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Physician Payments Three elements that will shape Medicare physician payment over the next ten yens
Steven LashManaging DirectorStrategic Healthcare Advisory Services
New pressures, new resourcesPressure: The SGR replacement
(MACRA) will impose 4-9% pay reductions on physicians who do not change
Resources: Practice Transformation Networks will provide regional assistance
Resources: Chronic Care Management (CCM) provides immediate cash flow for change
2026 and beyond0.25% annual
updates 0.75 annual updates
2019-20254-9% penalties/bonuses* 5% lump sum bonus
2015-20180.5% annual updates
Merit-based Incentive Payments
(MIPS)
Alternative Payment Models(APMs)
*Bonuses may be higher
What is MIPS?A fusion of the current incentive
systems: Meaningful use, Physician Quality Reporting System (PQRS), and the Value-Based Modifier
In 2019: 4% penalty/4% bonusGradual increases for three yearsBy 2022: 9% penalty/9% bonusBonuses could be larger if scaling
is applied
How to get out of MIPSMeet minimum participation thresholds
in APMs; either within Medicare caseload or across all payer caseload
APM participants who are close to but fall short of APM bonus requirements will not qualify for bonus but can report MIPS measures and receive incentives or can decline to participate in MIPS
What is an APM?Accountable Care Organization
(ACO)Innovation Center model,
particularly bundled paymentPatient centered medical home
Other models to be specified by the Physician-Focused Payment Models Technical Advisory Committee (TAC).
Practice Transformation NetworksCooperative agreements for 29
organizations across the countryEach must enroll and engage a
minimum number of physiciansGOAL: to prepare practices for
alternative payment models
PTNs as resourcesPhase 1: Develop patient and family
engagement toolsPhase 2: Expand care team, identify
community partners, improve care transitions, continuity of care, patient self-management
Phase 3: Use EHR, use team roles and functions, care plans, use risk stratification, coordinate care
Phases 4,5: Create care coordination reports, establish links with practice as medical home, enable practice to take risk associated with episode management…but no cash assistance
CCM could provide revenue for transformation
Fee-for-service payment of $42 pm/pm
Aligns patients with your practices and system
Has foundational pieces for PCMH, managing episodes, and population health to succeed in an APM
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