Mastering MACRA: A Beginner’s Guide to New Reimbursement Models
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The document is a beginner's guide authored by Ken Edwards on new reimbursement models, particularly focusing on the Quality Payment Program (QPP) under MACRA, which reshapes provider reimbursement systems in Medicare. Key topics include the transition from existing programs to MIPS and APMs, incentives and penalties affecting providers, and recommendations for practitioners to excel under QPP. It emphasizes the importance of preparation, understanding performance metrics, and the potential for financial penalties if minimal compliance is pursued.
![Quality Payment Program
CMS’s vision: To improve quality, improve care efficiency, while reducing
the cost of care
CMS wants focus on the health of the population through better care
coordination among providers
Quality Payment Program [QPP] goes into effect on January 1st, 2017 for
providers who participate in Medicare Part B [some 600k providers are
affected]
The Quality Payment Program ends Meaningful Use, PQRS and Value Based
Modifier as distinct and separate programs under Medicare](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-6-320.jpg)
![Quality Payment Program
Two tracks for providers
1. Merit-Based Incentive Payment System (MIPS), which is where
90% of Medicare Part B providers will be in 2017
2. Advanced Alternative Payment Model (APMs), which is where
the MACRA legislation ultimately wants all providers to be [Medical
Homes, Shared Savings, Bundled Payments]
The MIPS track is a short term training ground to learn how to successfully
adopt Advanced Payment Models
MIPS AND APM](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-7-320.jpg)
![Cost
(0% of score)
Replaces Value
Based Modifier –
Applicable from
2018
Advancing
Care
Information
(25% of score)
Replaces
Meaningful Use –
ensures effective
and meaningful
use of EMR
Quality
(60% of score)
Replaces PQRS on
the quality of care
provided to the
patients
Improvement
Activities
(15% of score)
New category –
focusing on care
coordination,
beneficiary
engagement, and
patient safety
Merit-based Incentive Payment System
90% of providers in 2017, which affects payments in 2019
Providers are scored on a scale from 0 – 100
There are 4 categories, and in 2017:
Exemptions:
• Advanced APM
• First year Medicare
• Low volume [< 100
patients]
• Low $$ [< $30k in
allowable]](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-11-320.jpg)
![Cost
(0% of score)
Replaces Value
Based Modifier –
Applicable from
2018
Advancing
Care
Information
(25% of score)
Replaces
Meaningful Use –
ensures effective
and meaningful
use of EMR
Quality
(60% of score)
Replaces PQRS on
the quality of care
provided to the
patients
Improvement
Activities
(15% of score)
New category –
focusing on care
coordination,
beneficiary
engagement, and
patient safety
Merit-based Incentive Payment System
90% of providers in 2017, which affects payments in 2019
Providers are scored on a scale from 0 – 100
There are 4 categories, and in 2017:
Exemptions:
• Advanced APM
• First year Medicare
• Low volume [< 100
patients]
• Low $$ [< $30k in
allowable]](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-13-320.jpg)
![Merit-based Incentive Payment System
PICK YOUR PACE
For 2017, the transition year, MIPS providers can choose to:
Submit no data [generally a bad idea, guaranteed 4% penalty]
Submit minimal data [no penalties]
Submit complete data for 90 days [chances of an incentive]
Submit complete date for the entire year [incentive]
Submission methods remain the same as before
Weightage changes yearly, Cost counts for more and more
Reduced requirements for hospital or non-patient facing clinicians,
rural practices, small practices [<15 physicians]](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-14-320.jpg)
![Merit-based Incentive Payment System
Top MIPS percentile in 2017, “high performer” bonus of 10%, derived from a
separate budget
Those scoring below a certain threshold, or those who don’t participate,
receive a negative 4% penalty, which will increases yearly
The incentives will come from the penalties collected from those who don’t
meet their MIPS performance threshold — MACRA legislation mandates that
MIPS must be revenue-neutral
Your results get published on the Physician Compare website
Successfully Meaningful Use and PQRS providers should easily meet the
performance threshold for MIPS [those categories represent 85% of the
composite score for 2017]
of providers are using
certified EHR technology](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-15-320.jpg)
![Alternative Payment Models
A payment model that deviates
from traditional fee-for-service
[CMS has been running pilots]
Some variation of the MPFS or a
new model all together
APMs require healthcare
organizations to align themselves
with the goal of taking better care
of a population of patients
E.g. MSSP/ACO: Provide high-
quality and low-cost care to a
defined group of Medicare
beneficiaries - Medicare will share
the savings](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-18-320.jpg)
![Checklist of things to do to
excel under this rule
Educate yourself and understand what is happening; check out
qpp.cms.gov for a great overview
Take a look at your QRUR Reports & understand where you stand based on
current MU and PQRS performance
Calculate financial impacts [both penalties and lost incentive revenue]
Talk to your MU/PQRS team to ensure that they’re up to speed and discuss
the resources they would need to succeed under QPP
Look at Physician Compare and see how you’re rated
$20million/year worth of assistance to small practices with MACRA has been
budgeted, reach out to participating entities](https://image.slidesharecdn.com/masteringmacra-161123120510/85/Mastering-MACRA-A-Beginner-s-Guide-to-New-Reimbursement-Models-24-320.jpg)
Mastering MACRA: A Beginner’s Guide to New Reimbursement Models
- 1. A Beginner’s Guide To New Reimbursement Models
- 2. ABOUT THE PRESENTER Ken Edwards is a Senior Manager at CureMD, overseeing the implementations of Meaningful Use, PQRS and Alternative Payment Models. Ken has led much of the company’s recent research on healthcare reforms, primary care clinic design and revenue cycle management.
- 3. AGENDA What is MACRA? And what happens to it under the Trump administration? Quality Payment program, incentives and penalties MIPS, APMs, Advanced APMs What’s the right track for your practice? Critical deadlines Checklist of things to do to excel under this rule
- 4. What is MACRA? MACRA is 2 years of work, signed into law in April 2015 Extends the Children’s Health Insurance Program (CHIP) for two more years Requires Medicare to move away from SSN based Medicare ID numbers Includes new funding for development and testing of performance measures Enables new programs and requirements for data sharing Establishes new federal advisory groups Repeals the Sustainable Growth Rate (SGR) formula Creates the Quality Payment Program (QPP)
- 5. What is MACRA? All signs point to MACRA not changing very much, especially not in 2017 MACRA has broad support from all political parties CMS has responded positively to concerns from physician associations and has them on board The healthcare industry is in agreement with the changes & has invested in MACRA preparation Possible rollback to sections of the Affordable Care Act (ACA) MACRA is not tied to the ACA and should remain unaffected What happens to it under the Trump administration?
- 6. Quality Payment Program CMS’s vision: To improve quality, improve care efficiency, while reducing the cost of care CMS wants focus on the health of the population through better care coordination among providers Quality Payment Program [QPP] goes into effect on January 1st, 2017 for providers who participate in Medicare Part B [some 600k providers are affected] The Quality Payment Program ends Meaningful Use, PQRS and Value Based Modifier as distinct and separate programs under Medicare
- 7. Quality Payment Program Two tracks for providers 1. Merit-Based Incentive Payment System (MIPS), which is where 90% of Medicare Part B providers will be in 2017 2. Advanced Alternative Payment Model (APMs), which is where the MACRA legislation ultimately wants all providers to be [Medical Homes, Shared Savings, Bundled Payments] The MIPS track is a short term training ground to learn how to successfully adopt Advanced Payment Models MIPS AND APM
- 8. Quality Payment Program MIPS AND APM
- 9. Quality Payment Program INCENTIVES & PENALTIES The Quality Payment Program actually recalibrates Medicare adjustments
- 10. Before we go further.. MACRA is the law that resulted in a new provider reimbursement model called the Quality Payment Program The Quality Payment Program is mostly good news: Meaningful Use + PQRS + VBM + ICD10 leads into QPP
- 11. Cost (0% of score) Replaces Value Based Modifier – Applicable from 2018 Advancing Care Information (25% of score) Replaces Meaningful Use – ensures effective and meaningful use of EMR Quality (60% of score) Replaces PQRS on the quality of care provided to the patients Improvement Activities (15% of score) New category – focusing on care coordination, beneficiary engagement, and patient safety Merit-based Incentive Payment System 90% of providers in 2017, which affects payments in 2019 Providers are scored on a scale from 0 – 100 There are 4 categories, and in 2017: Exemptions: • Advanced APM • First year Medicare • Low volume [< 100 patients] • Low $$ [< $30k in allowable]
- 12. Submit Merit-based Incentive Payment System TIMELINE Performance Year Feedback Available 2017 March 31, 2018 2018 January 1, 2019 Adjustment
- 13. Cost (0% of score) Replaces Value Based Modifier – Applicable from 2018 Advancing Care Information (25% of score) Replaces Meaningful Use – ensures effective and meaningful use of EMR Quality (60% of score) Replaces PQRS on the quality of care provided to the patients Improvement Activities (15% of score) New category – focusing on care coordination, beneficiary engagement, and patient safety Merit-based Incentive Payment System 90% of providers in 2017, which affects payments in 2019 Providers are scored on a scale from 0 – 100 There are 4 categories, and in 2017: Exemptions: • Advanced APM • First year Medicare • Low volume [< 100 patients] • Low $$ [< $30k in allowable]
- 14. Merit-based Incentive Payment System PICK YOUR PACE For 2017, the transition year, MIPS providers can choose to: Submit no data [generally a bad idea, guaranteed 4% penalty] Submit minimal data [no penalties] Submit complete data for 90 days [chances of an incentive] Submit complete date for the entire year [incentive] Submission methods remain the same as before Weightage changes yearly, Cost counts for more and more Reduced requirements for hospital or non-patient facing clinicians, rural practices, small practices [<15 physicians]
- 15. Merit-based Incentive Payment System Top MIPS percentile in 2017, “high performer” bonus of 10%, derived from a separate budget Those scoring below a certain threshold, or those who don’t participate, receive a negative 4% penalty, which will increases yearly The incentives will come from the penalties collected from those who don’t meet their MIPS performance threshold — MACRA legislation mandates that MIPS must be revenue-neutral Your results get published on the Physician Compare website Successfully Meaningful Use and PQRS providers should easily meet the performance threshold for MIPS [those categories represent 85% of the composite score for 2017] of providers are using certified EHR technology
- 16. Merit-based Incentive Payment System
- 17. MIPS Recap Combines PQRS, Meaningful Use & Value Based Modifier with a new program called Improvement Activities Performance across 4 categories is combined to calculate a composite score, results to be published online Incentives for top performers come from penalties applied to lower performers PQRS and MU are the biggest pieces in 2017, doing well in these categories is paramount
- 18. Alternative Payment Models A payment model that deviates from traditional fee-for-service [CMS has been running pilots] Some variation of the MPFS or a new model all together APMs require healthcare organizations to align themselves with the goal of taking better care of a population of patients E.g. MSSP/ACO: Provide high- quality and low-cost care to a defined group of Medicare beneficiaries - Medicare will share the savings
- 19. Advanced Alternative Payment Models Advanced APMs build on existing APMs and align with MIPS: Requires participants to use certified EHR technology Base APM payment on quality measures comparable to those in the MIPS quality performance category The APM entity (1) bears more than nominal financial risk for monetary losses OR (2) is a Medical Home Model expanded under Center for Medicare & Medicaid Innovation authority (CMMI) Providers in Advanced APMs avoid MIPS reporting requirements and get better incentives Providers with at least 25% of their Medicare patients engaged in Advanced APMs receive a 5% bonus in addition to the potential bonuses available through the APM’s themselves
- 20. Advanced Alternative Payment Models
- 21. Advanced Alternative Payment Models Medicare Shared Savings Program — Track 2 Medicare Shared Savings Program — Track 3 Next Generation ACO Model Medicare Shared Savings Program — Track 1+ Comprehensive Primary Care Plus (CPC+) Comprehensive ESRD Care Model (Large Dialysis Organization Arrangement) Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
- 22. What’s the right track for your practice? The Alternative Payment Models that are available in 2017 only apply to about 10% of all physicians. For most physicians, APMs may not even be an option MIPS allows a transition from the existing PQRS, Meaningful Use, Value Based Modifier world to something close to an Alternative Payment Model The ‘pick you pace’ options make it easy to participate without a lot of risk and providers get time to put new processes in place If you believe you can excel at MIPS, in the short term, it makes better financial sense
- 23. What’s the right track for your practice?
- 24. Checklist of things to do to excel under this rule Educate yourself and understand what is happening; check out qpp.cms.gov for a great overview Take a look at your QRUR Reports & understand where you stand based on current MU and PQRS performance Calculate financial impacts [both penalties and lost incentive revenue] Talk to your MU/PQRS team to ensure that they’re up to speed and discuss the resources they would need to succeed under QPP Look at Physician Compare and see how you’re rated $20million/year worth of assistance to small practices with MACRA has been budgeted, reach out to participating entities
- 25. Critical Deadlines Do your prep work Start collecting data for the full year reporting option; you can always fall back to a 90 day reporting period if you find that you need to chop and change things Start collecting data for the 90 day reporting option; if you want to be in the running for an incentive, this is the last day to get started
- 26. Closing Thoughts The smart move would be to commit to MIPS for the entire year in 2017. Determine your quality measures, get your systems in place and your staff thinking in the right terms. Come 2018, you’ll have tested the waters, made mistakes, and made corrections that will ensure future success Doing the minimum (or do nothing at all hoping for an extension of the grace period) will result in significant disadvantages going forward. Other practices will be better prepared by then and the stakes will be higher. Based on a survey of more than 50% of health insurance payers in the country (including Medicare and Medicaid)—25% of all payments to providers are being made under Alternative Payment Models in 2016. That number is projected to reach 50% by 2020. Commercial payers are onboard.
Editor's Notes
- #20: Bundled Payments for episodes of care [Joint Replacement, Cardiac Surgery, etc.] Capitation [care for a population, get fixed $$ per member per month] Make prospective payments and put them at risk [against cost/quality targets]