Understanding Value-Based Payment Models. Disclosures. Learning Objectives 3/23/2017

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1 Understanding Value-Based Payment Models Amanda Brummel, PharmD, BCACP Bob Davis, PharmD, FAPhA Sean Jeffery, PharmD, BCGP, FASCP, AGSF Tripp Logan, PharmD Sunday, March 26 th 1 3 PM Moscone - Esplanade 309 Disclosures Davis - none Brummel Johnson & Johnson Jeffery CVSCaremark, Donaghue Foundation, Main Street Foundation Logan AmerisourceBergen Corporation, MedHere Today LLC, Logan & Seiler Inc, Target Audience: Pharmacists ACPE#: Activity Type: The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Learning Objectives 1. Describe goals of value-based health care models and highlight key programs from the Centers for Medicare and Medicaid Programs such as the Medicare Access and CHIP Reauthorization Act, Merit- Based Incentive Payment System, Comprehensive Primary Care Initiatives, Star Ratings, and the Part D Enhanced Medication Therapy Management program. 2. Describe how pharmacists can impact quality measurement requirements in value-based health care models. 3. Discuss examples of how pharmacists are integrating into these models, including the value proposition that supports pharmacists inclusion. 4. Describe strategies to adapt the attendee s pharmacy practice in order to participate in these new models. 1. The Medicare Access and CHIP Reauthorization Act of 2015 replaces the formula for payments under the Medicare Physician Fee Schedule (PFS) with fixed annual payment updates for all years in the future. A. Patient Protection and Affordable Care Act B. Sustainable Growth Rate C. Medicaid Waiver Program 1

2 2. The Merit-based Incentive Program (MIPS) 3. An example of an Alternative Payment Model is: A. Is Budget-neutral B. Is set to sunset in 2019 C. Applies only to hospitals or facilities D. Includes pharmacists as eligible clinicians A. Physician Quality Reporting System B. Qualified Clinical Data Reporting Systems C. Bundled Payments for Comprehensive Joint Replacement D. Part D Prescription Drug Program 4. Pharmacists are integrating into emerging quality payment programs (models) by: A. Mining data, performing analysis, and reporting B. Developing productivity tools, care management pathways, and order sets C. Participating in Outcomes and Interventions Programs, TCM and CCM D. Educating providers on quality measures and care management pathways E. All of the above 5. What community pharmacy best practice can be utilized to optimize medication use, reconcile medications, improve adherence, consolidate fills, and coordinate patient care? A. Automated outbound phone calls B. Appointment based model patient care management C. On site immunization clinics D. Blood pressure screenings Superman or Batman? Who would you rather have in charge of Repeal and Replace? A. Superman B. Batman Overview of Value-Based Payment Models 2

3 Movement towards Value The move to alternative payment models requires a fundamental change in how we organize healthcare Traditional FFS Alternative Payment Value-Based Care Sick Care / Hospital Care Population Health + Sick Care / Hospitals Episodic care Individuals practicing in silos Variations in care Longitudinal care Team-based, coordinated, integrated care Evidence-based standards Many quality measures/ programs Value Based Purchasing Meaningful Use PQRS MSSP/ Pioneer/ Next Gen CPC+ HEDIS Commerci al ACO Enhanced MTM CAHPS STARs Medicaid CPC+ Comprehensive Primary Care Plus Comprehensiv e Care Functions Payment Elements Access and Continuity Care Management Comprehensiveness and Coordination Patient and Caregiver Engagement Planned Care and Population Health Care Management Fee (CMF) Performance-Based Incentive Payment Payment under the Medicare Physician Fee Schedule Source: EMTM Enhanced Medication Therapy Management Objective s Learn how to right-size their investment in MTM services Identify and implement innovative strategies to optimize medication use Improve care coordination Strengthen health care system linkages. Program Details 5-year performance period that began January 1, Model tested in 5 Part D regions Participating basic stand-alone PDPs Programs can vary the intensity and types of MTM items and services based on beneficiary risk level Source: 3

4 QUALITY PAYMENT PROGRAM MIPS Merit-Based Incentive Payment System MIPS Combines Rolls existing quality programs into one budget-neutral pay-for-performance program Medicare Meaningful Use (MU) ADVANCED APM Physician Quality Reporting System (PQRS) Value-Based Modifier (VBM) Providers will be scored on MIPS QPP APM MIPS Scoring Quality (50%) Resource use (10%) Improvement activities (15%) EHR3 use / advancing care information (25%) PHYSICIANS AND CLINICIANS Source: Centers for Medicare & Medicaid Services WHO IS IMPACTED? Overview of General MIPS Reporting Requirements for 2017 Performance Year Components of MIPS Performance Periods Where s the Pharmacist? Quality Replaces the Physician Quality Reporting System (PQRS) Report up to six measures including an outcome measure for a minimum of 90 days Cost Replaces Value-based Modifier Calculated from claims; no data submission required Counted in score beginning in % 50% 60% 30% 10% 25% 25% 25% 15% 15% 15% Quality Cost Advancing Care Information 4

5 Overview of General MIPS Reporting Requirements for 2017 Performance Year Components of MIPS Performance Periods Advancing Care Information Replaces Medicare EHR Incentive Program for Providers (Meaningful Use) Report four required measures for a minimum of 90 days Submit up to eleven measures for a minimum of 90 days for additional credit Improvement Activities Attest to completion of up to four activities for a minimum of 90 days Special consideration for smaller practices, patient-centered medical homes and certain APMs 60% 50% 10% 30% 30% 25% 25% 25% 15% 15% 15% Quality Cost Advancing Care Information APMs Alternative Payment Models APM Track Significant revenue share with two-sided risk Quality measurement EHR requirements APM track participants would be exempt from MIPS payment adjustments and qualify for a 5 percent Medicare Part B incentive payment in APM s include CMS Innovation Center Model MSSP (Medicare Shared Savings Program) Demonstration Under Health Care Quality Demonstration Program Demonstration Required by Federal Law Examples: ACOs, Patient Centered Medical Homes, and bundle payments Source: Centers for Medicare & Medicaid Services Advanced APMs APM Track An Advanced APM must meet the following three criteria: Require participants to use certified EHR technology Provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of the Merit-based Incentive Payment System (MIPS); and Either be: (1)be a Medical Home Model expanded under CMS Innovation Center authority; or (2)require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses. Source: Centers for Medicare & Medicaid Services

6 2019 Onwards CMS estimates > 75% of practices with less than 10 providers will receive a negative adjustment The Bottom Line Why this Matters to You Choosing six reported metrics Understanding payment adjustments Participation in Alternative Payments Models (APM) will provide safe harbor protection from MIPS, pay a participation bonus and there is an opportunity to benefit from cost (utilization) reduction Determining areas of greatest impact Preparing internally for coming changes Emphasizing quality Navigating both tracks: APMs/MIPs And now to the 115 th Congress Perspectives and Experiences with Value-Based Payment Models Fairview Health Services (ACO/IDN) Amanda Brummel, PharmD, BCACP Fairview Health Services provides a full continuum of health and medical services By the Numbers 1906 Fairview is established as a nonprofit 1997 Fairview partners with the University of Minnesota 20,000+ Fairview employees across Minnesota 3,052 Credentialed physicians 7 Hospitals/medical centers 1,602 Staffed beds 45+ Primary care clinics 55+ Specialty clinics 47 Senior housing locations 30+ Community pharmacies 30+ CMM practices 6

7 Fairview Pharmacy Services provides comprehensive pharmacy services that cover the entire spectrum of patient needs For consumers and patients Community pharmacies (36) Hospital pharmacies (7) Specialty Pharmacy (serves patients in all 50 states) Infusion services Comprehensive Medication Management (32) Mail Service Pharmacy Compounding Pharmacy Central Packaging Long Term Care/Assisted Living Pharmacy Clinical Trials Services Anti-coagulation clinics (30) Wholesale pharmacy Advanced Drug Therapy Program Center for Bleeding and Clotting Disorders For employers and health systems ClearScript SM prescription benefit management Fairview Purchasing Network Excelera Network 1,500+ FPS and inpatient pharmacy employees 2.5 million ambulatory prescriptions filled in 2015 $14 million in 1996 to nearly $1 billion in revenue Payment Models Value-based payment models Pay-for-performance incentives All major payers Shared Savings (one sided risk) Multiple Commercial Payers Shared Savings/Loss (two-sided risk) NexGeneration ACO Medicaid ACO Narrow Network Products 3 Products developed Global budget (PMPM) Full or partial capitation models Fairview Partners Our Clinic Care Team Primary Care Provider Health Coach CDE- Certified Diabetes Educator Care Coordination Clinical Pharmacist Pharmacist s Population Health Approach Direct Patient Care Comprehensive Medication Management Care Transitions Medication/Disease Therapy Management Community Pharmacy Clinical Interventions Population Health Management Integrated Database Analysis Medication utilization/ safety/gaps in care Developing Care Management pathways RN (disease management) Behavioral Health Clinician L&S Pharmacy, Medical Arts Pharmacy, New Madrid Pharmacy MedHere Today (Community Pharmacy) Tripp Logan, PharmD Background CLINICAL PHARMACIST / PHARMACY OWNER Multi-pharmacy owners in Southeast Missouri Quality & value driven pharmacy practices with a strong focus on appropriate medication use and coordinated patient care Offer: Residency program, care coordination, diabetes classes, medication use monitoring, MTM, compliance packaging, TOC, etc. PHARMACY QUALITY CONSULTANT MedHere Today is a Nashville, TN based health care quality and performance consulting firm created to help health care stakeholders expand and grow their quality and value based initiatives. MedHere Today uses a combination of education, reporting, and strategic patient targeting to assist our clients in achieving measurable population health improvements, as well as maximizing the clinical and financial benefits associated with those MISSION STATEMENT: improvements. At MedHere Today, we believe that pro-active pharmacy practice, in the form of pharmacist driven intervention, is the answer to improving patient outcomes, lowering overall health care costs, and improving pharmacy profitability. 7

8 Pharmacy Quality & Value As community pharmacists, we strive to provide the highest quality of care, for the sickest of the sick, to help them get better We welcome the opportunity to be defined by the quality of care we provide A Tale of Two Professions Intervention Strategies Claims Based OR Patient Based Fill reminders Med sync Fill gaps in care Medication safety CMR Packaging Days supply DIR reduction Copay assistance Medication access Transition of care Health literacy/social Care coordination Transportation Formulary assistance Education Take Home Points Community pharmacy is evolving beyond the prescription claim Medication use strategies should be patient focused NOT just claim focused Community pharmacy is well a positioned, accessible, partner in improving outcomes & reducing costs Kennedy Pharmacy Innovation Center at the University of South Carolina (Group Practice/Medical Home) Bob Davis, PharmD, FAPhA Palmetto Primary Care Physicians Early adopter medical practice in South Carolina to establish a successful Patient Centered Medical Home Program Group practice comprised of over 75 clinical providers through 21 physician s offices in 3 counties. Pilot Collaborative with Trident-North Charleston office Transitioning from Traditional FFS to Value-based payments Pay for Performance Shared Savings Capitation with reinsurance (ACO) 8

9 Quality-LDL Improvement Patients with LDL-C >130 Patients with LDL-C > % 16.2% 86.2% Patients Improved 79.1% Patients Improved Original Research Kennedy Pharmacy Innovation Center, APhA patients retrospective chart reviews - Evaluation period November 2013-October Minimum 2 pharmacist visits and pre/post LDL-C Original Research Kennedy Pharmacy Innovation Center, APhA2016 Anticoagulation Management Program 67 Unique Patients 411 Patient Visits Evaluation period November 2014-May 2015 Large VA Study 58%-Best Practice Rosendaal Method Low Range 2 High Range 3 Original Research Kennedy Pharmacy Innovation Center, APhA2016 Cost Avoidance Month Encounters Interventions $ Avoidance Avoid/Encounter April $139,260 $ May $148,379 $ June $151,531 $ Typical Interventions $1.8M Annually Projected Medication reconciliation Allergy identified, clarified or prevented Lab/test evaluation, patient consultation or recommendation Medication change of dose adjustment Patient counseling-self care: diet, exercise, checking blood sugars, OTC recommendation, smoking cessation Adverse effect identified/remedied Average savings per intervention was $153 Studies by Suh, Classen, and Bates and used by Pharmacy OneSource Quantifi software for reporting financial impact of pharmacist clinical interventions. Original Research Kennedy Pharmacy Innovation Center, APhA2016 Physician Productivity 2013 Payment/ Work Day 2014 Payment/ Work Day Contributing Factors: 1. Fee Increase November More New Patient Visits 3. More Complex Visits % Increase Payment/ Work Day % Total Referrals to PharmD 2013 Q Q2 Provider Visits/Day Visits/Day MDA $2,741 $3, % % MDB $3,100 $3, % % MDD $2,602 $3, % % MDT $2,582 $3, % % MDV $2,878 $3, % % AVERAGE $2,781 $3, % % Original Research Kennedy Pharmacy Innovation Center, APhA % Pharmacist Capacity and Revenue Nov 2013 Feb 2014 May 2014 Aug 2014 Oct 2014 Patient Encounters Encounters/Day Capacity Used 34% 46% 59% 83% 72% Encounters Billed 17% 15% 63% 71% 69% Revenue Collected $ 1,025 $ 1,830 $ 3,641 $ 7,490 $ 7,398 Original Research Kennedy Pharmacy Innovation Center, APhA2016 9

10 The Hospital of Central Connecticut MidState Medical Center Hartford Hospital Windham Hospital Backus Hospital 3/23/2017 MACRA and PCMH Practice Impact Volume Quality Receptivity to Change Teamwork Productivity Active Participation in QA Meetings Pharmacist Impact Direct Patient Care Population Health Management Data Mining and Analysis Care Pathways, Order Sets, Templates Educator -- Provider and Patient Contract Analysis and Payments Free image from A typical day in the life of a PCMH Pharmacist and MACRA Data Mining selected targeted population (Diabetes or Pre) Responding to providers clinical or quality Chart reviews of targeted population Gaps in care Med reconciliation Recommendations Care Plan Documentation Manage TCM Medication related issues Free image from Manage CCM Medication related issues resource Review data reports, contracts, and results with key payers Develop treatment algorithms, templates, and productivity tools Physicians one-on-one education and counter detailing Patient education classes (Diabetes) Integrated Care Partners Hartford Healthcare Group (ACO C-Suite) Sean Jeffery, PharmD, BCGP, FASCP, AGSF 58 Opportunity for Unique Public/Private Partnership Integrated Care HHC Management Service Care Area Partners Team Acute-Care RNs PCP (42% Hospitals employed) MSWs Ambulatory Specialists Satellites (60% employed) ,107 Health Other Employees coaches (86% employed) Pharmacists Providers (61% emplyd) 178 Community Providers MSSP Track 1 Shared Savings (one sided risk) with multiple commercial payers Preferred Provider Network for post acute care 10

11 1-4 54, , , , ,709 Grand total 98,787 HHC System Approach to Value-based Pharmacy Meducation Feedback/Awareness Pharmacy CME Programming Beers Criteria Target HRM/Combinations Cost savings opportunities Pharmacy Dashboard Polypharmacy Indicator GDR / RxPMPM Risk Index 17% 10 meds meds Outreach/Intervention TCM/CCM for High-Modifiable Risk Pts Multidisciplinary Homecare programs Consultations PRN Disparate Data Integration = CEO s Frustration 63 Provider Dashboards Claims Data GDR / RxPMPM Polypharmacy Medication Complexity/Risk ID High-modifiable risk Patients on >15 Data Warehouse medications Poor adherence High risk meds (BEERS) > 2 documented falls Risk Stratification EMR Data Cognitively vulnerable Opioid + Benzodiazepine ED utilization Multiple Platforms Inconsistent formats Disparate Metrics Timeliness?!? ~ 26 EMRs ~ 3 EMRs Medication reconciliation Align outpatient EMR order sets Outreach/Interventions Care Management Team Panel Discussion TCM/CCM referrals (RN/MSW) Commercial Payer Hotspotter lists Consults PRN Case Review Virtual MTM Clinic Co-visit Home Visit Care Coordination Documentation Communication w/ provider(s) Engage RN CM / Health Coach 11

12 What is the future of valuebased programs? What are the roles for pharmacists in value-based programs? What recommendations do you have to assist pharmacists/pharmacies in engaging in value-based programs? How can pharmacists demonstrate their value in value-based programs (what is the sustainable business model)? References What are your 3 key takeaways for audience participants? CMS Quality Payment Program: Comprehensive Primary Care Initiative: Care-Initiative/ Comprehensive Primary Care Plus: Medicare Part C and D Star Ratings Program: t-sheets/2016-fact-sheets-items/ html Part D Enhanced MTM Model: 12

13 1. The Medicare Access and CHIP Reauthorization Act of 2015 replaces the formula for payments under the Medicare Physician Fee Schedule (PFS) with fixed annual payment updates for all years in the future. A. Patient Protection and Affordable Care Act B. Sustainable Growth Rate C. Medicaid Waiver Program 2. The Merit-based Incentive Program (MIPS) A. Is Budget-neutral B. Is set to sunset in 2019 C. Applies only to hospitals or facilities D. Includes pharmacists as eligible clinicians 3. An example of an Alternative Payment Model is: 4. Pharmacists are integrating into emerging quality payment programs (models) by: A. Physician Quality Reporting System B. Qualified Clinical Data Reporting System C. Bundled Payment for Comprehensive Joint Replacement D. Part D Prescription Drug Program A. Mining data, performing analysis, and reporting B. Developing productivity tools, care management pathways, and order sets C. Participating in Outcomes and Interventions Programs, TCM and CCM D. Educating providers on quality measures and care management pathways E. All of the above 5. What community pharmacy best practice can be utilized to optimize medication use, reconcile medications, improve adherence, consolidate fills, and coordinate patient care? A. Automated outbound phone calls B. Appointment based model patient care management C. On site immunization clinics D. Blood pressure screenings 13