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2/27/2019
1
March 7, 2019
MACRA: Quality Maximus Valorem
Agenda
• VBP Level-Set
• Understanding Digital Healthcare
• QPP for Groups, Solo & New Provider
• A Word to Interop
• Questions
© 2018. SS&C Technologies. Confidential
2/27/2019
2
I paid my copay – Now what?
Today
• Category 1 Payments
• Fee-for-Service (FFS)
• Medicare FFS frozen 2019 rates
• Productivity Revenue Model
• Transaction-based Payments
© 2018. SS&C Technologies. Confidential
Result → Healthcare Spending State of the Union
Sources: 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; Population related calculations based on U.S. Census Bureau data, https://www.census.gov/data/tables/time-series/demo/popest/pre-1980-national.html
U.S. Gov’t HealthcareProgram
Eligibility
U.S. Population / Enrollment
(1965)
Healthcare Cost as %
of GDP (1965)
Medicare American Age 65+
18.5 Million (9.5% of U.S. Population)
5.6% ($42 Billion or $210 per person)
Medicaid Low-income Americans
4 Million (2% of U.S.
Population)
CHIPLow-income, Non-Medicaid Children
0
U.S. Population / Enrollment
(2016)
57.1 Million (17.6% of U.S.
Population)
72.3 Million (22.3% of U.S.
Population)
6.7 Million (2% of U.S. Population)
Healthcare Cost as %
of GDP (2016)
17.9%($3.3 Trillion or $10,180per person)
U.S. Population / Enrollment (2025/26)
74 Million (21.5% of US
Population
82 Million (23.8% of U.S.
Population)
TBD
Healthcare Cost as %
of GDP (2026)
19.7%($5.7 Trillion or $16,460 per person)
11.5% 41.9% 47.3%
© 2018. SS&C Technologies. Confidential
2/27/2019
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Bipartisan Answer – Value-Based Payment
Tomorrow
• Categories 2- 4 Payments– Category 2 – Pay-for-Performance
– Categories 3 & 4 – Alternative Payment Models (APMs)
• MACRA Advanced- APMs
• Outcomes Revenue Model
• Analytic-based Payments
© 2018. SS&C Technologies. Confidential
Individuals
CMS MACRA
U.S. Payment Trends 2015-2017
© 2018. SS&C Technologies. Confidential
Lives% of
Market2016 2017
Medicare Advantage 20,711,961 70% 41% 49.5%
Medicare FFS ~37,000,000 100% 31% 38.3%
Commercial 135,532,277 63% 22% 28.3%
Medicaid 31,331,995 50% 18% 25.0%
Categories 3 & 4
Source: HHS Health Care Payment Learning & Action Network, Measuring Progress: APM Adoption, October, 2018, https://hcp-lan.org/2018-apm-measurement/
Payment Category 2015 2016 2017Category 1 62% 43% 41%
Category 2 15% 28% 25%
Categories 3 & 4 23% 29% 34%
2/27/2019
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MACRA Three Policy Aims
Move Medicare to Value-Based Payment (VBP) by 2019 → MACRA
Ease Provider Burden and Abrasion• MACRA Proposed E&M Coding Redesign 99202-05
and 99212-15
Achieve Data Interoperability
MACRA = Medicare Access & CHIP Reauthorization Act of 2015;
1
2
3
Agenda
• VBP Level-Set
• Understanding Digital Healthcare
• QPP for Groups, Solo & New Provider
• A Word to Interop
• Questions
© 2018. SS&C Technologies. Confidential
2/27/2019
5
Digital Healthcare Evolution
1970s• Relational DB
• Microprocessor
• CT Scanner
1980s• HTML Prototype
• MS-DOS
• Digital Infusion Pumps
• PACs Systems
• DRGs
• Data Visualization
• Apple MAC
• DNA Sequencer
• T1 Data Lines
• Home Glucose Meter
• MRIs
1990s• Wrist BP cuff
• Nuclear Imaging
• HIPAA
• Personal Digital Assistants (PDAs)
• 2 Interop groups formed:
– CDISC
– IHE
2000s• Human Genome gets
mapped
• Software-as-a-Service
• iPhone
• “I’ve Got An App For That”
• Only eNew Drug Applications to FDA
• Google reports swine flu
• EHR penetration < 50%
• Fitbit
• ePrescribing
© 2018. SS&C Technologies. Confidential
2010s• VC Digital Health
investments > $11 Billion
• 50% have Wearable Tech
• Meaningful Use
• EHR adoption > 85%
• Affordable Care Act
• MACRA
• Telemedicine
• Uber Health
• Artificial Intelligence
• Machine Learning
Disruptive Technology and Digital Healthcare
• Innovation can disrupt existing market
• Think “free” digital info– Radically changes humanity
(e.g., GPS v. Paper Maps)
– Quick, fast, in a hurry
• Self-Driving Cars – Disrupts parking,
– Law enforcement (tickets),
– Car insurance,
– Lawsuits,
– Auto repair/manufacturing, and
– Even hotels
• Futurist View:
• Apple watch → “BP is High”• Miri, “Go see your doctor”• Worried → Go to Amazon Hospital
• Medical Team + My Doctor connect through Telemedicine
• Apple Health App → Medical Records
• Rx written → drug produced & researched by Google
• PCP uses social media to engage patient and remotely monitors patient
• Expert is brought in for Telesurgery
© 2018. SS&C Technologies. Confidential
2/27/2019
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Digital Health Economics: 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
© 2018. SS&C Technologies. Confidential
MIPS A-APMs
Digital Economics and Data AnalyticsData Availability Claims EHR Clinical Records
Demographics Yes Yes
Race/ethnicity Limited Limited
Diagnosis 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, CDA, QRDA)
Categories 1 & 2Transaction-Oriented
PaymentCategories 3 & 4Analytics-Oriented
Payment
© 2018. SS&C Technologies. Confidential
2/27/2019
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Strategy #2 – Data, Data, Data
• Shifting from Transaction-based payment to Analytic-based payment
• U.S. Core Data for Interoperability (USCDI) List of data to define a common clinical data set
(CCDS) – initially for 2015 Certified EHR Technology (CEHRT)
21st Century Cures Act → Expanding data liquidity
3 ongoing data classes for annual expansion
Supported Data Classes
Candidate Data Classes
EmergingData Classes
USCDI Task Force: https://www.healthit.gov/hitac/committees/us-core-data-interoperability-task-force
MIPS – Composite Performance Score (CPS)
Performance Year /
Application YearQuality Measures
Resource Use or Cost
Improvement Activities
Promoting Interoperability
Programs
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; 113 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 45% 15% 15% 25%
* In Performance Year 2019, claims-based quality reporting is only available to small group providers (≤ 15 eligible clinicians)
© 2018. SS&C Technologies. Confidential
2/27/2019
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MIPS – Earning More Than Fee Schedule
0 – 100 Points
2017 Final CPS Score
2019 Year Payment
Adjustment
2018 Final CPS Score
2020 Year Payment
Adjustment
2019 CPS Final Score
2021 Payment Adjustment
≥ 70 Points
• Positive adjustment up to +5%
≥ 70 Points
• Positive adjustment up to +5%
≥ 75 Points
• Positive adjustment up to +7%
• Potential Performance Bonus → 0.5% minimum
• Potential Performance Bonus –0.5% minimum
• Potential Performance Bonus → 0.5% minimum
3.1‐69.9 Points
• Positive adjustment 15.1‐69.9 Points
• Positive adjustment 30.1‐74.9 Points
• Positive adjustment
• Ineligible for Performance Bonus
• Ineligible for Performance Bonus
• Ineligible for Performance Bonus
3 Points• Neutral – Fee Schedule Only 15 Points
• Neutral – Fee Schedule Only 30 Points
• Neutral – Fee Schedule Only
0‐2.9 Points• Negative adjustment up to ‐4% (Non‐participation)
0‐14.9 Points
• Negative adjustment up to ‐5% (Non‐participation)
0‐29.9 points
• Negative adjustment up to ‐7% (Non‐participation)
Earn same 2019 Fee Schedule
Earn Less than 2019 Fee Schedule
Earn More than Fee Schedule
© 2018. SS&C Technologies. Confidential
2019 QPP Measures
DomainWeight of
CPSPerformance
PeriodOptimum Threshold
Quality Measures 45% Jan. 1 – Dec. 31
• 6 Measures or Specialty Measure Set (Including 1 outcomes measure)
• Groups of 16+ add All‐Cause Readmissions measures
Cost 15% Jan. 1 – Dec. 31
• Total Cost of Care measures
• 10 Measures
– Total Per Capita Cost
– Medicare Spending Per Beneficiary
– 5 Procedure Episode measures
– 3 Acute Inpatient Episode measures
Improvement Activities
15% 90‐days
• 2 High‐weighted activities
• 1 High‐weighted and 2 Medium‐weighted
• 4 Medium‐weighted activities
Promoting Interoperability
25% 90‐days
• 2015 Edition CEHRT & 3 Attestations
• Single measure set tied to 4 objectives
• 2 opioid bonus measures (5 bonus points each)
© 2018. SS&C Technologies. Confidential
2/27/2019
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Agenda
• VBP Level-Set
• Digital Healthcare
• QPP for Groups, Solo & New Provider
• A Word to Interop
• Questions
© 2018. SS&C Technologies. Confidential
Know the 5-Rights of Digital Data Redesign
© 2018. SS&C Technologies. Confidential
• Right Information
• Right Person Capturing
• Right Data Format
• Right Technology Channel
• Right Time in the Patient Workflow
2/27/2019
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• Providers reporting as individuals and/or as group• Benchmark performance data • Share performance data with providers • Identify potential constraints to success by
specialty, patient type, provider, workflow, etc.• Implement ongoing process improvement• Collaborate with other re: A‐APM positioning
QPP Decision Tree – The Group Practice
Other Payer MACRA Alignment
MIPS or A‐APM? A‐APM
• Identify QPP Quality & Value Measures• Harmonize measures across specialties, if able• Use 5‐Rights of digital data redesign• Determine measure reporting method• Confirm system can produce data• Educate, train staff and providers• Code claims with specificity
• Pinpoint Advantageous QPP Quality & Value Measures
• Use 5‐Rights of digital data redesign• Determine measure reporting method• Confirm EHR system 2015 cert. & abilities• Educate, train staff and providers• Code claims with specificity
OperationsRisk‐Bearing / Contracts
• Understand Value‐based Scoring Calculations• Reporting → Ongoing Performance,
Reconciliation, Appeals process• Population Health Management • Patient Attribution & Risk‐adjustment• System Integration & Payment• Supported through plan Benefit Design?
• Understand Payment Model Type• Recognize flow of risk/reward revenue
and corridors• Define Quality & Value Measures• Terms and Conditions• Negotiation, Execution & Renewal• Plan for Provider On‐boarding & Support
Are you a single or multi‐specialty group? MultiSingle
PlanPlan• Benchmark performance data • Share performance data with providers • Identify potential constraints to success by
patient type, provider, workflow, etc.• Implement ongoing process improvement• Collaborate with other re: A‐APM positioning• Register for Web Interface by June 30, if using
Operationalize
Performance Optimization
MIPS or A‐APM?
Operationalize
MIPS
Provider/Payer InitiationEligibility
• Payers initial first half of year prior to the Qualified Participant Performance Year
• Providers can initial thereafter• Provider qualified participation requires ≥
35% of patients or ≥ 50% of payments made through A‐APM
• APM Nominal Risk Standard Met?• Other Advanced APM (A‐APM)
Requirements Met:– Using certified EHR technology– MIPS‐like quality measures
Other Payers MACRA Alignment
Performance Optimization
MIPS
© 2018. SS&C Technologies. Confidential
QPP Decision Tree – The Solo Practice
• Identify QPP Quality & Value Measures• Use 5‐Rights of digital data redesign• Determine measure reporting method• Confirm EHR system 2015 cert. and abilities• Educate, train staff and providers• Code claims with specificity
OperationsOther Payers & MACRA
• Understand Value‐based Scoring Calculations• Reporting → Ongoing Performance,
Reconciliation, Appeals process• Population Health Management • Patient Attribution & Risk‐adjustment• System Integration & Payment• Supported through plan Benefit Design?
• Align model with MACRA statutory, policy requirements
• File Payer/Provider initiated submission paperwork with CMS
• Harmonize measures across payers• Qualified providers require ≥ 35% of
patients or ≥ 50% of payments
Are you MIPS or APM? APMMIPS
Plan
• Benchmark performance data • Share performance data with providers • Identify potential constraints to success by
patient type, provider, workflow, etc.• Implement ongoing process improvement• Collaborate with other re: A‐APM positioning
Operationalize
Alignment & Optimization
Payer Alignment & Optimization
No
• Identify Provider Leaders, Outreach• Pinpoint Mutually Advantageous Quality
& Value Measures • Share Data with Providers, Patients and
Performance
Collaborate• List payer contracts in place today• Benchmark priority performance data
including new compliance data needs• Identify potential constraints to success by
payer type, culture, services patients, etc.
Plan
Plan & Operationalize
Collaborate & Plan Yes
Yes
• Models, Risk-Bearing Corridors• Measures and Provider Participation• Successes and Challenges• Contracting Entities & Terms (e.g., CMS)• Performance Data
Assess
• Culture Change, Internal & External• Identify Champions, Official & Unofficial• Recognize gaps in infrastructure• Open Provider and Payer Communications• Educate Staff and Providers
Modernize
Assess & Modernize
Is it Risk‐Bearing?
Do APMs exist in your market?
NoAre you Exempt?
© 2018. SS&C Technologies. Confidential
2/27/2019
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QPP Decision Tree – New Practice Providers
MIPS or A‐APM? A‐APMMIPS
No
Medicare enrolled in 2019 for first time?
Yes
Partial QP
TIN 1 duringPerformance Year, TIN 2 during Payment Year Qualifies as QP
Performance Year score will carry to Payment Year with related adjustments
to TIN 2.
MIPSExempt
Check QPP Participation StatusMultiple TINs duringPerformance Year
Low‐volume threshold in either/both TINs?
NoYes
MIPSExempt
MIPS ineligible, 5% bonus as QP + APM rewards
Voluntary Option to submit MIPS data and receive MIPS adjustments
Best Practice: Confirm status of all eligible clinicians using NPI and the CMS Look-up Tool at https://qpp.cms.gov/participation-lookup
© 2018. SS&C Technologies. Confidential
Agenda
• VBP Level-Set
• Digital Healthcare
• QPP for Groups, Solo & New Provider
• A Word to Interop
• Questions
© 2018. SS&C Technologies. Confidential
2/27/2019
12
MyHealthEData and Blue Button
• MyHealthEData– Make data available through Blue Button
– Heightened in 21st Century Cures Act
• Blue Button – Branded Icon
– Introduced 2010 – DoD and VA
– Used today by Relay Health, Aetna, UHC and TriCare
– Moving to Blue Button 2.0
– Uses Application Programming Interface (API)
© 2018. SS&C Technologies. Confidential
CMS & ONC Proposed Rules – Feb. 11, 2019
• CMS – Interop for Patient Access (~250 pgs.)
– Payers must support electronic exchange of data by 2020
– Working to “standardize data and technical approaches”
– Essence of Digital Healthcare
• ONC – EHR Certification, Interop (~750 pgs.)
– Fast Healthcare Interoperability Resources (FHIR)
– Enable third party software apps
– Digital information available for use by patients, providers, and health plans
© 2018. SS&C Technologies. Confidential
2/27/2019
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What is a Use Cases?
• Develop Interoperability Use Cases
– Create business model framework
– Identify the problem and the needs (e.g., care coordination, data capture, provider feedback)
– Who has the need? (Actors)
– Map the solution to meet the needs for each actor
– What technology is needed? (e.g., CCDA, Direct Messaging, FHIR)
– Determine financial/operational impact (initial & ongoing costs, workflows)
© 2018. SS&C Technologies. Confidential
7 Identified Use Cases
Dual Eligible State‐Federal Data Updates
Daily update frequency
Electronic Notification of Hospital Use
Admissions, discharges, transfers
Provider Directory
In‐network patient navigation, transitions, care coordination
Trusted Exchange Framework
Verifies security and identity, IT agnostic, for nationwide exchange
Coordination Across Payers
• Patients moves from one plan to another
• Est. impact: 125M
Provider Digital Contact Info
• Added to NPPES• Public reporting of names July, 2020
© 2018. SS&C Technologies. Confidential
2/27/2019
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7th Use Case
• Pricing Transparency – Targets Hospitals
– Posting of Charge-masters
– Patient Cost Estimators
– Moving to make charges “machine-readable”
Facilitate informed decisions for patients
Allow consumers to “shop” for healthcare
• Concerns– Will data be in a format understood by patients?
– Charge-masters do not explain out-of-pocket
– Factors can influence actual services provided and change rates
© 2018. SS&C Technologies. Confidential
The Da Vinci Project
• ONC and CMS collaborative with HL7 → Jan. 2018 (10 Payers, 3 EHRs, 6 Providers)
• Includes ONC’s Payer and Provider (P2) FHIR Task Force → Dec. 2017
• Top 3 Priority Use Cases: Coverage requirements discover (CRD), Alerting ADT (e.g., emergency room), and Prior Authorization
• Goal of Prior Authorization → Ease Provider Burden
Government Payers Providers Vendors OtherCMS, ONC Anthem, BCBSAL,
BCBSA, Cigna,
HCSC, Humana,
UnitedHealth
EnableCare, Boston
Children’s Hospital,
Aegis
Imprado,
Optum, Security
Risk Solutions
EHNAC,
HIMSS
© 2018. SS&C Technologies. Confidential
2/27/2019
15
Prior Authorization and Reducing Burden
• Impacting delays and denials of treatment for patients
• Survey by the AMA in late 2017 showed:– Average 29 (14 Rx, 15 medical) prior authorizations/physician/week
– Average 15 hours in administrative labor per physician-clinician/week to complete
– 34% of physicians have a dedicated staff member exclusively administering PA
– 79% repeating PAs for Rx when patient is stabilized on treatment regimen for chronic condition
• Loss in revenue due to time/administration requirements
• Disparate PA types and processes (e.g., by payer)
• Lack of automation/technical solutions
• Use case would use FHIR-enabled algorithms
© 2018. SS&C Technologies. Confidential
Emerging Technologies In Healthcare
© 2018. SS&C Technologies. Confidential
Leading Edge
Bleeding Edge
Adopting too early
Quitting too early
Adopting too late
Hanging on too long
Source: Gartner Hype Cycle
2/27/2019
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Emerging Technologies in Healthcare - Providers
Source: Craft, Jones, Gartner, “Hype Cycle for Healthcare Providers, 2018,” Jul. 2018 © 2018. SS&C Technologies. Confidential
Emerging Technologies in Healthcare - Payers
© 2018. SS&C Technologies. Confidential Source: Cole, Bishop, Cribbs, Gartner, “Hype Cycle for Healthcare Payers, 2018,” Jul. 2018
2/27/2019
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Emerging Technologies in Healthcare - Consumers
© 2018. SS&C Technologies. Confidential Source: Cribbs, Gilbert, Gartner, “Hype Cycle for Consumer Engagement With Healthcare and Wellness, 2018,” Jul. 2018
Think Big!