Introduction to the QPP and MIPS

Introduction to the QPP and MIPS

Quality Payment Program Quality Payment Program November 7, 2016 1 Quality Payment Program Topics What is the Quality Payment Program? Who participates in the Quality Payment Program? How does the Quality Payment Program work? What is the Merit-based Incentive Payment System (MIPS) What are Advanced Alternative Payment Models

(APMs) Where can I go to learn more? 2 Quality Payment Program What is the Quality Payment Program? 3 Quality Payment Program Medicare Payment Prior to MACRA Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. The Sustainable Growth Rate (SGR) Established in 1997 to control the cost of Medicare payments to physicians > IF Overall physician costs

Target Medicare expenditur es Physician payments cut across the board Each year, Congress passed temporary doc fixes to avert cuts (no fix in 2015 would have meant a 21% cut in Medicare payments to clinicians) 4 Quality Payment Program The Quality Payment Program The Quality Payment Program policy will reform Medicare Part B payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system. Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population.

Two tracks to choose from: Quality Payment Program Who participates in the Quality Payment Program? 6 Quality Payment Program Who participates in the Quality Payment Program? Medicare Part B clinicians billing more $30,000 a year and providing care for more than 100 Medicare patients a year. These clinicians include: - Physicians - Physician Assistants

- Nurse Practitioners - Clinical Nurse Specialists - Certified Registered Nurse Anesthetists Quality Payment Program Who is excluded from the Quality Payment Program? Newly-enrolled Medicare clinicians - Clinicians below the low-volume threshold - Clinicians who enroll in Medicare for the first time during a performance period are exempt from reporting on

measures and activities for MIPS until the following performance year. Medicare Part B allowed charges less than or equal to $30,000 OR 100 or fewer Medicare Part B patients Clinicians significantly participating in Advanced APMs Quality Payment Program How does the Quality Payment Program work? 9 Quality Payment Program Transition Year Pick Your Pace MIPS Test Pace Partial Year Full Year Submit some data after January 1,

2017 Report for 90-day period after January 1, 2017 Fully participate starting January 1, 2017 Neutral or small payment adjustment Small positive payment adjustment Modest positive payment

adjustment Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment. 10 Quality Payment Program Choosing to Test for 2017 If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity), you can avoid a downward adjustment Quality Payment Program Partial Participation for 2017 If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment. That means if youre not ready on January 1, you can choose to start anytime between January 1 and October 2, 2017. Whenever you choose to start, you'll

need to send in performance data by March 31, 2018. Quality Payment Program Full Participation for 2017 If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment. The best way to earn the largest positive adjustment is to participate fully in the program by submitting information in all the MIPS performance categories. Key Takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted. Quality Payment Program The Merit-based Incentive Payment System (MIPS) 14 Quality Payment Program

The Merit-based Incentive Program One path of the Quality Payment Program that streamlines 3 legacy reporting programs (PQRS, Value Modifier and the Medicare EHR Incentive Program) Moves Medicare Part B clinicians to a performancebased payment system MIPS provides clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance There are four MIPS performance categories: Quality, Advancing Care Information, Improvement Activities, and Cost. 15 Quality Payment Program MIPS Performance Category: Quality Category Requirements

Replaces PQRS and Quality Portion of the Value Modifier 60% of final score Select 6 of about 300 quality measures (minimum of 90 days); 1 must be: Outcome measure OR High-priority measure defined as outcome measure, appropriate use measure, patient experience, patient safety, or care coordination May also select specialty-specific set of measures Readmission measure for group submissions that have > 16 clinicians and a sufficient number of cases (no requirement to submit)

Different requirements for groups reporting CMS Web Interface or16 Quality Payment Program Advancing Care Information Promotes patient engagement and interoperability using certified EHR technology Replaces the Medicare EHR Incentive Program Greater flexibility in choosing measures In 2017, there are 2 measure sets for reporting based on EHR edition: 1. Advancing Care Information Objectives and Measures 2. 2017 Advancing Care Information Transition Objectives and Measures 17

Quality Payment Program Advancing Care Information: Reporting Clinicians must use certified EHR technology to report. Reporting requirements are dependent on your version of Certified EHR Technology If youre reporting via EHR technology certified to the 2015 Edition: Option 1: Advancing Care Information Objectives and Measures Option 2: Combination of the two measure sets If youre reporting via EHR Technology certified to the 2014 Edition: or Option 1: 2017 Advancing Care Information Transition Objectives and Measures Option 2: Combination of the two measure sets 18

Quality Payment Program MIPS Performance Category: Advancing Care Information Advancing Care Information Objectives and Measures: 2017 Advancing Care Information Transition Objectives and Measures: Base Score Required Measures Base Score Required Measures Objective Measure Protect Patient Health Information Security Risk Analysis Electronic Prescribing e-Prescribing Patient Electronic Access

Objective Measure Protect Patient Health Information Security Risk Analysis Provide Patient Access Electronic Prescribing e-Prescribing Health Information Exchange Send a Summary of Care Patient Electronic Access Provide Patient Access Health Information Exchange Request/Accept a Summary of Care Health Information

Exchange Health Information Exchange 19 Quality Payment Program MIPS Performance Category: Advancing Care Information Advancing Care Information Objectives and Measures Objective Measure Patient Electronic Access Provide Patient Access* Patient Electronic Access Patient-Specific Education Coordination of Care through Patient Engagement Coordination of Care through Patient Engagement

2017 Advancing Care Information Transition Objectives and Measures Objective Measure Patient Electronic Access Provide Patient Access* View, Download and Transmit (VDT) Patient Electronic Access View, Download and Transmit (VDT) Secure Messaging Patient-Specific Education Patient-Specific Education Coordination of Care through Patient Engagement Patient-Generated Health Data

Secure Messaging Secure Messaging Health Information Exchange Send a Summary of Care* Request/Accept a Summary of Care* Clinical Information Reconciliation Immunization Registry Reporting Health Information Exchange Health Information Exchange* Medication Reconciliation Medication Reconciliation Public Health Reporting Immunization Registry Reporting Health Information Exchange

Health Information Exchange Public Health and Clinical Data Registry Reporting 20 Quality Payment Program Advancing Care Information: Flexibility 1.Clinicians recognized as participating in a MIPS-APM entity will automatically receive a 50% score in the category - Clinicians need to earn the remaining 50% to receive full credit in the category 2.CMS will automatically reweight the Advancing Care Information performance category to zero for Hospital-based MIPS clinicians, clinicians with lack of Face-to-Face Patient Interaction, NP, PA, CRNAs and CNS - Reporting is optional although if clinicians choose to report, they will be scored. 3.If clinician faces a significant hardship and is unable to report advancing care information measures, they can apply to have their performance category score weighted to zero 21

Quality Payment Program MIPS Performance Category: Advancing Care Information BASE SCORE + PERFORMANCE SCORE + BONUS SCORE Account for Account for up to Account for up to 50% 90% 15% of the total

Advancing Care Information Performance Category Score of the total Advancing Care Information Performance Category Score of the total Advancing Care Information Performance Category Score FINAL SCORE = Earn 100 or more percent and receive FULL 25 points of the total Advancing Care Information Performance Category

Final Score The overall Advancing Care Information score would be made up of a base score, a performance score, and a bonus score for a maximum score of 100 percentage points Quality Payment Program MIPS Performance Category: Improvement Activities Assesses participation in activities that improve clinical practice - Examples: Shared decision making, patient safety, coordinating care, increasing access Clinicians choose from about 90+ activities under 9 subcategories: 1. Expanded Practice Access 2. Population Management 3. Care Coordination 4. Beneficiary Engagement 5. Patient Safety and Practice Assessment 6. Participation in an APM 7. Achieving Health Equity 8. Integrating Behavioral and Mental Health

9. Emergency Preparedness and Response 23 Quality Payment Program Improvement Activities: Flexibilities Groups with 15 or fewer participants, non-patient facing clinicians, or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days. Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit. Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or the Oncology Care Model: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit. 24

Quality Payment Program MIPS Performance Category: Cost No reporting requirement; 0% of final score in 2017 Clinicians assessed on Medicare claims data Uses measures previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR), but scoring is different 25 Quality Payment Program Cost: Reporting Cost Measures from VM 1. Medicare Spending Per Beneficiary

(MSPB) 2. Total Per-Capita Cost for All Attributed Beneficiaries For the transition year, there are no requirements for the Cost Performance Category 26 Quality Payment Program Cost: Flexibilities For the transition year, the cost performance category will not impact payment in 2019 Clinicians Cost performance (episode groupers measures) will be included in 2018 performance feedback to help clinicians gauge performance and prepare for year 2 of the program. For data submission, no action is needed from the

clinician. 27 Quality Payment Program Example of MIPS Participation for a Cardiologist Sample Quality Measures: - Closing the referral loop with referring provider - Documentation of current medications - Statins for primary prevention in high-risk patients and for treatment in patients with known CVD - Beta blockers in patients with LV systolic dysfunction - ACE-Inhibitor or ARB in patients with LV systolic dysfunction - Antiplatelet therapy in patients with CAD - *Chronic anticoagulation therapy for patients with non-valvular atrial fibrillation (AFib) based on CHADS2 risk score - *Avoidance of inappropriate cardiac stress imaging in low-risk patients Sample Improvement Activities: - Telehealth services that expand access to care - Participation in a qualified clinical data

registry (QCDR), for example: - American College of Cardiology Foundation CathPCI Registry - American College of Cardiology Foundation (ACCF)-PINNACLE Registry - American Society of Nuclear Cardiology ImageGuide Registry - Implementation of specialist reports back to referring provider - Implementation of processes for timely communication of test results - Use of certified EHR technology (CEHRT) Advancing Care Information (Use of Technology): - Electronic Prescribing - Patient Electronic Access - Health Information Exchange - Exchange of patient care records - Reconciliation of clinical information Flexibility to CHOOSE WHAT and HOW you report Payment adjustments according to composite score

*measure supported by American College of Cardiology 28 Quality Payment Program Alternative Payment Models (APMs) 29 Quality Payment Program What is an Alternative Payment Model (APM)? Alternative Payment Models (APMs) are new approaches to paying for medical care through Medicare that incentivize quality and value. The CMS Innovation Center develops new payment and service delivery models. Additionally, Congress has defined both through the Affordable Care Act and other legislation a number of demonstrations that CMS conducts. CMS Innovation Center As defined by MACRA, APMs include: model (under section 1115A,

other than a Health Care Innovation Award) MSSP (Medicare Shared Savings Program) Demonstration under the Health Care Quality Demonstration Program Demonstration required by federal law 30 Quality Payment Program Alternative Payment Models An Alternative Payment Model (APM) is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide highquality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. APMs may offer significant opportunities to eligible clinicians who are not immediately able or prepared

to take on the additional risk and requirements of Advanced APMs. Advanced APMs are a Subset of APMs APMs Advanced APMs 31 Quality Payment Program Advanced Alternative Payment Models (Advanced APMs) Benefits 32 Quality Payment Program Advanced Alternative Payment Models Advanced Alternative Payment Models (Advanced APMs) enable clinicians and practices to earn

greater rewards for taking on some risk related to their patients outcomes. It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced Advanced APMs Advanced APM- specific rewards + 5% lump sum incentive 33 Quality Payment Program What are the Benefits of Participating in an Advanced APM as a Qualifying APM Participant (QP)? Are excluded from MIPS QPs: Receive a 5% lump

sum bonus Receive a higher Physician Fee Schedule update starting in 2026 34 Quality Payment Program The Quality Payment Program provides additional rewards for participating in APMs. Potential financial rewards In Advanced APM Not in APM In APM MIPS adjustments MIPS adjustments + APM-specific rewards APM-specific rewards

+ If you are a Qualifying APM Participant (QP) = 5% lump sum bonus 35 Quality Payment Program Advanced APM Criteria 36 Quality Payment Program Medical Home Model A Medical Home Model is an APM that has the following features: -

Participants include primary care practices or multispecialty practices that include primary care physicians and practitioners and offer primary care services. - Empanelment of each patient to a primary clinician; and - At least four of the following additional elements: Planned coordination of chronic and preventive care. Patient access and continuity of care. Risk-stratified care management. Coordination of care across the medical neighborhood. Patient and caregiver engagement.

Shared decision-making. Payment arrangements in addition to, or substituting for, fee-for-service payments. 37 Quality Payment Program Advanced APMs Must Meet Certain Criteria To be an Advanced APM, the following three requirements must be met. The APM: 1 Requires participants to use certified EHR technology; 2 Provides payment for

covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and 3 Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk. 38

Quality Payment Program Advanced APM Criterion 1: Requires use of Certified EHR Technology 1. Requires participants to use certified EHR technology Requires that at least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other health care professionals. Shared Savings Program requires that clinicians report at the group TIN level according to MIPS rules. 39 Quality Payment Program Advanced APM Criterion 2: Requires MIPS-Comparable Quality Measures 2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category.

Ties payment to quality measures that are evidence-based, reliable, and valid. At least one of these measures must be an outcome measure if an appropriate outcome measure is available on the MIPS measure list. 40 Quality Payment Program Advanced APM Criterion 3: Medical Home Expanded Under CMS Authority 3. Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority, OR (2) requires participants to bear a more than nominal amount of financial risk. Medical Home Model Expansion Medical Home Model Financial Risk Medical Home Models tested under section 1115A of the Act has an alternate pathway to meet the financial risk criterion through expansion under section 1115A(c) of the Act

While no medical home models have yet been expanded, medical home models can still be Advanced APMs if they include financial risk for participants. The medical home model financial risk standard acknowledges that risk under the terms of an APM can be structured uniquely for smaller entities in a way that offers the potential of losses without threatening their financial 41 Quality Payment Program Advanced APM Criterion 3: Bear a More than Nominal Amount of Financial Risk 3. Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority, OR (2) requires participants to bear a more than nominal amount of financial risk. Financial Risk Bearing financial risk means that the Advanced APM may do one or more of the following if actual expenditures exceed expected expenditures:

Withhold payment for services to the APM Entity and/or the APM Entitys eligible clinicians Reduce payment rates to the APM Entity and/or the APM Entitys eligible clinicians Require direct payments by the APM Entity to CMS. Total Amount of Risk The total amount of that risk must be equal to at least either: 8% of the average estimated total Medicare Parts A and B revenues of participating APM Entities; OR 3% of the expected expenditures for which an APM Entity is responsible under the APM. 42 Quality Payment Program Advanced APMs in 2017 For the 2017 performance year, the following models are Advanced APMs: Comprehensive End Stage Renal Disease Care Model (Two-Sided Risk Arrangements)

Comprehensive Primary Care Plus (CPC+) Shared Savings Program Track 2 Shared Savings Program Track 3 Next Generation ACO Model Oncology Care Model (Two-Sided Risk Arrangement) The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements on an ad hoc basis. 43 Quality Payment Program Future Advanced APM Opportunities MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and assess Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee. Comprehensive

Care for Joint In future performance years, weBundled anticipate that New Voluntary Payment Replacement (CJR) Payment Model Model (CEHRT) the following models will be Advanced APMs: Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT) Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model) ACO Track 1+ 44 Quality Payment Program Qualifying APM Participants (QPs)

45 Quality Payment Program What is a Qualifying APM Participant (QP)? Qualifying APM Participants (QPs) are clinicians who have a certain % of Part B payments for professional services or patients furnished Part B professional services through an Advanced APM Entity. Beginning in 2021, this threshold % may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid. 46 Quality Payment Program How do Eligible Clinicians become Qualifying APM Participants? Step 1 Qualifying APM Participant determinations are made at the Advanced APM Entity level, with certain exceptions: individuals participating in multiple Advanced APM Entities, none of which meet the QP threshold as a

group, and eligible clinicians on an Affiliated Practitioner List when that list is used for the QP determination because there are no eligible clinicians on a Participation List for the Advanced APM Entity. For example, gain sharers in the Comprehensive Care for Joint Replacement Model will be assessed individually. 1 47 Quality Payment Program How do Eligible Clinicians become Qualifying APM Participants? Step 2 2 CMS will calculate a percentage Threshold Score for each Advanced APM Entity using two methods (payment amount and patient count). Methods are based on Medicare Part B professional services and beneficiaries attributed to Advanced APM CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity. These definitions

are used for calculating Threshold Scores under both methods. Attributed (beneficiaries for whose cost and quality of care the APM Entity is responsible) Attribution-eligible (all beneficiaries who could potentially be attributed) 48 Quality Payment Program How do Eligible Clinicians become Qualifying APM Participants? Step 2 2 The two methods for calculation are Payment Amount Method and Patient Count Method. Payment Amount Method $$$ for Part B professional services to attributed

beneficiaries $$$ for Part B professional services to attributioneligible beneficiaries Patient Count Method = Threshol d Score % # of attributed beneficiaries given Part B professional services # of attributioneligible beneficiaries given Part B professional services = Threshol d Score % 49

Quality Payment Program How do Eligible Clinicians become Qualifying APM Participants? Step 3 3 The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result. Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements) Performance 2017 2018 2019 2020 2021 2022 Year and later Percentage of Payments through an Advanced APM Percentage of

Patients through an Advanced APM 50 50 Quality Payment Program How do Eligible Clinicians become Qualifying APM Participants? Step 4 Advanced APM 4 All the eligible clinicians in the Advanced APM Entity become QPs for the payment year. Advanced APM Entities Threshold Scores above the QP threshold = QP status

Eligible Clinicians Threshold Scores below the QP threshold = no QPs 51 Quality Payment Program What is the Performance Period for QPs? The QP Performance Period is the period during which CMS will assess eligible clinicians participation in Advanced APMs to determine if they will be QPs for the payment year. The QP Performance Period for each payment year will be from January 1 August 31st of the calendar year that is two years prior to the payment year. Performance Period: QP status based on Advanced APM participation Incentive Determination: Add up payments for Part B professional services furnished

by QP Payment: +5% lump sum payment made (excluded from MIPS adjustment) 52 Quality Payment Program What are the three Snapshots for QPs during the Performance Period? During the QP Performance Period (January August), CMS will take three snapshots (March 31, June 30, August 31) to determine which eligible clinicians are participating in an Advanced APM and whether they meet the thresholds to become Qualifying APM Participants. MAR JUN AUG 31

30 31 53 Quality Payment Program How are QPs determined during the Performance Period? For each of the three QP determinations, CMS will use claims data from period A for the APM Entity participants captured in the snapshot at point B. CMS then allows for claims run-out during period C and finalizes QP determinations at point D. If an APM Entity meets the QP threshold, subsequent eligible clinician additions to the Participation List do not automatically confer QP status to those eligible clinicians. If the group meets the QP threshold for a subsequent QP determination, then the new Jan 2017 Feb 2017 Mar 2017 QPs. Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017

Sep 2017 Oct 2017 Nov 2017 Dec 2017 additions become A B C D #1 B A C D B C #2 A D

#3 54 Quality Payment Program When Will Clinicians Learn their QP Status? Reaching the QP threshold at any one of the three QP determinations will result in QP status for the eligible clinicians in the Advanced APM Entity Eligible clinicians will be notified of their QP status after each QP determination is complete (point D). Jan 2017 Feb 2017 A Mar 2017 Apr 2017 May 2017 B

Jun 2017 Jul 2017 C Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 D #1 B A C D B

C #2 A D #3 55 Quality Payment Program What if Clinicians do not Meet the QP Payment or Patient Thresholds? Clinicians who participate in Advanced APMs, but do not meet the QP threshold, may become Partial Qualifying APM Participants (Partial QPs). Partial QPs choose whether to participate in MIPS. Medicare-Only Partial QP Thresholds in Advanced APMs Paymen t Year 2019

2020 2021 2022 2023 2024 and later Percenta ge of Payment s Percenta ge of Patients 56 Quality Payment Program Other Payer Advanced APMs 57 Quality Payment Program

Do payments from other payers apply to QP determination? Starting in the 2019 QP Performance Period, participation in payment arrangements with other, non-Medicare payers can contribute to meeting the QP threshold. The All-Payer Combination Option will be based on a combination of Advanced APM participation and participation in Other Payer Advanced APMs. - To be considered under the All-Payer Combination Option, eligible clinicians must also participate in an Advanced APM but not meet the QP threshold under the Medicare Option. Other Payer Advanced APMs must meet criteria similar to those for Advanced APMs. 58 Quality Payment Program What is the Performance Period for QPs?

The QP Performance Period is the period during which CMS will assess eligible clinicians participation in Advanced APMs to determine if they will be QPs for the payment year. The QP Performance Period for each payment year will be from January 1 August 31st of the calendar year that is two years prior to the payment year. Performance Period: QP status based on Advanced APM participation Incentive Determination: Add up payments for Part B professional services furnished by QP Payment: +5% lump sum payment made (excluded from MIPS adjustment) 59

Quality Payment Program All-Payer Combination Option How do Eligible Clinicians become Qualifying APM Participants? Step 1 Qualifying APM Participant determinations are made at the Advanced APM Entity level, with certain exceptions: individuals participating in multiple Advanced APM Entities, none of which meet the QP threshold as a group, and eligible clinicians on an Affiliated Practitioner List when that list is used for the QP determination because there are no eligible clinicians on a Participation List for the Advanced APM Entity. For example, gain sharers in the Comprehensive Care for Joint Replacement Model will be assessed individually. 1 60 Quality Payment Program All-Payer Combination Option How do you calculate Threshold Scores? Step 2 2

CMS will calculate a percentage Threshold Score for each Advanced APM Entity using two methods (payment amount and patient count). Methods are based on payments from and patient furnished services through agreements with all payers, with certain exceptions. CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity. These definitions are used for calculating Threshold Scores under both methods. The aggregate of all payments (or all patients given services) under the terms of the payment arrangement The aggregate of all payments (or all patients given services) from the payer 61 Quality Payment Program All-Payer Combination Option How do you calculate Threshold Scores? Step 2

2 Calculate the Threshold Score under the AllPayer Combination Option. PAYMENT AMOUNT METHOD $$$ the terms of Advances APMs and Other Payer Advanced APMs $$$ from all payers = Threshold Score % PATIENT COUNT METHOD # of patients given services under Advanced APMs and Other Payer Advanced APMs # of patients given services under all payers = Thresho ld Score %

62 Quality Payment Program All Payer Combination Option How do you calculate Threshold Scores? Step 2 Payments from the following sources are excluded from the calculation under the All-Payer Combination Option: 2 Department of Defense Health Care Programs Department of Veterans Affairs Health Care Programs Title XIX in a state with no Medicaid Medical Home Model or APM. In order not to adversely impact physicians who have no opportunity to participate, Title XIX payments or patients would be excluded unless: a state had at least one Medicaid Medical Home Model or APM in operation that is determined to be an Other Payer Advanced APM; and the relevant Advanced APM Entity is eligible to participate in at least one such Other Payer Advanced APM, regardless of whether the Advanced APM Entity actually participates in such Other Payer Advanced APMs. 63 Quality Payment Program

How do Eligible Clinicians become Qualifying APM Participants? Step 3 3 The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result. All-Payer Combination Option QP Payment Amount Threshold N/A N/A QP Patient Count Threshold N/A N/A 2021 Medicare

2024 and later Medicare 2023 Medicare Medicare Total 2022 Total 2020 Total 2019 Total Payme nt Year

64 Quality Payment Program QP Determination Tree Payment Years 2021 - 2022 QP QP YES YES Is All-Payer Threshold Score PARTIAL QP > 50% Is Medicare Threshold Score > 50% NO YES NO

YES Is All-Payer Threshold Score Is Medicare Threshold Score > 40% > 25% OR is Medicare Threshold Score > 40%? NO YES NO Is Medicare Threshold Score MIPS Eligible Clinician > 20% NO MIPS Eligible Clinician

65 Quality Payment Program How do Eligible Clinicians become Qualifying APM Participants? Step 4 All the eligible clinicians in the Advanced APM Entity become QPs for the payment year. 4 ADVANCED APM OTHER PAYER ADVANCED APM ADVANCED APM ENTITY ELIGIBLE CLINICIANS OR Entity-level Threshold Score below the QP

threshold = no QPs Entity-level Threshold Score above the QP threshold = QPs 66 Quality Payment Program APM Scoring Standard 67 Quality Payment Program What are MIPS APMs? Goals MIPS APMs are a Subset of Reduce eligible clinician APMs reporting burden. Maintain focus on the goals and objectives of APMs. How does it work? Streamlined MIPS reporting and scoring for eligible clinicians in certain APMs. Aggregates eligible clinician

MIPS scores to the APM Entity level. All eligible clinicians in an APM Entity receive the same MIPS final score. 68 Uses APM-related performance Quality Payment Program What are the Requirements to be Considered a MIPS APM? The APM scoring standard applies to APMs that meet these criteria: APM Entities participate in the APM under an agreement with CMS; APM Entities include one or more MIPS eligible clinicians on a Participation List; and APM bases payment incentives on performance (either at the APM Entity or eligible clinician level) on cost/utilization and quality.

69 Quality Payment Program What are key dates for the APM scoring standard? To be considered part of the APM Entity for the APM scoring standard, an eligible clinician must be on an APM Participation List on at least one of the following three snapshot dates (March 31, June 30 or August 31) of the performance period. Otherwise an eligible clinician must report to MIPS under the standard MIPS methods. MAR JUN AUG 31 30 31 70

Quality Payment Program To which APMs does the APM Scoring Standard apply in 2017? For the 2017 performance year, the following models are considered MIPS APMs: Comprehensive ESRD Care (CEC) Model (All Arrangements) Comprehensive Primary Care Plus (CPC+) Model Shared Savings Program Tracks 1, 2, and 3 Next Generation ACO Model Oncology Care Model (OCM) (All Arrangements) The list of MIPS APMs is posted at QPP.CMS.GOV and will be updated on an ad hoc basis. 71 Quality Payment Program Shared Savings Program (All Tracks) under the APM Scoring Standard REPORTING REQUIREMENT

Quality PERFORMANCE SCORE ACOs submit quality measures to the CMS Web Interface on behalf of their participating MIPS eligible clinicians. The MIPS quality performance category requirements and benchmarks will be used to score quality at the ACO level. MIPS eligible clinicians will not be assessed on cost. N/A No additional reporting necessary. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the Shared Savings Program. WEIGHT Cost

Improvement Activities Advancing Care All ACO participant TINs in the All of the ACO participant TIN scores will be ACO submit under this category aggregated as a weighted average based on according to the MIPS group the number of MIPS eligible clinicians in each reporting requirements. TIN to yield one APM Entity group score. 72 Quality Payment Program Next Generation ACO Model under the APM Scoring Standard REPORTING REQUIREMENT Quality Cost Improvement Activities Advancing Care

ACOs submit quality measures to the CMS Web Interface on behalf of their participating MIPS eligible clinicians. MIPS eligible clinicians will not assessed on cost. PERFORMANCE SCORE WEIG HT The MIPS quality performance category requirements and benchmarks will be used to score quality at the ACO level. N/A No additional reporting necessary. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the Next Generation ACO Model. Each MIPS eligible clinician CMS will attribute one score to each MIPS eligible in the APM Entity group clinician in the APM Entity group. This score will be the

reports advancing care highest score attributable to the TIN/NPI combination information to MIPS through of each MIPS eligible clinician, which may be derived either group reporting at from either group or individual reporting. The scores the TIN level or individual attributed to each MIPS eligible clinicians will be reporting. averaged to yield a single APM Entity group score. 73 Quality Payment Program All Other APMs under the APM Scoring Standard REPORTING REQUIREMENT Quality PERFORMANCE SCORE The APM Entity group will not be assessed on quality under MIPS in the first performance period. MIPS eligible clinicians will not be assessed on cost. N/A

No additional reporting necessary. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the MIPS APM. CMS will attribute one score to each MIPS eligible clinician in the APM Entity group. This score will be the highest score attributable to the TIN/NPI combination of each MIPS eligible clinician, which may be derived from either group or individual reporting. The scores attributed to each MIPS eligible clinician will be averaged to yield a single APM Entity group score. WEIGH T N/A Cost Improvement Activities Advancing Care Each MIPS eligible clinician in

the APM Entity group reports advancing care information to MIPS through either group reporting at the TIN level or individual reporting. 74 Quality Payment Program Physician-Focused Payment Model Technical Advisory Committee 75 Quality Payment Program Physician-Focused Payment Model Technical Advisory Committee MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and assess Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee. The PTAC is a federal advisory committee that

provides independent advice to the Secretary. The PTAC is supported by HHS Office of the Assistant Secretary for Planning and Evaluation. This committee provides a unique opportunity for stakeholders to participate in the development of new 76 models and to help determine priorities for the Quality Payment Program PFPM Technical Advisory Committee (PTAC) PFPM = Physician-Focused Payment Model Goal to encourage new APM options for Medicare clinicians Submission of model proposals by Stakeholders Technical Advisory Committe e

11 appointed care delivery experts that review proposals, submit recommendations to HHS Secretary Secretary comments on CMS website, CMS considers testing proposed models Models with favorable response go to CMS Innovation Center 77 Quality Payment Program How Does the PTAC Work?

78 Quality Payment Program Where can I go to learn more? 79 Quality Payment Program Help Is Available qpp.cms.gov CMS has organizations on the ground to provide help to clinicians who are eligible for the Quality Payment Program: Transforming Clinical Practice Initiative (TCPI): TCPI is designed to support more than 140,000 clinician practices over the next 4 years in sharing, adapting, and further developing their comprehensive quality improvement strategies. Clinicians participating in TCPI will have the advantage of learning about MIPS and how to move toward participating in Advanced APMs. Click here to find help in your area. Quality Innovation Network (QIN)-Quality Improvement Organizations (QIOs): The QIO Programs 14 QIN-QIOs bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality. More information about QIN-QIOs can be found here. If youre in an APM: The Innovation Centers Learning Systems can help you find specialized information about what you need to do to be successful in the Advanced APM track. If youre in an APM that is not an Advanced APM, then the Learning Systems can help you understand the special benefits you have through your APM that will help you be successful in MIPS. More information about the Learning Systems is available through your

models support inbox. Quality Payment Program Quality Payment Program When and where do I submit comments? The final rule with comment includes changes not reviewed in this presentation. We will not consider feedback during the call as formal comments on the rule. See the proposed rule for information on submitting these comments by the close of the 60-day comment period on December 19, 2016. When commenting refer to file code CMS-5517-F. Instructions for submitting comments can be found in the proposed rule; FAX transmissions will not be accepted. You must officially submit your comments in one of the following ways: electronically through - Regulations.gov -

by regular mail - by express or overnight mail - by hand or courier For additional information, please go to: QPP.CMS.GOV 82

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    Welcome to the Year 6 Parents' Evening

    Welcome to the Year 6 & Year 2 SATS Meeting Mrs Scattergood & Mrs Finney Statutory Assessment Tasks and Tests (also includes Teacher Assessment). Usually taken at the end of Key Stage 1 (at age 7) and at the end...
  • Presentation 1: Background

    Presentation 1: Background

    Questions about this presentation may be emailed to the email address on your screen. Thank you. * Welcome to the first in a series of educational presentations for the Hematopoietic and Lymphoid Neoplasm project. * This presentation covers the Background...
  • ADA Compliant Lecture PowerPoint

    ADA Compliant Lecture PowerPoint

    Conformity for normative reasons occurs in situations where we do what other people are doing not because we are using them as a source of information but because we won't attract attention, be made fun of, get into trouble, or...
  • SICK-Unternehmenspräsentation

    SICK-Unternehmenspräsentation

    The IO-EXP-AOD5 is an External input & output terminal for extended connectivity of the controller unit of OD Precision. The terminal board included in the scope of delivery only includes the power supply and all 6 analogue outputs. To use...
  • ANGER MANAGEMENT - psyking.net

    ANGER MANAGEMENT - psyking.net

    ANGER MANAGEMENT WHAT IS ANGER? An emotional state. Varies in intensity A coping mechanism. How you deal with events that threaten the body, self-esteem or values. Related to fear. Can be destructive and lead to problems - at work, in...
  • Safer Internet Week - Parent Awareness Session

    Safer Internet Week - Parent Awareness Session

    Where's Klaus is a CEOP film which can be downloaded from the "Thinkuknow" website. * * * Social Media Today is a CEOP film, available to download from the parent section of the "Thinkuknow" website. It's important to present a...
  • State Health Improvement Plan - Oregon

    State Health Improvement Plan - Oregon

    Finally, the work accomplished by the Opioid Prescribing Guidelines Task Force is a perfect example of how collective impact within the health system can be achieved when we pull together to address a health related crisis. Let me pause there...
  • Virtual Lab Seed Experiment - Loudoun County Public Schools

    Virtual Lab Seed Experiment - Loudoun County Public Schools

    Page number. Date. Title of Lab/experiment OR Research Question? Did you remember to add the date, title and page number to your Table of Contents? If not, do so! Only write on the Right Page: (right page) Example: Research Biology....