THE RELEVANCE OF MACRA TO CME AND HOW TO ENGAGE IN THE CMS COMMENT PROCESS - PowerPoint Presentation

1. THE RELEVANCE OF MACRA TO CME AND HOW TO ENGAGE IN THE CMS COMMENT PROCESSJune 16, 2016

2. 2Andrew Rosenberg, JDSenior Advisor, CME CoalitionFounding Partner Thorn Run Partners20 years of experience as a lobbyist, Capitol Hill staffer and former congressional candidateThomas SullivanPresident Rockpointe, Inc. , Potomac Center for Medical EducationEditor, Policy and Medicine, Life Science Compliance UpdateFounder CME CoalitionShea McCarthy, ModeratorPolicy Analyst, CME CoalitionVice President, Thorn Run Partners

3. AgendaReview MACRA and implications on physiciansDiscuss MACRA, MIPS and CPIA’s – Where CME Fits inEvaluate the Timeline of MACRAExplain how to submit comments to CMS

4. Medicare Access and CHIP Reauthorization (MACRA)Enacted in April 2015House Passed 392-37, Senate 92-8 Singed by President 4/2015Eliminates SGR; Requires EHR interoperability by 2018Clear Timelines for ImplementationMIPS 2017 performance measures determines 2019 PaymentsAPM selection is necessary before 2019

5. Goal of MACRAHHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.

6. In the HIMSS analysis of results, only 3 percent of respondents said they believe their organization is highly prepared to make the transition to pay for value from the current reimbursement approach of fee-for-service.http://s3.amazonaws.com/rdcms-himss/files/production/public/FileDownloads/2016-cost%20-accounting-survey-executive-summary.pdf

7. Payment EvolutionToday – MACRA → Two Payment PathsAlternative Payment Model Differential FFS based on measured performance (MIPS)

8. Path 1: Alternative Payment Models (APMs)2019-24 → 5% Medicare Bonus Under MACRA, APM includes the following for Medicare patients:Medicare Shared Savings Program (two-sided models: Tracks 2 and 3)Next Generation ACO ModelComprehensive ESDR Care (CEC) (large dialysis organization arrangement)Comprehensive Primary Care Plus (CPC+)Oncology Care Model (OCM) (two-sided risk track available in 2018)APM must accept more than nominal risk for financial lossesMust use MIPS Quality Measures and Certified EHR.Mix of Patients Change over Time – To Medicare and All PayersCMS Estimates 30,000 to 90,000 Clinicians will qualify in 2019

9. Path 2: Merit Based Incentive Payment System (MIPS) Incorporates three existing programs into one programMeaningful Use (Started in 2011)Physician Quality Reporting System (Started in 2007)Value Based Modifier (First applied in 2015)Adds an additional category “Clinical Practice Improvement Activities” (CPIA)MIPS Composite Scores will Drive reimbursement levels, andPosted publicly on Physicians Compare WebsiteCMS Estimates 687,000 to 746,000 Clinicians will be MIPS eligible

10. Eligible Professionals in MIPSEligible professionals (EPs) for 2017 and 2018 include: Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists.In 2019, more professionals become eligible for MIPS, including:Physical or occupational therapists, speech language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dieticians or nutrition professionals.

11. Some Providers Exempt from MIPSProviders who do not meet the "low volume threshold"Medicare Shared Savings Program Accountable Care Organization providers and other participants in alternative payment models andFirst Year Medicare providersThe aforementioned "low volume threshold" can be one of three things:The minimum number of individuals enrolled under Medicare who are treated by the EC for the performance period; <100 Medicare PatientsThe minimum number of items and services furnished to individuals enrolled under Medicare by the EC for the performance period or;The minimum amount of allowed charges billed by the EC under Medicare for the performance period. (<$10,000)

12. Difficult for Small Practices and Some SpecialtiesWinners Positive Adjustment Cardiology 62.1% Endocrinology 67.3%Emergency Medicine 64.0% Colorectal Surgeons 59.7% Family Practice 59.5% Gastroenterology 61.5% Nurse Practitioners 62.0% Pediatrics 79.3%Losers  Negative AdjustmentsChiropractors -98.4% Dentists -68.9% General Practice -69.4% Optometry -79.7% Podiatry -78.0% Plastic Surgery -65.4% Psychiatry  -68.8% Physical Medicine -57.9% Source CMS MACRA Proposed Rule, Table 63, pages 672-675

13. Performance Category - 2017Points Need to Get a Full ScoreMaximum Possible Points per Performance CategoryQuality: Clinicians choose six measures to report to CMS that best reflect their practice. One of these measures must be an outcome measure or a high quality measure and one must be a crosscutting measure. Clinicians also can choose to report a specialty measure set. 80 to 90 points depending on group size 50%Advancing Care Information: Clinicians will report key measures of interoperability and information exchange. Clinicians are rewarded for their performance on measures that matter most to them. 100 points 25%Clinical Practice Improvement Activities: Clinicians can choose the activities best suited for their practice; the rule proposes over 90 activities from which to choose. Clinicians participating in medical homes earn full credit in this category, and those participating in Advanced APMs will earn at least half credit. 60 points15%Cost: CMS will calculate these measures based on claims and availability of sufficient volume. Clinicians do not need to report anything. Average score of all resource measures that can be attributed. 10%

14. YearMeaningful Use – Advancing Care InformationQuality – PQRSResource Use - VBMClinical Practice ImprovementTotal Points2017 Reporting 2019 Payments25 Pts50 Pts10 Pts15 Pts100 Pts2018 Reporting2020 Payments25 Pts45 Pts15 Pts15 Pts100 Pts2019 Reporting2021 Payments and Beyond25 Pts30 Pts30 Pts15 Pts100 Pts

15. 2020202120222023 and BeyondPositive Adjustments Include up to 3x payment multiplier +10% Bonus for Exemplary Performance

16. Total Incentive PerformanceProgramParticipation Incentive PaymentNo DifferencePenaltiesPQRS51%39%12%49%Meaningful Use48%48% Stage 1 6% Stage 252%Value Based Modifier61%01%60%39%

17. Clinical Practice Improvement Activity (CPIA)Brand New Measurement CategoryDefinition: The term "Clinical Practice Improvement Activity" is defined as an activity that relevant eligible professional organizations and other stakeholders identify as one that improves clinical practice or care delivery and that the Secretary determines is likely to result in improved outcomes. Desired Results: The CPIA will assess healthcare professionals on their effort to engage in continuing education and working to improve their practices and facilitate future participation in APMs.

18. CPIA CategoriesExpanded Practice AccessPopulation ManagementBeneficiary EngagementPatient Safety and Practice AssessmentParticipation in an APM, including a medical homeAchieving Health EquityEmergency Preparedness and ResponseIntegrated Behavioral and Metal HealthCare Coordination

19. Proposed CPIA’s ScoringCategoryTotal Points Needed60 PointsHigh Rated Activity20 PointsMedium Rated Activity10 PointsParticipation in Certified (AAAHC, NCQA, URAC, Joint Commission)Medicare Medical Home or Medical Home Model60 PointsAlternative Payment Model (APM) Participation (ACO, Bundled Payment, PCMH (not certified)…30 Points + Combination of High and Medium Rated ActivitiesLarge Groups 16+Can use any combination of High and Medium Rated Activity to get to 60 pointsGroups of 15 or eligible clinicians and non patient facing cliniciansOne Medium or High Weighted provides 50% of ScoreTwo Medium or High Weighted Activities 100% of Score

20. Examples of Current CPIA’s

21. Reasons To Have CME Recognized In MIPSCME has long been recognized as a means by which physicians (aka Eligible Providers) demonstrate that they are engaging in Continuing Professional Development (CPD) to maintain the knowledge, skills, and practice performance that lead to optimal patient outcomes. Lifelong learning, assessment and improvement are integrally related. Learning is a necessary component of the change process that results in meaningful, sustained Clinical Performance Improvement. Without learning, assessment and professional development, the measurement of adherence to quality metrics, and health information technology usage on their own are insufficient to produce clinical performance improvement.

22. More ReasonsSociety will continue to need Health Care Professionals (HCPs), also known as Eligible Clinicians (EC’s) to engage in lifelong learning, assessment and improvement in practice. Thus, it is important that those activities be recognized and rewarded in the value-based payment constructs that are increasingly being promulgated by private payers and by CMS (MACRA). If CME/CE is not recognized within the new Value Based Payment constructs, there is a real risk that CME/CE/CPD may become a defacto “unfunded mandate” – a professional obligation without incentives or other reinforcing mechanisms.  EC’s should be credited for their efforts to stay current with clinical practice and quality measures by utilizing CME. The inclusion of CME as a Clinical Practice Improvement Activity recognized by CMS will help EP’s retain credit for the time EP’s invest in learning about practice improvement. EC’s Sources of Information on QI requirements are limited and participation can only be increased with education.Failure to learn about rampant change afoot under healthcare reform will place HCPs at risk financially, operationally and clinicallyAccredited Education is an understandable, predefined measure.

23. Another Key Reason: Accredited CME in MIPS Utilizes Existing Structures for ChangeThere are mechanisms in place to ensure that accredited/certified CME activities are:Designed to address clinicians’ practice-relevant learning needs and practice gaps;Evaluated to measure the educational and clinical impact of those learning activities;Planned and provided independent from commercial influence or other biases.

24. MACRA Implementation TimelineImportant EventDatesMACRA Draft RuleComments Due June 27thMACRA Final Rule 4th Qtr. 2016MIPS Initial Reporting Period (Application Year 2019)2017 MIPS Initial Feedback – Confidential Quarterly ReportingJuly 1, 2017Information about Plurality of Care and Medicare Spending Per Beneficiary (MSPB)July 1, 2018Payment Adjustment – 1st Year2019APM Election deadline for 2019TBD

25. Public CommentsPublic comments are encouraged – over 500 submitted on the rule so far, including approximately 80 on the importance of including a role for CME Easiest way is via www.cmecoalition.orgDraft template comment letterEditable, one-button to sendAlso, directly at https://www.regulations.gov/#!submitComment;D=CMS-2016-0060-0068Background material and CME Coalition comments available at www.cmecoalition.org

26. The Goal of Public CommentsDrive CMS awareness and attention to the importance of annunciating a clear role for CME500 comments is our goalGenerate enough public comment to put this on the radar of media, thought leaders and policy makers at CMS Ultimately – the goal is to drive explicitly recognition of a role for CME in driving physician adherence to clinical practice improvement activities, as defined MACRA

27. The CME Coalition’s Comments (key points)“Because CME has the ability to make a measurable difference in the way physicians practice their trade, accredited CME activities that are designed to further the objectives of MACRA, the “three aims,” and the NQS should result in credit as clinical practice improvement activities within the MIPS.”PARS Reporting SystemCan be augmented to assist CMS in tracking compliance“90-day” Rule Compliance Approved CME activities that incorporate a 90-day survey or evaluation period into the program should be considered to have met the proposed rule’s 90-day activity threshold

28. The CME Coalition Comments (continued)In specific, we seek explicit credit for certain defined CME activities in two of the CMS designated clinical practice improvement activities, namely: Accredited CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, such as Performance Improvement CME, Quality Improvement CME. Accredited CME that teaches the principles of quality improvement and the basic tenets of MACRA implementation, including application of the “three aims,” the NQS, and the CMS Quality Strategy, with these goals being incorporated into practice.

29. Proposed Table HSubcategory ActivityWeightPatient Safety and Practice Assessment Accredited CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, such as Performance Improvement CME, Quality Improvement CME Patient Safety and Practice Assessment Accredited CME activities that teaches the principles of quality improvement, explains MACRA or count towards MOC Part IV requirements such as MOC Part IV CME

30. SummaryMACRA is Complicated and will Need Significant Education to be SuccessfulCME has systems in place to ensure education and success of programPI-QI CME Should be includedSpeak with your organization about including CME in your overall MACRA CommentsSubmit Comments to CMS TodayYou Can Make A Difference

31. MACRA ResourcesCMS MACRA Proposed Rule - http://1.usa.gov/1PpBpMtCMS MACRA Executive Summary - http://go.cms.gov/1TfW6vhCME Coalition - http://www.cmecoalition.org/macra.htmlAmerican Medical Association - http://bit.ly/1miEtBDAmerican Academy of Family Physicians http://bit.ly/1HcWbABPolicy and Medicine – MACRA http://bit.ly/1PTLkKa MIPS http://bit.ly/20RoMzZ, APM’s http://bit.ly/1OlxoxH

32. Questions and Answers

33. For More Information CME Coalition www.cmecoalition.orgAndrew Rosenberg – arosenberg@thornrun.comThomas Sullivan – tsullivan@rockpointe.com