Macra 101
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Medicare Access and Chip Reauthorization Act (MACRA) is the law that changes how Providers are to be reimbursed. One of the key characteristics is that it rewards Providers based on value and not volume.
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Macra 101
- 1. MACRA 101 Understanding the basics of MACRA
- 2. Disclaimer "This information is not intended to be legal advice and does not intend to create an attorney-client relationship. The information hereby presented is for educational purposes only." 2 EPI Conferences
- 3. Introduction 3 This presentation covers the following: • MACRA Basics • MIPS • Categories and Payments • Recommended Actions • 2019 (3rd year) and Beyond
- 4. Objectives MACRA stands for Medicare Access and CHIP Reauthorization Act (MACRA) and in this seminar, you will learn the basics about this new quality initiative.
- 5. What is MACRA? Quality Initiative •Merges Quality Programs •Identifies Quality Measures Philosophy •Fee schedule and politics •Providers in control
- 7. Philosophy - Intent • Increase Utilization as Projected by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). • National health expenditure growth is expected to average 5.5 percent annually over 2017-2026, • Growth in national health spending is projected to be faster than projected growth in Gross Domestic Product (GDP) by 1.0 percentage point over 2017-2026. • Projected the health share of GDP is projected to rise from 17.9 percent in 2016 to 19.7 percent by 2026. • Inability to reduce fees. • MACRA replaces the Sustainable Growth Rate (SGR) formula.
- 8. CMS Goals • Reduces Overhead • Simplifies Administration • Simplifies Compliance Merge quality programs • Budget Neutral • Expects Healthcare Professionals to Assume Risks Reduce expenses
- 9. Key Considerations Budget Neutral Medicare will not increase budget Payments will vary based on Provider’s score Risk Providers expected to assume risk
- 10. 2019 2020 2021 2022 + 4% 5% 7% 9% 4% 5% 7% 9% Budget Neutral Lowest 25% = maximum reduction Exceptional performance bonuses can be up to another 10% up to $500M available each year from 2019 to 2024 MIPS will be a budget-neutral program. Total upward and downward adjustments will be balanced so that the average change is 0%. APM Model will pay 5% Annual Bonuses in Lump Sums. Performance Threshold Mean/Median CPS EPI Conferences 2019 2020 2021 2022 12% 15% 21% 27% Maximum Payment for High Performers
- 11. Effect on your Bottomline Adjustment Total Adjustment Bonus Bonus Amount Total Difference 2019 4% $ 4,000 12% $ 6,000 $ 10,000 2020 5% $ 5,000 15% $ 7,500 $ 12,500 2021 7% $ 7,000 21% $ 10,500 $ 17,500 2022 9% $ 9,000 27% $ 13,500 $ 22,500 Based on $50,000 increments of Medicare Receipts
- 12. Eligible Clinicians • Physicians (MD/DO) Physician Assistants • Podiatrists Optometrists • Nurse Practitioners Certified Nurse Anesthetists • Clinical Nurse Specialists Chiropractors • Dental Surgery Dental Medicine 2017, 2018 and 2019 • Physical Therapists Occupational Therapists • Audiologists Speech Pathologists • Clinical psychologists Dietitians / Nutritionist • 2019
- 13. Exceptions • ≤ $90,000 in allowed Part B charges • ≤ 200 Part B beneficiaries seen during the determination period • ≤ 200 in allowed Part B professional services • Clinicians new to Medicare Note: Individual clinicians may participate in MIPS if any one or two of the above thresholds are exceeded, but not all three.
- 14. How it works Two Parts (APM or MIPS) MIPS • Quality • Cost • Promoting Interoperability • Improvement Activities Four Categories
- 16. MACRA Models Advanced Alternative Payment Models (APMs) Higher risk model Risk is shared throughout APM Limited number of acceptable models Rules to being considered a qualified provider (QP) Merit Based Incentive Program (MIPS) Designed for individuals and small group practices Not all or nothing. Can receive partial credit. Incentive based on sliding scale. Replaces all current incentive programs Fee for service with adjustments based on performance 16 Note: APM = Risk Most Providers are expected to choose MIPS EPI Conferences
- 17. MIPS Categories Quality 45% Cost 15% Promoting Interoperability 25% Improvement activities 15% MIPS
- 18. Quality Similar to PQRS • 45% in 2019 Weight • 12 Month Performance Period • About 300 quality measures to pick from • Report on 6 measures and one outcome measure Measures
- 19. 2019 Quality Measures Changes • Groups may submit and be scored on quality measures using more than one “collection type.” • Scores for same measure may vary depending on benchmarks tied to the measures collection • Small group practices may report via the claims reporting mechanism • 10 new quality measures • Removed 26 “topped-out” measures • Topped out measure as one whose median performance is 95 percent or higher.
- 20. 2019 Topped-out measures • May make it difficult for practices to receive the maximum number of points • Will be phased out over a four-year timeline • Measures are normally capped to a lower maximum score, followed by the measure’s removal entirely Goal - incentivizing practices to choose other measures where considerable performance improvement is more likely
- 21. Promoting Interoperability Formerly Advancing Care Information Similar to Meaningful Use • Weight • 25% in 2019 • Measures • 90 Consecutive Days Performance Period • Almost all the 2018 MIPS measures were either removed or modified • Fall under one of four objectives • e-Prescribing, • Health Information Exchange • Provider to Patient Exchange, and • Public Health and Clinical Data Exchange. Annual security risk analysis must be reported in order to score any points in this category.
- 22. 2019 Promoting Interoperability Changes • The total number of potential “Promoting Interoperability” category points has been reduced from 165 points in 2018 to 110 points in 2019 • The score is capped at 100 points • 50-point base measure score has been removed • Changes have been made to this category making it more challenging for practices to achieve a high score • Annual security risk analysis must be reported in order score to any points in the category.
- 23. 2019 Promoting Interoperability Bonus Clinicians, groups, and virtual groups can earn 5 bonus points each for the submission of these optional measures: • Query of Prescription Drug Monitoring (PDMP) • Verify Opioid Treatment Agreement
- 24. Improvement Activities •Weight • 15% in 2019 •Measures • 90 Consecutive Days Performance Period • No change in the number of activities that MIPS eligible clinicians have to report • Total of 40 points.
- 25. 2019 Improvement Activities Change • CMS is proposing more activities to choose from and changes to existing activities for the Inventory. • Reporting • Small practices and rural areas will keep reporting on no more than 2 medium or 1 high-weighted activity to reach the highest score. • For group participation, only 1 MIPS eligible clinician in a TIN • 5% Promoting Interoperability bonus has been removed
- 26. Cost also known as Resource Use • Weight • 15% in 2019 • Measures • 12 Month Performance Period • There is no reporting requirement • CMS will calculate the clinician’s performance using claims data • Clinicians will be assessed on their performance of Total per Capita Cost, Medicare Spending per Beneficiary (MSPB), and applicable episode-based measuresSimilar to Value Based Modifier
- 27. 2019 Cost Changes •Increased weight to 15%* •Eight episode-based cost measures for the 2019 performance period •Two types of episode-based measures approved for 2019 • Procedural measures, and • Acute Inpatient Medical Condition measures * This percentage can change if the measures' minimum case volumes are not met. If there are not enough attributed beneficiaries for any of the 10 measures to be scored, the Cost performance category percentage will be added to the Quality performance category.
- 28. Composite Performance Score (CPS) MIPS 2019 0-100 point scale EPI Conferences Interoperability 25% x Score Quality 45% x Score Cost 15% x Score Improvement 15% x Score X 100
- 29. Reporting Same Reporting Options as Year 2 • Individual • Group • 2 or more clinicians (NPIs) who have reassigned their billing rights to a single TIN • As an Advanced Alternative Payment Model (APM) Entity • Virtual Group • solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter what specialty or location) to participate in MIPS for a performance period for a year
- 30. Summary • Philosophy • Cost Effect • Goals Basics of MACRA • APM • MIPS Tracks • Basics • 2019 Changes MIPS Basic Recommendations
- 31. Recommended Steps ANALYZE GUIDELINES AND CONDUCT COST COMPARISON REVIEW RESOURCES AND SELECT PLAN OF ACTION USE PROFESSIONAL ASSISTANCE AS NEEDED
- 32. Recommended Resources • Visit the 2019 Quality Requirements page and explore the 2019 measures on the QPP website. • https://qpp.cms.gov/ • Review the 2019 Quality Performance Category Fact Sheet on the QPP Resource Library.
- 33. Dr. Jose I. Delgado Taino Consultants Inc., CEO DrDelgado@tainoconsultants.com tainoconsultants.com 33 MACRA 101 April 2019