All right. Well, hi. So welcome all. I know that we're probably going to have some more people sort of trickle in for the actual presentation. So you're in the session 1311. This is MIPS reporting for the upcoming year 2022, preparing your practice for reporting and strategies to improve performance. Let me go ahead and share my screen here. And we'll get started with the presentation. We're just going to go ahead and get started in the interest of time because we actually have a lot of information to present. So just a little bit of housekeeping in regards to this particular webinar. So audio and video have been restricted for the duration. At the end of the talk, we'll open up the audio lines for questions. So you can ask questions in two ways. You can either raise your hand and we'll call on you and you can unmute your mic for an actual audio question. You can also use the chat box to include your questions. Those questions in the chat box, since they don't actually appear in the recording, we're going to go ahead and read those off in sequential fashion and answer those verbally. And if you're watching this particular presentation on demand and you have questions, you can email your questions to healthpolicy at aapmnrm.org. So we'll go ahead and get started. Just some housekeeping disclosures. At this point, neither myself or Bob have disclosures. Just as reference, I'm Mark Wong. I'm the chief medical information officer at the Shirley Ryan Ability Lab. I deal a lot with regulatory compliance in regards to MIPS and reporting. So I work intimately with our regulatory team and physician practice team and IT teams to help make that happen. And then we also have Bob Jasik, who I'll introduce formally in the subsequent slides, in addition to go over more specifics in regards to what's going to happen for 2022. So what are the objectives today? We're going to review changes to reporting requirements and performance categories for MIPS and the new MIPS value pathways, otherwise known as MVPs, which we're starting to hear a lot more about. Also going to identify quality measures and improvement activities for inpatient, outpatient and small practices. And then we're going to finally analyze methods that you can monitor costs and meet the promoting interoperability measures. So we will proceed first with the final update. I'm going to stop my share so that Bob can share. But Bob is the vice president for coverage and payment policy at Heart Health Strategies. It's a health care policy and advocacy consultant for the American Academy of Physical Medicine and Rehabilitation. He served in several roles working on health care policy and regulation with the federal government. He's also served in advocacy positions working on payment policy at professional associations, including the American College of Surgeons and the American Association of Orthopedic Surgeons. Bob received his law degree from Emory University and completed his undergraduate work at the University of Michigan. So welcome, Bob. Thank you very much. Does the slides look all right? Yes. Perfect. All right. I'll go ahead and get started then. As Dr. Huang mentioned, we have a lot to cover during this session. And so we'll try and move through it as quickly and efficiently as we can, but also make sure that I'll try to be mindful of the fact that there's a lot of acronyms and a lot of different technical terms and specific government terminology that's been given to a lot of what we're going to talk about today. So I'll make sure that we go through it step by step. So the first thing that I want to start out with is, you know, we're here to talk about MIPS and the quality measures that go along with that and how that affects your payments. But I just wanted to sort of start out with a quick reminder that MIPS is a payment update that is applied to your normal Medicare payments. And so it's important to also understand, I think, what's just generally happening with Medicare payments writ large. And so one of the ways that your payments are affected each year is the conversion factor that your RVUs get multiplied by. And there's always a lot of contention about how that number is calculated. And I just wanted to show you what's happening related to that so that if you see fluctuations in payments, they may or may not be related to MIPS. It could be because of what's happening with the conversion factor. So the first thing that Medicare does each year when they're trying to figure out what the conversion factor is, is they look at the last year's conversion factor. And then if the statute tells them to increase that by a certain percentage, they will do that. And in 2021, you can see that there was a 3.75% bump up. But I put an asterisk next to it because that's not baked into the conversion factor. That was a one time thing. And it's going to get sucked back out of the conversion factor in 2022. So what you can see here is our year to year change in the conversion factor. And unless Congress does something between now and January 1st, your conversion factor that had been $34.89 is going to drop to $33.59. And again, you can sort of see here what the percentage effect of that year over year changes. So again, I mentioned that just because there are a lot of other things that are happening with payment just to the system overall, even if it's not specifically to your codes. In 2021, I think it's important also to mention that that 3.3% drop that you see in the conversion factor was hopefully partially made up by the increases to the values of the office and outpatient E&M codes. Those went up by a large degree. And so that might not have made it feel like there was a cut. But in 2022, those increases to the office and outpatient E&Ms are baked in now. And so the conversion factor cut would sort of be happening on its own without commensurate increases. So we'll keep an eye on that. You'll hear from the Academy if that gets fixed. There's a lot of efforts to try and get that 3.75% 2021 increase extended to 2022. But keep that in mind that there are other big pressures that are happening inside of Medicare, in addition to what we're about to talk about with MIPS and APMs. But once your baseline Medicare payment is made for Medicare services, then there are adjustments that are made to that based on the Quality Payment Program. Quality Payment Program is really divided into two silos. There's the MIPS side of the house, which we're going to talk about first. And then there are advanced APMs, which I'll mention now and then just a little bit at the end. But for MIPS, I hope most folks are familiar with this at this point, and I'll give everybody that is a little bit of a refresher. And for anybody who isn't, basically, this is a performance-based Medicare payment adjustment that's based on a composite score across four categories. And those categories are quality, cost, promoting interoperability, which is really sort of the EHR component to this, the old meaningful use, and then improvement activities, which we'll talk a little bit more about. As we move through the presentation, a couple of important things to keep in mind. There's a two-year gap between performance and payment. So, for example, when you're looking at your payments this year, if you see a MIPS-related adjustment on that here in 2021, that is the adjustment that you're receiving based on the reporting and the quality measures that you reported on in 2019. When your payments are adjusted next year, that will be based on 2020. So, on the flip side of that, if we're looking at it from the performance year, when we're talking about the performance requirements for 2022 in the rest of this presentation, we're talking about reporting that you're doing that's going to affect your payments in 2024. So I know that gets a little bit confusing, but just keep that two-year gap in mind, and how it's the performance year and the payment year are two different numbers. The other thing to keep in mind is that in 2021-2023 and going forward, the maximum penalty is a negative 9%. So if in the past you have done an evaluation that has said the reporting burden is not worth it, keep in mind that now we've gotten to the point where if you don't do anything, and there are no hardship exemptions available to you, you would be subject to a 9% penalty, which is a big cut across all of your Medicare payments. On the upside, the maximum positive adjustment that we've seen so far is only 1.88%. So I hear you that that's not a huge incentive to meet all of the requirements. Maybe avoiding the 9% cut is a bigger incentive than the upside. One thing that I will mention, and we'll come back around this as a reminder at the end, is that the reason that number is so low is that the MIPS program is budget neutral. So the only money that the program has available for bonuses is what it collects in penalties. So while the threshold to avoid a penalty has been low, what that's meant is they've collected so few dollars in penalties that there's not a lot to dole out on the plus side. That's eventually going to start to change as the requirements continue to escalate. But in the short term, that will likely be mitigated by the hardship exemptions for COVID, where a lot of people are not having to report and are having a 0% update applied to them. So again, there wouldn't be as much to collect in penalties to dole out in bonuses. Once we move past COVID and the public health emergency, that could begin to change a little bit because the reporting thresholds have started to increase so precipitously. We'll spend a lot of time talking about a lot of all of those things that I just said on the MIPS side. But just for a quick moment, on the advanced APM side, when all this was introduced, the goal of the legislation that brought this to be and the goal of the Centers for Medicare and Medicaid Services has been to slowly move people into more value-based care, so that your payments are based on performance, on quality and cost measures. One of the ways that the law introduced encouraging participation in APMs is creating a subset of alternative payment models called advanced alternative payment models. We won't get into all the details, but if you are in an advanced APM and you are performing a significant number of your services inside of the context of that advanced APM, so let's think of maybe a Medicare ACO to make it easier to wrap our heads around, then you will be deemed a qualifying participant, and you will live here on the right side of our slide under the advanced APM update piece of this. If that's you, you're going to be exempt from MIPS reporting as we otherwise discuss it here. You would also get a 5% lump sum payment, an incentive payment on all of your Medicare services. And then just like MIPS, we have that two-year gap between when you're assessed to be a QP and when that payment is issued two years later, so that's important to keep in mind as well. Another thing that I'll highlight here, as well as several other times throughout the presentation, and this is because of statute, there are components to the whole QPP framework that are starting to expire, and that, again, was set in law. So your 2022 performance year and the 2024 payment year will be the last year that this 5% APM incentive payment exists. So unless Congress steps in and extends that, it's an important component to keep in mind here about how things are going to be changing over the next few years and one of the last opportunities to capitalize on the opportunity of that incentive to move into an advanced alternative payment model. So, again, we have sort of your base conversion factor payment update, right? That gets multiplied by your RVUs, and then on top of that, you'll either have an update applied to your individual claims based on your MIPS update, or you'll get that 5% advanced APM bonus that I just mentioned. That's the overall framework to this program and how Medicare calculates these. One of the first steps to take in this, and again, this is even for people who have been participating in MIPS in past years, is to look up your NPI to see if Medicare has deemed you as required to participate. So if you go to the website that you see here, you can put in your NPI and then check your status. You will see a screen that comes up like this, and it will organize it by each participation year, and you'll see those tabs along the bottom there, and you can see whether you're required to participate. When you do that, you want to look at the information that it provides you in detail. So in MIPS, you have the opportunity to report either as an individual, if you would like, or as a group, and your group is defined as your TIN, your tax ID number, and because of the requirements about whether you're required to participate, this lookup will tell you whether you're required to participate if you were to participate as an individual, and then whether you're required to participate if you were to participate as a group. And then you can sort of see how CMS views you in that regard. There are other items that you will see that will come up as part of this lookup, and basically there's more information that you can click through when you look that up to find it, but there are scoring bonuses and scoring advantages to some of these special statuses that you see here for existence. If you are offering services in a health professional shortage area, there are scoring advantages that come along with that. So when you do your lookup, you will see that. If you are billing Medicare under multiple different TINs, you will see this repeated for each tax ID number that you're affiliated with, and so it's important to evaluate your participation requirements for each individual tax ID that you submit claims through. So if you are submitting some through one practice and another through a facility or whatever it may be, you want to make sure you're meeting these requirements in each of those TINs that you bill under. I also mentioned the APM participation piece of this. When you look up your NPI, if you are affiliated with an alternative payment model that's recognized by Medicare, it will show you that here over at the left, it will tell you whether you're a QP. And again, just as a reminder, a QP is that advanced APM participant that CMS has determined is doing enough of their care inside of that APM that you're exempt from MIPS and that you are eligible for the 5% bonus. And if you look over at the right, it'll tell you which APM you're affiliated with. Some people are sometimes caught by surprise that they've been listed. If you're in a very large ACO, it might not be sort of a daily reminder that you're in there, so make sure to take a look at this because it might alleviate some of your reporting responsibilities, and I'll show you how as we move through this. But make sure to look at your NPI on this website because there's a lot of useful information there. All right, so now let's say you've looked it up on the CMS website, you're required to participate, and you're living under the MIPS side of the house. There are two real reporting frameworks to that. One is traditional MIPS, and the other is an alternative payment model performance pathway. So we'll spend some time talking about traditional MIPS. On the APP, I'll provide you some more details after we get through traditional MIPS, but just as a heads up so we don't get too confused here, there is a version of an alternative payment model that you can participate in that does not make you a QP that gets you out of the MIPS reporting requirements. But if you are in one of these special APMs, even if you're required to report in MIPS, it can help you meet your reporting requirements. So that's what that number two is there, and we'll talk about how those alternative payment models might help you do that. I already mentioned this, but again, when you're reporting in MIPS, you can report as an individual clinician, you can report as a group. If you are in an APM, you can report at the APM entity level. If you are part of a larger group practice or an APM, check to make sure whether your group or APM entity is handling that reporting for you. Also, one thing to mention here, because it also has led to a lot of confusion, is that if you're in a multi-specialty group and you're reporting as a group, the group reports sort of collectively on the measures that it likes, and we'll talk about that. But basically, a group only needs to report on six measures. In a lot of instances, you'll see very large multi-specialty groups that basically just lean on the primary care measures and use that for the whole group, and so it's possible that your group is reporting on measures that don't affect the codes that you're billing or the services that you're billing. So just make sure that you're aware of whether your group is handling the reporting and what measures they're using to meet your reporting requirements. All right, so the structure of MIPS, traditional MIPS. I mentioned before there are four performance categories. These are the four, quality, cost, promoting interoperability, which is the EHR component to this, and then improvement activities, which again are quality improvement activities, a lot of which you're probably already likely engaging in, and it gives you credit for purposes of your MIPS score for your payment update. The performance on those four categories are combined to give you a score of between 0 and 100, and that will translate to your MIPS update, and as you can see below, the percentage of your Medicare payment that's on the line has changed by year. We're moving into that area where you could be subject to a 9% penalty. And then again, just another reminder that the reporting year is two years before the payment year. Those four categories are not all created equal. What you can see here is the performance, the weighting by category per year. Before we look at next year, I did wanna highlight to you a performance year 2020. Because of the COVID-19 public health emergency, after the fact, CMS zeroed out the cost category and then readjusted the other categories. And so there have been some fluctuations in the initial reports of what people's payment updates were gonna be because of this. So we're still waiting for final numbers there for 2022 payments. But part of the reason for the delay on that was this reweighting because of the COVID-19 public health emergency. If you look over at the right though for 2022, what you can see are the weights for next year. This was recently finalized. The important takeaway here is that you can see cost increasing to 30%. And that is coming primarily at the expense of the quality category, which has gone down to 30% of the score. So now I just wanna spend a few minutes talking about the quality performance category, what the general reporting requirements are and a couple of highlights of measures that might be available to you. But these are your 2022 finalized reporting requirements. The first thing is just the required measures. So there is a general presumption that you're able to report on six quality measures. One of those should be an outcome or a high priority measure. And part of the reporting requirement is that if you were to report on fewer than six measures and CMS determines that there were other ones that you could have reported on based on the codes that you bill, then you would be given a score of zero on the missing measures. If you want to, in order to maximize your score, or because you're trying to create, have a history of a reporting experience with multiple measures and you report on more than six measures, don't worry that that would disadvantage you. CMS will base your final score based on the six measures on which you perform the best. The next component to reporting on these measures once you've identified them is what is referred to as the data completeness threshold. Basically, you have to report on each measure for at least 70% of the patients to which those measures apply. This is not Medicare only patients unless you're reporting via claims. This is across all patients. You have to report that measure on 70% of the patients to which that measure applies. The performance period is the full calendar year. So you look at all the patients that it would apply, the measure would apply to over the course of the year and you need to be reporting on at least 70% of them to have access to the full scoring potential for that measure. When the agency goes to score it, there are achievement points and there are improvement points. Achievement points, baseline, there are 10 points per measure and you're scored relative to national benchmarks. A couple of variations of that, if you don't meet that data completeness threshold we mentioned above, then you would be assigned zero points unless you're a small practice. If you're a small practice, then you would report on some of those measures but don't hit the 70%, you would get three points. Also, if you report on less than 20 patients, you can't get more than three points for that measure. If you're reporting on a measure that has no benchmark associated with it, then there's also a three point cap. And then for topped out measures, which are those measures which CMS is deemed to sort of only result in high performers, everybody is doing really well on that measure, then if it's kept it in the program, then it would put a seven point cap on it. In addition to achievement points, there are also improvement points. Basically, these are points that will get added to your score if you're improving in the quality category. This is a comparison that's done on your quality score overall, not sort of measure by measure. So you don't have to worry about being disadvantaged here if you switch measures from one performance year to another. They'll look at your score and if that quality score is increasing, you may be eligible for improvement points. Your small practice, and that would be designated on that NPI lookup that I showed you at the beginning, you will get six points automatically added to your quality score. And then finally, I just wanted to highlight a couple of changes for 2022. We have a couple of eliminated policies. So first, CMS is ending bonus points for reporting additional high priority measures. So if we go back up to the top where I mentioned you have to report on one outcome or high priority measure, there is in place for 2021. And what's going away is if you kept reporting on more high priority measures, then you would get bonus points for that. That's going away. And then also they're eliminating their bonus points for end-to-end reporting, which is an EHR HIT reporting component to the reporting here. Next thing I wanted to show you is just an example of some of the quality measures that are available to you as part of MIPS. This is specifically the physical medicine specialty measure set. Before I show it to you, I just want to mention a couple of things about it. These are just suggestions. There's nothing about it being called the physical medicine specialty measure set that requires you to report on this. If you're in a multi-specialty group, you might have selected different measures. Also, if you report on some of these measures, just because they're in the same measure set, it doesn't mean that you're required to report on all of them, but it's basically CMS's way to assess whether there are measures available to every specialty. So these are just suggestions. What you can see here, this list has been pretty stable. There are measures like documentation of current medications in the medical record, advanced care plan measure, you can see those there. I also wanted to highlight that if you've been relying on measure 154, the risk assessment for falls measure, that's being eliminated from your measure set because it's being completely eliminated from MIPS altogether. And then the other thing I wanted to highlight is if you look at measure number 317, 317, the screening for high blood pressure, if any of you have been using that to meet your MIPS reporting requirements, CMS had proposed getting rid of that measure for MIPS altogether. They didn't ultimately do that for 2022, so it will still be available to you. But I did want to highlight that because we could sort of say it's on the watch list. CMS believes that people are performing pretty well on that. They'd rather see it turn into something more of an outcome measure. And so I don't know how much longer that will be in the program. So if you're thinking about your reporting strategy and want it to stretch years beyond 2022, you might want to keep that in mind when you're thinking about which measures you're selecting. The next thing I wanted to talk about is the cost performance category. So again, this is increasing to 30% of your score. It is based on the Medicare spending per beneficiary cost measure, the total per capita cost measure, and then any episode-based cost measures that are assigned to you. I will give you a quick preview. Right now, there likely are not any that would be assigned to you. So if you are getting a quality score, it would probably be due to the Medicare spending per beneficiary or the total per capita cost measure. That could change over time, though. You have no affirmative reporting obligations under this category. CMS runs the score off of your administrative claims data. So there's no reporting burden associated with this. You can go to the QPP data submission portal if you want feedback reports on these measures and to see if any of these measures are being assigned to you. If no measures are assigned to you, you won't get a zero score for it. Basically, the weighting to that category would be zero, and then the weights to the other categories would increase. One other thing that I wanted to mention here in the cost performance category, and I've tried to share this over the last couple of years when we've talked about this, but there is a code out there that's called a patient relationship code. And it is a code that you can append to your claims that is intended to communicate your relationship to the patient. So is this episodic care, or have you taken on, you know, longer-term care for a chronic condition? Those codes are here. They are not required, but I mention them because the statute suggests that they will eventually be required. And the idea, and why I put it here in the cost performance category, is that when CMS starts to create more episode-based cost measures, in certain instances, it won't make sense to assign all of the costs to you. In other instances, it might. And so this patient relationship code is intended to help start to communicate whether this is sort of a long-term cost, you know, and continuum of care relationship, or if it's something shorter, to inform how they should be allocating costs that are associated with patient care. So I mention it, one, because you may want to start getting used to using these codes, because they may become permanent. But also, CMS recently started recognizing them under the improvement activities category. So that's the category I had mentioned was 15% of your score. And if you report these codes on more than 50% of your Medicare claims, then you can attest to having met this improvement activity, and that could help improve your score and hopefully maximize your potential points under the improvement activity. And that's a pretty easy lift. So I just wanted to mention that for those two reasons here as well. So again, the main measures under the cost performance category are the Medicare spending per beneficiary, as well as the total per capita cost measures, and then any episode-based cost measures that are attributable to a clinician. And you can see here, they start to get more specific. There are two that are directed at chronic conditions. These are not episodes that I expect you to be tagged with. There are also others for acute inpatient conditions. Again, I would not expect you to be tagged with the cost of any of these. There are also procedural ones. You can see there's a good number of them here. And I highlighted the lumbar spine fusion for degenerative disease episode for a couple of reasons. Knowing what we know about that episode, I don't believe that you would be attributed the costs associated with this. This is generally gonna gravitate to the surgeons in these instances. But I did want to mention it because for those people and those facilities that employ the surgeons that are doing these, this is gonna become an important component of their cost score under this category. And so you may see people paying more attention to it. And the care that you deliver for these patients is gonna get lumped into that total cost. So even if it's not a score that you're receiving, people are gonna start paying more attention to this. So if you see others at your facility starting to pay attention to this or try to bring you in on these measures, you'll know why. Also, I will mention that there's a lot of work to try and create more cost measures that are similar to these, but in different clinical conditions or for different procedures. And so it is possible that in the future, you will see a cost episode-based cost measure under this category that will have a higher degree of likelihood that you're gonna start getting attributed costs. So something to watch out for because there's a lot of resources that are being directed in that direction. Okay. Now, we're gonna talk a little bit about APMs. We're still on the MIPS side of the house. This is that pathway that I had mentioned to you before where you're participating in an APM, but it is not at a high enough level to where you're exempted from MIPS, but maybe the APM can help you meet some of your reporting obligations. So again, let's say it's a Medicare ACO. So again, if you're not a QP, if you're not exempted, you would still be required to report into MIPS. The way that you're reported on via this APM has changed over the last couple of years. If you have been following this at all prior to this year, 2021, you were scored under what was called the APM scoring standard. When that happened, you were automatically given full credit for improvement activities. The cost category was weighted to 0%, and that is under the theory, right, that if you're in an APM, APMs inherently are already tending to cost in some way, shape, or form. So they don't wanna sort of score you again under MIPS if the APM is already doing that. And then one of the key features here in the old scoring standard was that clinicians were only scored at the APM entity level. So let's say we're talking about a Medicare ACO, everybody in that Medicare ACO essentially received the same scores under the APM scoring standard. Now we have what's called the APM performance pathway. So it's a reconfigured version of that, APP. It started this year. It retired that old scoring standard. And this is a single list of predetermined quality measures for MIPS APMs. You can report as an individual, a group, or at the APM entity level. Again, if you choose this, you would get automatic full credit for improvement activities. Again, cost would be weighted at 0% because you're already, again, having cost addressed and measured under the APM. But the promoting interoperability requirements would be the same as traditional MIPS. So the EHR reporting component stays the same and you would report as an individual as you otherwise would. Some of the flexibilities that this offers is that it's one optional. If you're in the MIPS APM, you can report through the APP or through traditional MIPS at an individual level. If you want to cover all of your bases and kind of report however it's eligible to you, you can do that with, again, not that you want to, but you don't have to worry about being disadvantaged by doing that because if your reporting mechanisms generate several scores, CMS will award the highest available score. The Medicare ACOs have to use the APP, but then if you're a clinician inside of that ACO, you have the option to report that, or you can go outside of the ACO and report through traditional MIPS. And again, you would get the highest score that's generated by those reporting options. Here's just a graphic to show you a couple of things. You can see how the quality score this year is a little bit different. Its quality is 50%, whereas it would only be 30% under MIPS. Promoting interoperability counts for a little bit more and improvement activities account for a little bit more. And again, this is all leading to that last bullet there, the green graphic, that cost is zero. So all of the other categories increase in weight. And I mentioned the specific list of measures that this APP pathway focuses on, and you can see those over there at the right. When you're sort of thinking about this, if you are participating in a MIPS APM, I think there's some challenges for specialists. It could be less burdensome, but if you are looking to these programs to really give you information about quality improvement, you may not sort of find it here. These are really population health measures that the APP is focused on, so it might not be giving you a lot of useful information for your practice, but could help you meet your MIPS reporting requirements. And we don't always find the measures over there to be completely helpful either, so it may be better to just have the APM help you meet your reporting requirements anyway. These next few slides, I'm gonna, it's a lot of numbers, a lot of graphics. What I really want you to see is how these reporting thresholds are trending year over year. So I'm gonna show you the sort of 2019 schematic because that's what's affecting your payments right now. So if you've had the time this year to take a look at your MIPS payment updates and you wonder what's behind that, it was these 2019 scores. And you can see the weights that were assigned to the categories we've been talking about. And then over at the right, what you can see is sort of the score ladder, I call it. The important takeaway over there at the right is that the neutral payment threshold was 30 points. So that's, you had to get 30 points to make sure that you didn't get a negative payment adjustment. The other thing to point out is if you look at that top row, you see that bullet for those that are eligible for the exceptional performance bonus, that was 75 points for 2019. So if you're getting that exceptional bonus this year, that means you cleared the 75 points in 2019. What we know about those who received or are receiving a positive payment updates this year is that those payments basically range from about plus 0.09% to 1.79%. I will mention that for those that are closer to that 1.79, because of that budget neutrality piece that I mentioned earlier, those are predominantly exceptional performance clinicians, right? They've cleared the 75%. There's a separate pool of money that's just for that, that's available for exceptional performers. It is not contingent on people being penalized. So even though there weren't a lot of people receiving penalties, there was still some money left for exceptional performers. That's what's really driving the difference between the 0.09 and the 1.79 ranges that you see here. For 2020, I'm showing you this just again, as a reminder as to what's gonna affect your payments next year. You can see that the weights have shifted a little bit. And then when we look at avoiding the penalty, that threshold is now increased to 45 points. And the threshold for becoming an exceptional performer is now 85 points. If you look down at the bottom, which just came up, what we know about potential payment adjustments here is that they're ranging from about 0.01% to 1.87%. These are not final yet. If you haven't looked up what your score is, you should take a look at that. They may be adjusted though. There's a way to basically, for lack of a better word, appeal your score, and CMS is going through finalizing that now, so those numbers could change a little when they figure out how much money there is to distribute based on how much they collected in penalties. Then for what you're reporting this year, that will affect your payments next year. Again, that negative payment adjustment has now gone up to negative 9%. If you want to avoid that, you have to get at least 60 points so you can see that increasing, and the exceptional performance eligibility threshold is 85 points. And then finally, I just wanted to show you next year. Again, the reporting that you'll do next year will be premised on the weights for the categories you see here, and then over at the right are finalized numbers, again, affecting your payments in 2024. If you do nothing, negative 9% with a footnote because of COVID-19 related to that that we'll get to in one minute. If you want to avoid a negative adjustment, you can see that number increasing to 75%, and the eligibility for the exceptional performance bonus goes up to 89 points. Another thing to mention here about what's changing, that is the last year that that exceptional performance bonus is going to be available. So next year is your last chance to try and access that. Like I said, it's a separate pool of money that was only created to last through the 2024 payment year. So to the extent that we're leaning on that money to have sort of higher payment updates, we could see that start to wane after the next performance year as well. Now, before we get close to wrapping up here, I did want to mention the COVID-19 public health emergency flexibilities that have been introduced. There are a lot of them. We're not going to talk about the ones that are related to telehealth or any of those, but what I wanted to specifically talk about here was the extreme and uncontrollable circumstances exemption that the agency is providing for MIPS. So you can see the flexibilities here listed by the performance year. Under 2021, the first thing to notice is that there is an automatic extreme and uncontrollable circumstances policy. And if you are reporting as an individual, there is now an automatic exemption that could be applied to your MIPS reporting requirements. They recently announced that this was available for 2021, just like it was in 2020. So note that that is out there. If you look at the third row, there's an application process for this as well. So groups can request reweighting. If you are scoring well on certain performance categories and you don't want to be exempted because you think it's going to help you access a score that maybe will get you up to the exceptional performance bonus, you don't have to be exempted from the whole thing. So you can just request reweighting of certain categories. What I will mention about that is if you submit that application and you are granted it, if you submit data on that category, it will override your application and you will be scored on whatever that submission is. So make sure that you're being purposeful about the route that you want to pursue there. The next row, note also in our improvement activities category that there is a high-weighted improvement activity for clinical data reporting on COVID-19. It doesn't have to be a clinical trial, but if there's a clinical data registry that you're reporting into, that can give you points under the improvement activities. And then also there's a complex patient bonus, potential bonus points for your MIPS final score. What do we know about those, all of this for 2022? As far as the automatic exemption, we do not know if it will exist in 2022. So I would not bank on that yet. As far as the application for this, what we also recently learned was the CMS statement that you see there. We anticipate that the National COVID-19 Public Health Emergency will continue into 2022. We have an established application-based extreme and uncontrollable circumstances policy that will continue to be available to clinicians on the front lines of the PHE. So it looks like it will be there, whether it's exactly in the same form and whether they said clinicians on the front lines of the PHE is meant to somehow narrow the application, we're not sure, but it looks like in some form it will be available. And then for 2022, the improvement activity is still there and the complex patient bonus is still there with a slightly revised methodology. Now, the last thing that I want to talk about here before we move over to a couple of closing comments from Dr. Huang and question and answer is what we know about what's going to happen beyond 2022. And what I really want to focus on is something that you might've already heard of, MVPs or MIPS Value Pathways. So, oops. So basically MIPS Value Pathways were finalized last year, but they are not set to start until 2023. What MVPs are, it's a clinically cohesive set of measures and activities that are centered around a specific specialty, a clinical condition or procedure. The ones that have already been finalized, you can see listed here, stroke, rheumatology and others that are listed there, but there is a clear intent for them to include more. And the Academy is involved to make sure that these are things that make sense for your specialty, just as the Academy has been involved with the development of episode-based cost measures into the cost category and the development of quality measures, making sure that you're at the table. The whole idea between the MIPS Value Pathways, to put it very simply, is to break down the silos between the categories. So right now, right, you could be reporting on a set of patients for your quality measures that's completely different than the set of patients on which cost measures are being calculated for you. So this is an attempt to bring that together to give a fuller picture of the efficiency or the value of the care that you're delivering. The requirement will be to report on four quality measures under that and a population health measure. There'll still be improvement activities. You have to attest to one or two of those, and then cost and the promoting interoperability reporting will look a lot like it does now. What's key here to keep in mind, and why you want to keep an eye on this, is that right now they're voluntary, but they have talked about making these mandatory. And not only that they would be mandatory, but that they believe there will be enough that are applicable to all specialties that they could sunset traditional MIPS as we know it. We'll see if that happens, but it's on the table. The other thing that I wanted to mention, because I brought up this sort of MIPS reporting as a multi-specialty group a couple of times, this is now introducing a way for specialties that are inside of a group, inside of a TIN, to sort of break off and report just on something that is applicable to the care that they deliver. So if the group is, in 2026, if the group is eligible for, is participating in the MVPs and eligible, or it's applicable, an MVP is applicable to that subset of specialists inside of that group, it will begin to be required. So something to keep in mind. So we'll watch this. It's meant to streamline reporting. It feels a lot like the old MIPS. We're not sure that it's really gonna provide the burden relief that it sets out to. It primarily relies on the measures that already exist. So we're not sure that it's really gonna provide you more useful information than traditional MIPS, but that could change as this goes on. And again, the Academy has been working to try and make sure that if they are gonna be out there in the market, that there's something that's valuable for you out there. So a couple of takeaways here as I wrap up and get ready to turn it back over. One, remember that MIPS is not an all or nothing program, like a lot of previous Medicare quality reporting programs have been. It's get as many points as you can. So reporting on as much as you can will help you move up that scoring ladder. The higher performance threshold and other scoring changes could make it more difficult for clinicians to avoid a penalty. That means there might be more money available to provide higher adjustments for the high performers. But remember the caveat that I mentioned before, there are the COVID-19 flexibilities that are still in place for the foreseeable future, which is good to provide flexibility under these pressures that everybody's feeling, but it may sort of mitigate the funding that's available for high performers under MIPS if there aren't a lot of penalties being collected. In 2021, that extreme and uncontrollable circumstances application is due by December 31st. So if you're looking to utilize that for your reporting this year, make sure to write that down and get that in. You can find the applications at the website that you see listed here. I mentioned this at the beginning, the measures that are available, the specifications that go along with those measures, the requirements, as you can see throughout the presentation, they change every year. So just make sure that you revisit your reporting strategy annually. This will be ongoing, even if MVPs are introduced, there will be changes that are constantly happening. So you wanna make sure to reevaluate this every year. If you're employed by a hospital, you're a member of a large group, ensure that the reporting requirements are being met by somebody for you. The requirements apply to all eligible clinicians that submit claims under the Medicare physician fee schedule. So whether it's your practice taking care of it for you, whether it's an alternative payment model like an ACO, whether you're employed by a hospital, make sure that somebody is doing that for you because it could change how you look on paper from a revenue standpoint, if there's a penalty that's being assessed to every claim that comes in with your NPI on it. So you wanna make sure that somebody is meeting these reporting requirements for the services that you provide. And then lastly, watch out for the expanding opportunities to participate in APMs and MVPs. And if you believe that your organization is involved in an APM, whether it's an ACO, whether it's the Bundled Payments for Care Improvement Program, BPCI, make sure you check with your organization to see whether you're on the organization's quote unquote participant list because the APM shares that with CMS and that's how they would know if you're eligible for these APM incentives or APM scoring advantages. I know that's a lot of information. So we wanted to put up here the Academy resources. You can see the website where you'll find a lot of information related to what we talked about today. There'll be additional educational opportunities in the future and we are about to take questions. But again, for any of you that are watching this on demand, there again is the email address where you can submit questions if you're watching this after the fact. So with that, I will stop sharing my screen and turn it over to you, Dr. Huang, for the rest of the time we have. Okay, I think we're sort of out of time, so to speak. So we wanna go straight to questions, but just to sort of emphasize a little bit from, I do have in my slide deck some of the takeaways and I think we're just gonna make that available just to summarize. But really the important thing to understand really from Bob's presentation is just the thresholds have become higher. The cost has become higher. And the other thing is that your performance threshold increase has gone up to 75 points. If you can't meet 75 points, this is the year, I think next year is the year we're gonna see a lot of people get significantly impacted by MIPS. And so it's really important to try and figure out how you can score as many points as possible. I'm not gonna go into that in the slides, so I wanna release to additional questions. But so one of the questions that came up is why doesn't PM&R have an MVP representation for reporting? And it's really frustrating because MIPS, frankly for PM&R is square peg round hole. If you look at those quality measures, even that Bob put up there, how many of those are really relevant to what a physiatrist is actually doing with a patient? Like almost none, like maybe the Favre, which of course, ironically was taken away. There's a different fall risk measure that you can use instead. But really on a day-to-day basis, the problem is there is a complete lack of quality measures that are relevant to PM&R. And you can see that's a big portion of your score is quality and also cost. And then some of these costs and just making sure we assign correctly costs. And that's why relationship codes is now becoming something I think CMS is trying to pay attention to because they wanna inadvertently associate you with costs that may not be necessarily related. So again, cost association is a double-edged sword. It's cost you not to report anything for it, but what if you're reporting incorrectly? Just to answer that, the basic way how you can maximize your cost in the sense of the cost score, so to speak, is really good coding with your ICD-10, coding a lot of the comorbidities. You wanna achieve, you wanna get to the point where you can portray your patients if it's appropriate with significant medical comorbidities that really drives up the complexity of the patient. That's how you get those complex bonuses. So anyway, but as far as that, there isn't a good MVP because there's really no good quality measures out there to measure what we do specifically. So I think PM&R is always gonna have some challenges until new measures are being developed. That was an area of emphasis from the CMS measure development plan. We had a technical expert panel, which I was actually on. So we really have to help create some of these measures over time. Hopefully that's one of our long range goals with the registry, the APM&R State of Registry is really we're collecting data in ischemic stroke, low back pain, and trying to get better quality improvement there, but eventually that will hopefully drive us in a direction of using some of those areas for quality measures. We did actually have some proposed measures for our QCDR when we had one at that point, and hopefully we can revisit that as we go through this. All right, do we have any other questions it looks like? Dr. Huang, if I could just add to that too. One of the other things about those MVPs that exist is that a lot of them were premised on the cost measures, the episode-based cost measures that I had put up that were already in NIPS. And the Academy has been involved really, really deep working with CMS and the contractor about developing a cost-based measure that would be more reflective of the care. And so you might see that come online soon if you can find something workable, and that would also make it more likely that an MVP that would be applicable to the services you provide would become available to you sooner rather than later. Yeah, and that's a good point that really the staff has been working behind the scenes to help make sure that an MVP that's developed is gonna be relevant. Now, we certainly don't wanna be trying to report on another measure that's, or in this case, an entire pathway that doesn't work for most of the specialties. So yeah, stay tuned for that. Were there any other questions the audience may have here? Again, a lot of information, it's complicated to say the least, shall we say, but I think strategies moving forward just to sort of along these lines is really, the big thing is looking at your quality measures because what are the things you can control? Reporting on quality measures, what quality measures you're picking. And notice some of the subtle nuances that Bob has suggested in terms of quality measure reporting the thresholds are higher, you have the point scoring, especially for top-down measures is less. There's no ceiling starting in 2023 or sort of say no floor, meaning if you score poorly, you used to get three points, now you could get zero points as a minimum. And so these are very important factors. And the other thing is paying attention to new measures as they get developed because they actually have a good automatic floor, seven points in the first year, then five points in the next year, which is kind of nice in 2023. And so that's important to consider. So a lot of different variables in there. There was a question of using Cerner MIPS functionality for our EHR at the Shirley Ryan Ability Lab. We do use Cerner, one of the few places that's using Cerner still in the world of Epic, but yes, we do use that functionality for our quality measure reporting. So we actually use Cerner for our MIPS reporting. We actually report separately on improvement activities, don't really do that through the EHR, but certainly for the quality piece we do. And then of course we use that for promoting interoperability. I'm going to say one shout out for small practices. The good news is that for small practices for promoting interoperability at all meaningful use or whatever, we went through six different name changes, but regardless you're automatically exempt. You get also extra bonus points as a small practice. So it's great, but just some things that can, at least there's some relief for the small practices in regards to promoting interoperability. So I think we'll end here. There's no other questions. Feel free to, again, go back to the questionnaire in terms of going to healthpolicyatapmnr.org. That is a way that you'll be able to then be able to go ahead and ask questions after this presentation. Okay, we thank you all for joining. I know it's after two.

MIPS reporting requirements

performance categories of MIPS

quality

cost

data completeness threshold

payment adjustments

challenges for PM&R

COVID-19 flexibilities

MIPS value pathways

revisiting reporting strategies