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