2017 Cardiovascular Market Update

Transcription

1 Cardiovascular Roundtable 2017 Cardiovascular Market Update Aaron Mauck, Ph.D. Senior Consultant Cardiovascular Roundtable research technology consulting

2 Road Map The New Health Care Reality 3 Impact of Key Market Forces on CV Strategy Achieving Excellence in Patient-Centered CV Care 2016 Advisory Board All Rights Reserved advisory.com 33793A

3 7 Introducing the 45 th President of the United States Trump Wins in Stunning Upset Congress and Executive Branch Now in Republican Control 52/100 Senate Republicans 241/435 House Republicans Image: 2016, Chip Somodevilla/Getty Images 2016 Advisory Board All Rights Reserved advisory.com 33793A Source: Health Care Advisory Board interviews and analysis.

4 8 Value-Based Care Still Has Strong Support Commitment to Fee-for-Service Alternatives Spans Party Lines CMS Sets Timeline for Rapid Transition to Risk Bipartisan Support of Payment Reforms Reinforces Commitment 90% Target percentage of Medicare payments tied to quality or value by Senate vote in favor of MACRA House vote in favor of MACRA Where CMS Goes, Private Payers Follow 75% Percentage of payments members of Health Care Transformation Task Force will tie to value-based arrangements by 2020 August 19,2016 Moving the Needle on Health Care Transformation Bipartisan joint op-ed by former Senate Majority Leaders Tom Daschle (D-S.D.) and Bill Frist (R- Tenn.) in favor of new cardiac bundling proposal 1) Medicare Access and CHIP Reauthorization Act of Source: Burwell SM, Progress Towards Achieving Better Care, Smarter Spending, Healthier People, HHS, January 26, 2015, Health Care Transformation Task Force, Daschle T and Frist B, Moving the Needle on Health Care Transformation, The Hill, August 19, 2016; Cardiovascular Roundtable research and analysis.

5 9 The Bar for CV Programs Has Been Set Foot in Two Boats the New Normal, But No Longer an Excuse Taking Away the Luxury of Time MACRA TIMELINE Nine months to prepare Building a High-Value CV Foundation Now to Prepare for Future Mandates Offer convenient access to comprehensive services April 2016 Proposed Rule released October 2016 Final Rule released January 1, 2017 First performance period begins CARDIAC BUNDLING MODEL TIMELINE Fourteen months to prepare Deliver coordinated cross-continuum care to improve long-term outcomes Reduce waste, inappropriate utilization Contain episodic costs Provide patient-centered care July 2016 Proposed Rule released December 2016 Final Rule released October 1, 2017 First performance period begins Enhance specialist partnerships with CV service line, referring physicians Source: Cardiovascular Roundtable research and analysis.

6 Cardiovascular Market Report Key Observations on Market Trends and Impact on CV Strategy Volumes and Growth Outlook 1 2 Regulatory, payer, and consumer forces continue to spur transformation of the CV business; the shift to outpatient settings and a greater emphasis on medical management require programs to realign offerings to market demands. Healthcare consumerism is an increasingly important dynamic for CV providers; to meet the new demands of patients and referring physicians, programs must focus on access, experience, and value. Medicare Reimbursement Policy Fee-for-service payment updates are not keeping up with cost growth, demanding efficiency gains across inpatient, outpatient, and physician practice settings. Site-neutral payment threatens the economic advantage of the hospital outpatient setting, requiring programs to reassess the most attractive placement of CV services. Reimbursement is increasingly tied to longitudinal efficiency and outcomes, pressuring CV programs to expand their scope of accountability across the care continuum. Source: Cardiovascular Roundtable research and analysis.

7 Cardiovascular Market Report Key Observations on Market Trends and Impact on CV Strategy Care Delivery and Payment Transformation MACRA expedites the shift to performance-based physician payment, requiring and enabling increased hospital-specialist alignment on value-based care goals. New mandatory bundles signal a paradigm shift toward episodic payment for CV, requiring programs to accelerate building an infrastructure for episodic cost management. CMS is beginning to incentivize prevention; however, secondary prevention remains the most immediate and controllable opportunity for most CV programs. Source: Cardiovascular Roundtable research and analysis.

8 Road Map The New Health Care Reality 3 Impact of Key Market Forces on CV Strategy Achieving Excellence in Patient-Centered CV Care 2016 Advisory Board All Rights Reserved advisory.com 33793A

9 Observation #1: CV volume mix shifting to medical, outpatient services 13 An Evolving CV Growth Dynamic Demand Continues to Shift to Medical, Outpatient Services Key Market Forces Influencing CV Volumes Growing prevalence of CV disease due to patient demographics Greater regulatory oversight of appropriate site-of-service Appropriate use scrutiny Care sites shifting outpatient to meet patient access needs Population health emphasizing early diagnosis, secondary prevention to reduce readmissions Technology advancements expand minimally invasive treatment options Contemporary CV Growth Dynamics Inpatient CV services moving outpatient Shifting case mix favoring medical services over procedures De novo growth in primary, secondary prevention services Source: Cardiovascular Roundtable research and analysis.

10 14 Forces Playing Out in CV Volume Forecasts CV Five-Year Growth Projections by Sub-Service Line All-Payer, % 19% 18% 11% Inpatient Arterial Disease Inpatient Cardiac Surgery Inpatient Cardiac EP Inpatient Cardiac Cath Outpatient Cardiac Cath Inpatient Medical Cardiology Inpatient Other Vascular Outpatient Outpatient Cardiac EP Vascular Cath Outpatient Medical Vascular Outpatient Medical Cardiology (4%) (4%) (6%) (8%) (11%) (12%) (14%) Size Your Own Market Access the Regional Utilization Profiler to gain visibility into regionspecific Medicare utilization rates Access the CV Market Estimator for 5- and 10-year forecasts for CV services in your market Source: Cardiovascular Roundtable research and analysis.

11 15 Forcing CV Programs to Re-Evaluate Growth Goals Matching Service Offerings to the Changing Market Demands Choosing Your CV Program Identity DESCRIPTION PRIORITIES Comprehensive CV Center of Excellence Tertiary Care Partner Community Program Provide complete array of CV treatments Invest in niche service offerings Promote program as an early adopter of cutting-edge treatments Select COE partners for most advanced care Strengthen PCP partnerships, referral streams for traditional CV volumes Keep patients in network through optimal experience, accessible follow-up care Focus on population health, wellness, rather than high-end services Provide accessible, convenient care to enhance patient experience with upstream services Optimize downstream patient management Source: Cardiovascular Roundtable research and analysis.

12 16 Action Items for CV Leaders 1 2 Determine CV patient volumes and growth forecasts for your market to guide business development and service distribution Use the CV Market Estimator to view market-specific estimates of inpatient and outpatient CV services over the next five to ten years Use the Regional Utilization Profiler to gain visibility into market-specific Medicare utilization rates Read New CV Volume Forecasts Explained for a detailed explanation of the barriers and inducements to growth across CV sub-service line Enhance CV service line oversight of outpatient sites providing an increasing level of care for your patients Review the Toolkit for Optimizing CV Organization and Leadership Structures for examples of integrating ambulatory services into the reporting structure 3 4 Improve access to upstream CV services to strengthen downstream market capture of advanced procedures Read Guide for Assembling the Accessible CV Network to learn best practices to optimize geographic reach and enhance outpatient availability Rightsize your CV service offerings to meet the changing demand in your market Read Realigning CV Service Distribution for best practice strategies Access our implementation tools for rightsizing your CV service portfolio, including a CV services site audit and redistribution guide, consolidation readiness self-assessment and partnership and affiliation diagnostic Source: Cardiovascular Roundtable research and analysis.

13 Observation #2: Health care consumerism impacting referral decisions 17 Patient Consumerism Still Not Full Force in CV Limited Influence on Provider Selection for High-Cost CV Treatments Key Drivers of Patient Consumerism Increasing Responsibility for Costs Growing prevalence of HDHPs 1 Greater out-of-pocket responsibility for patients Acclimation to Retail Experience Growth in accessible retail clinics Raising consumer expectations for access, convenience, service Impacting CV Services Unevenly Influence of Factors on Patient Care Decisions for CV Services Convenience, patient access Cost UPSTREAM DIAGNOSTICS ADVANCED PROCEDURES 1) High deductible health plans. Greater Transparency New tools offer access to cost, quality, experience data Influencing patient choice of hospital, physician Quality Physician referral Source: Cardiovascular Roundtable interviews and analysis.

14 18 Physicians Still Largely Driving CV Referrals But Referring Physicians Are Changing Their Expectations, Too 86% Percentage of CV specialist referrals that are physician-driven versus self-referrals 1 Care Innovations Increasing Focus on Quality, Value in Specialist Referrals Case in Point: ACO Physicians Developing Preferred Networks Suggestions for ACOs to Influence Referrals Distribute lists of preferred providers for referrals based on cost, quality, and patient-centered outcomes Encourage shared decision making about referrals ACOs Patient-centered medical homes MACRA Provide individual feedback on referral performance to both referring physicians and specialists Provide financial bonus to referring clinicians on the basis of referral patterns 1) Online survey of 12,610 patients who had specialist appointments in the past 12 months. Source: 2015 Marketing Innovation Center Specialist Consumer Choice Survey; Decamp M et al., Guiding Choice Ethically Influencing Referrals in ACOs, New England Journal of Medicine, 372, no.3 (2015): ; Cardiovascular Roundtable research and analysis.

15 19 Appealing to the New Consumer Demands Patients, Referring Physicians Have Similar Expectations of CV Patient and Referrer Expectations Convenient Access Long-Term Quality Positive Experience High Value Expanded capacity Convenient sites Geographic reach Timely availability for appointments High-quality care Cross-continuum coordination Exceptional longitudinal outcomes Information continuity Care coordination Personalization Patient experience Referring physician communication Competitive unit prices for upstream services Total cost management Source: Cardiovascular Roundtable research and analysis.

16 20 Action Items for CV Leaders 1 Strengthen partnerships with referring physicians through demonstrating care value, patient experience, access, and service standards Read Enhancing CV Specialist Partnerships with Primary Care for strategies and implementation tools to improve relationships with PCPs and hardwire referral streams 2 Increase accessibility and convenience of CV services for patients, particularly for upstream diagnostics and ambulatory care sites Read Bolster CV Presence at Patient Entry Points for strategies to collocate CV staff and specialists with key referring providers to increase patient capture Read Redesigning the CV Clinic Schedule for best practices to improve access and availability of outpatient services 3 Focus on improving the patient experience to keep patients loyal and within the network, and to attract new patients Read Optimizing the CV Patient Experience for successful patient engagement strategies across the continuum Source: Cardiovascular Roundtable research and analysis.

17 Observation #3: Meager payment updates require efficiency gains 21 CMS Kicking the Legs Out From FFS Reimbursement Not Keeping Pace with Costs CV Facing Meager Payment Updates Medicare Payment, 2017 Versus % 1.4% Cardiovascular 1 0.0% 0.0% Vascular Surgery Cardiac Services Vascular Services -0.2% Cardiology Cardiac Surgery -1.0% INPATIENT OUTPATIENT PHYSICIAN FEE SCHEDULE Access a complete list of 2017 payment updates on the online resource page 1) Coding changes make it difficult to accurately parse out outpatient cardiac and vascular as separate services. Source: CMS; Cardiovascular Roundtable research and analysis.

18 Coding Freeze 22 ICD-10 Has Landed Greater Complexity Makes Coding Diligence All the More Important The Transition to ICD-10 FY 2017 Brings Significant Coding Updates to CV October 2011 Last regular annual updates to codes, freeze begins October 1, 2015 ICD-10 implemented 97% Percent of FY 2017 inpatient procedure code changes that are CV Select CV Coding Changes 3,549 Number of CV code changes October 1, 2016 Resumed regular updates to ICD-10 codes for FY Coronary arteries now identified by number of 2 arteries treated vs. specific sites Added codes to indicate when multiple stents are used on a single coronary artery lesion Prepare Your Team for Success Under ICD-10 Access general equivalence maps for ICD-9 to ICD-10 conversions Review the ACC s ICD-10 resources for CV programs us to learn more about Advisory Board s revenue optimization solutions Source: CMS; Cardiovascular Roundtable research and analysis.

19 23 Key CV Technology Payment Updates (Cont.) New Technology Add-On Payments Approved and Removed for FY 2017 NEW ADD-ONS CONTINUING ADD-ONS DISCONTINUED ADD-ONS Idarucizumab 1 Maximum add-on: $1, GORE EXCLUDER Iliac Branch Endoprothesis Maximum add-on: $5, CardioMEMS HF Monitoring System Maximum add-on: $8, LUTONIX Drug-Coated Balloon Percutaneous Transluminal Angioplasty Catheter Maximum add-on: $1, IN.PACT Admiral Paclitaxel Coated Percutaneous Transluminal Angioplasty Balloon Catheter Maximum add-on: $1, MitraClip System MitraClip will reach the three-year mark in the first half of FY 2017 and will no longer meet the new technology criteria 1) First FDA-approved NOAC reversal agent for dabigatran. Source: CMS FY 2017 Inpatient Prospective Payment System Final Rule; Cardiovascular Roundtable research and analysis.

20 24 Short-Stay Scrutiny Intensifies in 2017 Two-Midnight Rule Here to Stay, NOTICE Act Goes into Effect! CMS Removes Payment Adjustment Associated with Two-Midnight Rule In 2014, CMS projected Two-Midnight Rule would lead to a national increase of 40,000 inpatient cases, introduced inpatient payment cuts as a balance Inpatient volumes did not increase as anticipated, stayed relatively even For FY 2017, CMS removing 0.2% annual cuts and introducing a one-time retrospective payment But the Two-Midnight Rule Hasn t Gone Away This update does not impact the actual two-midnight admissions standard, and CMS has upheld the rule for FY 2017 MOON 1 Form Supports Implementation of NOTICE 2 Act NOTICE Act requires hospitals to notify patients in observation care >24 hours Ensures patients understand implications on financial obligations, PAC 3 eligibility Hospitals must use a standardized MOON form to convey this notice Final version of MOON form available online at cms.gov 1) Medicare Outpatient Observation Notice. 2) Notice of Observation Treatment and Implication for Care Eligibility. 3) Post-acute care. Source: CMS Standard Analytical Files (SAF) Claims; CMS; Cardiovascular Roundtable research and analysis.

21 25 Action Items for CV Leaders 1 2 Determine what you ll be paid in 2017 based on CMS reimbursement updates Visit the registration desk for a complete list of FY 2017 reimbursement updates Access the APC Rate Calculator for CMS s latest hospital outpatient payment rate updates adjusted to your local market Access the Customized Medicare Inpatient Payment Assessment for a estimate of the impact on your hospital s inpatient Medicare reimbursement based on CMS s latest rule Improve operational efficiency to maintain margins despite softening reimbursement updates Use the Hospital Benchmark Generator to see how your organization's performance on finance, quality, and utilization metrics stacks up against your peers Read The Highly Productive CV Enterprise for best practices on improving CV efficiency 3 Understand coding changes for FY2017 and engage your physicians and coders in ensuring accurate documentation for optimal revenue capture Review updated general equivalence maps (GEMs) Share ACC s ICD-10 resources with your team 4 Optimize short-stay patient triage in light of heightened inpatient payment scrutiny Use the Two-Midnight Rule Impact Assessment tool to identify Medicare cases at your facility that potentially fall short of CMS's "two-midnight" admission threshold and may be at risk for auditing Read Perfecting CV Short-Stay Patient Management for tactics to optimize short-stay ED and observation cases and improve efficiency Source: Cardiovascular Roundtable research and analysis.

22 Observation #4: Site-neutral payments changing the financial outlook for outpatient services 26 Congress First to Move on Site-Neutral Payments Addressing Discrepancy in Hospital, Office-Based Outpatient Payments Budget Deal Modifies Payment for Hospital-Owned Physician Practices Bipartisan Budget Act of 2015 Limits hospital-owned off-campus practices from billing on higher HOPPS 1 fee schedule Beginning January 1, 2017, these practices will have to bill on lower fee schedule CMS s 2017 HOPPS Final Rule Implements Law Affected sites will bill on new MPFS site-specific rate for 2017 MPFS site-specific rate set at 50% of HOPPS payment CMS aims to devise a new method of payment for subsequent years 1) Hospital Outpatient Prospective Payment System. 2) Medicare Physician Fee Schedule. Impacts Sites Meeting All Three Criteria: Hospital-owned practices designated as off-campus, provider-based sites Acquired or opened after November 1, 2015; includes sites mid-build or built but not yet seeing patients at that date Located more than 250 yards from hospital s main campus Exemptions for Any of These Criteria: Outpatient facilities billing on HOPPS 2 prior to November 1, 2015 Located less than 250 yards from hospital s main campus All emergency department services, even if not emergent Source: H.R Bipartisan Budget Act of 2015; CY 2017 Hospital Outpatient Prospective Payment System Final Rule, CMS; Cardiovascular Roundtable research and analysis.

23 27 Medicare Facility Payment Halved for Impacted Sites Site-Neutral Policy Takes Shape; Further Adjustments Possible by 2017 Billing, Payment Changes for Impacted Sites in 2017 Impacted sites required to use modifier on claims Reimbursed for all services on site-specific MPFS rate set at 50% of HOPPS payment Modifier PN required on all claims for services provided at impacted sites Sites should continue billing via the Outpatient Code Editor currently used for HOPPS reimbursement Two Other Notable Components of Policy As law mandates that impacted site cannot bill on HOPPS, CMS established site-specific MPFS rates for this policy To set rates, CMS analyzed top 25 procedures performed at offcampus HOPDs 1, comparing HOPPS and MPFS 2 rates, and found a 45% average difference in payment Despite MPFS name, site-specific MPFS rates will incorporate HOPPS policies, e.g. C-APCs and packaging 8 of the top 25 were diagnostic imaging 1 This is an interim final rule with comment period meaning that changes could be made for 2017 Comment by December 31, Site-specific MPFS payment rates are exclusively for this policy meaning that these rates will not apply to neither professional payments nor other sites billing on MPFS 1) From claims with mandatory PO modifier in ) Non-facility technical component The Advisory Board Company advisory.com A Source: CY 2017 Hospital Outpatient Prospective Payment System Final Rule, CMS; Cardiovascular Roundtable research and analysis.

24 28 Likely Not the Last We ll Hear of Payment Leveling CMS Signaling Potential Future Expansion of Site-Neutral Payments Exempted Sites Could Lose Ability to Bill on HOPPS 1 Through: Site Acquisition Facility Relocation 1 Office Extension CMS Collecting Site-of-Service Data January 2016 Mandatory reporting of site-of-care modifiers for hospitals and physician practices begins CMS using data to identify sites that receive hospital-based outpatient rates but are off-campus Looking to the Future Exempted Sites May Continue to Bill on HOPPS Even If: Services Expanded Facility Relocated due to Extraordinary Events (e.g., Natural Disasters) CMS may look to more widespread rollout of site-neutral payments Opportunity for greater impact through: - Expanding to practices grandfathered in from current Budget deal - Further levelling payment rates, beyond the site-specific MPFS rate of 50% of HOPPS Source: MedPAC, CY 2017 Hospital Outpatient Prospective Payment System Final Rule, CMS; H.R Bipartisan Budget Act of 2015; Cardiovascular Roundtable research and analysis.

25 29 Requiring a New Outpatient Strategy Changing Our Assumptions on Physician Acquisition, Service Placement Yesterday s Strategy Today s Strategy Physician practice acquisition viewed financially attractive due to ability to repatriate ancillaries onto higher HOPPS fee schedule Strategically place services to be most accessible to patients CV diagnostic services often provided in setting that offered higher payment Direct volumes to lower-cost sites to be attractive to payers 72% Percentage of CV programs that repatriated and converted CV imaging services to HOPD after acquiring a physician practice, in Shift lower-acuity volumes to physician offices to allow greater access to hospital-based care for higher-end care needs 1) Of respondents to 2012 Cardiovascular Roundtable member benchmarking survey. Source: 2012 Cardiovascular Roundtable CV Imaging Benchmarking Survey; Cardiovascular Roundtable research and analysis.

26 30 Action Items for CV Leaders 1 Reassess your current outpatient service distribution in light of site-neutral payments, and consider placing services based on cost and patient access versus legacy payment differentials Read our FAQ on Site-Neutral Payments for additional information on the legislation and potential impact Read Redistribute CV Imaging Services to Align with Institutional Goals for tactics and implementation advice on appropriate service placement 2 Evaluate potential physician practice acquisition based on value-based measures rather than ability to repatriate ancillaries and convert to higher HOPD payment Read Maximizing the Value of CV Specialist Integration for strategies to evaluate potential physician partners Source: Cardiovascular Roundtable research and analysis.

27 Observation #5: Reimbursement increasingly tied to cross-continuum value 31 CMS Upping the Ante on Episodic Efficiency New P4P 1 Metrics Continuing to Shift Focus from Process to Outcomes Value-Based Purchasing FY 2021 Added: AMI 2 30-Day Episodic Payment HF 30-Day Episodic Payment FY 2022 Added: CABG 30-Day Mortality Inpatient Quality Reporting FY 2019 Added: Aortic Aneurysm Procedure Clinical Episodic-Based Payment Measure FY 2019 Removed: AMI-2 Aspirin at discharge AMI-7a Fibrinolytic therapy within 30 minutes arrival AMI-10 Statin at discharge VTE-3 Anticoagulation overlap therapy VTE-4 Unfractionated heparin VTE-5 Venous thromboembolism discharge instructions VTE-6 Potentially preventable venous thromboembolism 1) Pay-for-performance. 2) Acute myocardial infarction. In addition, we are considering adopting a scoring methodology for a future program year that would assess quality measures and efficiency measures in tandem to produce a composite score reflective of value - CMS, FY 2017 Inpatient Final Rule Source: CMS; Cardiovascular Roundtable research and analysis.

28 32 CABG Readmissions Penalties Have Arrived Requiring Programs to Expand Readmissions Reduction Efforts Conditions Included in HRRP 1 HF COPD AMI THA/TKA Penalties Continue to Increase Average Penalty per Hospital 2 Maximum penalty = 3% 3% 2% Pneumonia CABG 1% 0.42% 0.38% 0.63% 0.61% 0.73% Majority of Hospitals Still Face Penalties 0% FY 2013 FY 2014 FY 2015 FY 2016 FY % Percentage of eligible hospitals receiving readmissions penalties in FY 2017 Uptick in total penalties attributed to new CABG measure and expanded pneumonia measure cohort 1) Hospital Readmission Reduction Program. 2) Penalty applies to all Medicare payments. Access the CV Procedural Readmissions Reduction Toolkit for cross-continuum strategies to reduce CABG readmissions Source: CMS; Cardiovascular Roundtable research and analysis.

29 33 Action Items for CV Leaders 1 Know how your CV program is performing on CMS pay-for-performance metrics Use the Pay-for-Performance Customized Assessment to view your organization s estimated VBP, HAC 1, and readmissions performance Use the Hospital Benchmark Generator for instant access to custom Medicare benchmarks for financial, operational, and quality metrics 2 Take our readmissions diagnostic to identify your program s strengths and areas of opportunity for coordinating CV care across the continuum CV Readmissions Reduction Strategy Audit 3 Develop a comprehensive readmission reduction strategy for CV patient populations Access the Medical Readmission Reduction Toolkit for best practices and implementation resources to develop a comprehensive readmission reduction strategy for CV medical patients (e.g., AMI, HF) Access the CV Procedural Readmission Reduction Toolkit for cross-continuum strategies to reduce CV procedural readmissions (e.g., CABG, PCI) 1) Hospital acquired condition. Source: Cardiovascular Roundtable research and analysis.

30 Observation #6: MACRA a dramatic shift to risk-based physician payments 34 MACRA Replaces Flawed Sustainable Growth Rate Final Rule Accelerates the Shift to Performance-Based Physician Payment Two Physician Payment Tracks Under New Quality Performance Program 1 Merit-Based Incentive Payment System (MIPS) Consolidates existing quality programs 1 into one budget-neutral pay-forperformance program Providers will be scored on quality, cost, clinical practice improvement, EHR 3 use Annual adjustment of +/- 4% based on performance starting in 2019; increases to +/- 9% in Advanced Alternative Payment Models (APMs) Requires physicians have significant share of revenue in APM contracts with two-sided risk Provides 5% annual participation bonus , exemption from MIPS Eligible APMs must involve downside risk, quality measurement 1) Meaningful Use, Value-Based Payment Modifier, and Physician Quality Reporting System. 2) Electronic Health Record. 5-8% Clinicians currently projected to qualify for APM track in 2017 Source: CMS, CY 2016 Physician Fee Schedule Final Rule, Oct 30, 2016, Cardiovascular Roundtable research and analysis.

31 MACRA a Dramatic Shift to Risk for Physicians (Cont.) 35 MACRA in Brief Legislation passed in April 2015 ending the Sustainable Growth Rate (SGR) formula, which threatened significant physician payment cuts for 13 years Final rule released in October 2016 with program starting January 1, 2017 Implements the Quality Payment Program (QPP), consisting of two new Medicare payment tracks that eligible clinicians will fall into: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) Holds physician payment updates relatively flat for 2016 onward, with payment bonuses/penalties applied based on track and performance Providers are required to participate in MACRA if they: Bill Medicare more than $30,000 per year or provide care for more than 100 Medicare patients a year, AND Are a physician, PA, NP, clinical nurse specialist, or certified RN anesthetist Represents a significant move to increase pay-for-performance and risk models for physicians Source: CMS, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, October 14, 2016; Cardiovascular Roundtable research and analysis.

32 36 Payment Updates, Bonuses Dependent on Track Providing Incentive for Physicians Taking on Greater Risk Through APMs Annual Baseline Physician Payment Updates Under MACRA MIPS vs. AAPM Tracks 0.5% 0.5% 0.0% 0.0% 0.25% 0.75% Onward MIPS AAPM Additional Bonuses/Penalties MIPS Track +/-4% +/-9% $500M APM Track 5% +/- Annual adjustment in 2019 Annual adjustment in 2022 Additional bonus pool for high performers Annual lump-sum bonus from Bonuses/penalties from Advanced Payment Models themselves Source: The Medicare Access and CHIP Reauthorization Act of 2015; CMS, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, October 14, 2016; Cardiovascular Roundtable research and analysis.

33 37 MIPS Enhancing Pay-for-Performance Payment Based on Performance Across Four Categories Category Quality Advancing Care Information Improvement Activities Cost/ Resource Use Key Takeaways for CV Choose six quality measures to report, including an outcome measure, for at least 90 days >200 measures, 80% specialty-specific (e.g., cardiac, EP, thoracic, vascular surgery) Replaces pay-for-reporting with pay-for-performance May increase required outcome measures in future Report on five measures, with additional credit for optional measures No longer requires all-or-nothing EHR measure Attest completion of four clinical practice improvement activities for at least 90 days Over 90 activities to choose from Will not count toward performance until 2018 Includes total per capita cost and Medicare spending per beneficiary Adds ten episode-based measures, including aortic/mitral valve surgery and CABG Claims-based, no reporting required Category Weight Over Time By Performance Measurement Year 15% 10% 15% 25% 25% 60% 50% 30% 15% 25% 30% Cost/Resource Use Improvement Activities Advancing Care Information Quality Explore the measures in more detail at qpp.cms.gov Source: CMS, MIPS and APM Incentive under the PFS, and Criteria for Physician-Focused Payment Models, October 14, 2016; Cardiovascular Roundtable research and analysis.

34 38 Relatively Positive Performance Outlook for CV CV Positioned to be Comparatively More Successful Under MACRA 83% Strong History of Physician Alignment of Cardiovascular Roundtable members engaged in employment or co-management with at least one CV physician group CV a Familiar Target for Quality Measures MIPS Final Rule Estimated Payment Impact on Select Specialties for 2019 Payment Year 1 Provider Type Percent Eligible Clinicians with Positive or Neutral Payment Adjustment Percent Eligible Clinicians with Negative Payment Adjustment ALL 94.7% 5.3% Hospital-based VBP includes AMI, HF 30-day mortality rates AMI, HF 30-Day payment and excess days metric reporting 50% Pay-for-Performance Participation of the six conditions included in the HRRP for FY 2017 are CV-related 1) Standard participation assumptions; scoring model assumes that a minimum of 90% of clinicians within each practice size category would participate in quality data submission. Cardiology 95.0% 5.0% General Practice 90.0% 10.0% General Surgery 94.5% 5.5% Neurology 94.3% 5.7% Radiology 95.3% 4.7% Thoracic/Cardiac 97.5% 2.5% Vascular Surgery 94.5% 5.5% Source: 2014 Cardiovascular Roundtable Physician Alignment Benchmarking Survey; CMS, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, October 14, 2016; Cardiovascular Roundtable research and analysis.

35 39 A High Bar for Advanced APM Track Most Providers Will Not Qualify in Year One 1 2 Participate in qualifying advanced APM with downside risk Meet threshold of payments or patients covered through the APM: 1) Medicare Shared Savings Program. 2) End-stage renal disease. Criteria for Clinicians to Qualify for Advanced APM Track performance year: 25% of Medicare payments or 20% of patients through advanced APM - Thresholds increase beginning in 2019 Eligible Advanced APMs FOR 2017 PERFORMANCE YEAR MSSP 1 Tracks 2 and 3 Comprehensive Primary Care Plus Next-Generation ACO Model Comprehensive ESRD 2 Model Oncology Care Model (Two-Sided Risk) FOR 2018 PERFORMANCE YEAR MSSP Track 1+ New voluntary bundled payment model CJR Certified Electronic Health Record Technology (CEHRT) track Cardiac EPMs Track 1 (CEHRT track) Excluded APMs Bundled Payments for Care Improvement MSSP Track 1 Source: CMS, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, October 14, 2016; Cardiovascular Roundtable research and analysis.

36 40 Three Avenues to Report Performance Data Group Reporting Options Require Collaboration on Similar Goals REPORTING LEVEL OPTIONS STAKEHOLDER IMPLICATIONS Accountable Care Organization (ACO) Taxpayer ID Number (TIN) Hospital Physician Group All clinicians participating in an ACO will receive the same MIPS/APM score and the same payment adjustment If specialists participate in multiple ACOs, CMS will apply the highest APM entity score If clinicians are employed, hospital is responsible for performance under MACRA Providers in multispecialty practices reporting at the group level must all choose the same metrics to report Individual Provider Clinicians can choose specific CV metrics to report from the following categories: - Cardiac - EP - Thoracic - Vascular Surgery All CV-specific MIPS quality metrics available at qpp.cms.gov Source: CMS; Cardiovascular Roundtable research and analysis.

37 41 MACRA Driving Alignment from Both Directions Hospital and Physician Incentives Become More Aligned Under New Model Physician Practices Considering Employment Hospitals Becoming More Strategic About Partnerships Cost, administrative burden of MACRA will be harder for smaller physician practices to adopt Hospitals employing physicians will be accountable for physician performance under MIPS 67% Many practices considering partnering with health systems Gain access to EHR, reporting infrastructure without large upfront investment Protection from negative financial implications of poor performance of small physicians groups 1 foresee the end of their independence due to MACRA Institutions likely to be more selective in contractual alignment with physicians based on MACRA performance Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA 1) Out of 1,300 physician groups of 5 clinicians. Source: Black Book Market Research, May 2016 Survey Report; Cardiovascular Roundtable research and analysis.

38 42 Not Much Time to Prepare The First Performance Period Has Begun MACRA Implementation Timeline First Performance Period for MIPS, APM (Impacts 2019 Payment) Notification of Track Assignment First Payment Adjustment Year (Based on 2017 Performance) Final Rule Released October 14 th Jan. 1-Dec. 3 Transition year with flexible options for MIPS; can delay collecting data until Oct. 2 Providers may not know which track they will be in when reporting in 2017 Must submit data by March 31, 2018 Medicare will provide performance feedback on 2017 data Positive and negative payment adjustments for MIPS distributed Jan. 1 AAPM participants in 2017 could earn a 5% incentive payment in 2019 Preparation for MACRA Cannot Happen Overnight EHR optimization Strong physician partnership on value-based goals Aligned physician incentives, performance metrics Source: CMS, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, October 14, 2016; Cardiovascular Roundtable research and analysis.

39 43 CMS Announces Pick Your Pace MIPS Flexibility Three Options For 2017 Transition Year, But You Must Participate % 0 +% +% Don t Participate Submit Something Submit Partial Year Submit Full Year Not participating in the Quality Payment Program: If you do not send in any 2017 data, you will receive a -4% payment adjustment Test: If you submit a minimum amount of 2017 data to Medicare (e.g., one quality improvement measure), you can avoid a downward payment adjustment Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment Full: If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment Flexibility on Program Start Date JAN OCT 1 2 Programs can start collecting performance data anytime between January 1 and October 2, 2017 Programs have to send in 2017 performance data by March 31, 2018 Source: CMS, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, October 14, 2016; Cardiovascular Roundtable research and analysis.

40 44 Action Items for CV Leaders Make sure you and your team understand MACRA, which track your program will likely fall into for the first year, and what metrics you will be held accountable to Watch our webconference MACRA: How the Final Rule Impacts Providers for a detailed review of the framework CMS plans to use to implement MACRA in 2017 and how providers should respond Access qpp.cms.gov for additional information on the Quality Payment Program Review and select metrics for MIPS in the QPP measures tool Focus on improving quality now as 2017 performance will impact your opportunity for payment in 2019 Read The New Economics of Quality to learn best practices to enhance the value of CV services through evidence-based practice appropriate care delivery Strengthen alignment with physicians to meet the value-based measures and succeed under MACRA Read Design Effective Physician Compensation Models for guidance on developing incentive models that align with CV service line goals, including measurements under MACRA, as well as benchmarks on incentive models Read Integrate the Service Line and Affiliated Groups to develop strategies for partnering and engaging in performance improvement Source: Cardiovascular Roundtable research and analysis.

41 Observation #7: Mandatory cardiac bundling demands episodic cost management 45 Doubling Down on Bundled Payments Mandatory Cardiac Bundling Rule the Latest Move Toward Episodic Value Major Recent CMS Risk Model Initiatives April 2016 CJR 1 introduces mandatory bundling for THA/TKA 2 in 67 markets across the country June 2016 OCM 3, a physicianled episodic oncology care demo, begins December 2016 CMS finalizes three new EPMs 4 for hip and cardiac episodes 1) Comprehensive Care for Joint Replacement Model. 2) Total hip/total knee arthroplasty. 3) Oncology Care Model. 4) Episodic payment model. An Overview of the Two CV Episodic Payment Models Coronary Artery Bypass Graft (CABG) Episode Timeframe Acute Myocardial Infarction (AMI) MS-DRGs MS-DRGs ; Includes AMI treated both medically and with PCI Index hospitalization to 90-days post-discharge Accountable Stakeholders Does not include elective PCI Hospitals selected for inclusion in the model financially responsible for both cost and quality of the entire episode Implementation Timeline Year 1 pushed to begin October 1, 2017, may be pushed again to January 1, 2018 no downside risk Downside risk begins in Year 3, with optional downside risk in Year 2 Will run for five years Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

42 46 Participants Have Been Chosen Hospitals in 98 Markets Randomly Selected for Mandatory Participation Key Elements of Cardiac EPM Market Selection 98 markets chosen randomly from 284 eligible MSAs across the country Eligible MSAs had more than 75 AMIs per year, more than 75 non-bpci AMIs per year, and at least 50% of non-bpci AMIs per year MSAs where there is no CABG were still be eligible for inclusion AMI and CABG episodes are implemented together Hospitals participating in BPCI Models 2 or 4 for EPM CABG/AMI MS-DRGs are excluded from the EPM model for those DRGs for as long as they are participating in BPCI 1 1,120 hospitals included in selected MSAs for cardiac bundles Even if your institution does not perform CABG or PCI, if your MSA is selected for inclusion you are still included in the model and are responsible for AMI care episodes Complete list of selected institutions is available here 1) E.g., if in BPCI Model 2 for CABG but not AMI, will still have to participate in the AMI EPM. Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

43 47 Breaking Down Bundling CMS Using Retrospective Reconciliation to Adjust Hospital Payments Hospital Payment Process Under Cardiac EPMs Fee-for-Service Billing Comparison to Target Providers (e.g., acute hospital, physicians, PACs) receive FFS payment as usual; CMS tracks claims Total costs compared to quality-adjusted target price based on historic claims Payment Reconciliation If over target, hospital repays CMS; if under, receives reconciliation Target Price a Blend of Regional and Facility Historic Claims Data Target price based on 3 years of historic claims, updated bi-annually Target price a blend of hospital and regional claims For years 4 and 5, only regional data will be used Each MS-DRG included in the EPMs will have its own target price 1) For those programs looking to qualify for the APM track under MACRA. Phases in Upside and Downside Financial Risk Final rule delays downside risk to year 3, with option for risk in Year 2 1 Downside risk phases in to 20% of target price by Year 5 Partial upside risk in Year 1, phased to 20% of target price by Year 5 Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

44 48 Calculating Repayment or Reconciliation CMS Will Get Their Cut No Matter What Episodic Target Price a Discount of Historical Average Target price reflects a 3% discount from historical average, plus adjustment based on hospital s quality performance Quality-Adjusted Target Price Repayment to CMS Episodic Spending Under EPM Episode 1 Reconciliation from CMS Episode 2 CMS Capping Gains and Losses 1 Year 1 Year 2 Year 3 Year 4 Year 5 Stop Gain Threshold on Reconciliation (payment from CMS) 5% 5% 5% 10% 20% Stop Loss Threshold on Repayment (payment to CMS) No Repayment 5% (Voluntary Downside Risk) 5% 10% 20% 1) Stop losses/gains based on percentage of the target price. Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

45 49 Taking a Long View of Patient Care EPMs Track Costs, Outcomes for 90 Days Post-Discharge EPM Episode and Included Services Anchor Hospitalization 1 Episode Trigger Select Related Services Included in EPM Inpatient services Outpatient services Related readmissions Clinical lab services Outpatient cardiac rehab Physician services Post-acute care (LTACH, IRF, SNF, home health) Other part A and B covered services (DME 2, part B drugs, hospice, etc.) 90 Days Post-Discharge Episode Ends Only Related Services Included Readmissions and costs incurred that are unrelated to the initial EPM diagnosis will not count against the bundle EPM model parameters including list of excluded DRGs available at cms.gov 1) For either eligible CABG or AMI MS-DRGs. 2) Durable medical equipment. Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

46 50 Key Opportunities to Succeed Under Bundling Episodic Cost Management Requires a Comprehensive Strategy Percentage of Total Costs Attributed to Each Setting Across 90-Day Episode National Average, Medicare, 2015 Immediate Opportunities for CV Leaders CABG AMI with PCI 4% 6% 11% 3% 7% 14% 10% 7% 76% 62% Index Admission Maximize Post-Acute Care Collaboration Improve Performance Against Quality Metrics Optimize Inpatient Operational Efficiency to Sustain Margins AMI Treated Medically 35% 10% 27% 22% 6% Physician Readmission PAC 1 Outpatient Access the Care Coordination Episode Profiler for average episodic costs specific to your institution 1) Post-acute care. Source: Cardiovascular Roundtable research and analysis.

47 51 PAC Partnerships Critical for Success EPMs Hold Hospitals Accountable for Quality, Cost in Post-Acute Settings Outsized Opportunity to Reduce Unnecessary PAC Spending Percentage of Geographic Variation in Medicare Spending Attributed to Each Area of Spend 1 73% Key Opportunities to Maximize Post-Acute Care Collaboration Discharge patients to appropriate setting Identify high-value preferred PAC providers 27% 14% 14% 9% Develop and share post-acute care pathways Post-Acute Care Acute Care Procedures Diagnostic Prescription Tests Drugs Provide support for PAC performance improvement, readmissions reduction PAC accounts for three quarters of the geographical variation in the total Medicare spending Best practices to optimize PAC collaboration available in the Playbook for CV Episodic Cost Management 1) Among Dartmouth Atlas of Healthcare Hospital Referral Regions, Source: Newhouse JP, et al., Variation in Health Care Spending; Institute of Medicine of the National Academies, 2013; United States Senate Committee on Finance, Press Release, June 2013; Cardiovascular Roundtable research and analysis.

48 52 CMS Provides Options to Partner and Gainshare Ability to Develop Preferred Partnerships with PAC Providers 1) Under the EPM, some ACOs are permitted to be formal partners and do not have to directly furnish billable services. CMS allows EPM hospitals to enter into financial arrangements with other providers (e.g., PACs, physician groups, ACOs) Providers must have directly furnished a billable item or service to a hospital s EPM beneficiary 1 To share financial risk, must have established a sharing arrangement before services are rendered Hospital may only share funds from internal savings or portions of final reconciliation/repayment within limits specified by CMS Gainsharing payments cannot be based on referrals/patient volumes; must be partly based on quality metrics set by the hospital Rule Maintains Protections on Patient Choice of Post-Acute Provider Hospitals May: Include objective data (e.g., Nursing Home Compare) on facility list distributed at discharge Point out a facility s high quality performance without making an explicit recommendation List providers with shared financial interests/partnerships, so long as patients are made aware of ties Hospitals May Not: Explicitly recommend a facility Omit facilities from the list that are within the patient s chosen geographic area Not charge fees from PAC partner to be on a preferred list, nor accept these payments Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

49 53 Quality More Important Than Ever Bundling May Emphasize Cost, but Quality Also Essential for Success Both Cost and Quality Determine if You Get Money Back from CMS 1 2 Quality Metrics Included: CABG 30-day mortality STS Composite CABG voluntary data submission Hospital HCAHPS 1 score Episode payment must be below target price for EPM EPM quality composite score determines discount amount and eligibility for reconciliation payment AMI 30-day mortality Excess days Hybrid AMI mortality voluntary data Hospital HCAHPS score Quality-Adjusted Discount Factor Eases Episodic Spending Pressure Threshold price Programs performing well on quality measures have an increased episodic spending threshold Without Quality Bonus With Quality Bonus Hospitals Must Meet Minimum Quality Standard for Payment Discount up to 1.5% of historic spending in Year 5 If hospitals come in below target price but do not achieve at least acceptable rating, they will not be eligible for reconciliation payment. 1) Hospital Consumer Assessment of Healthcare Providers and Systems survey; not DRG-specific. Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

50 54 Focus on Operational Efficiency to Preserve Margins Hospitals Can Gainshare on Internal as Well as Episodic Cost Savings Eligible Funds to Use for Physician Alignment Payments Under EPMs 1 Reconciliation Payments Performance-based payment from reconciliation earned through reduction in episodic spend to CMS 2 Internal Cost Savings Savings achieved as a result of care redesign activities for services delivered to beneficiaries during an episode of care Incentives from the Cardiac Rehab Incentive Payment Model are not eligible for gainsharing Case in Point: Variation in Operational CABG 2 Metrics Signal Opportunity for Savings Medicare, FY Days 9.7 Days Average LOS 20th Percentile 100% 44.7% Percent of Days in ICU/CCU 80th Percentile 1) Physician fee schedule. 2) CABG MS-DRG 333. Source: CMS, innovation.cms.gov/initiatives/epm; Cardiovascular Roundtable research and analysis.

51 55 An Uncertain Future for Mandatory Bundling New Administration May Aim to Roll Back Mandatory CMMI Programs HHS Secretary Opposed to CMMI s Mandatory Demonstrations The broad powers vested in CMMI, and the agency s interpretation of that authority, have the potential to further degrade Congress s lawmaking authority by shifting decision-making away from elected officials into the hands of unelected bureaucrats. Representative Tom Price (R-GA) Chairman of the House Budget Committee CMS Delays Implementation of New EPMs by at Least Three Months On March 21, 2017, CMS delayed implementation of EPMs and cardiac rehab incentive payment model from July 1 to October 1 Indicated they may delay the model further to January 1, 2018, to enable the first year to have a full 6 months 1) Center for Medicare and Medicaid Innovation. Source: Price T, Obamacare Agency Escapes Congressional Oversight, available at: Cardiovascular Roundtable research and analysis.

52 56 Episodic Cost Scrutiny Will Only Intensify Mandate for Managing Long-Term Costs Extends Beyond EPM Rule Regulators Continue to Push Hospitals from Acute to Episodic Mindset Hospital quality programs (e.g., IQR, VBP) continue to add metrics evaluating episodic value Cost/resource use category in MIPS consists of Medicare spending per beneficiary, ten episode-based cost measures Signaling Intention for Future Expansion [In the proposed rule] we sought comment on model design features for potential future condition-specific episode payment models that could focus on an acute event or procedure or longer-term care management We believe such future models may have the potential to be Advanced APMs Such condition-specific episode payment models may provide for a transition from hospital-led EPMs to physician-led accountability for episode quality and costs EPM Final Rule The Time To Start Preparing Is Now Even in markets that are not chosen for participation, CV leaders should consider this proposal to be a signal that future bundling or episodic payment reform is likely to occur Source: Cardiovascular Roundtable research and analysis.

53 57 Action Items for CV Leaders Determine the sources of cost in CV episodes at your institution. Use the Care Coordination Episode Profiler to assess your institution s episodic spending up to 90 days after index hospitalization for AMI, AMI with PCI, and CABG Identify key opportunities to reduce internal and episodic costs to minimize spending within a bundle as well as safeguard margins Read the Playbook for CV Episodic Cost Management to learn strategies for CV leaders to manage cross-continuum costs in preparation for risk-based payment models Read the Highly-Productive CV Enterprise for lessons on enhancing operational efficiency Strengthen partnerships across the continuum to improve costs and quality outside the four walls of your hospital Read Integrating the Service Line and Affiliated Groups for strategies to coordinate strategic goals between the CV service line and practices Read Maximizing Post-Acute Care Collaboration for tactics for CV leaders to create collaborative relationships with PAC providers to enhance care value in these settings Engage your team in understanding the final ruling and preparing for implementation Watch our two-part webinar series (Part I and Part II) unpacking the cardiac bundling final rule with your team for additional details on the final rule and to collaboratively discuss your strategy to prepare Read The Mandatory Cardiac Bundling Final Rule--Your Questions Answered Sign up for our weekly CV Insights mailing to get up-to-date analyses of the final rule and the latest best practice strategies for managing episodic costs Source: Cardiovascular Roundtable research and analysis.

54 Observation #8: CMS beginning to incentivize CV prevention 58 The Cure for CV Disease? Red Wine, Tea, Chocolate, Coffee, and Aged Cheese Huffington Post June 23, 2015 Medpage Today May 15, 2016 A Glass of Red Wine is the Equivalent to an Hour at the Gym Study: Aged Cheese Lowers Blood Pressure Cardiovascular Business Sept. 26, 2016 American Heart Association Nov. 16, 2015 Drinking Tea May Improve Cardiovascular Health Moderate Coffee Drinking May Be Linked to Reduced Risk of Death Harvard Health Publications April 15, 2015 More Than a Stretch: Yoga s Benefits May Extend to the Heart PBS April 28, 2015 For a Healthy Heart, You May Have to Eat More Cheese Source: Cardiovascular Roundtable research and analysis.

55 59 Million Hearts Tests Paying for Primary Prevention CMS Pilot Rolls Out to Institutions Across the Country Million Hearts Initiative CMS launches Million Hearts : CV Disease Risk Reduction Model in January 2016 First model tying payment to CV risk reduction, incentivizing primary prevention of ASCVD 1 through ABCS approach: Aspirin for high-risk patients Blood pressure control Cholesterol level management Smoking cessation Five-Year Pilot Now Underway 516 Program awardees in 2016 Still awaiting results of initiative, but early evidence suggest positive CV outcomes based on ABCS approach Expected Program Reach Over Five-Year Period 2 3.3M Medicare FFS beneficiaries Program provides evidence-base protocols, quality data, patient education materials, and more 20K Health care practitioners 1) Atherosclerotic cardiovascular disease. 2) From September 2016 to August Source: Million Hearts, CMS, Hearts-CVDRRM; Cardiovascular Roundtable research and analysis.