MACRA and the New Quality Payment Program: Most Frequently Asked Questions

MACRA and the New Quality Payment Program:
Most Frequently Asked Questions
November 2, 2016



Welcome, Bobbie.

[Bobbi Brown]

Hi.  Good afternoon.  It’s a beautiful day here and we are in Salt Lake.  (00:06) a poll on the World Series.  I felt we should have done a poll on because I am rooting for the Cubs and I just want to get out of the webinar and go to watch that game.  I will see that game.  But anyway, because I have been so busy since October 14th, all I’ve done is read those regulations, 2400 pages.  So I hope that you have not done that.  I hope we are here today to share some of what we have learned and we titled this session ‘Most Frequently Asked Questions’ because, as Tyler mentioned, we are a company that work on outcomes improvements and we work with a lot of data and our clients of course have been asking a question.  So we wanted to share what we have heard from our clients with you and also update some of the regulations and all the new outcomes from this and see what is going on.

Okay.  Tyler?

How ready are you to participate in MACRA? [01:03]

[Tyler Morgan]

We have got another poll for you.  How ready are you to participate in MACRA?  Not at all, somewhat, unsure, ready, or very ready?  Now Bobbi, this is a question that we asked in our previous MACRA webinar, right?

[Bobbi Brown]

Yes, we did.  And so, we want to compare the two results.  So we did the webinar back in May 2016.  So once you respond to this, we will put it up and then we will show you what the response was in May.

[Tyler Morgan]

Alright.  Let us go ahead and show our results for today and it is looking like we have over 40 percent saying unsure.  As people are still entering in with ‘somewhat’ about 27 percent, 11 percent is saying ready.

Are we ready? [01:46]

[Bobbi Brown]

Okay.  This is what we said in May.  How ready are you to participate?  58 percent unsure.  So, similar.

October 14 – Wall Street Journal Article [02:00]

The Wall Street Journal, I always think whenever the Wall Street Journal picks this up and the AP on October 14th, they took it up, and I always like to see how they explained it.  They said this is a new rule on how Medicare is going to pay doctors.  So they are always going to get to the simplest way of explaining it and it is a broader push to overhaul Federal spending and there is going to be penalties and bonuses tied to performance.  So those were their three main takeaways in the Wall Street Journal.  And also I noticed they quoted someone from Deloitte who said “it’s a disruptive law” and they did not elaborate a lot on that but it was just what was in there.  So I just thought I’d bring that forward and see how the rest of the world views us and go forward and talk about some new regulations.

Aims of Quality Payment Program [02:55]

It has MACRA, it has a new three letter (02:57) saying the quality payment program which is really how they are trying to unify all the policies that go in.  And again, the aims are very good on this.  We are trying to get better outcomes for patients.  They do mention decreased provider burden and preserve the independent clinical practice.  So that was what they were trying to do with this.  And as we go through this at the end, we can reflect and see if we think they did this.

They want to promote alternative payment options and make sure that our delivery system, that we can reform our delivery system so that we are giving high quality, good, efficient care.

What is a good source? [03:35]

I will tell you that the best source, a very good source is  You just type that in and you will see.  And on there, you might not be able to see it real well, but they have ‘explore the measures’ and they have education there.  And also at the end of the webinar, we have some professional societies and associations that have done a really good job at providing educational materials for everyone and they are free and they are out there on their website.

Are we at a tipping point? [04:03]

So are we at a tipping point?  Well in a book that I read said ‘well, disruption signs are a new future, a new language, a new economics’ and to me this just fits exactly in there, especially the new language, the new words and the acronyms that you have to learn are amazing in this.  The new economics, yes, there is going to be – you are still paid the same way but you can get pluses or minuses to that payment based on what is going on and how you perform on all of these different measures that we are going to talk about, and we are getting to more measurement.  And I think you need to think about what kind of new capabilities do you need in this new environment and what existing capabilities do you have that you might need to reshape a little bit.  And should we think about limiting anything that we are doing or move anything around that we are doing, because this is, there’s a lot of change in here.  Let me just talk about the two tracks that Medicare is going to put you in.

Two Tracks [05:07]

Through 2019, we are still getting a half percent annual update.  2017 is the base performance year and then after that you go into one or two tracks, either a MIPS or an APM qualified provider.  If you fit in that APM qualified provider, you are going to get a bonus, automatic participation bonus to 5 percent.  So, if you do not, then you are up in the MIPS and most people will be in the MIPS and it will be plus or minus 4 percent and the payment will start in 2019.  So, we are starting now, we are starting right away actually, and then you have this plus and minuses that go throughout the years.  And I even purposely leave out anything after 2023 but it is just too far out there for me.  I cannot think that far ahead.  So, plus or minus, and you also have this potential of bonus.  I love bonuses.  I love bonuses.  What could be more fun than to get a bonus?

Why is 2017 so important? [06:02]

2017 is the transition year.  That is going to be the performance period.  And believe it or not, that starts in 59 days from now.  So I usually just count down to Christmas but this year I am going to count down to the beginning of MACRA.  What kind of a person am I?  So anyway, 2017, like I said, that is the performance period.  We are going to go into more depth on what you have to report during that performance period.

CMS Expenditures [06:29]

I just wanted to give a little background about breakout of CMS expenditures.  We have the inpatient, the outpatient, the post-acute care area, and then the physician and the way they have it broken out, its physician E&M codes.  And right now, that represents 26 billion of the payments.  It is about 11 percent.  And I looked and saw that in this, for Medicare, the rate is 13,000 encounters per every thousand of beneficiaries.  So it is used a lot.  And 89 percent of the beneficiaries used in E&M code.  So this is an area that hits a lot of people and a lot of physicians.

Potential for Bonus Points [07:08]

I love this part, report cards.  At one time I was a school teacher and I just loved being able to have bonus points, and I loved it when I was in school too.  So, you know, I did not focus on a lot of this (07:19) all the time.  I focused on, well if I go to the museum, I can get (07:25).  How can I get extra points instead of just studying what I’m supposed to study.  But you can get extra points and Dorian is going to go through that and there are some areas where you can get more points because they give you a median high.  And so, there’s lots of areas.  It still ads like a little bit of fun to this and a little bit of confusion and a little bit of extra work that we all have to think about, but Dorian is going to make it so simple for you.  You are going to love it.

Cost Performance – Weighted 0% [07:50]

So, cost performance.  Next year, this one, it is not in for next year, it will be weighted 10 percent the following year, and it will be based on 10 episodes and the CMS is going to calculate this from the forms.  And so I always love and you know, and CMS says we are going to calculate this for you.  It is very good.  But you are going to have to look at your attribution and you are going to have to look at this and you are going to have some that is going to be weighted 10 percent and growing up to 30 percent over time.  You are going to have some interest in this measure.

Did you know this data is available? [08:25]

There is nothing right now that I can point you to but there is a website out there under geographic variation on CMS and they do it.  It is a file that you can download and you can get the county spending and you can also get it by state.  The state has this nice spending.  And I picked a state that was red, Florida.  So if anybody is on the phone from Florida, I just picked you because you are red, and just to show you, and they (08:55) positioning with outpatient and test and imaging.  So you do not get a real percent.  But you can see the state of Florida overall, you know, 19 percent higher than the national average.  The physician, also 19 percent higher than the national average.  The inpatient side is 7 percent higher.  So you can see that those people in that state are going to have to be worried a little bit about their spending.  That may not be you but that is going to be coming up.

I am going to turn it over to Dorian DiNardo now.  She works in product development, and I love to work with her, and we are working on products and services to help you through this.  And so we just want to talk about, again, what we have learned from clients and prospects and help you understand some of the regulations.


When do I need to report for 2017? [09:47]

[Dorian DiNardo]

Thank you.

MIPS – Merit-based Incentive Payment System [09:47]

So Merit-Based Incentive Payment System, MIPS, is the section that I am going to be covering today.

Status quo [09:55]

So what is happening today?  A bi-annual survey from the Physicians Foundation showed 46 percent of physicians plan to accelerate their retirement.  Cut back on patients or seek non-clinical role.  14.4 percent of physicians are saying they will retire in the next one to three years, compared to 9.4 percent in 2014.  Meanwhile, 21 percent will cut back through hours and another 13.5 percent will seek non-clinical jobs.  Doctors are being dogged by poor morale and invasive regulations, according to the survey.

Interesting Fact #1 [10:32]

In another survey conducted recently, it found the physicians spend an average of 15.1 hours every week processing quality metrics.

Interesting Fact #2: [10:43]

And another interesting fact in the same survey, the time physicians spend processing these quality metrics translates to an average cost of over $40,069 per physician, per year.

CMS expects MIPS to evolve and change [10:56]

So, CMS and MIPS.  Well, CMS does expect MIPS to evolve and change.  They are listening.  And with that, they are talking about combining three existing programs.  So they are combining Meaningful Use, the EHR Incentive Program, Value Based Payment Modifier, and the Physician’s Quality Reporting Program.  They are adding the clinical practice improvement activities category.  So, between approximately 592,000 and 642,000 eligible clinicians will be required to participate in MIPS in the transition year.  Practices with fewer than 15 providers and in rural areas may be qualified for technical assistance.  This is new and very important because really take advantage of that opportunity.  Estimate of 14 percent of providers will be low volume and excluded.

The rule defines a group as a single Taxpayer Identification Number (TIN)…[11:52]

The rule defines a group as a single Taxpayer Identification Number (TIN) with two or more MIPS eligible clinicians, as identified by their individual National Provider Identifier (NPI), who have been reassigned their Medicare billing rights to the Tax ID Number.

For MIPS do I need to report individually or as a group? [12:11]

So for MIPS, do I need to report individually or as a group?  Well, are you part of that exclusion criteria?  So are you in that low volume threshold, are you a newly Medicare enrolled eligible provider, or are you a qualified provider as part of the APM?

Additional considerations for reporting as an individual or a group: [12:27]

Other considerations for reporting as an individual or a group are do you report to other external agencies today for your Tax ID Number or your NPI number?  Do you participate in Meaningful Use, PQRS or other reporting agency today?  If so, you should really review that performance and look at how successful you are to those organizations.

The submission requirements for Groups and individuals are different.  For example, CMS will apply the readmission measure to groups of more than 15 who meet the case volume of 200 cases.  You must participate in MIPS as a whole, so either as a group or as an individual.  It is not mixed.  There is not an ‘and’ in there.  Group reporting performance will be assessed and scored across the Tax ID Number and MIPS payment adjustments apply to the group level of the eligible clinicians in that group.

You can join virtual groups in the future years once CMS has determined that definition.  We should see more about that definition after the first of the year.

Composite Performance Score (CPS) [13:27]

So the Composite Performance Score in MIPS, how does that work?  There’s the four areas – quality, cost, improvement activities, and advancing care, which was the Meaningful Use, and you could see the weight for 2019.  Now, those weights do change, as Bobbi talked about, in future years.  So, be aware of how those weights change and that might help with what you select in this transition year.

Pick your pace in 2017 [13:57]

So the transition year is pick your pace.  So, you have four options – stay in the pit and get a penalty, try one lap, trip one lap for 90 days, or go for the entire rice.  So what do I mean by that?

Full vs Minimal Participation [14:11]

So, full participation is going that entire race, and minimal participation is try it out.  So, full participation is report on 6 quality measures OR 1 specialty specific or subspecialty specific measure set.  Report on 4 medium weighted activities or 2 high weighted activities, and report on 5 advancing care measures for the full year.

Minimal participation is report on 1 quality measure and/or one high weighted measure, and/or 5 required advancing care measures.  You should try to do the 90 days minimal but you do not have to.  The number of full participation will potentially qualify clinician for the 4 percent bonus while minimal participation will avoid a negative adjustment.  The bonuses and penalties rise in the subsequent years.  The more you do in 2017, the easier that subsequent years will be.

Scoring for Minimal Participation for the first year [15:15]

So, in this example, individual A submits one quality measure with low performance and no improvement activities or measures specified for the advancing care information performance category.  This individual would have the following performance category scores – the quality performance category score is 3 points out of the possible points or 5 percent, 3 divided by 60 equals 5 percent, improvement activities is zero and the advancing pair is zero, just like in participating in those two categories.  So the final score of the performance category score is times the performance of category weight, that is 5 percent times 60 percent, plus the zero percent times the 15 percent, plus the zero percent times the 25 percent times 100, equals 3 points.  Gee, this yet eligible clinician would receive a neutral MIPS adjustment because the performance threshold is set at 3 points.

Scoring Minimal Participation for the first year [16:16]

Now let us look at the group that is doing minimal participation for the first year.  This score is reporting 16 or more clinicians would receive at least 3.7 points for submitting at least one improvement activity.  They did not send anything in the quality or in the advancing care category.  So this is also a neutral MIPS adjustment because of the performance threshold at 3.

Scoring Full Participation for the first year [16:45]

Next, let us look at full participation for the year.  So this could be an individual or a group in this example and we are looking at a group where they did not get all 60 points in quality, they did not get all the 40 points in improvement, and they did not get the full 100 percent out of the advancing care categories.  And through this they got 50 out of 60, 30 out of 40, and 60 out of 100.  So they get 76 points.  What is important about this is clinicians who achieved a final score of 70 or higher will be eligible for the exceptional performance adjustment, which is funded from a pool of $500 million.

What Quality Measures should you report? [17:24]

So what quality measures should you report?  What is your organization currently doing?  Keep in mind that there are alignment efforts with CMS.  They are looking at the Medicaid measures.  They are looking at core quality measures.  They are looking at other payer measures and aligning all these measures with other payers.  So what successful measures can you continue doing that you are already doing as part of MACRA measures?  For example, do you have quality initiatives around screenings or immunizations?  These measures may be easy to incorporate into your existing workflow.  There are about 26 specialty and subspecialty measure steps to review.  Just as an example, if you are a dermatology group, you may want to look at the specific dermatology measures rather than reviewing the approximately 270 individual measures from its quality reporting.  And it is 60 percent of your composite score in the first year.

Improvement Activities [18:22]

In the next category, improvement activities, there are 13 high quality measures and at least one must be selected from these 8 subcategories.  The most important takeaway on this slide is what are you already doing today?  Are you in a registry?  Million Hearts, CMS, Transforming Clinical Practice Initiative?  Are you in health information exchange?  Are you doing surveys such as the patient experience, satisfaction survey.  Are you a volunteer for more than 60 days in the year that those automatically are in the high quality improvement activity measures and you can just start to align with stuff that you are already working on or that you wanted to start working on.

Advancing Care Information Performance Category [19:09]

In the Advancing Care Information Performance Category, this focuses on the secure exchange of health information and the use of the certified electronic health record.  So in the sides that are top  required measures or at the top there and at the bottom you can see the bonus question.  These are yes or no statements.  So if you are in there answering these questions, go for the bonus questions.  Why not?  They are yes, no and this is 25 percent of your score.

Measure Alignment [19:41]

In your view, look at what you are already doing and where you can incorporate those efforts in your MIPS measures.  On the slide you can see one of our clients.  What we did was we lined up some of their contracts with some of their measures and some of their internal initiatives and what they are doing, looking across, we lit up their data to look at how they are doing against their benchmark and it was surprising because where some of the areas they thought they were doing really well, they actually weren’t.  And so, review your performance on these measures and make sure you should not strategically align with the different measure.

Work Towards [20:20]

Finally, 2017 is the transition year.  CMS expects this program to evolve and change.  Stay aware of the changes, especially if MIPS continue to work to support multi-payer alignment.  CMS’ goals are aligning reimbursement with value and this way rewards provider for efficiency in achieving good outcomes while creating accountability for substandard care.

And with that, I am going to turn the slide back over to Bobbi to talk about the APM.  Thank you.

Advanced APM [20:51]

[Bobbi Brown]

Sure.  I think you got a little feeling there for the typo measures that are going to be important for the waiting of the measures where you should spend your time.  Dorian gave some great ideas on how to get started and how to look at this and now we will talk about the advanced alternative payment model, a little more complicated.  I believe that is complicated.

Goals of CMS [21:13]

Medicare, again, they have announced and they may have gone on record that they really want to move by 2018, 50 percent of the payment shifting over to alternative payment model.  So this is part of that progress.  They really are encouraging participation in these advanced payment models.  There is very much a potential they are going to be expanding into other payers, the first year not so much, but as we get into those later years, definitely.  And again, the goal, better care, smarter spending and healthier people.  So, it is what we are trying to do with all of these.

Advanced APM requirements [21:52]

Now, Medicare is essentially are going to tell you what an APM is but these were their requirements and they came out with another list.  The good thing about this is, well, I don’t know if you think it is good or not but they released the rigs on October 14th.  Then on October 25th, they released a list of organizations that they are going to designate as eligible entities in this area.  So they are continuing to update, which means you have to stay on top of things.  And if you do sign up for that, there is a place in there to put your email and you will be on an email list.  So then you will know all these wonderful new things that are coming out.

So you have to participate.  Generally, these are what the requirements are going to be, but they are going to tell you the organizations, that these organizations fell into these categories, that the participants are using a certified health record, that the payments that are going on in these alternative payment models, some of them are based on quality measures that are comparable to the quality measures under MIPS, and that there is a risk in there that you have to be able to bear a monetary law or be what I call – it is not called the “MACRA” Medical Home, but they did come out with definitions of medical home model in this legislation and in the regulation.

So, there were a lot of and usually, there were a lot of complicated formulas in this.  Now, they made it pretty a lot easier for organizations to meet this, but a lot of people were disappointed when the track 1 Medicare Shared Savings Program did not make it and it mainly had to do because again, you did not meet that criteria of bearing risk for a monetary loss.

Models that Qualify for Advanced APM [23:50]

And it has to be more than just a nominal amount.  And so, again, they are saying that 8 percent of your part A or part B, that what you would owe back to CMS will have to be at least that much or I will set now what they considered nominal.  So again, they have gone through these programs and said these are the ones that qualify and then they are adding on to this and they are going to publish a final list by 2017.

Standard Provisions for Financial Risk [24:19]

So, what do they call, again, provisions, what is this financial risk that they are calling this, and it has to do with, again, that it is two-sided, that you have to up and down – so, your actual expenditures versus an expected expenditure, and when you look at it and if your actual was above expected, you either would get payments withheld or payments reduced or you owe back money to CMS.  And then they have come up with this totally – this medical home model and gone through and there is a lot of criteria for the medical home model, a lot of qualifications for that, mainly having a primary care focus and the patients need to be in panels too at primary clinicians and then you have to have elements in there, again, that you can show that patient access, that you have coordination of care, that you have care management, that you have shared decision-making.  And the payment arrangements, again, what they are going to use is 2.5 percent of Medicare per diem in part B revenue but it has to be at risk for this.

Pathways to performance-based risk [25:32]

And they did just come out and announced a new one this week.  The Vermont All-Payer ACO Model is approved and it will count for MACRO.  So again that would be an entity.  If you are participating with them, that you would participate and be eligible for this.  They have also wanted to have, they know they need to have more methods for people to get in, to be able to get into this alternative payment model.

So, this list is going to grow, and they forecast by 2018 that there will be 25 percent of the physicians there but they are going to have this new Medicare ACO track 1+.  I’ve seen 1.5 on things, they like 1+ better.  But another new one is a voluntary bundled payment program.  And then they are talking about what we already have, the bundled payment.  So the joint care.  But again, it has to be under certified technology and advancing care coordination through different episodes, again certified technology, and this Medical Home Model that I talked about.

Process [26:37]

So this whole process is a nice one to do a chart on.  First, it has to be an alternative payment model and then an advanced alternative payment model.  Then you have to be an entity in that advanced payment model.  And then next you have to be a qualified participant.  Again, they are setting up criteria for all this so that other payers can join in on this.

Advanced APM Entry [27:01]

The QP, this is something that you can calculate once you are in the advanced program.  Then you can go to the next step and see am I a qualified participant or not and they are estimating this number went up from when they first did this because they lowered some of the restrictions a little bit, 70,000 to 120,000 providers in 2017 will be in this.

Quality Participants (QP) Thresholds [27:25]

And it is done.  The qualified thresholds are done with the payment amount formula.  So, do I have at least 25 percent of my payment that I am getting in one of these payment models, advanced payment models, and you can do either a payment amount or a patient count amount.

You can also be a partial QP.  If you are a partial QP, you could elect to select MIPS and they also have some nice arrangements in here for their Critical Access Hospital, allowing them to participate and do the patient formula, count formula, and they get a little more flexible.  So fairly qualified health centers and the rural health centers.  If you are an ACO in those, you can also potentially, if again on the patient count, qualify to be a qualified provider.

Met all criteria [28:20]

Now, why would I want to do that?  Well then I do not have to participate in MIPS and you will automatically get the 5 percent increase in the fee schedule.  But you are doing work, you do have to fill out, if you are in an ACO, you do have to complete, you have to walk through and make sure that you are completing the quality metrics that are for that particular organization.  And again, they have requirements for quality organizations across multiple organizations.

So I am going to turn the time over to Dr. Oshiro.  We did mention that he is a physician.  He is a practicing physician and this weekend he was delivering babies and reading regulations.  I mean what more could we ask for?  So he is going to share some thoughts with you.  But before we do that, I will turn it over to Tyler.

Which of the four reporting options are you planning on participating in? [29:01]

[Tyler Morgan]

Thanks, Bobbi.  We do have the poll question up.  Which of the four reporting options are you planning on participating in?  Are you a going to submit some data to the quality payment program, submit 3 months of data, submit data for the full year, participate in an APM, or do not plan on reporting?

We will leave this up for a few moments.  We have had a lot of questions regarding the slides.  Yes, we will be making these slides available to everyone after the event.  We also had a question regarding the recording and slides of the previous MACRA webinar earlier this year and yes, that is available on demand on our website at

Alright.  Let us go ahead and share the results of this poll question.  It looks like 33 percent, a third of everyone are suggesting they are going to submit data for the full year.

[Bobbi Brown]

Yeah.  That is great.

[Tyler Morgan]


[Bobbi Brown]

Yeah.  So that’s fantastic.  Yeah.

Physicians [30:07]

[Dr. Bryan Oshiro]

Okay.  So, hi, this is Bryan Oshiro,  I am a perinatologist by training and have been working in the field of healthcare quality improvement for over 20 years now, and it has been really a fun journey.  But now I was getting paid for the quality that we actually have been providing and so forth.  And now it is up to us to get involved here and do something of it.

Who are eligible clinicians subject to MIPS? [30:34]

And the other thing I just wanted to add is that it is not just physicians that are going to be eligible under MIPS.  It is PAs, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include clinicians who go under Part B.  And it is very interesting and as we go forward, it is going to include more people as well such as certified nurse midwife and so forth.  However, there is a volume threshold.  So it is not everybody that is going to have to participate.  They did make it such that people that have low volumes or low billings under Medicare Part B are going to be exempt in this process.  However, I would not hold my breath and say, that is going to continue forever.

Defining Providers in Unique Situations [31:19]

So there are some unique hospital-based or non-patient facing criteria that the final rule actually has changed, and it has the changes on the right side of that column there, the right column, the changes.  And they lowered the eligible clinicians from 90 percent to 75 percent of the hospital-based patient volumes and so forth.  And they have also changed a little bit the non-patient facing clinicians and this includes practitioners and you think, well they really do not do patient care necessarily but radiologist who do interventional cardiology, for example, or maybe telehealth services, they are also going to be included in this.  And the rule changes that the threshold for determining non-patient facing status has increased from 25 to 100 encounters.  So that is a new change that has just occurred.

How many clinicians will be eligible for MIPS? 32:21]

And how many estimated clinicians?  Well, you know, it is quite a few.  So it is half a million plus providers and so forth are actually going to be required to participate in this for 2017.

What doctors are saying about MACRA [32:35]

And this is what really I have heard or read about in the literature and actually query.  Physicians who are practicing in big, well-organized organizations were not worrying about MACRA and if he were in a small practice, “there would be no way I could deal with this…It requires scale and leadership and management to respond.”  This is by Tomas Lee, Chief Medical Officer for Press Ganey patient experience consulting firm.  And this is quite true.  I have spoken over the last month because they are so interested and what physicians felt or heard or their thoughts on this is that many people in large organizations, such as Kaiser and so forth, they have actually expressed to me, I think the organization is taking care of it.  I would say that if you do not know for sure it behooves you because of the reporting requirements that really talk to the leadership and make sure that you know what you are reporting on because you are going to have to actually participate in this reporting.  It is not all going to be automatic.

A family practitioner in Georgia wrote, “MIPS and APM are very bad for the solo practitioner.  They likely signify the destruction and death of the one- and two-doctor practices, particularly primary care physicians.”  And I have spoken with a lot of my colleagues as they travel across the country and it just (33:53) them if they are in small practices and they have actually said that they are actually planning on retiring early, that maybe for 2017 they will not even report on MIPS because they are so discouraged about all the reporting requirements.  And in Southern California, that is exactly what I heard as well around my neck of the woods.  When I talked to people in my organization or people in the community and so forth, that’s what they’re planning on doing.

How did MACRA benefit practitioners? [34:21]

However, I think most people do not really realize that without the passage of MACRA, that there are some negatives for that.  So, physicians would have been subject to a negative payment adjustment of 11 percent or more in 2019 as a result of meaningful use, PQRS, value-based programs and so forth, with even greater penalties in the future.  And so, with the advent of MACRA and institution of MACRA and a repeal of FDR, there has been a lot of stability that actually has been brought forth in the reimbursement landscape.  So the largest penalty anybody can actually receive is 4 percent.  So this really is a way to incentivize the right behaviors, cost-efficiency, and not penalize, make it too onerous, for all of us practicing physicians and so forth.

Another reason to report:  It’s all reported publicly [35:22]

And the others that are thinking about, “well I am not going to report at all.”  But it may be harmful and that this is all going to be publicly reported information and data and so forth – so through physician compare and stuff.  So if you are trying to get a job with another healthcare organization, for example, if you are leading a private practice or your patients are looking at on your performance across the board, many patients today are so sad that they looked at Dr. Google.  So by the time they come and see me in the office, they have already had several consults with Dr. Google.  So this may be something that social media is really going to take a hold of and so forth when they are doctor shopping.

Is CMS Listening? [36:04]

And the other thing that’s really kind of encouraging for me is that whenever you deal with politics or with the government or agencies or something of that nature, you feel like, you know, nobody ever listens to me, but it is really interesting that they actually heard all these public comments and that’s why this flexibility for 2017 actually got revised in the final rule.  It’s because they heard that doctors have urged CMS to “make the transition to MACRA as simple and as flexible as possible.”  So, it may not seem all that flexible to everybody and it may not seem all that simple but it is a lot more flexible than whatever was proposed to be.  So they are moving in the right direction.

AMA Commends CMS [36:47]

And the AMA actually also weighed in on this.  Andrew Gurman, who is the president of American Medical Association, states that, “AMA believes that the actions that the administration announced will help give physicians a fair shot in the first year of MACRA implementation.  This is the flexibility that physicians were seeking all along.”

So, I would not look at it in terms of, boy, this is the worst thing that’s ever happened, but that there are some major concerns with regards to healthcare expenditures in our country while where the number one healthcare expending country per capita nearly doubled the next closest industrialized country and so forth, and we have to do something.

What are the Main Benefits of Participation in MIPS? [37:30]

So what are the main benefits of participating in MIPS?  There are new opportunities to earn incentive payments for above-average performances and you know, this is supposed to be a cost neutral venture so that the lower tier people are going to be subsidized and the upper tier people, but in essence, there is going to be some gaps in that.  So (37:51) actually appropriated $500 million a year from 2019 to 2024 to make up that difference in expected cost for the program and so forth.  And there is going to be some separate bonuses about the 10 percent for exceptional performance.  So the main thing that we have to consider is we have to participate so that you do not get negatively affected.  Would not that be great if everybody participated and not got a negative weep hole from their CMS reimbursement.

It also gives a streamlined performance reporting system, which should be more easily managed than the multiple existing reporting systems that are out there currently.  So in that way, they have really started to sort of streamline.  So, it behooves us to take a look at what we can do across reporting lines so that it makes it also easier as well.

And then the current improvements in performance scoring over current quality program, there’s the sliding scale assessment and the flexible weighting and the new measurements.  And also, small practices will receive $100 million in technical assistance.  That is not directly they are going to give money to you but that means that there is going to be money set aside for training for small programs and small practices so that they can comply and participate in MIPS.  So that’s $20 million per year to assist with practice up to 15 professionals participating in a MIPS program and/or transitioning to this new payment model.

How Ready are Physicians for MACRA?

And just as in the side, I was able to kind of review the Deloitte Health Solutions Center survey in 2016 at the US Physicians and this is how ready they were according to the survey.  Fifty percent say that they have never heard of a law which is really astounding and 32 percent recognize it by name but are not familiar with this requirement.

Twenty percent of self-employed or independent physicians say that they are somewhat familiar with the law, compared to nine percent of physicians employed by hospitals, health systems or medical groups owned by them.

So it really is amazing that if you can just read through that on your own, and the slides will be made available, is that there really is ambiguity in the marketplace amongst physicians as to exactly what this means and what this actually entails and how much work is actually going to go into participating in MIPS.  So that is why we, from our company, we decided we need to educate our population as well.

So I am going to go and transition over to Tyler.  Tyler, we have another poll question here.

Based on the final regulations, how do you think your organization will fair under MACRA? [40:30]

[Tyler Morgan]

Right.  Thank you, Bryan.  So based on the final regulations, how do you think your organization will fair under MACRA?  It will break even, do you believe you will receive a bonus with positive adjustment, receive a penalty or negative adjustment, you don’t know, or not applicable?

I will leave this open for a few moments to give everyone a chance to respond.  I would like to remind everyone that we are recording this webinar and that we will be providing a link to the recording, as well as the presentation slides.

Alright.  Let us go ahead and share those results.  We have got about a third of the individuals say they don’t know but we believe that about 27 percent believe they will receive a bonus with positive adjustment.

[Dorian DiNardo]

Well if you are going to do a full year, you should.

[Bobbi Brown]

Yeah.  Yeah.

[Dr. Bryan Oshiro]

Right.  Why list my name on the table and why let somebody take money away from you?

Assistance Needed! [41:29]

So, like I said earlier, there is some help available and you know, take advantage of it.  The government really does not want to leave physicians in the lurch here because the intent, again, is not to save money for our saving money space.  The way that the government program is actually setting up is to actually incorporate financial incentives in order to take care of patients in a more efficient way, in a more beneficial way for patients and so forth to obtain the benefit of our expertise as it is.  So again, there is some training available and there are some additional websites, which we have actually put at the end of this presentation and in the references so that you can find them after the presentation is ordered.

What are steps can we take to prepare? [42:21]

So what steps can we take to prepare?  Well, I think we all need to evaluate where we fall under MACRA.  Are we going to be in MIPS or are we going to be APM or are we exempt?  So the AMA website actually has a payment model evaluator and I actually went on online to take that for our group and it turns out that, yes, we are subject to MIPS and we are not exempt.  So we have to report on something in this coming year.  So anyway, it is a pre-calculator, there is no sign-up and stuff.  I do not even think you have to actually be an AMA member to take it but I am not quite sure on that but you can actually peruse that website.

And are you participating in a qualified clinical data registry already?  If not, there are specialty societies that have these registries and so forth and they can really streamline your reporting and assist you with MIPS performance scoring.  And if you practice with more than one eligible clinician, as Dorian said earlier, you know, the ask the questions, decide whether or not it is beneficial to you to report individually or as a group.  Now, the other downside is that if you report as a group, you are not going to be able to really have picking and choosing which measure you are going to be working on as an individual.  You have to determine it as a whole and so forth.

So really you have to kind of look at your practice and evaluate and see what is really beneficial for our group or what are we doing well already.

And then determine whether you need the requirements for small, rural or non-patient-facing physician accommodations as well.  So like I said earlier, if you have a hundred encounters or more, then that is something that you have to be promising of.  And if you are in a hospital-based practice, you may qualify under MIPS anyway from that.

Steps to take – continued [44:21]

So number 5 step is access and review the 2014 annual PQRS feedback reports to see where improvements can be made.  Again, if there’s something that you currently aren’t reporting on or you do not have data on, it is really going to be hard for you to get started in 2017 because 2017 is only less than two months away.  So pick something that you are already reporting on.

And you have to have some cost data to review the cost data from CMS in the summer of 2017 for ongoing things.  Again, you should look at 2017 as not only participating for the sake of not losing any money and potentially gaining a little bit extra money, but 2017 is an opportunity to test your systems, to test your processes, such that going forward, where there is going to be increasing gains, rewards, and penalties, that you really need to have your systems in place for that.

And then consider how you plan to report through claims, electronic health record (EHR), clinical registries, qualified clinical data registries, or other means and so forth.  The GPRO Web-interface is only available for physicians in larger practices, for example.  So make sure that you know how you are going to report.

Resources – MACRA READY programs [45:42]

The next steps that I kind of summarized here as you can take a look at the resources, there’s really kind of four steps in summary that I would like to say – is that you should focus on evaluation and strategic planning in the following areas – financial, which we have sort of talked about, clinical, technical, and staff training.  So, really for the next 2017 year, stabilize and optimize your registries so that you ensure that your practice is not needing  money on the table.  So make sure that you do staff audits, that you are working on (46:20) management to help close your revenue weeks and so forth and helping yourself to really know and scrutinize your reimbursements and so forth.

With clinical successes, because there’s such a big emphasis on 2017, 60 percent of your score through MIPS is based on quality targets and that is where you should be putting on a lot of your emphasis on.  So take advantage of the measures that appear across multiple categories and things that you are already reporting on.  And remember that population health and care coordination are really at the heart of the QPP models and so forth.  So focus on expanding communication with your beneficiaries and patient care teams, as well as specialists, per se.

And then technological success is so key to this.  So make sure that you are able to access information through your EHR templates, your workflow customized, and that maybe you have some dashboards that you can create, or you need to create.  And then finally, what I would say is that really you have to train your staff.  So, practices really need to have some help in this many times, so you may need to align with partners who can help you show the burden of having expertise and implementation and educating your stakeholders all along the continuous and things, and still really focusing in on, the patient is probably number one.  This is quite evident with the new MACRA laws and so forth.  So, involve the entire staff.

So anyway, I am going to turn it back over to Tyler for a wrap-up here.

[Bobbi Brown]

Okay.  Thank you very much.  I got some great ideas just listening to that.  I hope you all did too.  I had one slide in there I am reporting and I probably skipped right by it in my nervousness.  But anyway, you will be reporting for 2017.  You will have to report by March 31st of 2018.  I got my years right here.  and you can go through the reporting options that Dorian mentioned.  So again, you may not be reporting a full year but you may just be reporting the 90 days in there or the full year, whatever you decide to do.

Questions [48:38]

And then CMS is committed to give us some feedback reports in the next summer, which those of, I am just waiting to get to see some of those.  And again, they will not have all of our data in there but they will have some data in there that they had pulled a lot from claim.  And get started.

And we have some questions now we want to get into.

[Tyler Morgan]

That is right.  We have got a lot of great questions.

Upcoming Webinar [49:05]

Before we get to the questions though, I would like to highlight that we do have an upcoming webinar, ‘Introducing the New Health Catalyst Care Management Suite’, provided by Russ Staheli.  We did announce earlier that we have a couple of webinar series coming up in population health, as well as predictive analytics, and this is the first webinar in the population health series.

How interested are you in someone from Health Catalyst contacting you about a demonstration of our solutions? [49:23]

But the other thing is that before the questions, you know, our webinars are meant to be educational, but sometimes we do get questions about who we are and what we are doing.  So, if you are interested in someone from Catalyst reaching out to you about a demonstration of our solutions, please feel free to respond to this poll question.

While you are responding, let us get right in.  So we have had multiple questions around this topic – where can I find those quality measures?  Quite a few folks are very interested to know where they can find those.

[Dorian DiNardo]

So you can find those quality measures at the QPP website and that was on, I believe, slide 62, when you get the slide deck back,  You can walk right through that website and it is very guided.  It is a great website.  You can download information.  It will show you what kind of, how you submit those measures, can you do it to your claims and/or registry and/or your EHR.  If you are a group and reporting through the CMS web interface or a GPRO-type submission, it walks you through all of that.  So, it is very educational.

[Bobbi Brown]

And you have right in there is the list of each measure and I am pretty sure there is a download feature, then you can sort in different ways and say, I only want to see these measures, I want to see all over 200 of them, and they are listed with a title and very descriptive.  And like she mentioned, the and up on the right-hand side I think it’s all the explore measures.  So they are right there.  Or you can of course can go to the (51:13) the pages of the rigs but you do not need to do that.  Just go to

[Tyler Morgan]

We have also had a lot of questions around multispecialty groups, questioning about what do we do, do we report as a group, do we report individually based on how we are set up.  There’s a lot of questions, a good around how multispecialty practices are supposed to function under MACRA.

[Dorian DiNardo]

So you have a choice under CMS with multispecialty clinics.  You can report as a group through the Tax ID Number and all of the NPIs and that Tax Id Number will be in that group.  If you are choosing not to use your Tax ID number to report, then you would do, each NPI number would go in, and answer the questions at a station, at the advancing care questions category, if you are wanting to do the full thing.  If you are just wanting to test that program out and do 90 days, figure it out, submission and do your claims data or something like that, that works great.

[Dr. Bryan Oshiro]

Well I think for most groups, it would be beneficial to report as a group, because some of the easiest ones to do are something like care coordination, for example, where you really kind of are making sure that there’s communications between providers and patients and specialists and so forth.  So those things can go across and everybody can participate.  If you do an individual type of reporting in a multi-specialty group, it is going to be quite difficult and I think onerous to address those issues and so forth, and it is going to be quite confusing for the staff.  So what you want to do is you want to actually set up a system for the entire clinic enterprise rather than doing individual one off because that is not going to help you set up a system for the future.

[Tyler Morgan]

Alright.  Thank you.  Well our next question is to get the maximum possible score for next year.  Is it to your understanding, you must report for the full year, the new QPP site CMS seems to contradict itself, saying in one place that you can do 90 days for the maximum option then the other side to full year.

[Dorian DiNardo]

So that depends on the data quality of what you are submitting.  If you have excellent data quality for the measures that you are submitting, you could potentially get above the 7 points required for full participation.  It really depends on how good your data quality is.

[Dr. Bryan Oshiro]

So the 90-day threshold, again, you know, this is a great way that if you are going to report for greater than 90 days, that you may not be quite ready at the beginning.  So CMS actually, through this program, has allowed and given flexibility to clinicians who say we were not quite ready in January of 2017 but we’re going to be ready some time in the interim.  So then you can start reporting and to continue with the 90-day process, from where I understand.  So they could be a little bit later.  You could start the process early on but you are gaining that expertise, you are gaining that understanding, or getting the processes in place.  So I think this is a great flexibility element that they have built in.

[Tyler Morgan]

Alright.  Thank you.  Our next question is with the baby boom of population just getting into Medicare, this is the worst time to be using practitioners, as slide 49 noted.  Has CMS acknowledged this possibility, this case scenario?

Dr. Oshiro, would you like to (55:09) first?

[Dr. Bryan Oshiro]

Yeah, I am not sure if actually, you know, they know that there is a big hump in this group of individuals that’s aging and so forth.  That is going to comprise the largest group in the Medicare population.  So they do realize that it is the patient population, that there is going to be a great need.  They also know that there is a great mismatch with a number of clinicians that are able to take care of them, primarily primary care doctors.  And so, that is why they have actually said this is not a program just for physicians but anybody that’s patient-facing, including PAs and nurse practitioners and so forth.  And you know, because of the large care gaps that may develop, and we know from modeling that CMS is gone, that this is potentially going to astronomically increase the process of care.  So this is really a desperate attempt to handle this large influx.  And so, that’s especially one of the reasons, a big reason, why they are actually doing.

[Tyler Morgan]

Alright.  Thank you.  We are very near the top of the hour.  So we just have one last question that we can fill.   If we did not get your question, Bobbi and Dorian and Dr. Oshiro have committed that they will reach out and respond to every question that’s been asked.  So this question that we can fill quickly is what website was the AMA Payment Model Evaluator on?  And I believe we have it up here on this slide.  Bobbi?

[Bobbi Brown]

Yeah.  Yes.  That is the general and under that you will find the payment evaluator.

[Tyler Morgan]

Alright.  Well, thank you everyone.

[Bobbi Brown]

Thank you.

[Tyler Morgan]

I’m so glad you make it.  Shortly after this webinar, you will receive an email with links to the recording of the webinar, the presentation slides, and the audio download.  Also, please look forward to the transcript notification we will send you once it is ready.

On behalf of Bobbi Brown, Dorian DiNardo, Bryan Oshiro, as well as the rest of us here at Health Catalyst, thank you for joining us today.  This webinar is now concluded.



What do we have to report?

Reporting Option 1: No Reporting

Reporting Option 2:  Minimal Reporting

Reporting Option 3: Partial Reporting

Reporting Option 4:  Full Reporting

Reporting Option 5:  Advanced APM