MACRA The shift to Value Based Care and Payment. Michael Munger, M.D., FAAFP

Transcription

1 MACRA The shift to Value Based Care and Payment Michael Munger, M.D., FAAFP

2 Current State Silos of Care Over Utilization Volume over Value

3 Push Towards Value and Quality 85% Medicare Payments tied to quality or value by end of 2016; 90% by the end of % Of those payment through Alternative Payment Models (APMs) by end of 2016 This goal was met 75% Commercial Payer business through valuebased arrangements by 2020

4 SGR Repeal changes Medicare Payment to Physicians House (392 37) Senate (92 8)

5 MACRA Legislative Timeline April 16, 2015 MACRA Enacted April 27, 2016 Proposed Rule Released October 14, 2016 Final Rule Released

6 What Does MACRA Do? Merit Based Incentive Payment System (MIPS) Consolidates Quality Programs Advanced Alternative Payment Model (AAPM) Potential for Bonus Payment for participation

7 QPP Participants Physicians Certified Registered Nurse Anesthetist Physician Assistants Clinical Nurse Specialist Nurse Practitioners

8 Merit Based Incentive Payment System (MIPS)

9 MIPS Highlights Consolidates existing quality and value programs Establishes a Final Score Provides an opportunity for payment adjustment

10 What s it Called? Existing Programs VBM PQRS MU Law & Proposed Rule Resource Use Quality Advancing Care Information Clinical Performance Improvement Activities Final Rule Cost Quality ACI Improvement Activities

11 Improvement Activities Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Achieving Health Equity Emergency Response and Preparedness Integrated Behavioral Health

12 Weighting by Category Quality 60% ACI 25% Cost 0% for 2017 Improvement Activities 15% Certified PCMH receives full IA credit; APM receives half credit

13 Weighting Progression 2017/ / /2021 Quality Cost Advancing Care Information Improvement Activities

14 Pick Your Pace Options for 2017 Test Submit some data to QPP Partial participation Report minimum 90 days some metrics Full Participation Report required metrics for 90 days up to full year No negative payment adjustment Eligible for small positive payment adjustment Eligible for modest payment adjustment

15 Pick Your Pace Reporting Test Report one quality measure, one improvement activity or all four of the required measures within ACI Partial Participation Report a minimum 90 days of more than one quality measure, more than one improvement activity or all four of the required ACI measures Full Participation Report to MIPS for full 90 day period to one year

16 Annual Performance Threshold Established by Secretary for Years 1 and 2 - For transition year 2017 threshold is set at 3 Below = negative payment adjustment Above = positive payment adjustment

17 Adjust Payments % +4% % +5% % +7% % +9% Adjustment is to Provider s Medicare Part B payment

18 Adjustment Summary Performance Score Payment Adjustment Exceptional Performers (Final Score over 70) Eligible for up to a 10% positive adjustment in th Percentile or lower Maximum negative payment adjustment At Threshold Stable Payment

19 MIPS Exemptions Year 1 of Medicare Participating in an Advanced Alternative Payment model eligible for a bonus payment Below low volume threshold -Less than or equal to $30,000 Medicare payments, or less than or equal to 100 Medicare Beneficiaries.

20 Advanced Alternative Payment Models (AAPMs)

21 Definitions Qualifying APM Based on existing payment models Advanced APM Based on the criteria of the payment model Qualifying AAPM Participant Based on individual physician payment or patient volumes

22 Qualifying APMs MSSP (Medicare Shared Savings Program) Expanded under CMS Innovation Center Model Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episodes Demonstration Demonstration required by Federal Law

23 Advanced APM Eligibility Quality measures comparable to MIPS Use of certified EHR technology More than nominal risk OR Medical Home model expanded under CMMI authority

24 Primary Care Advanced APMs Shared Savings Program (Tracks 2 & 3) Next Generation ACO model Comprehensive Primary Care Plus (CPC+) Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

25 Qualifying AAPM Participant Percentage of patients or payments through eligible APM In 2019, the threshold is 25% of Medicare payments or 20% of beneficiaries Qualifying Participant will be determined at the group level

26 Additional Rewards for Qualifying Participants Not subject to MIPS 5% bonus Higher fee schedule update to 0.75% 2026

27 What if???? Don t qualify as AAPM Fail Patient thresholds MIPS APM Fail Payment thresholds

28 MIPS APM Scoring Standard Quality Measures Cost Advancing Care Information Improvement Activities Report through AAPM metrics 0% Indefinitely Must report Same requirements Automatic 100% CMS will calculate the final score for MIPS APM at the APM Entity level

29 Questions? Michael Munger, M.D., FAAFP VPMA Primary Care Division St. Luke s Physicians Group