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Reimbursement Under MACRA: Value based purchasing
and your practiceSarah Freymann Fontenot, BSN, JD, CSP
Speaker DisclosureMs. Fontenot has disclosed that she has no actual or potential conflict of interest in relation to this topic.
©2017/SHFF/TMLT
Learning ObjectivesBy the end of this activity, the participant should be better able to:
Define the components of MACRA and evaluate the differences between MIPS and APM reimbursement options;Identify the IT support and infrastructure necessary to be successful under MACRA; andDescribe how this structure replaced the SGR formula and its impact on physician practices.
©2017/SHFF/TMLT
NoticeSarah Freymann Fontenot, J.D. and TMLT present this seminar with the
express understanding that:
1. No attorney‐client relationship exists,2. Neither Ms. Fontenot nor TMLT are engaged in providing legal advice, and 3. That the information is of a general character.
You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be
sought.
©2017/SHFF/TMLT
Agenda
Where Did MACRA Come From?MACRA: Two PathwaysWho, When, What & How Much?What To Do NOW, What To Do LATERQuestions & Answers: Discussion
©2017/SHFF/TMLT
May The Era Of Medicare’s Doc Fix (1997‐2015) Rest In Peace. Now What?“After seventeen years (eight months, 9 days…), over a dozen acts of Congress and innumerable reams of debate and conjecture about its fate, it’s time to say goodbye to the Medicare Sustainable Growth Rate (SGR) formula. As a proper wake, let’s take a moment to reflect on this enigma of health care economic theory. And then let’s not ever do it again.Health Affairs Blog 4/14/15http://healthaffairs.org/blog/2015/04/14/may‐the‐era‐of‐medicares‐doc‐fix‐1997‐2015‐rest‐in‐peace‐now‐what/
©2017/SHFF/TMLT
Well…
●Medicare Access and CHIP Reauthorization Act of
2015[MACRA]
●
©2017/SHFF/TMLT
High & Low Performers
Under MACRA “there will be a growing divide between high and low performers and how they are reimbursed as Medicare moves away from volume to value. Medicare will clearly differentiate high, middle and low performers in a way that will optimize both reimbursement and market share for high performers. It will also drive lower performers further from narrow network contracts that both employers and commercial payers will utilize to differentiate performers in the new highly differentiated value
stream that will represent the healthcare system of tomorrow.”MACRA is now! A roadmap to compliance
FierceHealthcare Jun 15, 2016
©2017/SHFF/TMLT
Quality Payment Program
Pay for Performance●
Value Based Purchasing●
MACRA
©2017/SHFF/TMLT
Final Rule: Pick Your Pace 2017
©2017/SHFF/TMLT
OK!
●Time to get moving!
●
©2017/SHFF/TMLT
Agenda
Where Did MACRA Come From?MACRA: Two PathwaysWho, When, What & How Much?What To Do NOW, What To Do LATERQuestions & Answers: Discussion
©2017/SHFF/TMLT
MACRA: Two Paths1. Advanced
Alternative Payment Models (APMs)
2. The Merit‐based Incentive Payment System (MIPS)
©2017/SHFF/TMLT
APMs: The Other Choice
For clinicians who take a further step towards care transformation, the law creates another path.Clinicians who participate to a sufficient extent in Advanced APMs would qualify for incentive payments.Under the law, Advanced APMs are those in which clinicians accept risk for providing coordinated, high‐quality care. These clinicians are also exempt from MIPS
©2017/SHFF/TMLT
APMs = More Money!
For years 2019 through 2024, a clinician who meets the law’s standards for Advanced APM participation is excluded from MIPS adjustments and receives a 5% Medicare Part B incentive payment. For years 2026 and later, a clinician who meets these standards is excluded from MIPS adjustments and receives a higher fee schedule update than those clinicians who do not significantly participate in an Advanced APM.
©2017/SHFF/TMLT
More Money?●
I like that!
APMs
©2017/SHFF/TMLT
So What is an APM?To be an Advanced APM, models must be a CMS Innovation Center model or a statutorily required demonstration and must generally:1. Require participants to bear a certain amount of
financial risk.2. Base payments on quality measures comparable to
those used in the MIPS quality performance category.3. Require participants to use certified EHR technology
©2017/SHFF/TMLT
Special Rules for Medical HomesUnder the statute, medical home models that have been expanded under the Innovation Center authority qualify as Advanced APMs regardless of whether
they meet the financial risk criteria. While medical home models have not yet been expanded, the proposed rule lays out
criteria for medical home models to ensure that primary care physicians have
opportunities to participate in Advanced APMs.
©2017/SHFF/TMLT
APMs ‐What QualifiesThe proposed rule includes a list of models that would qualify under the terms of the proposed rule as Advanced APMs. These include:
Comprehensive ESRD Care Model (Large DialysisOrganization arrangement)
Medicare Shared Savings Program—Track 3
Comprehensive Primary Care Plus (CPC+) Next Generation ACO Model
Medicare Shared Savings Program—Track 2 Oncology Care Model Two‐Sided Risk Arrangement (available in 2018)
©2017/SHFF/TMLT
APMs ‐What QualifiesAre you Specialty Care?
●Look Again!
Comprehensive ESRD Care Model (Large DialysisOrganization arrangement)
Medicare Shared Savings Program—Track 3
Comprehensive Primary Care Plus (CPC+) Next Generation ACO Model
Medicare Shared Savings Program—Track 2 Oncology Care Model Two‐Sided Risk Arrangement (available in 2018)
©2017/SHFF/TMLT
Qualifying APMs
Under the proposed rule, CMS would update this list annually to add new payment models that qualify to be an Advanced APM. In addition, starting in performance year 2019, clinicians could qualify for incentive payments based, in part, on participation in Advanced APMs developed by non‐Medicare payers, such as private insurers or state Medicaid programs.
©2017/SHFF/TMLT
Final Rule Options Expand Somewhat
©2017/SHFF/TMLT
Final Rule Options Expand Somewhat
©2017/SHFF/TMLT
Is an APM Your Future?
1. Avoid MIPS2. Make more
money
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APMs are the Ultimate Goal
MACRA initially conceived of MIPS as an intermediary step toward [value‐ and
quality‐based reimbursement through] APMs
What doctors need to know to get ready for MIPSFierceHealthcare 6/23/16
©2017/SHFF/TMLT
But… RISK?
Few Providers Ready To Accept Risk Under MACRA’s Alternative Payment Models
“Hospitals, health systems and physician groups are currently figuring out which of the two possible reimbursement paths they will take: or accepting “payment adjustments based on their performance under already existing alternative payment
models.”Health & Life Sciences Law Daily [8/15/16]
©2017/SHFF/TMLT
The APM Option is not Available for Most
“CMS's proposal… helps most practices solve the dilemma of whether to participate in MIPS or attempt an exemption via an Advanced Alternative Payment Model (APM)… the list of what would qualify as an
advanced APM is so narrow, that virtually no physicians are going to be advanced APMs anytime soon.”
3 Ways to Prep Physicians for MACRA's UnknownsHealthleaders Media, May 5, 2016
©2017/SHFF/TMLT
Polling the Room
●Is anyone here today
anticipating they will be perusing the APM
alternative?●
©2017/SHFF/TMLT
MACRA: Two Paths
1. Advanced Alternative Payment Models (APMs)
2. The Merit‐based Incentive Payment System (MIPS)
©2017/SHFF/TMLT
This is Actually Not all NEW
“With a complete roadmap unavailable, and rank‐and‐file physicians not really paying attention, the next‐best guides for physician practice leaders include existing
programs such as PQRS, the Value BasedPayment Modifier (VBM), and meaningful use.”
3 Ways to Prep Physicians for MACRA's UnknownsHealthleaders Media, May 5, 2016
©2017/SHFF/TMLT
MIPS: Quality
©2017/SHFF/TMLT
Quality
60%* of total score in year 1●
replaces the Physician Quality Reporting System
[PQRS]* Final Rule
For this category, clinicians would choose six measures to report (versus the nine measures currently required under Physician Quality Reporting System). In addition, for individual clinicians and small groups (2‐9 clinicians), MIPS calculates two population measures based on claims data, meaning there are no additional reporting requirements for clinicians for population measures. For groups with 10 clinicians or more, MIPS calculates three population measures. The measures would be each worth up to ten points for a total of 80 to 90 possible points depending on group size.
©2017/SHFF/TMLT
Quality
When choosing the 6 quality measures, clinicians would choose 1 crosscutting measure and 1 outcome measure (if available) or another high quality measure.High quality measures are measures related to patient outcomes, appropriate use, patient safety, efficiency, patient experience, or care coordination. There will be more than 200 measures to pick from and more than 80% of the quality measures proposed are tailored for specialists.
©2017/SHFF/TMLT
There will be more than 200 measures to pick from and more than 80% of the quality measures proposed are tailored for specialists.
Quality
©2017/SHFF/TMLT
Quality●
The proposal strives to align with the private sector and reduce the reporting burden by including the core quality
measures that private payers already use for their
clinicians.●
●Clinicians may also choose
to report a specialty measure set‐ which are
specifically designed around certain conditions and
specialty‐types‐ instead of the six measures described
above.●
©2017/SHFF/TMLT
Quality: 5 Take Homes
1. What measures are you currently reporting under PQRS that are most meaningful to your practice?
2. What quality measurements are you submitting to private sector that you would like to align with MIPS?
3. Would a specialty measure set be more appropriate?4. Do you currently have a sufficient HIT platform to gather
and report your Quality measures?5. Does your staff accurately and consistently enter patient
data so the measurements reflect what is true about your practice?
©2017/SHFF/TMLT
MIPS: Advancing Care Information
©2017/SHFF/TMLT
Advancing Care Information
25% of total score in year 1●
Replaces Meaningful Use●
The overall Advancing Care Information score is a maximum of 100 points
This category would no longer require all‐or‐nothing EHR measurement or quality reporting. Clinicians would choose to report a customizable set of measures that reflects how they use EHR technology in their day‐to day practice, with a particular emphasis on interoperability and information exchange.
©2017/SHFF/TMLT
Base Points= 6 Objectives/Measures
Protect Patient Health Information (yes/no)*
Patient Electronic Access (numerator/denominator)
Coordination of Care Through Patient Engagement (numerator/denominator)
Electronic Prescribing (numerator/denominator)
Health Information Exchange (numerator/denominator)
Public Health and Clinical Data Registry Reporting (yes/no)
©SHFF/2016
*Because of the importance of protecting patient privacy and security, clinicians must achieve the
Protect Patient Health Information objective to receive any score in the Advance Care Information performance category.
ACI Replaces MUACI replaces Meaningful Use for individual Medicare‐based providers (but not for hospitals or Medicaid‐based providers) starting in 2017.
How the MACRA Proposed Rule “Replaced” Meaningful Use
Acumen Physician Solutions [May 2, 2016]http://acumenmd.com/blog/how‐the‐macra‐
proposed‐rule‐replaced‐meaningful‐use/
Clinicians will still report on the majority of measures listed in the Stage 3 ruling but will have more flexibility.Most of the objectives have a strong focus in the areas of patient engagement, electronic access, and information exchange.
©2017/SHFF/TMLT
ACI Replaces MU ‐ But not Today!
“For the 2016 reporting period, everything remains status quo. If you do not qualify for a MU hardship exception this year, you will have to satisfactorily meet MU for the entire calendar year in order to avoid a
2018 payment adjustment.●
MACRA will begin its first surveillance year in 2017 with payment adjustments starting in 2019.
How the MACRA Proposed Rule “Replaced” Meaningful Use Acumen Physician Solutions [May 2, 2016]
http://acumenmd.com/blog/how‐the‐macra‐proposed‐rule‐replaced‐meaningful‐use/
©2017/SHFF/TMLT
Advancing Care Information: 5 Take Homes
1. Do you currently have Certified EHR technology?2. Are you confident that PHI in your practice is created, maintained and
transmitted to ensure privacy, and that you are absolutely following Best HIT Practices in ensuring the security of your information?
3. Start looking at the customizable set of measures available under ACI that best reflect how you use EHR technology in your day‐to day practice, and emphasize your interoperability and information exchange
4. Are you prepared to segue into MIPS/ACI while still concluding MU as scheduled?
5. Do you have excellent HIT support?
©2017/SHFF/TMLT
MIPS: Clinical Practice Improvement Activities
©2017/SHFF/TMLT
Clinical Practice Improvement
15% of total score in year 1●
Maximum of 60 points
For this category, MIPS would reward clinical practice improvement activities such as activities focused on care coordination, beneficiary engagement, and patient safety, which clinicians would select from a list of more than 90 options. In addition, clinicians would receive credit toward scores in this category for participating in Alternative Payment Models and Patient‐Centered Medical Homes.
©2017/SHFF/TMLT
What is CPIA?
“Unlike the other 3 MIPS categories, CPIA does not replace any current program and is a completely new concept
brought to us by CMS. ●
It is also a category with little detail and a lot of uncertainty.”
Practice Improvement Activities: The New Kid on the BlockAcumen Physician Solutions [June 13, 2016 ]
https://acumenmd.com Clinical
©2017/SHFF/TMLT
Clinical Practice ImprovementCMS includes more than 90 activities (which will be updated annually) that clinicians may choose from in the following categories:
©2017/SHFF/TMLT
Expanded Practice Access Beneficiary Engagement Achieving Health Equity
Population Management Patient Safety and Practice Assessment
Emergency Preparedness and Response
Care Coordination Participation in an APM, including a medical home model
Integrated Behavioral and Mental Health
CPIA: Lots of Unknowns
“CMS also makes it clear that the first year will be the ‘easiest’ year for CPIA. They hope to create baseline requirements the first year and then build more stringent requirements in future years, laying the groundwork for expansion towards continuous
improvement over time.”Practice Improvement Activities: The New Kid on the Block
Acumen Physician Solutions [June 13, 2016 ]https://acumenmd.com Clinical
©2017/SHFF/TMLT
●“We’ll get back to you on
that…”●
CPIA: What Is It
©2017/SHFF/TMLT
CPIA: 5 Take Homes1. Are you currently become involved in care coordination, and
documenting/billing as allowed under Medicare?2. What steps are you taking to improve beneficiary engagement, such as
utilization of your patient portal, disease‐specific support groups, maximizing community resources, and addressing satisfaction scores?
3. Are you involved in your Community Needs Assessment under the ADA with your hospital‐ and addressing equity issues accordingly?
4. How are you currently integrating behavioral and mental health into your medical practice?
5. What current practices/procedures to you have in place to address patient safety issues, and are they an actual, ongoing priority in your day‐to‐day office management?
©2017/SHFF/TMLT
MIPS: Cost
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Cost
0% of total score in year 1Begins 2018*
●Replaces the Value Modifier
Program[also known as Resource Use]*Final Rule
This category uses over 40 episode‐specific measures to account for differences among specialties. For cost measures, clinicians that deliver more efficient, high quality care achieve better performance, so clinicians scoring the highest points would have the most efficient resource use.
©2017/SHFF/TMLT
©2017/SHFF/TMLT
Cost●
For this category, MIPS calculates scores based on Medicare claims, meaning there are no additional reporting requirements for clinicians under the
cost category●
©2017/SHFF/TMLT
Cost
Each cost measure would be worth up to 10 points. Clinicians must see a sufficient number of patients in each cost measure to be scored, which is generally a minimum of a 20‐patient sample. The clinician’s cost score would be calculated based on the average score of all the cost measures that can be attributed to the clinician. For example, if a clinician only has two cost measures with sufficient patient volume to be scored, then the total number of points they could earn is 20 points. Their score will be the number of points they earned divided by the 20 possible points.
©2017/SHFF/TMLT
BUT!!!
LET ME MAKE THIS VERY CLEAR…
©2017/SHFF/TMLT
MACRA: Disrupting the health care system at every levelDeloitte Health Policy Brief
©2017/SHFF/TMLT
Cost: 5 Take Homes
1. Do you have any idea how your Medicare cost per beneficiary currently compares to your peers?
2. Do you have any idea how your Medicare cost per beneficiary currently compares to your peers?
3. Do you have any idea how your Medicare cost per beneficiary currently compares to your peers?
4. Do you have any idea how your Medicare cost per beneficiary currently compares to your peers?
5. Do you have any idea how your Medicare cost per beneficiary currently compares to your peers?
©2017/SHFF/TMLT
Agenda
Where Did MACRA Come From?MACRA: Two PathwaysWho, When, What & How Much?What To Do NOW, What To Do LATERQuestions & Answers: Discussion
©2017/SHFF/TMLT
MIPS
WHO?●
WHEN?●
WHAT?●
HOW [much]?
©2017/SHFF/TMLT
Who?
“Eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that
include such clinicians.”
Health Affairs Blog [2/29/16]http://healthaffairs.org/blog/2016/04/29/breaking‐down‐the‐macra‐proposed‐rule/
©2017/SHFF/TMLT
You may be Excluded from Participating If:
2017 is your first year participating in Medicare;
Have less than or equal to $30,000* in Medicare charges
and less than or equal to 100
Medicare patients* Final Rule
Are significantly participating in an Advanced Alternative Payment Model (APM)*
*Physicians who meet the criteria for Advanced APM incentive payments do not receive a payment adjustment under MIPS and instead receive a 5% Medicare Part B incentive payment. Clinicians who significantly participate in an Advanced APM, but do not qualify for incentive payments can choose whether to receive a payment adjustment under MIPS.
©2017/SHFF/TMLT
MIPS
WHO?●
WHEN?●
WHAT?●
HOW [much]?
©2017/SHFF/TMLT
When?
“CMS would begin measuring performance for doctors and other
clinicians through MIPS in January 2017, with
payments based on those measures beginning in
2019.”MACRA Fact Sheet
©2017/SHFF/TMLT
Final Rule: Pick Your Pace
©2017/SHFF/TMLT
©2017/SHFF/TMLT
MIPS
WHO?●
WHEN?●
WHAT?●
HOW [much]?
©2017/SHFF/TMLT
What do Clinicians Report?
Clinicians can report as an individual MIPS‐eligible clinician or as part of a group. Some data could be submitted through third‐party entities, such as
qualified clinical data registries, health IT vendors, qualified registries, and CMS‐approved survey vendors.
MACRA: Disrupting the health care system at every levelDeloitte Health Policy Brief
http://www2.deloitte.com/us/en/pages/life‐sciences‐and‐health‐care/articles/macra.html
©2017/SHFF/TMLT
Speaking of ReportingThe results of the Quality Payment Program will be publically available on the Physician Compare website to help patients make informed choices. The law requires public reporting of the following information:
©2017/SHFF/TMLT
Names of clinicians in Advanced APMs
As feasible, the names and performance of Advanced APMs
MIPS scores for clinicians, including aggregate and individual scores for each performance category.
MIPS
WHO?●
WHEN?●
WHAT?●
HOW [much]?
©2017/SHFF/TMLT
How Much is at Stake?“Providers will receive positive,
negative, or no payment adjustments depending on their performance in four categories, compared to
the average of their peers in the MIPS program.”
MACRA: QUALITY INCENTIVES, PROVIDER CONSIDERATIONS, AND THE PATH FORWARD
Leavitt Partners [December 2015]
©2017/SHFF/TMLT
Summary of Major Provisions: Payment Adjustments
As specified under the statute, negative adjustments would increase over time, and positive adjustments would correspond. The maximum negative adjustments for each year are:
2019 2020 2021 2022and after
4% 5% 7% 9%©2017/SHFF/TMLT
MIPS Payment Adjustments
“The law requires MIPS to be budget neutral. Therefore, clinicians’ MIPS scores would be used
to compute a positive, negative, or neutral adjustment to their Medicare Part B payments.”
Notice Of Proposed Rule MakingMedicare Access and CHIP Reauthorization Act of 2015
Quality Payment Program Fact Sheet
©2017/SHFF/TMLT
MIPS v. APMsMIPS
MIPS will initially place at risk up to 8% of Medicare Part B payments in 2019 that will
increase rapidly to 18% at risk by 2022.
Jon Burroughs, M.D MACRA Roadmap
FierceHealthcare Jun 15, 2016
APMsAPMs will place at risk up to 5% of Medicare Part B payments based
upon: conformance to pre‐determined quality and cost metrics, shared savings and
contractual lump sum payment incentives based upon pre‐
determined contractual targets.
©2017/SHFF/TMLT
©2017/SHFF/TMLT
MACRA: QUALITY INCENTIVES, PROVIDER CONSIDERATIONS, AND THE PATH FORWARDLeavitt Partners [December 2015]
Agenda
Where Did MACRA Come From?MACRA: Two PathwaysWho, When, What & How Much?What To Do NOW, What To Do LATERQuestions & Answers: Discussion
©2017/SHFF/TMLT
What To Do
●NOW●
●LATER●
©2017/SHFF/TMLT
Final Rule: Pick Your Pace
©2017/SHFF/TMLT
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What To Do
●NOW●
●LATER●
©2017/SHFF/TMLT
Is an APM Your Future?
1. Avoid MIPS2. Make more
money
©2017/SHFF/TMLT
MIPS Now ‐ APM Later?
“Readiness for both MIPS and APM participation will take time, but those who wish to participate in APMs need to start preparations soon if the target start date
is 2019.”
MACRA: QUALITY INCENTIVES, PROVIDER CONSIDERATIONS, AND THE PATH FORWARDLeavitt Partners [December 2015]
©2017/SHFF/TMLT
The Future
“In the first few years, we expect many physicians—especially physicians not aligned with physician group practices, IPAs, or health systems—to participate in MIPS due to lack of provider experience in APMs and current availability of eligible models. However, MIPS will likely serve as a stepping stone to encourage
providers to participate in APMs”MACRA: QUALITY INCENTIVES, PROVIDER CONSIDERATIONS, AND THE PATH
FORWARDLeavitt Partners [December 2015]
©2017/SHFF/TMLT
Agenda
Where Did MACRA Come From?MACRA: Two PathwaysWho, When, What & How Much?What To Do NOW, What To Do LATERQuestions & Answers: Discussion
©2017/SHFF/TMLT
ARS Question 1In order to be successful under MACRA
physicians must have
1. A separate staff person to coordinate2. A contract with a clearinghouse to process MACRA
claims3. A robust IT infrastructure4. A large supply of antidepressants
©2017/SHFF/TMLT
ARS Question 2Physicians must report for MIPS individually, even if they participate in a bona fide group
practice
1. True 2. False
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ARS Question 3Physicians that may be exempt from MACRA
include
1. Physicians with less than $40,000 Medicare charges2. Physicians with 100 or less Medicare patients3. “Non‐Patient facing” physicians such as Radiologists4. All of the above
©2017/SHFF/TMLT
ARS Question 4MACRA was passed
1. With strong bipartisan support2. As a replacement for the SGR3. With an affirmative vote from [now] HHS Secretary
Tom Price4. All of the above
©2017/SHFF/TMLT
ARS Question 5MIPS reporting in 2017 does not include
1. Quality measures2. Advancing Care Information3. Quality Practice Improvement4. Cost
©2017/SHFF/TMLT
Thank You!
Thank you for your attention
●Thank You TMLT
©2017/SHFF/TMLT