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4/3/2018
1
IMPACT MACRA: ESSENTIAL STRATEGIESPart I: Foundations – Trends, Data & EconomicsAdele Allison, Director of Provider Innovation StrategiesApril 11, 2018
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3
AGENDA
• Evolution of Reimbursement
• Overview of Value-Based Payment
• Perspective on Data
• Your Data is Your Voice
• Break
4/3/2018
2
4
EVOLUTION OF U.S. HEALTHCARE
• 20th Century Emerges – 1 Specialty → The Family Doctor
• 1929 – Texas Hospital Assoc. → “prepaid health” → Blue Cross
• 1930 – Ratio of generalists to specialists 80/20
• 1934‐1939 – Great Depression → Roosevelt enacts SSA as part of the “New Deal”
• 1939 – CA Medical Assoc. → Blue Shield
• 1945 – Blue Cross serves 59% of health insurance market
• 1954 – IRS solidifies “prepaid” insurance → tax deduction
• 1961 – Ratio of generalists to specialists 50/50
5
EVOLUTION OF U.S. HEALTHCARE
• 1965 - Medicare / Medicaid established – Pres. Johnson− Life Expectancy – 68.2
− U.S. Population age 65+ – 18.5M
− Cost of Care as a % of GDP – 5.6% → $42BN or $210/person
• Today – Medicare (58 M) and Medicaid/CHIP (72.3 M)
− Life Expectancy – 78.74 (UK – 81.6; Canada 82.2)
− U.S. Population age 65+ – 46.2M
− Cost of Care as a % of GDP – 17.9% → $3.3 Trillion, $10,348/person
• Congressional Budget Office – Medicare Part A insolvency by 2028• Projected spending – $5.7 Trillion, 19.7% of GDP by 2026• Cannot be sustained!
Source: CMS National Health Expenditure Data published Dec.2, 2017, https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/NationalHealthExpendData/index.html
6
CLAIMS PAID ON HIAA / MDR
CPT Code: 99213Zip Codes: Nashville, AR
100%
50%
$100
$89$87
$85
$82
$79
$75
$73$70
$98
$95
$92
85% $85 = UCR
Issues:• Fees are Charge Driven• Unscientific / Arbitrary
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CALCULATING FEE SCHEDULES• Claims paid by RBRVS – Resource-Based Relative Value Scale
o 1985 – Secretary commissions Harvard School of Public Health
o 1988 – Phase 1 RBRVS issued to Health Care Financing Administration (HCFA)
o 1989 – Omnibus Budget Reconciliation Act → Create Medicare RBRVS Fee Schedule
o 1992 – RBRVS Medicare Fee Schedule Implemented
• RBRVS uses weighted, 3-part formula:o Physician Work (skill, time, effort, and stress) = 50.9%
o Physician Expense (E.g. supplies, Rx, devices, etc.) = 44.8%
o Malpractice Risk (e.g. Office Visit vs. Brain Surgery) = 4.3%
o RVUs are adjusted → Geographic Practice Cost Index (GPCI)
• Medicare Fee Schedule → RBRVS x Conversion Factor (CF)
• 2017 Medicare CF = $35.89; 2018 CF = $35.99
8
CALCULATING FEE SCHEDULES
Math Components
Work RVU x GPCI
+ Expense RVU x GPCI
+ Malpractice RVU x GPCI
= Total RVU
X CY2018 Conversion Factor
= Medicare Payment
The Equation Nashville, TN – 99213Item Values
Work 0.97 x 0.976 = 0.95
+ Expense 1.02 x 0.901 = 0.92
+ Malprac. 0.07 x 0.526 = 0.036
Total RVUs 1.906 RVUs
X CF $35.99/RVU
= Payment $68.60
9
AGENDA
• Evolution of Reimbursement
• Overview of Value-Based Payment
• Perspective on Data
• Your Data is Your Voice
• Break
4/3/2018
4
10
Claims Data
Voluntary Clinical Reporting
Pay-for-Reporting
Pay for Higher “Value” Value = f (Quality + Efficiency)
MACRA – 2 Payment PathsAlternative Payment Model or MIPS
FEDERAL REFORM
Reform Paradigm Shifts• Delivery → Prevention, Health and Patient-
Centeredness
• Payment → Redesign Compensated
• Data → Distribute and Move Information
Affordable Quality Health Care
11
HIPAAMIPPATRCHAARRAPPACAMACRA Era
HHS Healthcare
Reform Factory
Status QuoPay-for-Service
Providers CEHRTData
Comparative Effectiveness Research
Guidelines
Educate Pop. HealthMeasures
Advance HITProviders
PerformanceData
New Status QuoPay-for-Value
12
HIPAAMIPPATRCHAARRAPPACAMACRA Era
HHS Healthcare
Reform Factory
Status QuoPay-for-Service
Providers CEHRTData
Comparative Effectiveness Research
Guidelines
Educate Pop. HealthMeasures
Advance HITProviders
PerformanceData
New Status QuoPay-for-Value
MIPPA – eRx and QRUR
ARRA – Meaningful Use
TRHCA –PQRS
PPACA – Define “Value”
MACRA – APMs or MIPS
HIPAA – ICD-10
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1. Condition-Specific Population-Based Payment
2. Comprehensive Population-Based Payment
3. Integrated Finance & Delivery System
1. Alternative Payment Models (APMs) with Upside Gainsharing
2. APM with Upside Sharing & Downside Risk
1. Pay for Infrastructure & Operations
2. Pay-for-Reporting
3. Pay-for-Performance
4. Performance Rewards and Penalties
4 CATEGORIES OF VALUE-BASED PAYMENT (VBP)
Category 4Population-Based Payment (PBP)
Category 3Alternative Payment Built on FFS Architecture
Category 2FFS Linked to Quality & Value
Category 1FFS No Link to Quality & Value
Starting Point
Advancing Provider Alignment Creates Data and Operational ComplexitiesSource: HHS Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework White Paper, July 11, 2017
Non-Risk-Bearing Risk-Bearing
14
CMS Risk-BearingAlternative Payment Models
• Advanced-APMs• Includes CPC+ and
Oncology Care Model (OCM)
• 5% Lump Sum Bonus
• No MIPS
CMS Risk-BearingAlternative Payment Models
• Advanced-APMs• Includes ACOs and
CJR Bundles• Must be a
Qualified Participant (QP)
• 5% Lump Sum Bonus
• No MIPS
Merit-Based Incentive Payment System (MIPS)
• Budget Neutral Differential FFS Payment
• Earn > MPFS by comparative performance
• ~ 621,700 Cliniciansimpacted
Medicare Physician Fee Schedule (MPFS)
• Frozen CY2019• ~ 23% of Medicare
Provider Total Revenue
• Traditional MPFS obsolete
MEDICARE ACCESS & CHIP REAUTHORIZATION ACT (MACRA)
Category 4Population-Based Payment (PBP)
Category 3Alternative Payment Built on FFS Architecture
Category 2FFS Linked to Quality & Value
Category 1FFS No Link to Quality & Value
Tra
ditio
nal M
edic
are
Pay
men
t C
Y 2
019
Category 4Category 3
CMS → 185,000 – 250,000 QPs in 2018 (More than 2x 2017 estimates)
15
• Private Cat. 1 = 4% ↓
• Private Cat. 2 = 1% ↓
• Private Cat. 3-4 = 5% ↑
• $354.5 Billion
• ACOs Q1 2016 to Q1 2017 grew by 92 (Total 923)
U.S. PAYMENT TRENDS 2015-2016• 2017 Public and Private National Health Plan Survey• Participants → > 245.4 million Americans, ~ 84% of Market
− Represents ~ 84% of the total covered population− Data collected from 78 plans, 3 managed FFS Medicaid states, and FFS Medicare
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HEALTH-VALUE MANAGEMENT
Managing “Healthcare”(Resource-Based)
Managing “Health” (Outcomes-Based)
Category 1 Category 2 Category 3 Category 4
Plan Risk Provider Risk
OLD NEW
17
4 Owned Business Capabilities• Intelligent health value administration and application (“Advanced Analytics”)
• Provider Alignment
• Purchaser Alignment
• Alternative Payment Model Administration
3 Shared Business Capabilities• Population Health Management
• Consumer Engagement Management
• Data Interoperability
HEALTH-VALUE MANAGEMENT
Source: Adapted from Bryan Cole, Gartner, “Introducing Provider/Partner Alignment: U.S. Healthcare Payer CIOs’ Transformative Relationship Model,” Feb. 1, 2017
18
AGENDA
• Evolution of Reimbursement
• Overview of Value-Based Payment
• Perspective on Data
• Your Data is Your Voice
• Break
4/3/2018
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BITS, NIBBLES AND BYTES
• Bit = 1 or 0 (on / off) → Binary Digit
• Nibble = 4 Bits of Data
• Byte = 8 Bits of Data
• Kilobyte (KB) = 1,024 Bytes
• Megabyte (MB) = 1,048,576 Bytes or 1,024 KB
• 1 MB = 873 Pages of Plain Text (1,200 characters)
• 800 MB = Human Genome (2001) → (700,000 pages of data)
Source: doi:10.1093/bioinformatics/btn582
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GIGABYTES (GB) AND TERABYTES (TB)
• 1 GB = 1,024 Megabytes
− 1 GB = 7 Minutes HD‐TV Video
− 2 GB = 20 Yards of Books on a Shelf
• 1 TB = 1,024 GBs
− 1 TB = All X‐rays in large hospital
− 7 TB = Amount of Tweets/Day
− 10 TB = All Printed Materials of U.S.
Library of Congress
− 45 TB = Data Amassed by Hubble
Telescope first 20 years (launched 1990)
Source: www.mozy.com
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PETABYTE (PB)• 1 PB = 1,024 TB
• 1 PB = 20 Million, 4‐drawer filing cabinets of text
• 1 PB = DNA of U.S. population
• 1.5 PB = Size of Facebook photos → 10 Billion
• 20 PB = Data processed by Google EVERY DAY!
• 50 PB = ALL Mankind’s written works from Beginning of Recorded
History (All Languages)
• 100 PB = Facebook data storage before IPO (2.1.2012)
• 300 PB = Facebook data today (600 TB/day)!
Sources: www.mozy.com and Computer Weekly
‐ and then clone them 2x
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FACTS ABOUT TECHNOLOGY
• Rate of Advancement → Double capabilities & information every 12-18 months, known as the “Doubling Rate”
• Law of Accelerating Returns → 18-20 years out = 100,000’s-Millions of times more advanced
• 40 Years Out → Technology will be a trillion times more advanced
• Humans cannot conceive of these advances− What industries are headed for oblivion right now?− Do you have foresight to understand relevance in the next 3-5 years?
Example:Today: Regenerative medicine in trial
20 Years Later: Grow a new arm
23
EXAMPLE → SPACE TRAVEL
• Apollo 11 (1969) → 2K of Memory• Guidance Computer
− Nouns + Verbs for commands− Less advanced electronics than modern toaster
• IBM communications computer− 3,500 IBM employees to build− Huntsville, AL
• Today → iPhone 8 has 64-256 GBs
24
DISRUPTIVE TECHNOLOGY
• Innovation creates new market/value that disrupts existing market/value
• Started with “free,” constant digital info− Radically changes humanity− Quick, fast and in a hurry
• Some of today’s disrupters:− Personal guidance− Desktop fabricators− Accident-free, autonomous transportation− Cybernetic/bionic senses, organs, limbs− Computer-brain interfaces− Manipulation of molecules/atoms
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THINK BIG!
26
AGENDA
• Evolution of Reimbursement
• Overview of Value-Based Payment
• Perspective on Data
• Your Data is Your Voice
• Break
27
ROLE OF HEALTH IT
PrescriptiveHow can we make it happen?
PredictiveWhat will happen?
DiagnosticWhy did it happen?
DescriptiveWhat happened?
Val
ue a
nd D
iffic
ulty
Con
tinuu
m
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WHO’S USING DATA?• Guest ID Number → Every Customer
− Credit Card
− Name
− Email Address
• Data Collection → Purchases, Demographics,
Other Data Sources
• Comparative Analysis to Baby Registries− Unscented Lotion
− Large Purse and Bright Blue Rug
− Zinc and Magnesium
• “Pregnancy Prediction” Score
• 87 Percent Accuracy!NY Times, “How Companies Learn Your Secrets,” Feb. 16, 2012,
http://www.nytimes.com/2012/02/19/magazine/shopping‐habits.html?_r=0
29
IMPACT OF DOCUMENTATION & CODING
Source: BCBSAL, Complete Picture of Health Documentation and Coding Improvement Initiative
Diagnosis DescriptionEstimated
Cost of Care
E11.8 – E11.9 Type 2 Diabetes w/ no complications $1,400
E11.311 – E11.39Diabetes with Ophthalmic
Manifestations$2,239
E11.40 – E11.49Diabetes w/ neurological
complications$3,527
E11.21 – E11.29
E11.51 – E11.59
Diabetes with renal or peripheral
circulatory complications$4,391
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CLINICALLY-DRIVEN FINANCIALS
• Patient Presents with a broke forearm
• Where on the forearm?
• Which arm?
• What kind of fracture?• First encounter? Subsequent Routine Healing? Subsequent Delayed Healing? Sequela?
• S52
• Lower end of the radius – S52.5
• The right – S52.52
• Torus – S52.521• Subsequent
encounter with delayed healing –S52.521G
Documentation Coding
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CLINICAL DOCUMENTATION IMPROVEMENT
↑ Documentation = ↑ Performance
32
THANK YOU!Adele Allison | [email protected] | 205.563.2210
@Adele_Allison | Adele Allison
10-MINUTE BREAK
4/3/2018
1
IMPACT MACRA: ESSENTIAL STRATEGIESPart II: MPH – Rethinking Your ProcessAdele Allison, Director of Provider Innovation StrategiesApril 11, 2018
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3 CAMPS OF TRANSFORMATION
Pragmatist Collaborator Innovator• 60% Aim for Minimum
• Only Core Processes for admin./compliance
• Last Minute Adoption
• Penalties may occur
• Aiming for Average = High Potential Risk
• 20-25% Aim for Opportunity
• Improve Processes• Advanced Analytics,
Process Improvement• Incentives Attained• Aiming for Improvement =
Potential Value for Costs
• 15-20% Aim for Transformation
• Complete Change Agent• Training, Outcomes Mgmt.
Incentives Attained• Aiming for Excellence =
Competitive Advantage & Strategic Positioning
Adapted from Deloitte, ICD‐10 Turning Regulatory Compliance into Strategic Advantage, 2009.
4/3/2018
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HIPAAMIPPATRCHAARRAPPACAMARCA ERA!
AnxietyChangeChaossClutterComplexityComplicationDistasteDisorderDoubtFearfulJumbleMessMuckSnafuPickleNightmarePredicamentMuddl
Healthcare is overwhelming!
5
INFORMATION OVERLOAD
We have to move to
Value-BasedPayment
I don’t understand
my condition
Our CEO says the future is in documenting
with structured data (?)
We need a new
server
We don’t like the word
“Bundled” We must contain costs
Quality Reports
are almost due
I can’t afford my
meds
I’m not hitting my
performance measuresThe
Internet is down
We need to issue the regs by
November
The Federal Marketplace is imploding!
I can’t afford
coverage!
Our Hospital revenues
are declining
We cannot sustain
Medicare
Why are my claims
are rejecting?
6
DEALING WITH THE COMPLEXITIES
Ready,
Set,
HOW?
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LEADERSHIP MAKES A DIFFERENCE
Being a Leader/Champion vs. Management
Management Leaders
Administer Innovate
Maintain Develop
Control Inspire
Short‐Term View Long‐Term View
Ask, “How” and “When” Ask, “What” and “Why”
Initiate Originate
Accept Status Quo Change Status Quo
Do Things Right Do Right Things
8
COMMIT TO STAYING INFORMED
• Professional Associations, Societies & Organizations (MGMA, HFMA, AHIMA, CHIME, HIMSS, etc.)
• Vendor → Training, Upgrades, etc.• Federal Tools
– CMS Quality Payment Program (QPP) Website– Health Care Payment Learning & Action Network
(HCPLAN)– AFMC → Arkansas Quality Improvement
Organization
• Payers → Training, Portals, Reps, etc.
9
HOW DO YOU EAT AN ELEPHANT?!
• One bite at a time → Iterative Design Process• Remember, cultural changes take time• Pursue active interventions through “coaching” formal / informal
leaders• Provide techniques to mark and encourage progress• Celebrate your Success!
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ONE BITE AT A TIME … KEY POINTS
• Knowledge is gained through testing (vs. planning, brainstorming)• Tests should be small, rapid, sequential• Developing a theory and prediction before each test and reviewing in
comparison to test results is essential• Learning from other teams can accelerate learning and
understanding• Measurement does not have to be hard and should aid learning
11
PLAN, DO, STUDY, ACT (PDSA)
• Developed by the Institute for Healthcare Improvement (IHI)
• PDSA → Documenting a test of change
• Think:– What are we trying to accomplish?– How will we know that change is an
improvement?– What changes can we make that will result in
improvement?
12
THANK YOU!Adele Allison | [email protected] | 205.563.2210
@Adele_Allison | Adele Allison
10-MINUTE BREAK
4/3/2018
1
IMPACT MACRA: ESSENTIAL STRATEGIESPart III: MACRA Essential StrategiesAdele Allison, Director of Provider Innovation StrategiesApril 11, 2018
2
3
4/3/2018
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AGENDA
• MACRA 2018
• Data-Driven Operations
• Community-Level Population Health
• Essential Strategies
• Questions / Wrap-Up
5
MACRA BY THE NUMBERS
• 95 – Pages long
• 8 – Meaningful Use
• 18 – Risk
• 19 – Resource Use or Efficiency
• 31 – “Reasonable Cost Reimbursement”
• 27 – EHR or Technology to Manage, Measure and Report
• 38 – Quality Measures
• 171 – “Measures” or “Measurement”
• 103 – Data
6
2018 – SOLO & SMALL GROUP MIPS PROTECTIONS
• Solo practitioners up to groups ≤ 15 clinicians
• MIPS Exemption Volume Thresholds
− ≤ $90,000 in billable Part B allowables (up from $30,000 in 2017), or
− ≤ 200 Part B patients (up from 100 in 2017)
• Automatic +5 bonus point if not exempt
• Form or join Virtual Groups (made up of ≤ 10 clinicians groups)
• Quality performance +3 points when measures do not meeting data completeness criteria
• Hardship exception for Advancing Care Information
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7
MERIT-BASED INCENTIVE PAYMENT SYSTEM
MIPSCategory 2Payments
8
MIPS – GET YOUR DUCKS IN A ROW
Will you submit as an individual or part of a group?• Individual → submit by NPI/TIN; Group → submit by group TIN
How will you submit your data?• Choices → Registry, EHR, Claims, CMS Web Interface; verify capabilities
Can your system create the data for the time periods you need?• Contact your EHR or registry vendor to validate
Choose your path and measures.
9
PICKING MEASURES & LEARNING MORE
CMS QPPURL: https://qpp.cms.gov/
CMS ResourcesURL: https://www.cms.gov/Medicare/Quality‐Payment‐Program/Resource‐Library/Resource‐
library.html
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10
MIPS COMPOSITE PERFORMANCE SCORE (CPS)
CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.
Performance Year /
Application Year
Quality MeasuresResource Use
or CostImprovement Activities
Advancing Care Information
DescriptionReplaces CMS Physician Quality Reporting System (PQRS)
Replaces ACA Value‐based Payment Modifier
New category of measurement; Medical Homes and NCQA PCSR receive full credit; 112 activities available
Replaces CMS EHR Incentive Programs f/k/a Meaningful Use
Reporting Methods
Claims, CSV, Web Interface (for group reporting), EHR, Qualified Clinical Data Registry (QCDR); QualifyingRegistry
ClaimsAttestation, QCDR, Qualified Registry, EHR Vendor
Attestation, QCDR, Qualified Registry, EHR Vendor, Web Interface (groups only)
2017 / 2019 60% 0%* 15% 25%
2018 / 2020 50% 10% 15% 25%
2019 / 2021 30% 30% 15% 25%*Measured for feedback only in 2017
11
2017-2018 MIPS CHANGES
• Solo/Small practice bonus available in 2018 → +5 Points
• Complex Patient bonus available in 2018 → +5 Points
• Performance Periods:
Year Quality CostImprovement Activities
Advancing Care
Information
2017 90‐day minimum 12‐months 90‐day minimum 90‐day minimum
2018 12 months 12‐months 90‐day minimum 90‐day minimum
2017/18Exception
Measures thru CMS Web Interface, CAHPS,and readmissions are for 12 months
NoneMeasures thru CMS Web Interface, CAHPS, and readmissions are for 12 months
None
12
Fee 2019 Schedule
Earn Less than 2019 Fee Schedule 0 – 100 Points
MIPS – CPS PAYMENT ADJUSTMENTS2017 Final
ScoreTransition Year Payment
Adjustment2018 Final
Score2018 Proposed Payment
Adjustment
≥ 70 Points
• Positive adjustment up to +4%
• Potential Performance Bonus → 0.5% minimum
≥ 70 Points
• Positive adjustment up to +5%
• Potential Performance Bonus → 0.5% minimum
4-69 Points
• Positive adjustment • Ineligible for Performance
Bonus
16-69 Points
• Positive adjustment• Ineligible for Performance
Bonus
3 Points • Neutral – Fee Schedule Only 15 Points • Neutral – Fee Schedule
Only
0 Points • Negative adjustment of -4% (Non-participation) 0 points • Negative adjustment of -
5% (Non-participation)
Earn More than Fee Schedule
CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.
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13
MERIT-BASED INCENTIVE PAYMENT SYSTEM
Advanced APMsCategories 3 & 4
14
CMS APM vs. A-APM
CMS Alternative Payment Model (APM)
CMS Advanced Alternative Payment Model (A‐APM)
There is a difference!
15
3-PART QUALIFIER FOR A-APMs
APM Nominal Amount of Risk Standard
Additional APM MACRA Statutory Req.
2017 2018
• Marginal Risk ≥ 30%;
• Minimum Loss Ratio capped at 4%; and,
• Total Risk ≥ 3% of expected APM expenditures
• Adds revenue-based nominal standard for total risk of 8% for APM under revenue models (through Performance Year 2020)
• Quality Measures align with MIPS
• Using certified EHR Technology (CEHRT) –currently requiring 2014 Edition certification
• Is a CMS expanded medical home (Optional to Nominal Risk Standard of 3%)
CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.
1 2
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3-PART QUALIFIER FOR A-APMs
Eligible ClinicianVolume Threshold
2017 2018
• Volume ≥ 25% of Part B payments; or,
• Volume ≥ 20% of Medicare patients
• No Change
CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.
32019
• Adds the CMS All-Payer Combination Option
• Incorporates Other Payers into a threshold calculation
17
ALTERNATIVE PAYMENT ADMINISTRATION
Shared-Savings Population-BasedEpisode Payment
• Upside Only
• Downside Financial Risk
• Total Cost of Care
• Member-Patient Attribution
• Risk-Adjustment
• Quality Measures
• Retrospective
• Prospective
• Target Spend
• Inclusions & Exclusions
• Quality Measures
• Inclusion & Exclusions
• Performance Period
• Risk-Adjustment
• Stop Loss
• Quality Measures
18
AGENDA
• MACRA 2018
• Data-Driven Operations
• Community-Level Population Health
• Essential Strategies
• Questions / Wrap-Up
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THE BASICS OF RISK
Attributed Population’s
Inherent Risk
Control
Exposure
Options: Accept Risk or Take Action
20
VBP AND ADVANCED ANALYTICSData Availability Claims EHR Clinical Records
Demographics Yes Yes
Race/ethnicity Limited Limited
Diagnosis(a) Yes Yes
Procedures Yes Yes
Eligibility Yes Limited
Medications Medications dispensed Medications prescribed
Socioeconomic data Zip‐code derived Coded and zip‐code derived
Family history Not available Yes
Problem list Not available Yes
Procedure results Not available Yes
Laboratory results Not available Yes
Vital signs Not available Yes
Behavioral risk
factorsNot available Limited
Standardized
surveysLimited Limited
• Mile Wide, Inch Deep
• CPT, ICD Nomenclatures
• ANSI X12 Standards
• Inch Wide, Mile Deep
• CPT, ICD, LOINC, SNOMED, NDC Nomenclatures
• HL7 Standards (e.g., ADT, VXU)
Categories 1 & 2 Transaction-Oriented Categories 3 & 4Analytics-Oriented
21
CLAIMS SUBMISSION = DATA REPORTING
Claims Data Reporting
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ITS ALL ABOUT THE DATA
• Provider Demographics• Provider-Patient Relationships• Provider Performance
23
MACRA EXPANDED CODING – 2018
• MACRA → CMS required to define 3 new code sets
• Patient Relationship Codes → 2018 Medicare PFS Proposed Rule
– Purpose → Attribution of Patients & Episodes to 1+ physicians/clinicians; Plurality of care to pinpoint resource use
– Reported through claims using Level II HCPCS Modifiers
– “Voluntary” to start → Not a condition of payment
• Today → Traditional Medicare Only
• Tomorrow → Mainstream for VBP
24
MACRA EXPANDED CODING – 2018 Continuous/broad
i. Provides ongoing principal care
ii. E.g., PCPs and Primary care specialists
Continuous/focusedi. Provides ongoing
management of chronic condition
ii. E.g., Rheumatologist
Episodic/broadi. Provides broad
responsibility during a brief defined period of time
ii. E.g., Hospitalist
Episodic/focusedi. Provides time‐limited
treatment or intervention
ii. E.g., Ortho performing knee replacement
Ordered by Anotheri. Provides care only as
ordered by another clinician
ii. E.g., Radiologist
1 2 3
4 5
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26
AGENDA
• MACRA 2018
• Data-Driven Operations
• Community-Level Population Health
• Essential Strategies
• Questions / Wrap-Up
27
CMS – 6 NAT’L QUALITY STRATEGY DOMAINS Domain Description
Efficiency and Cost
Reduction
Annual spending measures per capita, episodic care costs and quality‐to‐
cost metrics
Care CoordinationMeasuring successful transitions of care, admissions and readmission
rates and provider communication
SafetyPatient and Provider safety, including healthcare acquired infections and
conditions
Clinical Care Acute, Chronic, Preventive and Clinically Effective
Person‐ and Caregiver‐
Centered
Experience and Outcomes reported by patients and caregivers and
functional outcomes
Population and
Community Health
Measuring health behaviors, access, social / economic factors, physical
environ., disparities
Lower Costs
Better Care
Better Health
TRIPLE A
IM
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Low/No Risk
Moderate Risk
High
Risk
BUILDING PHM PROGRAMS
Attributed Population
Health Assessment
Intervention
Risk Stratification
Incr
easi
ng In
tens
ity
Who?
What? How?
29
UNDER FFS, WHO HOLDS THE “RISK” BAG TODAY?
30
COMMUNITY LEVEL RISK
Health Plans have been in Community Level Risk Management for Years
… but not care delivery
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ANSWERING THE “WHO,” “WHAT” AND “WHERE”
CMS Risk Adjustment Payment Transfer Formula
32
MANAGING RISK FOR HEALTH PLANS
Analytics
• Benefits & Plan Design• Enrollment Data• Prevalence / Utilization Data• Burden of Disease
• Network Adequacy• Performance Data• Conditions by Specialty• Patient Capacity
• Administration• Compliance by Business Line• Provider Reimbursement Rates• Patient Out‐of‐Pocket• Inbound Revenue (e.g., premium)
Members
Providers Plan Operations
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E.G. #1 – RISK MANAGEMENTJOHNS HOPKINS ACGS – POPULATION DECISION TREE
The Whole Population
Non‐Users Single Morbidity (either acute or
chronic)
Commonly occurring morbidity
combinations
Complex morbidity
combinations
PregnantWomen
Infants (<12 months of age)
• No utilization, No or Invalid diagnoses
• Invalid Age
• Acute Minor• Acute Major• Likely to Recur• Asthma• Chronic Medical• Chronic Specialty• Eye• Dental• Psycho‐social• Preventive/
Administrative
• Acute: Minor and Acute: Major
• Acute: Minor and Likely to Recur
• Acute: Minor and Chronic Medical: Stable
• Acute: Minor and Eye/Dental
• Acute: Minor and Psychosocial
• Acute: Major and Likely to Recur
• 2‐3 morbidities• 4‐5 morbidities• 6‐9 morbidities• 10+ morbidities
• Further differentiated by age, sex and major morbidities
• 0‐1 morbidities• 2‐3 morbidities• 4‐5 morbidities• 6+ morbidities
• Further differentiated by major morbidities and delivery status
• 0‐5 morbidities• 6+ morbidities
• Further differentiated by major morbidities and low birthweight
4/3/2018
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E.G. #1 – RISK MANAGEMENTIndividual Population Health Intervention
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AGENDA
• MACRA 2018
• Data-Driven Operations
• Community-Level Population Health
• Essential Strategies
• Questions / Wrap-Up
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Category 2 Category 3 – Bundle Payment/ACOCategory 4 – Global PBP
Category 1
PAYER A-APM ALIGNMENT – WHY CARE?Productivity-Based
PaymentPopulation-Based
Payment
Category 1 or 2
4/3/2018
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• Payer ABC – Hospital Performance-based Fee-for-Service
• Goals → Come to us! “Low wait-times for our Emergency Room”
• Payer ABC – Per Member Per Month (PMPM)
• Goals → Reduced ER and hospital admissions during chemo episode
PAYER A-APM ALIGNMENT – WHY CARE?
Category 2 Category 4 – Oncology Care Model
Utilization
Utilization
ER ~$1,233Per Visit
UC ~$155Per Visit
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• Payer ABC – Hospital Performance-based Fee-for-Service
• Goals → Come to us! “Low wait-times for our Emergency Room”
• Payer ABC – Per Member Per Month (PMPM)
• Goals → Reduced ER and hospital admissions during chemo episode
PAYER A-APM ALIGNMENT – WHY CARE?
Category 2 Category 4 – Oncology Care Model
Episodic Care available now for your pain (short‐term)
Care Plan so pain is always well controlled (long‐term)
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IT’S HARD TO HAVE A FOOT ON BOTH PATHS!
Productivity-Based Payment
Population-Based Payment
4/3/2018
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ALL-PAYERS, MULTI-PAYERS, & OTHER PAYERS
CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.
• MACRA expands into additional payers beginning performance year 2019
− All-Payer Combination Option includes Medicare Advantage, and Medicaid Medical Homes
− Other-Payer Advanced APMs are those non-Part B payers that have similar payment arrangements as the Medicare Option
− Multi-Payer Models includes APMs under the CMS Innovation Center
• Enables clinicians to join the A-APM track by aligning payers and meeting volume thresholds – SMART!
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A-APM ALIGNMENT
CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.
• VOLUNTARY → Strong positioning to align A-APMs
• CMS Other Payer Advanced APMs qualification vetted annually in year prior to the applicable performance year
• Qualification can be initiated by Payer or Eligible Clinician
TIMELINES FORPAYER INITIATED
MedicaidCMS Multi-Payer
ModelsMedicare Health Plan
Other Payer A-APMs (Starting in 2019)
Description Title XIXInnovation Center
model with other payersMedicare Advantage
Commercial & other payers not in the other
groups
Annual Submission Period
Jan. 1 – Apr. 1 Jan. 1 – Jun. 30
Opens when bid package is sent in Apr. & closes
with bid deadline (1 Mon. of June)
TBD
Approval By Sept. Sept. Sept. TBD
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ELIGIBLE CLINICIAN A-APM ALL-PAYER VOLUME
CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.
TIMELINES FORELIGIBLE CLINICIANS
MedicaidCMS Multi-Payer
ModelsMedicare Health
PlanOther Payer A-APMs
(Starting in 2019)
Description Title XIXInnovation Center model
with other payersMedicare Advantage
Commercial & other payers not in the other
groups
Annual Submission Period
Sept. 2018 – Nov. 30 2018; annually
thereafter
Aug. 2019 – Dec. 2019; annually thereafter
Aug. 2019 – Dec. 2019; annually
thereafter
Aug. 2019 – Dec. 2019; annually thereafter
Approval By Dec. 2018; annually Dec. 2019; annually Dec. 2019; annually Dec. 2019; annually
• Qualification can be initiated by Eligible Clinician subsequent to Payer timeline
4/3/2018
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FUTURE OF FINANCIAL REWARDS
• Non-advanced APM or MIPS APM− APM-specific Rewards
− MIPS Opt-In – Collective Scoring
• Clinicians Scored Individually• Scores averaged across APM• Average score applied to all APM clinicians subject to MIPS
− MIPS Opt-Out – No Scoring
• Advanced APM− APM-specific Rewards− Lump sum incentive of 5% of Medicare payments− Qualified Participants (QPs) not subject to MIPS
• Not in APM− MIPS Rewards (or penalties)
Earning more than
fee schedule
1
2
3
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ESSENTIAL STRATEGIES
• #1 Assess → Payers & Patient Health Status
• #2 Recognize → Majority Revenue Source
• #3 Identify → Essential Data Points
• #4 Communicate → Remember Claims = Reporting Data
• #5 Document → Clinical Documentation Improvement (CDI)
• #6 Redesign → Use “5-Rights” for Strong Data Capture
• #7 Align → Payers, Provider Community, Patients
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AND REMEMBER …
We’re all in this together –by ourselves!
‐ Lily Tomlin
4/3/2018
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THANK YOU!Adele Allison | [email protected] | 205.563.2210
@Adele_Allison | Adele Allison