Objectives. Preparing for Value-Based Reimbursement 3/28/2016

Transcription

1 Preparing for Value-Based Reimbursement Tracy Bird, FACMPE, CPC, CPMA, CPC-I, CEMC Sr. Advisor Education and Consulting KaMMCO April 12, Objectives A look back - how did we get here Existing and emerging models of care Steps to prepare for the change 3 1

2 The next 3-5 years The last 100+ years s s and Beyond 4 Current Healthcare Spending 17.7% of GDP Rising costs of 7%-8% annually 36% of GDP by 2030 No money for education, infrastructure, police, and fire 5 Case Study Example A patient with hypertension not controlled averages 12 visits per year versus a patient whose hypertension is under control averages 2 visit per year. Up to 20% of all Medicare patients are readmitted within 30 days of discharge due to poor follow up. 6 2

3 Case Study Example Shift change at the hospitals put patients at greater risk for medication errors due to the failure of communication from one shift to another. A group of ER docs felt pressured by administration to provide controlled pain medications such as Oxicontin to patients complaining about pain and requesting drugs, in order to yield high patient satisfaction scores. 7 Medicare s Plan for the Future End of % payments tied to Alternative Payment Models ( APM s) 30% payments for ACO s or Medical Homes End of % payment tied to APM s 50% payment for ACO s, and Medical Homes tied to quality 8 Increase Risk Decrease Cost 9 3

4 Existing and Emerging Models 10 Objectives Financial Viability Payment incentives Accountability Effectiveness Ensuring access Medicare Goals for Value-Based Reimbursement Ensure the traditional Medicare fee for service program is protected Link payment to the value, quality and efficiency of care Providers share clinical and financial accountability for healthcare Care is evidence based and account driven to better manage disease Ensure patient access to high quality affordablecare Safety and transparency Smooth transitions Beneficiaries receive information on the quality, cost and safety of their care Payment systems support well-coordinated care across providers and settings Improved technology EHR s help providers deliver high quality, efficient and coordinated care 11 PQRS The first quality reporting program tied to physician payments PQRI-PQRS- from voluntary to necessary Encourages providers to report quality measures for Medicare patients Scheduled to continue until

5 Meaningful Use 2? 1 3 Stages 13 Stage 1 Data capture & Sharing Electronic capture in standardized format Track key clinical conditions Communicate care coordination processes Reporting clinical quality measures and public health information Use information to engage patients and their families in their care Meaningful Use Stage 2 Advance clinical processes More rigorous health information exchange Increased requirements for e-prescribing and lab results Electronic transmission of care coordination documents across settings More patient controlled data Stage 3 MU criteria focused on Improve quality, safety, efficiency for improved outcomes Decision support for national high priority conditions Patient access to selfmanagement tools Access to comprehensive patient data through patient centered HIE Improving population health 14 Value Based Payment Modifier Performance year is 2015 to be applied in 2017 ( 2016 performance applied in 2018) Mandatory quality tiering (upward, neutral, downward) VBPM program until 2018 TINs receiving an upward adjustment - eligible for an additional +1.0x if their average beneficiary risk score is in the top 25%t of all beneficiary risk scores nationwide 15 5

6 Value Based Payment Modifier Information Analyzed PQRS Quality Measures Outcomes Measures Cost Measures 4 Chronic conditions: Diabetes COPD CAD Heart Failure Value Based Payment Modifier 2017 All Physicians Category 1 Category 2 Satisfactory 2015 PQRS Reporters Register for GRPO and meet requirements 50% of EP s in group successfully report individually Solo practitioners successfully report individually Non-Satisfactory 2015 PQRS Reporters Groups and solo practitioners that do not meet the reporting criteria to avoid the 2017 PQRS penalty Quality-Tiering Payment Adjustment ( Potential) Payment Penalty Applied Solo practitioners & groups with up to 9 EP s Groups of physicians with 10 or more EP s Solo practitioners and groups with up to 9 EP s Groups of physicians with 10 or more EP s Upward or neutral adjustment 0% to +2X Upward or neutral or downward adjustment -4% to +4X -2% automatic adjustment in addition to the -2% PQRS penalty -4% automatic adjustment in addition to the -2% PQRS penalty 17 Value Based Payment Modifier Reporting year Modifier Year Providers Impacted Groups with 100+ Eligible professionals Groups with 10+ Eligible professionals All Physicians Physicians not participating in PQRS receive automatic VBM penalty Opportunity for additional bonuses or penalties under quality tiering 18 6

7 2018 Value Modifier 10+ EP s Successfully reported in 2017 Quality tiering applies Non-Physician Practitioners included: PA, NP, CRNA, CNS Cost/Quality Low Quality Average Quality High Quality Low cost +0.0% +1.0X* +2.0X* Average Cost -1.0% +0.0% +1.0X* High Cost -2.0% -1.0% +0.0% * Eligible for additional +1.0X if reporting PQRS quality measures and average beneficiary risk score is in the top 25% of all beneficiary risk scores Value Modifier for Groups 2-9 & Solo EP s Unsuccessful reporters received automatic -2.0% adjustment Quality tiering applies with a maximum of +2.0X Held harmless for downward adjustments for poor performance This policy mirrors how VM is applied to first year groups & solo providers Non-Physician Practitioners included: PA, NP, CRNA, CNS Cost/Quality Low Quality Average Quality High Quality Low Cost +0.0% +1.0X* +2.0X* Average Cost +0.0% X* High Cost +0.0% +0.0% +0.0% * Eligible for an additional +1.0X if reporting PQRS quality measures and average beneficiary risk score is in the top 25% of all beneficiary risk scores 20 Accountable Care Organizations Groups that can include physicians, hospitals and other healthcare providers Voluntary commitment Provide coordinated high quality care at lower cost Right care, right time, right provider Today s model of care ACO model 21 7

8 Accountable Care Organizations 3 Core Principles of an ACO Provider led- strong primary careaccountable for quality and cost Payment linked to quality improvement Use of sophisticated performance measures - Proving savings come from improvements in care 22 Pioneer Shared Savings Advance Payment Next Generation ACO Models 23 Patient Centered Medical Home This is a primary care designation providers have adopted to better coordinate care of a group of patients It has been viewed as a vehicle to re-build primary care Approximately 8200 practices have been recognized as NCQA PCMH. Joint Commission also has a designation for primary care medical home 24 8

9 Key Elements of PCMH A personal physician who provides continuous and comprehensive care to his/her patients A physician led care team approach to treating the whole person with care coordination across all care settings. Facilitated by technology Emphasis on high quality, safe care Enhanced access through open access scheduling, expanded hours, and secure 25 Bundled Payments for Care Improvement (BPCI Initiative) Made up of 4 broad care models which links the separate payments for an episode of care into one lump payment to be shared among all providers caring for that patient. Financial and performance accountability is included in the initiative 26 Comprehensive Care for Joint Replacement Next phase of bundled payments Start date April, facilities/providers in 75 markets 5 performance years for this model This is a retrospective, 2 sided risk model 27 9

10 Comprehensive Primary Care Initiative Launched in 2012 Collaborative effort of Medicare, Medicaid, and commercial plans to deliver coordinated care PCP s acted as quarterbacks 2.7 million patients 483 practices 24$ million in savings 28 Specialty Care Models Comprehensive ESRD Care Model 600,000 have ESRD or 1.1% of Medicare population 5.6% of Medicare spending Oncology Care Model 1.6 million cases diagnosed each year Financial and performance accountability model Better coordinated care Million Hearts CVD Risk Reduction Model Prevent a million heart attacks 720 practices are enrolled. Patients will be put in 2 groups ( Interventional and Control) 29 Medicare Advantage Value Based Insurance Design Model To begin January 2017 goes for 5 years Test modeled in 7 states (Arizona, Indiana, Iowa, Mass, Oregon, Pa, Tenn) Provide supplemental benefits tailor made to the enrollees clinical needs Diabetic eye exams no copay Smoking cessation no copay 30 10

11 What s Common In All These Models? Moving the risk Forced innovation Economize on care and regimen choice Bundling 31 The Straddle Delivery Models Reimbursement Models Unsustainability gap 32 No Longer Business as Usual Telehealth High deductible health plans Walk-in Clinics Transparency/ Price & performance Virtual healthcare 33 11

12 Medicare Access and CHIP Reauthorization Act (MACRA) Repealed the SGR (Sustainable Growth Rate) Further defined how PQRS, MU, VBPM and other programs would transition to a new reimbursement model 2 new models of care delivery MIPS APM s 34 Merit-Based Incentive Payment System Combines: PQRS- Physician quality reporting system VBPM- Value based payment modifier EHR Meaningful Use 35 MIPS Performance Measures 30% 15% 25% 30% EHR Use Quality Clinical Improvement Resource use 36 12

13 MIPS Performance Categories Year Quality measures Resource Use Clinical Improvement Activities MU of EHR technology MIPs Adjustment factor % 10% 15% 25% +/-4% % 15% 15% 25% +/-5% % 30% 15% 25% +/-7% Beyond 30% 30% 15% 25% +/-9% 37 MIPS Measure Development Plan Assessment-Instruments/Value-Based-Programs/MACRA- MIPS-and-APMs/MACRA-MIPS-and-APMs.html]. Identifies gaps from previous reporting methods Prioritize person and caregiver centered experience of care Patient reported outcomes Patient health outcomes Communication and care coordination Appropriate use of resources 38 6 Quality Domains of MIPS 1. Clinical care 2. Safety 3. Care coordination 4. Patient and caregiver experience 5. Population health and prevention 6. Efficiency and cost reduction 39 13

14 Alternative Payment Models (APM s) APM entities include: ACO- Advance payment model ACO Shared Savings model Patient Centered Medical Home Bundled Payment Models Qualifying APM s (QP) receive a lump sum incentive equal to 5% of the prior year s estimated aggregate expenditure if criteria are met. The incentive is available between Alternative Payment Models Provisions Include Increased transparency of physician focused payment models Will need criteria and processes for submission and review Incentive payments for participants Encourage development and testing of new models Integrate Medicare Advantage Fraud reporting Incentive Payments PCMH, ACO s, Bundled care Healthcare innovation awardees' excluded Requires use of: Certified EHR technology Reported measures comparable to MIPS reporting Bear financial risk for losses in excess of nominal amount 41 Alternative Payment Models APM Participants Incentives Qualified providers under the APM track receive 5% annual lump sum bonus on their Medicare Physician Fee Schedule (MPFS) payments Qualifying Participants Increased thresholds of percentage of revenue received % Medicare Revenue % Medicare OR 50% all payer revenue and 25% Medicare must be received through APM % Medicare OR 75% all payer + 25% Medicare Revenue 42 14

15 Participation in Risk Based Models Evaluate strengths and weaknesses Have a deep understanding of your costs Identify long term priorities Understand the market Create a tolerance for change 43 Map adapted from the Sg2 report, The Race to Risk Tracking Markets' Evolution Toward Value-Based Care 44 Preparing for the future 45 15

16 Achieving high value for patients must become the overarching goal of healthcare delivery, with value defined as the health outcomes achieved per dollar spent. Michael Portner, The New England Journal of Medicine Preparing for the Future 1. Understand the true cost of care delivery 2. Engagement ( Provider & Patient) (Culture Shift) 3.Leverage technology 4.Bring clinical and claim data together for meaningful purpose 47 Cost of Care Fee for Service Bend the Cost Curve 48 16

17 Cost Management Know the cost of care Identify patient population in need of intervention Assess financial limitations of the organization Where is the revenue coming from 49 Provider Engagement Dr. John Evans Iowa Healthcare Collaborative 50 Provider Engagement -Selling the Value Proposition- New Clinical leadership roles Become active business partners Referral patterns Narrow networks Marketing strategy Proactive partnerships Patient retention and leakage 51 17

18 Provider Engagement -Become Clinically Mature- Monitor existing quality programs Standardize protocols and care pathways Use care coordinators when appropriate Mobile inter-operability ( Fit bit, personal health records) Evaluate care gaps Whole patient focus Promote team based care 52 Patient Engagement Increased access High quality- low cost Shared decision making Customer service and satisfaction 53 What Patients Value Online reviews increased 68% between 2013 and Factors that mattered most to patients: Quality of care Provider rating Patient experience Accurate diagnosis Wait times Doctor s listening skills Source: Practice Management Consultancy Software Advice. Debra Beaulieu-Volk : Physicians online reviews gain power 54 18

19 Healthcare Consumerism PATIENT RETENTION Consumers expectations of good customer service 70% 38% 33% Providers Retail Airline, Banking & Hotels The Health Research Institute survey 55 Customer Service Changing a poor customer service image takes 10 years on average 56 Technology EHR benefits Efficiencies in automation Negotiating power Eliminate and automate Delegate to top of licensure Push for inter-operability Innovative technology options 57 19

20 Technology -Data- The New Currency- Analysis of claims and clinical data Evidence based care of the future Use data to categorize health risks Maturation of data The future of relational data bases Barriers to use of advanced data Predictive modeling 58 Technology -Issues Impacting Quality Data- Incomplete, ambiguous and/or clinically incongruent documentation Incorrect or incomplete coding Sequencing of codes Understanding the complexity of the patient (Severity of Illness-SOI or Risk of mortality- ROM) Potential compliance risk Multi-disciplinary training 59 Practice Transformation Yesterday s Practice Patient s chief complaint determines care Care is determined by today s presenting problem and the time available Care varies by scheduled time and memory/skill of he doctor Patients responsible for coordinating their own care Clinicians know they deliver high quality care because they were well trained It is up to the patient to tell us what happened to them Tomorrow s Practice Systematically assess all patients health needs to plan care Care is determined by a proactive plan to meet patient needs Care is standardized according to evidence-based guidelines A prepared team of professionals coordinates a patient s care Clinicians know they deliver high quality care because they measure it and make rapid changes to improve You can track tests, consults, and follow-up after the ED and hospital 60 20

21 At the End of the Day Value Based Reimbursement Improved Financial Performance Enhanced Patient Experience Improved Outcomes Organizational Structure Physician Leaders and Change Agents Clinical Integration