS ACI bonus points for 2015
Edition CEHRT in 2018
June, 2017 We recommend the upgrade to 2015 Edition
Proposed CEHRT in 2017 as soon as it is available
Broadens the MIPS exclusion, from $30,000 to
Rule for $90,000 Medicare reimbursements per provider
2018 MIPS per year
Dramatically affects optometrists: AOA
(1 of 3) estimates that all but 4000 optometrists
nationwide will be able to exclude from MIPS
Declares 2018 as 2nd and final transition year
easier MIPS scoring than later years

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 Adds a 5-point small practice bonus, starting in 2018
group TIN with no more than 15 individual NPI numbers
intended to counteract the Table 64 issue

Regulatory Larger practices should re-assess their group TIN structure

Reinstates critically missing EHR workflow exclusions,
Update: retroactive to 2017
Exclude from eRx measure if writing fewer than 100
CMS prescriptions
Exclude from send summary of care measure if referring
June, 2017 / transitioning fewer than 100 patients
Exclude from new receive summary of care measure in

Proposed
case of fewer than 100 new patients in the reporting
period
But Direct messaging capability is still part of the
Rule for definition of Base EHR and required for CEHRT!
With increased CMS auditing scrutiny, the practice must
2018 MIPS purchase a HISP license!

(2 of 3) Reinstates hardship exclusion for use of CEHRT

available only to small practices, no more than 15 eligible
clinicians (or to ones in rural or HPSA locations)
We do not recommend to plan a priori to take advantage of
this, but it is a welcome safety valve in case of CEHRT
implementation issues

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 Delays MIPS Cost of Care scoring until 2019
Extends transition year MIPS quality scoring rules
3-point floor for MIPS quality measure scores
Regulatory Small practices earn the 3 points even if the data
threshold is not met
Update: Introduces Improvement component to MIPS
Quality scoring
CMS Nothing to do with Improvement Activities

June, 2017 Adds 11 new Improvement Activities all eligible for

EHR bonus points
Proposed Sadly, none appear attractive for eye care

Rule for Modified scoring with more points for public

health reporting measures
2018 MIPS Eye care practices should sign up for syndromic
surveillance reporting if their state PHA allows it
(3 of 3) Virtual Group option for solo and small practices
to cooperate for a joint MIPS submission and
score
Contact Eye Care Leaders if you may be interested
in having us facilitate this option for you

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 2017 & 2018 MIPS transition years will be far easier than 2016 MMU2
/ PQRS / VM

CMS estimated that for 2017 MIPS:

At least 90% of MIPS eligible clinicians will receive a positive or neutral MIPS
payment adjustment (for) the transition year, and that
at least 80% of clinicians in small and solo practices with 1-9 clinicians will
receive a positive payment adjustment.

The MIPS If you do nothing, you will be penalized the full amount
4% for 2017; 5% for 2018
Transition To avoid a penalty, only need to report a single performance
category
Years: Quality, or
Improvement Activities, or
2017 & 2018 ACI (formerly called Meaningful Use of Certified EHR Technology)

Dont let the easy rules lull you into a false sense of security
If you only target 2017 and 2018, the gap with very large practices will only
grow
You would fail in later years
It is time to plan and implement your long-term MIPS strategy now
Take proper advantage of the Transition Years

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 MACRA requires payment adjustments to be budget-
neutral
Positive adjustments are subject to a Scaling Factor based on
available funds from negative payment adjustments
With over 90% of physicians expected to receive positive or
neutral payment adjustments for 2017, the funds from negative
payment adjustments are expected to be very small
Physicians who will not bother with MIPS will be those planning to
Limited retire by 2019 or those who receive relatively low total Medicare
reimbursements, further limiting the available funds
Positive Expect positive adjustments earned for the 2017 performance
year to be very small maximum possible may be less than
Payment +0.8%
Expect positive adjustments tfor the 2018 performance year not
Adjustments to be much larger maximum possible may be less than +1%

Main positive incentive will be for an exceptional

performance bonus
Allocated from a $500M / Year fund not required to be budget-
neutral
Shared by all eligible clinicians who exceed a MIPS score above an
exceptional performance threshold
A MIPS score of 70+ in the transition years will earn this bonus

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 MIPS Payment Adjustments in the First 4 Years
2017 2018 2019 2020

Quality Reporting 90 days Full year Full year Full year

ACI & CPIA Reporting 90 days 90 days TBD Full year

CEHRT Edition Required 2014 2015 for 2015 2015
higher
score
MIPS Performance 3 15 Mean Mean
Threshold
MIPS Exceptional Performance 70 70 Derived Derived

Phase-In Threshold
Floor for MIPS Quality 3 3
from PT
0
from PT
0
measures
Quality Weighting 60% 60% 30% 30%
Cost Weighting 0% 0% 30% 30%
Max. Negative -4% -5% -7% -9%
Adjustment
Max. Positive Adjustment +0.8% +1% +7% +9%
(Estimated)

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You have to learn the rules of the game. And
then you have to play better
than anyone else.
Albert Einstein

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The MIPS
Composite
Performance
Score

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 Diagram Legend
PT Performance Threshold
The mean or median of all MIPS composite
scores for the performance year nationwide
APT Additional Performance Threshold
The 1st quartile of MIPS composite scores
above the PT or
the MIPS composite score corresponding to
the 1st quartile of participants above the PT
25% of PT
1st quartile of MIPS composite scores below
the PT
SF Scaling Factor
A factor calculated to ensure that MIPS
payment adjustments stay budget neutral
AAF Additional Adjustment Factor
Used to calculate the exceptional
performance bonus budgeted for $500M
total nationwide per year

Participant Grades
A meets or exceeds the APT; receives a positive adjustment proportional to score plus an exceptional performance bonus
B exceeds the PT but is below the APT; receives a positive adjustment proportional to score, no exceptional performance bonus
C exactly at the PT; receives zero payment adjustment
D below the PT but above 25% of PT; receives a negative payment adjustment proportional to score
F in bottom 25% below PT; receives maximum negative payment adjustment

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 Diagram Legend
PT Performance Threshold
The mean or median of all MIPS composite
scores for the performance year nationwide
APT Additional Performance Threshold
The 1st quartile of MIPS composite scores
above the PT or
the MIPS composite score corresponding to
the 1st quartile of participants above the PT
25% of PT
1st quartile of MIPS composite scores below
the PT
SF Scaling Factor
A factor calculated to ensure that MIPS
payment adjustments stay budget neutral
AAF Additional Adjustment Factor
Used to calculate the exceptional performance
bonus budgeted for $500M total nationwide
per year

Participant Grades
A meets or exceeds the APT; receives a positive adjustment proportional to score plus an exceptional performance bonus
B exceeds the PT but is below the APT; receives a positive adjustment proportional to score, no exceptional performance bonus
C exactly at the PT; receives zero payment adjustment
D below the PT but above 25% of PT; receives a negative payment adjustment proportional to score
F in bottom 25% below PT; receives maximum negative payment adjustment

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 MIPS Reimbursement:
Every Performance Point Will Count
Year 2016 (VM) 2017 & 2018 MIPS in 2019 &
MIPS Transition Later Years
Year
Description Top 5% of Quality Minimum reporting Payment adjustments
and/or Cost get + for one of: depend linearly on
payment adjustment 1. Quality (PQRS) performance:
Bottom 5% get - 2. Improvement 1. Quality
payment adjustment Activities 2. Cost
3. ACI 3. Improvement
Activities
4. ACI
Most Providers Get no payment Will avoid a negative Will get a payment
adjustment payment adjustment adjustment
Payment Very few Very small
Adjustment + Depends on
Payment Very few Very few performance
Adjustment -

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MIPS ACI
(Advancing Care
Information)
Performance

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