Well, hopefully everybody is sort of getting the flavor and the feel of what we're going to spend our time on today, and I'm going to talk a little more in depth on a few of the concepts that Bob started to bring up, and then I'm going to add some to it, and we're going to go from there. So, as Bob said, I'm Jill Rathbun, and I get to spend my time in Washington, D.C., which is a really interesting place to be right now, but also I really hope today that we're going to have a good dialogue. Right? I've taught a lot of these courses now on MacroAdmits and APNs and the alphabet macaroni soup, and you guys have an advantage that many of the folks I've taught don't, which is there's a small group of us here today, and we can really get into some good nitty-gritty and really talk about your own personal situations and try to get you as much personalized help and tools as we can today. So let's all really take advantage of that, because a lot of times we're doing this webinar-based and we've got 100 people and you can't get personalized help, so let's make sure we're really dialoguing today. We've got the microphone. We have our folks at home, I guess, maybe in their jammies still, but maybe not. It's almost lunchtime. It's almost past lunchtime. And so hopefully we'll get a good dialogue going. So I'm going to talk a little bit about, a little bit of additional information, layering on what Bob started with some Medicare history. I'm going to talk about the MIPS Quality Payment Program, and I'm going to talk a little bit about 2017 particularly. There are some elements of 2017 that are different that allow sort of a transition year into the program that we want to make sure everybody is well aware of and is able to take advantage of. We're going to talk a little bit about some tools. We're going to have more about that later this afternoon, too. We're going to have a demonstration of Acquire and how to get your practice set up on it, et cetera, that Miles is going to do for us, and then Bob's going to come and talk more about the clinical performance improvement activities. So as I said, we got to talk a little bit more about the past, right? We got to understand the current program. So as Bob said, we had this thing called the Sustainable Growth Rate, started in 97. We had these horrible cliffs every December, and we did that for 10 years. Congress did that for 10 years. Congress bailed out physicians for 10 years. A lot of times when they were bailing out these big cuts, they were cutting other physician services to do it. Physicians don't realize that. We paid for a lot of those cliff cuts with our own revenue, changes to the fee schedule particularly. Misvalued services review, cuts to imaging services, cuts to other ancillaries, et cetera. So physician community got really sick of that, and the other person that kept getting cut all the time to bail out physicians were the hospitals, and they got really sick of it. So they came in with us, and we got rid of the SGR finally. As Bob mentioned, we have these existing quality payment programs, and one thing everybody needs to understand is that they don't sunset till 2018, till the end of 2018. So what your practice or your group, depending on how you're reporting, did in 2016 is still going to affect your payment in 2018. And what your practice did in 2015 is affecting your payment now. So one of the things to understand in everything we talk about today is that the Medicare program does everything on a two-year data lag. They're not in real-time activity. So if you don't make provisions in 2017, you will not be able to fix it, and you will get cut or a bonus in 2019. So we've got this whole lagging system. So it's not like I can forget about it and not do it, and I can still get out of all the penalties in 2019, the penalty year. It doesn't work that way. So PQRS still lives in regards to payment changes. So right now, if you did no quality reporting in 2016, or somebody didn't do it for you, if you're a big academic, you're going to get a 2% cut in 2018. And if you didn't do it in 2015, you're getting a 2% cut right now. How many of you check your earnings on billing statements or your earnings statements on all your claims on some sort of frequency? Okay. When you check them, and everybody should be checking them, right, particularly if you're an academic. People are like, why? Somebody's billing for me. I don't need to know. They don't always bill correctly for you. And that's why Mitch will be here later today is to help people out on certain things. But you also want to look and see because CMS takes the penalties out on your earnings statements. So they pay the claim, and then they take the cut off the bottom. So you can tell exactly what they're doing to you off these quality programs off your statements back from Medicare. So the value-based payment modifier affects both large practices and big practices, but it affects them slightly differently. The other thing on both the current programs and the future programs, and I'll show you this again in a minute on another slide, is it's this thing called eligible clinicians. That's not just physicians, right? So the counting is based on eligible clinicians, which includes physicians, nurse practitioners, PA, advanced practice, et cetera. And I'll show you the actual categories in a minute. So you may say, well, we only have three physicians. But if you have three nurse practitioners and two PAs, you technically are at an eligible clinician count of eight, not three, right? So in here, in the current programs, we were split between 10 and above and nine and below, right? So in the value-based payment modifier, in 2016 activity for 2018 payment, if you were 10 and above eligible clinicians, you had 4% at risk. And as Bob said, there's winners and losers. The value-based payment modifier is a winner-loser game. The losers pay for the bonuses of the winners. And you can lose as much as 4% if you're a big practice, and you can gain as much as 4% if you're a big practice, 2% if you're a nine and under. And then we add that to the 2% for PQRS. So here's another hit on the new program, on the old programs. Not quite the same on the new programs, thank the Lord. But if you blew out on PQRS in 2016, you automatically will get the full penalty on the value-based payment modifier. The quality quotient of value-based payment modifier comes from your PQRS activity. So if you don't do PQRS and you're over 10, you're going to get cut by 6% in 2018. And guess what? Right now, there's nothing you can do about it, because 2016 is over. Now, we'll see. We may try to fix something legislatively or regulatorily to try to provide some relief yet in 2018, because we have a new secretary who is a physician, HHS secretary. But we can't guarantee that. Then we have meaningful use on top of it. And meaningful use has its own penalty structure and escalates. Now I have a penalty in here of 5% in 2019. And it's going to sunset at the end of 2018, so that's going to get cut off. Right? So as you can see, right now, in the current programs, on 16 activity, if you're a practice over 10, in 2018, if you did nothing, if you sat on your hands and did nothing, you put 10% at risk. If you did quality reporting, you didn't sit on your hands, you may be somewhere up there. If you're going great guns, you could be looking at 10% bonus. But we are also in these same numbers in 2015 to 2017 payments. So if you pull your 2017 Medicare payments, and you see what your percentages are, and you didn't change any of your behavior in 2016, you've got a good budget tool that you're going to have to start thinking about what to do. Right? So these are the old programs. These are the programs that have been in effect for quite some time. As Bob said, we ended all this. Right? But we're in this time period where they don't end until 2018. They still affect your payments, but we did end it. Congress ended it all. We got rid of the SGR. We put in positive updates into the amount of money available for physician payment. So the number that plays with that conversion factor. Right? The dollar amount. Does anybody tell me what the conversion factor equates to? This is kind of a tough question. I wouldn't expect you to know it per se, but maybe. So this 35,8887 is what one RVU is worth. Right? So when you're doing RVU production for contracting, this is a number that you want to remember. We get a lot of calls from that at OGS, the coding committee thinks about that sometimes for our members. So this half percent goes into the whole pool. And then over the years, so 18, 19, it'll help determine what this conversion factor is. But this conversion factor also changes with other policies that are going on in Medicare as well. So just because we're putting positive money into the pool doesn't mean the conversion factor is automatically going to go up. Because there are other factors at work as well. I'm happy to talk about those if we have time. So then Congress said, okay, well then we're going to have a five-year period where it's going to be flat. We're not going to put any more money into the pool. We're going to try to see if some of these quality programs sort of work that volume down so that the conversion factor doesn't vacillate too far down. We'll see. This is what medical societies do, though. We go to Congress and we say, well, that was a great idea, but it's not working. You got to give us some money. So I think in that five-year window of 2020 to 2025, all medical societies will be working with Congress to see if that's the right thing. Then in 2016 and beyond, how much your conversion factor is worth will depend on what you choose to do in the quality payment program. Now one of these is bigger than the other, right? One is .75 and one is .25. Why is that? It's because Congress wants physicians out of fee-for-service. They want to incentivize activity and action into advanced alternative payment models. There's a method to their madness. They didn't just decide all this willy-nilly. They want to move physicians over to risk-based payment, right? They want physicians, hospitals, all providers to have skin in the game. This whole program, as Bob said, CMS went out and actually did focus groups. Seems like a kind of waste of time, but however, they did it and found that physicians didn't understand what MACRA meant, so they changed it to the quality payment program. We spent, medical societies, we all spent a year and a half educating everybody to the acronym of MACRA, and then we said, no, CMS said, no, we want it to be QPP, quality payment program. Okay, so now we all talk about the quality payment program. That's sort of the vernacular. So here's a timeline for the program. And so you can see, as I just mentioned, we have the half, half, half in the SGR, then we have the changeover to different conversion factors depending on activity choice. We have the old programs in the green. They're still going till 2018, so they're affecting payment. Then we have the new four categories under the MIPS program, Medicare Incentive Payment System that start up in 17. We have the bars here because we're getting ready for them. Then here's the adjustment percentages. So right now, in 19, so here in 18, we're at 10% risk. So in 19, we're going to knock back to 4%. The law knocks it backward and then revs it back up, right? So we're down by six, which is good, but we're going back up, right? Then we want to get people down here, not up here. So this is the Alternative Payment Model. Now this is technically the advanced Alternative Payment Models. These are not MIPS Alternative Payment Models. These are advanced. So you get a 5% incentive payment if you meet the qualifications, and you get excluded from MIPS. So all your quality, all your electronic health record, everything is done through the Advanced APM, excludes you from MIPS, and you get 5% if you meet the thresholds for patient volume or cost volume. And then whatever bonuses your Advanced APM has in its methodology, you get those as well. Nobody's, well, I shouldn't say this. Most medical societies' intent is to not build Advanced APM models that don't provide their physicians with some level of extra money. Will we succeed? We'll see. But that is the premise, is that we will use these Advanced APM to particularly get physicians paid for things that you don't get paid for now, like patient coordination, telephone calls, emails, working with the patient one-on-one, covering your staff. All those things that you don't get paid for now, we want to build that into these models so that we get you paid for that, and we get back to some evidence-based care pathways that may cause some other services to come down slightly to pay for that. And also, don't tell your hospitals, we're going to take some of their money, right? Because if we pull their money down and move it over to physicians, that saves the system money, right? So that's sort of part of the beauty, and you'll, John and Jerry will talk a little bit about that later. So as Bob said, it's your choice. It's physicians' choice what to do in these programs. You're not mandated into PQRS, Value-Based Payment Modifier, and electronic health record like the old programs. You can choose whether you want to be in MIPS, or whether you want to be in Advanced Alternative Payment Model, or whether you want to be in a MIPS Alternative Payment Model. And you can switch each year. So let's say that you are in an Advanced Alternative Payment Model. It's not working for whatever reason, and you're like, I'm losing money. I want out. You can get out the next year and go back to MIPS for a year, or two years, or three years, four years, right? So you can switch back and forth if things aren't working for you in one or the other. So who participates? So first, this is eligible clinicians. This is not physicians. Physicians is one category. So this program covers physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse anesthetists. Now what is the one type of practitioner that OGS members work with that's not on this list? PT. So PT and OT are not currently in the program. The law gives the flexibility that they can come into the program in 2021. So 2019 reporting for 2021 payment. And their medical societies want to come in, by the way. So they will probably try to come in. But right now, PT is not part of your count. But your nurse practitioners and your PAs are, and if you use advanced practice nurses like nephrology nurses, oncology nurses, some surgical nurses, et cetera. Now the other thing is people have to bill more than $30,000 to Medicare, get paid more than $30,000 to Medicare, and have treated more than 100 Medicare patients in a given year. That's called being above the low volume threshold. Now I think it'd be very hard for an OGS member not to treat over 100 Medicare patients in a year. But maybe there are some scenarios where you would not. But I think that would be unlikely. But as you can imagine, our OB colleagues in ACOG, it might be likely, right? And this is sort of where this is for, is pediatrics, OBGYN, et cetera. So as I said, who's excluded? So there are three categories of exclusion. So first is newly enrolled Medicare clinicians. So these are folks who are coming out of practice and have never had a Medicare ID number. They're starting practice for the first time. This is not somebody who is moving their practice, right? If you're just changing practice locations or you're changing your site of service, et cetera, this is not, you are not excluded during that time. These are for folks who are sitting over, sweating it out, trying to figure out how to take their board exams, right? These are those folks, right? Even if you have somebody who is a fellow coming into your practice, if they were billing as a generalist to Medicare and have a Medicare ID number, they are probably not going to be excluded because they've been billing, right? But if they didn't, if they never signed up for Medicare during training, their first year with you, they could be excluded. So you do have to understand that with our new incoming professionals. Then if you are below the low volume threshold, 30,000 allowables, 100 patients, you would be excluded. Then if you're in an advanced alternative payment model, you would not be in MIPS. Those are the three ways you get out of MIPS, otherwise, you're in. So let's talk about this MIPS thing, whoa, MIPS, MIPS, MIPS, MIPS. So all the quality programs by end of 2018 are gone, right? They can't affect your payment anymore, they're out of here. But it's not like we didn't spend a lot of time building them, right? So they continue to exist in regards to the elements in them get moved over to the new programs, right? We're not starting from scratch building all brand new quality measures, right? Medicare can't afford that, for one thing, and neither can all the medical societies who invest a lot of money in quality measure development and time and treasure and talent for all of its members. Value-based payment modifier, it's going away, but parts of it will live on the cost side. Meaningful use of electronic health record, you're going to see some of the measures or things you've been measuring for that program already, right? So we're not totally starting from scratch. So as Bob said, there's four components of MIPS, right? So there's the quality component that replaces PQRS. There's clinical improvement activities, also known as improvement activities, also known as clinical performance improvement activities. That's brand new, brand new. But I would say when Bob talks to you about the various categories this afternoon, there's going to be things you do every day, you're just finally going to get some credit for it, right? These are not going to be above and beyond stuff you're already doing, I can tell you. And if you get into a choir, it's really not going to be above and beyond what you're doing. Advancing care information is the old EHR, although nicer, I would say, easier, less to report. Cost is the old cost quotient value modifier, and unfortunately it still has some of the challenges that that program had in regards to measuring people's costs. So how you work in each of these areas combines to give you a score, right? And so somewhere between one and a hundred will be your score. And we lay, Medicare lays all the physicians in the country down on a piece of paper and then cuts, right? And benchmarks all of you, and the people below the benchmark pay penalties, people above get bonus, people in the middle, that sort of big middle thing that Bob had on his one side, they just stay static, right? They just say no penalty, no bonus, just there. So how much is each of these parts worth? They're not worth equal amounts, right? They're not worth equal. So in the first year, the 2017 reporting year, so 2019 payment, 60% will be quality. So what you do with your quality measures will affect 60% of this score. 15% is clinical improvement activities, 25% is meaningful use. I still call it meaningful use, I'm old school, but advancing care information. And cost is zero. 2017, your cost, i.e. how much Medicare spends on each of your patients, you will not be scored on that. 2018, though, cost right now comes back into play, although the medical society community is going to try to knock that back to zero for 2018. 50% will be quality. I can tell you if we knock cost back to zero, quality will probably go back to 60. Although we'd like to see a higher percentage here with the clinical improvement activities and then that's meaningful use. The law requires that at some point in 2019, as in the law, that cost and quality are equal in regards to their impact on your score. So cost is still going to be important, right? This volume thing is still in everybody's mindset, right? So that's how the scoring works, up to that. Now each one of these categories has its own methodology for scoring. And we're also trying to get this with CMS a whole lot easier than it is right now, right? It's very, very complicated right now, unfortunately. So as I mentioned, this is a budget-neutral program. But if this amount is way more than plus 4% for these people, right? So if this group, unfortunately, is really large, this bonus can be three times this number by law. So let's say, unfortunately, everybody who hasn't been doing anything continues not to do anything. And we get a big dollar pool here. Probably not this year, but this year you could be as high as 15% bonus money. The law would allow the top bonus people to get a lot of the bottom people's money. Then it goes seven and nine. But the negative can be no more than the negative. But the top can be more than the top, if that makes sense. But this year we're going to talk about it because there's some unique factors here with go at your own pace. How are you going to report all this menagerie of information to the Medicare program? There's two ways to report. You can report as a group or you can report as an individual. If you report as a group, it's your tax identification number that will be used by CMS to identify the group. If you report as an individual, it will be your NPI number plus your tax identification number. Group is two or more. So even if you have a practice of two eligible clinicians, you can technically be a group. The law does allow for this thing called virtual groups, but CMS doesn't know how to do that yet. But that would allow small practices to band together into a big group, like if you wanted to create sort of a cooperative type thing. But we don't know exactly how that's gonna work because CMS doesn't know how it's gonna work. A virtual group could make your benchmarks better, could allow you to use a single reporting apparatus where you all then pay part, could allow you to create a state-based or regional-based registry. We've seen some of that in GI, particularly. So that would be sort of the reason to do it. We don't know that now, with so many medical societies having national registries, there may be less interest than there was when the law was being written, where the small practice folks were like, hey, we wanna band together, we wanna go against the big academics and see if we can do better than them. That was sort of the mentality behind it. But the reality is, with registry participation, there may be no need, right? But that was the sort of philosophy behind it. How does all this work, timing-wise, right? Because we have this two-year lag, right? We're putting information in. So for 2017, the performance period is January 1 to December 31, 2017. CMS allows practices to put data in all the way till March 31, 2018. Why? Because you treat patients in December, right? And they would only have to get all your data in by December 31st. So you can put data in on 2017 all the way through the first quarter of 2018. Then by law, CMS is required in the summer of 2018 to provide every physician a feedback report to show them what data CMS has on that physician, quality data. Actually, in 2018, they are also required to show you your cost data, what your cost score would have been had we been using cost in the calculation, your improvement activities, and your EHR. How many of you have ever looked at a feedback report known as another acronym, QRUR, for the existing programs? That Ryan, he is on the ball. He's a good private practice man. You guys gotta look at your reports. First of all, CMS makes tons of mistakes. There were a number of large physician groups that challenged CMS last summer on their value-based modifier data, because it was wrong. CMS then recalculated, didn't recalculate their score because CMS has no ability to recalculate, but they then dropped them into a neutral position, and so therefore they didn't get a penalty. So you have to check these feedback reports. They come in through your Medicare contractor. You get information about them being available. OGS will be putting information out about them being available. But I would challenge everybody to go home and put a little note on your Outlook calendar or Google, whatever you use, for July 2018 bullseye, I will check my feedback report. Right, because CMS makes mistakes, a lot of mistakes. Anybody who does billing for a practice knows CMS makes a lot of mistakes. These programs are no different. So we must check our feedback reports. Then, in January, the payment adjustment will happen. So again, two-year lag. So then, July of 2018, now CMS could be late. We're not expecting them to do this without a lot of hiccups, but that's when the law requires them to bring it out to all physicians. So how are we gonna get all this information to CMS? Right, it's not like they're gonna come to your practice and write it all down and take it back to Baltimore. Right, that's not how it works. So CMS has said there are several options for how they will accept the data, your data. So for quality of care, quality measures, you can do it through a qualified clinical data registry. You can do it through a qualified registry. Qualified registry was the old, first quality registry program. Qualified clinical data registry is the second one, second generation. Electronic health record. Many electronic health record companies are now offering quality reporting modules. Of course, many of them for a fee. These are for-profit companies. Let's not kid ourselves, but they do offer them. Claims data, there's still a few handful quality measures in the program that could be reported through just CMS claims, CMS 1500 claim forms. And then if you're a large group, mostly these are the big academic groups, CMS is still gonna offer what we call the GPRO option, which is an option for physicians that are in tax identification numbers over 100. And you have to sign up for that, you have to sign up your measures for that. There's a whole secondary process of deadlines for that. Resource use, if we had had resource use going in in 17, it would have come in through the claims data. You would do nothing extra. CMS would use your claims data to calculate your cost scores. If there was ever a time to check and make sure you're coding correctly, this would be it. Because if you've got an accidental coding problem going on where you're coding a procedure incorrectly, it's going to affect your cost score. Right, so this is a time to make sure that your institution is coding all of your procedures correctly, that they don't accidentally have, you know, I don't know, every hysterectomy at over 200 grams, right? And coding those codes instead of the right uterus size, right? I don't know. I mean, we've found some things, interestingly, where major institutions were coding incorrectly for some repair procedures. You know, the repair procedure coding can sometimes be complicated, right? But we need to check that because those codes pay different amounts of money, they will affect your cost score if they come in incorrectly because CMS is using claims data. All right, so we have to make sure that data is as good as it can be. Advancing care information. Again, Meaningful Use Electronic Health Record. CMS is going to have an attestation process, not unlike the current Meaningful Use programs where you will go to a CMS portal or website or fill out information directly to CMS. The Qualified Clinical Data Registries. Some of them are going to have the functionality to do your EHR reporting if they're integrated. Very few yet, but eventually more. And then your EHR company itself could be sending in the information for you. Then the Clinical Improvement Activities or Clinical Practice Improvement Activities or Clinical Improvement Activities, whatever we would like to call them. CMS is going to set up an attestation process for that. It's not up yet. Qualified Clinical Data Registries are going to be able to submit the information and when we talk about all the activities, you'll see why that's a good way to go. Qualified Registries are your EHR company. So those are the ways the data can go into Medicare on you. All elements. So you have to have a plan. Right, we're going to talk a little bit in some of our sessions and things about what planning people have done for their own personal practice and hopefully we can really get into what you all are hoping to do for your own practices. Right, and we'll talk about which EHR companies we think have different products. If we know, we'll share that information. That's why we're going to have a demonstration of Acquire because Acquire is free to AUGS members. Could be a really good tool for all size practices to go into Acquire. And we'll see if we can get the job done for everybody. So let's talk about quality. Quality is where 60% of your score, right? So currently for 2016 reporting under the old PCRS program, you had to do nine quality measures plus one outcome. For MIPS reporting for 2017, it's six measures. We're going down back to six. And you have to do it, and even though the reporting period is 12 months, you have to do it only for a minimum of 90 days. So if you unfortunately don't get signed up with Acquire until the summer, you will still meet your 90-day window, right? As long as you start by October 2nd. That is the last day in the 90-day window to be able to do 90 days. Of these six measures, one must be an outcomes measure. That's not really in the true sense of the word though. Many of AUGS measures are classed outcomes measure. It's not as we as researchers would maybe think of outcomes measures. Or a high priority measure. Again, many measures have that status. Also, some specialties have put together groups of measures that there are specialty-specific. We have not done that. But some of our colleagues have, particularly cardiology is one that's done that. If you are a large group, CMS is gonna run a readmissions measure on the group automatically. And they just wanna do that. So that's not something you're gonna pick. It's just gonna happen to you. And then, if you are in a MIPS APM, your quality measures are gonna come in through that APM. So you're not gonna separately report quality. Your APM's gonna have to report quality for you. And also, they would use a different CMS interface. So now, advancing care information. This is the old EHR program. Now here's where this gets a little complicated. And I'm gonna confess to you, I am not a technology wizard. I'm not even close to a technology wizard. I am an old school, I like paper person. So this is a challenging program. Because right now, EHRs are certified either to 2014 certification standards or 2015 certification standards. And most standards are 2014. But CMS provides for two different measure sets depending on which certification your EHR has. So one thing you need to ask your EHR company is what ONC standard are they certified to? 2014 or 2015? So that's question number one, because that'll dictate where you're gonna go with your quality measures. So here, this gives you kind of a sense of what type of areas these quality measures are in. And you have to do this for 90 days. The reporting window is 90 days. So does your EHR system have a security risk analysis process? Does your EHR system do e-prescribing? Which I would assume they all do. Does it provide patient access? Do you have a patient portal? Do you have some sort of way that your patient can communicate with you using the EHR system? Do you send summary of care to the referring physician through your EHR system? Does the referral physician send it to you? Or can they? Can your system accept it? So can your system receive and can your system send electronically? So that gets to the interoperability question, right? Do these systems talk to each other, right? So those are the minimum measures. If you do the measures in that minimum area, you get your EHR score. Now let's say you'd like to get a higher score, more than the minimum. Then there's an additional nine measures that you could report for 90 days to get a better score. So not just the minimum score. And if you integrate your EHR, using your EHR to report to a public health or clinical data registry, you can get a bonus point. So CDC has a number of public health registries that are integrating with EHRs. And if you're doing that, most of those state-based programs, you can get a bonus point. Or if you're doing ACQUIRE, you can get a bonus point, right? So there's some bonus ability here. But the five categories on the top, that's sort of the minimum. You gotta do those if you're gonna not fail in the EHR category. So then we have improvement activities. And Bob's gonna go into depth on this, because I believe this is the area where most people are going to A, be successful, and B, be able to use it for go at your own pace, which we're gonna talk about in a minute. So there's 90 activities. There are nine big category buckets, which you can read here. As I said, you're probably already doing care coordination. You probably already are doing some expanded access, like Saturday availability, or other sorts of availability for your patient, or your patient can get ahold of you, or one of your staff, 24-7, through the EHR, through the email. I mean, a lot of you are probably doing these things, beneficiary engagement, patient safety, et cetera. If you're in a MIPS APM, you automatically get your total clinical improvement score, automatically. Boom, you're done. So that's, again, you sort of see a theme here, right? Go to the APM, go to the APM, right? I mean, you can see the incentive. Okay, so that's the base program. That's the main program, right? That is the one that if nothing had happened, we would have all been focused on. But when these rules came out, there was a lot of angst in the physician community, because even though we have had the PQRS program since 2008, so nine years, we still have only 50% of the physicians in this country participating. And so everybody was like, we don't even have them doing that, and now we're gonna move to another program. Woo, scary. So the physician community went to CMS, and some members of Congress went to CMS and said, well, we gotta help these guys out. We gotta transition here. We can't, you know, we already are cutting all these people 10% in 17 and 18, and now we're gonna make them switch to another program. So CMS put out a program called Go at Your Own Pace. So this, technically 2017, is now known as a transition year. Right, it's known as a transition year. So there's test pace, partial year pace, and full year pace. Test pace, we're basically gonna get everybody through the year. Partial year pace is, let's try to get a little bonus money. Full year is, let's take everybody's money, and get as much bonus money as we can. We're gonna talk about that, because there's some extra incentive. If you sit on your hands and act like none of this is happening, you will get the 4% penalty. If you at least do test pace, which we're gonna talk about here next, you will avoid the 4% penalty. But if you do nothing, you will get the 4% penalty. That's how Go at Your Own Pace works. So test pace. If you submit a minimum amount of 2017 data, so one quality measure, or one improvement activity, you can avoid the 4% penalty. Now, I have on this slide one quality measure for 90 days, or one clinical improvement activity for 90 days. CMS is now saying, although I'm being a little nervous about this myself, but CMS is saying one quality measure, one patient, and that's test pace. Given the amount of possibility that CMS could screw up, I would at least try to do one quality measure for 90 days so I knew I had enough data in the system. But they're saying one quality measure, one patient. That would be like one submission. That's a little nerve wracking what if that one submission screws up, right? So I would try to do 90 days. Or you can do the five elements of meaningful use, clinical care, but holy night, right? That's a lot more than one measure or one clinical improvement activity. So that's just get out of 4% penalty free card, right? And Bob's gonna talk to you about clinical improvement activities. That may be the easiest way to go if you've never been doing any quality reporting at all. But let's say you've been doing some PQRS reporting. You didn't get cut on the value modifier. You didn't get any bonus money, but you didn't get cut. And you wanna see if you can do a little better. So partial pace or partial participation may, depending on how many people get penalized, unfortunately, may lead to some bonus money. And I'd say 2017 would be the year if it was gonna do it. So partial pace is you try to do more up to the six measures, up to the clinical improvement activity requirements, up to the EHR. You may not get all the way, but you try, right? You try to get to that point. CMS has not said what is the partial participation requirement. They've just said do more. They haven't said here are the numbers. So they've just said do more. Now let's say you wanna go for it. You wanna do full participation for 2017. You wanna try to get the bonus money. You wanna get your whole 4% if 4% is gonna be available, maybe even more. You want to try to get this extra money, which we're gonna talk about in a minute. So that means you basically run the program straight up. All the things that we just talked about, you try to do them for a whole year, the full reporting period, not just 90 days. And you try to do six measures. You try to do all the activities. You wanna try to get the entire program done, right? And do it for a full year. That's full participation. And that program will have the largest bonus pool, and they'll also be able to go after some additional money. So the additional money is this exceptional performer money. So the law requires that CMS give the top 25th percentile performers an additional $500 million for each year through 2024. If there ever was a year to be in the top performance group, it's 17 reporting year, because there's gonna be a lot of people in pick your own pace, level one, test pace, right? So the threshold for the top 25% is gonna be a little lower, right? It's gonna probably capture possibly people who maybe in other out years won't be in the top 25%, right? But by law, this extra $500 million has to go out. So this is a good opportunity this year to see if you can get in that top 25%. These are MIPS people, and it can be as much as 10% additional money, right? And it's 10% of your Medicare payments, all of them. All of them. So you can see why the big groups are putting some resources in, right? I mean, we've heard of a lot of big groups that have hired a lot of big consultants to come in and help them because they want this money. But little groups, I think, are gonna have just as good a shot getting this money because of the fact that we're gonna have so many people in pick your own pace, just do the one measure, one improvement activity, right? So this money has to be spent. CMS cannot not spend this money. And I don't want it all to go to Ophthalmology, right? They got a lot of the bonus money in Value Modifier. I do not want all this money to go to them, although I love them dearly. So today we're gonna talk about getting started, right? We're gonna have a practical panel here to talk about how to get started. But the first thing is you gotta figure out, are you gonna report as an individual or a group? If you're gonna report as a group, who's your group and what are they doing? Right, I mean, you gotta go find those people. Who's the person in charge of selecting the measures for your group? Who's the person in charge of selecting the EHR? Is there a committee? Can you get on the committee? Then you gotta do a little readiness test. Have I been reporting? How have I been reporting? What have I been reporting? Do I wanna work with a third party? Do I wanna sign up for a registry? Do I wanna buy a module with my EHR vendor? If I'm gonna try to do a full year, do I have the ability to back put in data? Right, because we're already at the end of March. We're through the first quarter. Do I have the ability to put in data because I can find those patients and put them in because my EHR system's easy to find? Or do I wanna do 90 days? Or do I just wanna do the one measure or the one improvement activity? You have to figure those things out. And how am I gonna get the data in? And I'm assuming that everybody who's on the virtual or here today is gonna get bonus payments. Don't figure out how you're gonna split the bonus payments when the check comes. Figure it out ahead of time. Also figure out ahead of time how the penalties are gonna get split. A number of big academic folks are now going to their big faculty practice plans and telling them that they will take the penalty individually by physician. Right, so you have to figure these things out. You have to know how you're going to be assessed in your practice group. Is the bonus money or the penalty is gonna be assessed based on E and M volume? Right, what's the methodology? Then you gotta do your feedback report and then you gotta go, you gotta do it. Right, so that's sort of in a nutshell. So we're gonna talk a little bit about some quick tools. So CMS has a really good website for all of this. Kind of amazing, but they do. And so this website has some very nice search engines in it. And so this web link that I have up here right now is the search engine for quality measures. You can go in and find the six measures that are best for you. You can click into the specifications and you can download those measures. Similarly with improvement activities, same thing. They have a search engine, you can go in, you can find the activities, you can get the specifications, et cetera. Here's a couple little tips about improvement activities, which I'm sure Bob's gonna talk about more later. But one of the things to know is if you are a small group, fewer than 15 participants or in a rural or health professional shortage area, you only have to do two improvement activities to get your full score. If you're a larger group, it'll probably take you four activities to get your full score. So that's something to remember, et cetera. As I said, if you're in certain APMs that are MIPS APMs like ACO track one or the oncology care model, which none of you would be in probably, or you're in a CMS designated medical home, not just any medical home, you automatically get your full improvement activity score. So also on the CMS website, on the QPP website under the tools, it gives a list of all the APMs that are MIPS APMs and all the APMs that are advanced APMs. We have a minute later today, we might go to the QPP website. We have internet and show it all to you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

Medicare Quality Payment Program

QPP

Sustainable Growth Rate

quality measures

clinical improvement activities

advancing care information

physician participation

scoring process