Getting Ready for the Post-SGR World. Presented by: Sybil R. Green, JD, RPh, MHA. West Virginia Oncology Society Spring Meeting May 5, 2016

Transcription

1 Getting Ready for the Post-SGR World Presented by: Sybil R. Green, JD, RPh, MHA West Virginia Oncology Society Spring Meeting May 5, 2016

2 CME/CE Information For Physicians: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Institute for Medical & Nursing Education (IMNE), Missouri Oncology Society (MOS). IMNE is accredited by the ACCME to provide continuing medical education for physicians. IMNE designates this educational activity for a maximum of 4.5 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity.

3 CME/CE Information For Nurses: This activity has been planned and implemented through the joint providership of IMNE, Missouri Oncology Society (MOS). IMNE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s (ANCC s) Commission on Accreditation. This educational program provides 4.5 contact hours of continuing nursing education credit.

4 Disclosure Statements It is the policy of IMNE to ensure fair balance, independence, objectivity, and scientific rigor in all programming. In compliance with the ACCME, ANCC, and ACPE it is the policy of IMNE that faculty disclose all financial relationships with commercial interests within the past 12 months. Disclosure information can also be found in the MOS Brochure on page 9

5 Program Evaluation and CME/CE Credit A completed Participant Demographic & Evaluation Form is required in order to receive your CME certificate Upon completion of these forms you will be issued a certificate of continuing education credit. If you have any questions please contact IMNE at info@imne.com

6 Financial Disclosures I have not had any relevant financial disclosures during the past 12 months to disclose

7 Off-Label Use Disclosures I do not intend to discuss an off-label product during this activity.

8 MACRA Knowledge Check How much do you know about MACRA? A. Congress and CMS are at it again B. SGR is gone C. It will impact my practice and reimbursement D. Quality and value-based services will be the new norm

9 Presentation Overview: Review SGR/SGR Appeal MACRA Goals CMS Quality Improvement Goals General Timelines and Milestones MACRA Details MIPS APMs ASCO Member Readiness

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11 MACRA MACRA MACRA MACRA

12 Built in period of stability but things are moving now Push to Alternative Payment Models Focus on Registries and QCDRs Streamlines current reporting requirements Provides some support for practice transformation

13 We Caught the Car; SGR is gone. Now What? Driving Change Quality and Value with MACRA

14 PQRS, MU, VBM continue Funding for technical assistance to practices begins Resource Use: Episode/Patient Relationship Group development Draft Measure Development Plan First annual list of MIPS quality measures released Criteria for APMs/PFPMs published Performance Year for 2019 adjustments 2019 PQRS, MU and VBM end MACRA Program begins including incentive payments 2020 Automatic.5% update ends. Update 0% 2026 v.75% update for APM;.25% for MIPS 2015 TAC Appointments RFI on implementation issues

15 Shared Purpose Better Care Experience Improved Health Lower Cost

16 So how do we get from

17 No Single Solution Evidence-based practice Efficient use of resources Quality measurement and improvement Engage and support practice transformation Innovation

18 MACRA makes three important changes to how Medicare pays healthcare providers who care for Medicare beneficiaries: Repeals the Sustainable Growth Rate (SGR) formula as a mechanism for determining Medicare payments for physicians services Establishes two payment options MIPS APM Incentivizes practice transformation

19 Merit Based Incentive Payment System Alternative Payment Models Default Composite Scoring PQRS, RU, CPIA, MU +/- 4-9% Adjustments New Delivery Models Physician Focused Payment Model 5% Payment Adjustment Quality & Value Measures

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21 Merit-Based Incentive Payment System MIPS Eligibility Scores will be publicly reported on the CMS Physician Compare website MIPS consolidates and leverages the MU, PQRS, and VBM programs The MIPS payment adjustments can be significant

22 Current Programs Physican Quality Reporting System Meaningful Use Value-Based Modifier Incentives/Penalties Sunset Dec MIPS 2019 and Beyond Merit-based Incentive Payment System Consolidates existing program Adds Clinical Practice Improvement Activity Incentives/Penalties Focuses on quality, not volume Jan Implementation

23 Category Maximum Points Quality points 50% ACI 100 Points 25% CPIA 60 Points 15% Composite Percentage Resource Use Average Score of All Cost Measures that can be attributed 10%

24 15% 25% Advancing Care Information (25%) Quality (50%) 30% Resource Use (10%) 30% Clinical Practic Improvement Activity (15%) Low Performers -9% National Median Composite Score Medicare Provider Composite Score High Performers +9% Top Performers +27%

25 APMs 5% Payment Bonus 0.75% for QUALIFYING APMs 0.25% + MIPS adjustment for NON- QUALIFYING APMS 0% Increase and MIPS Adjustments +/- 4% /- 5% /- 7% /- 9% % increase in PFS

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27 New approaches to paying for care Incentivizes quality and value Some existing models will be eligible APMs Non-qualifying APM participants get favorable MIPS scoring NEW Accountable Care Organizations Primary Care & Medical Home Models Bundled Payment Initiatives Integrated Care & Care Management PHYSICIAN FOCUSED PAYMENT MODELS (PFPM)

28 I provide services through an alternative payment model: A. Yes B. No

29 I provide services through an alternative payment model: A. Yes B. No

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31 Eligible APMs are the most advanced APMs: Base payment on quality measures comparable to those in MIPS Require use of certified EHR technology Either: (1) bear more than nominal financial risk for monetary losses; or (2) is a medical home model expanded under CMMI authority

32 Participation in an eligible (advanced) APM APM must comprise a significant share of provider revenue or patients 25% % * 75% 2023 and on * Beginning in 2021 may be Medicare revenue or revenue from Medicare and other payers (including Medicaid) Can partially qualify if close (specified in law)

33 Qualifying APM Participant (QP): participation in most advanced APM Not subject to MIPS : 5% lump sum bonus payment 2026 beyond: higher fee schedule updated NOT ALL APM PARTICIPANTS RECOGNIZED AS QPs, but most APM participants will receive favorable MIPS scoring.

34 APMs 5% Payment Bonus 0.75% for QUALIFYING APMs 0.25% + MIPS adjustment for NON- QUALIFYING APMS 0% Increase and MIPS Adjustments +/- 4% /- 5% /- 7% /- 9% % increase in PFS

35 MIPS Only MIPS adjustment APMs APM- Specific Rewards MIPS Adjustment Eligible APMs Eligible APM- Specific rewards 5% lump sum bonus Adapted from: CMS THE MEDICARE ACCESS & CHIP REAUTHORIZATION ACT OF 2015 Path to Value, MIPS-and-APMs/MACRA-LAN-PPT.pdf

36 Yes Am I in an eligible APM? Yes No Am I in an APM? Yes No Is this my first year in Medicare OR am I below the low-volume threshold? No Do I have enough patient payments? No Exempt from MIPS Subject to MIPS Yes QUALIFYING APM PARTICIPANT 5% lump sum bonus payment Higher Fee Schedule updates APM-specific rewards Excluded from MIPS Subject to MIPS Favorable MIPS scoring APM-Specific Rewards Adapted from: CMS THE MEDICARE ACCESS & CHIP REAUTHORIZATION ACT OF 2015 Path to Value, MIPS-and-APMs/MACRA-LAN-PPT.pdf

37 Some Common and Difficult Issues Inadvertently penalizing high performers Ongoing infrastructure cost/requirements not covered Attribution How to measure Outcomes Shared decision making Care coordination Resource use

38 Rulemaking on various programmatic aspects Requests for Information Proposed Rule: released April 27, 2015 Measure development plan Final MDP publication May 2, 2016 Resource Use Methodology Episodes and bundling: Draft list, Nov 2016 Patient Relationship Groups: RFI issued, comments due Aug 8, 2016 Physician Focused Payment Model Technical Advisory Committee Proposed criteria publication, Apr, 2016 Next meeting: May 4, 2016 Meaningful Use EHR Certification Standards HCPLAN APM Framework Whitepaper Clinical Quality Improvement Activity 2016

39 MACRA will transform all oncology practices in two major ways: how you conduct your Medicare reporting requirements, and how you are paid for the services you provide to Medicare beneficiaries The ultimate goal of these changes is to move toward a value-based healthcare system that ensures high-quality, affordable health care. ASCO has long embraced this goal and has dedicated significant resources that will provide you with the foundation needed Quality Oncology Practice Initiative (QOPI ); and Patient-Centered Oncology Payment Reform model

40 For the latest MACRA developments, please visit:

41 2016 Medicare Program Part B Drug Payment Model Proposed Rule

42 Part B Drug Payment Model Proposed Rule Authority: CMMI ACA Waiver authority 5 year demonstration 2 Phases Model Phase I Tests adjustment to ASP + 6% Reimbursement Begins later this year Payment Model Phase II Test various Value Based Purchasing (VBP) Begins January accessed Mar 12, 2016

43 CMS Goals Impact prescribing behavior to control Part B drug spending growth Modest shift of reimbursement from hospital and specialists with high drug costs to low drug cost specialists Consider other ways to control spending Bundled Payments Episodes of Care Modified Competitive Acquisition Program (CAP)

44 Payment Model Phase I Mandatory Participation Random assignment by zip codes Primary Care Service Area (PCSA) Proposed rate: (ASP+2.5%) Add on: $16.80 Subject to annual CPI for Medical Care Calculated from difference in drug reimbursements divided by drug days System wide revenue neutral Sequestration applied S o l v e t h i s e q u a t i o n : = 90% Fail ((ASP+2.5%) +$16.80)*2% = (ASP + 2.5%)+ (ASP +0.86% )

45 Payment Model Phase II Mandatory Participation Tests Value Based Purchasing (VBP) approaches Reference Pricing Outcomes Based Pricing Indication Based Pricing Clinical Decision support Tools Reduced Cost Sharing for Patients Bundling CAP ASP + 6% ASP + 2.5% ASP + 6% VBP Model ASP + 2.5% VBP Model

46 ASCO Proposed Arguments Phase I Patient care will be adversely impacted Disruption of patient services CMS proposal is not budget-neutral for oncology Diversion to hospitals will increase costs to system Practice consolidation likely Will eliminate funding necessary for practices to prepare for MACRA and OCM Current methodology is problematic CMS does not adequately reimburse for other services provided Proposed model exacerbates this problem Risk of incentivizing physicians to not prescribe best treatment No real opportunities to switch drugs

47 ASCO Proposed Arguments Phase II PCOP offers a more appropriate way to reimburse oncologists Pathways, QOPI, CancerLinQ and ASCOs value measures are better tools to manage care and measure quality Tools like ASCO s Value Framework and Choosing Wisely could serve as evidence-based tools used to support shared decision-making

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