Understanding MACRA: Planning for Success; Now and in the Future

Understanding MACRA: Planning for Success; Now and in the Future Adam Strom Health Care Consulting Manager astrom@eidebailly.com 612.253.6606 Dan Schletty ACO Program Manager / Health & Wellness Coach dschletty@riverwoodhealthcare.org 218.927.5168 1

Objectives Define the MACRA program and the changes for the 2018 performance year Identify the requirements to be successful under MACRA Understand the impact of utilizing data to achieve goals and process improvements Determine the financial and process downstream effects of MACRA on your organization Identify next steps of alignment in your organization 2

Medicare: Changing the Landscape From Nine individuals under 65 contributed to each person over the age of 65. 19,000,000 enrolled in Medicare in 1967 1982 Prospective Payment System implemented to control costs To Five individuals under 65 who contribute to each person over the age of 65. 49,435,610 enrolled in Medicare as of 2012 2003 Medicare Modernization Act mandated hospital inpatient quality reporting, Value Based Purchasing 2006 Tax Relief and Health Care Act (PQRS initiation) Affordable Care Act extended PQRS incentives through 2014 with penalty beginning in 2015 2015 Value Based Modifier 2015 January HHS announced 85 percent of Medicare payments tie to quality or value by 2016 and 90 percent by 2018 3

What is the MACRA Quality Payment Program (QPP) 4

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Repeals the Sustainable Growth Rate (SGR) Formula Changes the way Medicare rewards clinicians for value over volume Streamlines multiple quality programs under the Quality Payment Program (QPP) Provides Bonus Payments for participation in eligible Alternative Payment Models (APM) Source: CMS 5

The Quality Payment Program (QPP): Two Pathways Merit-based Incentive Payment System (MIPS) If you decide to participate in traditional Medicare, you can earn a performance based payment adjustment through MIPS. OR Advanced Alternative Payment Models (APMs) If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model. Source: CMS 6

Which Program Is Best For Your Organization Source: CMS 7

What is the Merit Based Incentive Payment System? Source: CMS 8

What is the Merit-Based Incentive Payment System (MIPS) A performance based payment adjustment to your Medicare payment. CMS estimates approximately 500,000 clinicians will be eligible for MIPS reporting in the first year of the program. MIPS aligns PQRS, Value-Based Modifier (VM), and Medicare Meaningful Use (MU) into one reporting program. If you have participated in these programs in the past, the reporting requirements are similar. Source: CMS 9

Reporting Categories 10

MIPS Reporting: Quality Source: CMS 11

Quality Measure Take Away 1. Eligible clinicians 2. Are you going to report as a group or individual 3. Choose the measures that best fit your organization 4. Decide your reporting mechanism 12

MIPS Reporting: Improvement Activities Source: CMS 13

Improvement Activities Take Away 1. Most participants will need to attest that you did 4 improvement activities for 90 days 2. HPSA designation or 15 eligible clinicians lower reporting requirements 3. Patient Centered Medical Home, APM designated as a Medical Home automatically receive full credit 4. Shared Saving Track 1 or Oncology Care Model all current APMs this will be automatically full credit, for future APMs the score will be automatically half credit 5. Any other APM you will automatically receive half credit 14

MIPS Reporting: Advancing Care Information Source: CMS 15

Advancing Care Information Take Away 1. Focus on: Patient Electronic Access Coordination of Care Through Patient Engagement Health Information Exchange 2. Need to attest to base measures to be eligible for score in this category 3. Bonus score for submitting quality measures through CEHRT 4. Bonus score for a MIPS eligible clinician if they can attest to using the associated CEHRT when carrying out an activity. Example: secure messaging functionality used to provide 24/7 access for advice about urgent and emergent care 16

MIPS Reporting: Cost Source: CMS 17

Cost Take Away 1. Data will not be submitted in the 2017 performance year 2. This is your opportunity to get processes in order for accurate reporting starting 2018 18

MIPS Payment Adjustments Source: CMS 19

Pick the Pace that Works for YOUR Organization CMS Acting Administrator Andy Slavitt announced that further evaluation of the MACRA Program will result in options of participation for the performance year January December 2017. Clipartpanda.com 20

Pick your Pace in Reporting Not participating: If you don t send in any 2017 data, then you receive a negative 4% payment adjustment. Testing: If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), 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. Source: CMS 21

Eligible Clinicians 22

So Who is In Reporting for MIPS IN Year 1 and Year 2 If you bill more than $30,000 to Medicare or provide care to more than 100 Medicare patients and if you are a: Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist CRNA Includes Specialties Includes non-patient facing clinicians* Year 3 and beyond expand to include PT, OT, CSW Source: CMS 23

CAH Billing Designations Method I MIPS adjustment will apply to payments made for items and services billed under the PFS but not the facility payment itself Method II o Eligible clinicians who have NOT assigned their billing rights to the CAH, the MIPS adjustment would apply in the same manner as Method I o Eligible clinicians who HAVE assigned their billing rights to the CAHs, those professional services would constitute covered professional services and the MIPS adjustment would apply to these professional services Source: CMS Source: CMS 24

So Who is Out of Reporting for MIPS Out RHC and FQHC All services billed under the all-inclusive payment methodology are exempt from the MIPS adjustment Option available to voluntarily report on these services ***All services billed under the PFS, the MIPS adjustment does apply Examples include billing of professional services for Inpatient services, Observation services, Emergency Room services, and Outpatient services provided in the hospital setting Source: CMS 25

Exclusions to MIPS Reporting New Medicare Enrolled Eligible Clinician Those eligible clinicians who are newly enrolled in Medicare: and have not previously submitted claims as a Medicare, enrolled eligible clinician either as an individual, an entity, or part of a physician group or, under a different billing number or tax identifier Will not be treated as a MIPS Eligible Clinician until the subsequent year and performance period for the subsequent year. Low-Volume Threshold Medicare billings less than or equal to $30,000.00 OR Provides care for 100 or fewer Part B enrolled Medicare beneficiaries Source: CMS 26

Advanced Alternative Payment Models Source: CMS 27

What are Alternative Payment Models (APMs) and Advanced Alternative Payment Models? An alternative payment approach that provides added incentives to those clinicians who provide high-quality and cost effective care. APMs can apply to a population, a specific clinical condition, or a care episode. Advanced APMs are a subset of APMs and can earn more by taking on more financial risk of the health care outcomes. Source: CMS 28

Advanced APMs Advance Alternative Payment Models (Advanced APMs) enable clinicians and practices to earn greater rewards for taking on risk related to their patient outcomes. The QPP does not change the design of any particular APM. It creates extra incentives for sufficient degree of participation in Advanced APMs. Source: CMS 29

Advanced APMs in the 2017 Performance Year Source: CMS 30

MIPS APM 31

MIPS APM MIPS APM is an alternative payment model that meets three criteria: APM entities participate in the APM under an agreement with CMS. The APM requires that APM entities include at least one MIPS eligible clinician on a Participation List. The APM bases payment incentives on performance (either at the APM entity or clinician level) on cost/utilization and quality measures. Source: CMS 32

Reporting Requirements for MIPS APMs in 2017 MSSP Track 1 Reporting in 2017 Quality 50% Improvement Activities 20% Cost 0% Quality Advancing Care Information 30% Cost Improvement Activities Advancing Care Information Source: CMS

Data Timelines: Data Gathering: January 1 October 2, 2017: Submission of data by: March 31, 2018 How much data will you supply?? Source: CMS 34

Riverwood Healthcare Center 25-bed Critical Access Hospital 3 Rural Health Clinics Specialty Clinic Surgical Services 400+ Employees Collaborative Partnerships Top 20 CAH Award by the National Rural Health Association 35

Why Join an ACO? Aligns with Strategic Plan Several Advantages to Track 1 ACOs Potential for shared savings, low risk Automatic full credit for improvement activities No additional quality reporting 36

Resources to Drive Performance Internal Data EHR registries & dashboards Press Ganey Quality Scorecards External Data MNCM, etc. ACO Claims data Game Changer

Resources to Drive Performance Claims Data~ Lightbeam Risk Stratification (ED visits, risk analysis, etc.) Utilization Leakage

Resources to Drive Performance Medicare Wellness Visits 11 Quality Measures Prevention Attribution

Planning for the Future Access to care Clinic expansion project Dialysis Care Coordination 5 RNs Community Partnerships Majority of care is outside clinic walls Data Analysis More important than ever Keep Learning!

What is the Right Choice For Your Organization? 41

Your Choice: MIPS or APM Start here Are you participating in an Alternative Payment Model? Do you meet partial qualifying participant (QP) revenue requirements 2? Yes No Yes No Is it an eligible Alternative Payment Model 1? Are you in your first year of Medicare participation? Yes No Yes No Do you meet qualifying (QP) participant revenue requirements 1? Are you below the low volume threshold 1? Yes No Yes No APM Not subject to MIPS or APM MIPS Optional MIPS 4 1) Threshold that will be set by CMS that will set a minimum number of Medicare services, patients, or Medicare charges necessary (as determined by the Secretary) to qualify for the MIPS payment track. 2) If decide against the MIPS, will receive no payment adjustment for that performance year. Source: H.R. 2: Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board Company interviews and analysis.

What is the potential financial impact of MIPS? Budget neutral initiative There will be winners and there will be losers Organizations will be compared to peers and payment impact will be dependent on the comparative performance Source: http://power-hand-tools2.imblogger.net. Source: CMS 43

CMS providing technical assistance 100 million dollars in technical assistance will be available to MIPS eligible clinicians in: small practices, rural areas, and practices located in geographic health professional shortage area (HPSAs), including IHS, tribal, and urban Indian clinics, More information is available at www.fedbizopps.gov. Source: CMS 44

Down Stream Effects 45

What We Know Now MIPS Reporting in 2017 Cost 0% Quality 60% Advancing Care Information 25% Improvement Activities 15% Quality Cost Improvement Activities Advancing Care Information Source: CMS

Allocation of Resources Shift of care focus from inpatient and high cost resources to chronic disease management and preventative services Growing complexity of patients as Medicare population ages Care coordination Risk segmentation and stratification to target resources and interventions where needed

Revenue Cycle Focus Reduced admissions coupled with high deductible plans and movement to alternative visit methods hold the potential for increasing bad debt and decreasing revenue from acute care volume. Process review and standardization of: Denials Management Charge Capture Upfront Collections 48

Technology Utilization of Qualified Clinical Data Registry (QCDR) for reporting Technical assistance available at www.fedbizopps.gov Movement to a CEHRT Data gathering and reporting

Physician Compare Consumer driven market Designed to provide consumers (patients, caregivers, referring health care organizations) the data needed to make an informed choice regarding where to receive their health care services https://www.medicare.gov/physiciancompare/search.html Source: CMS

There Will be a Shift Away from Quality Advancing Care Information Improvement Activities Cost Quality Quality Quality Quality Cost Improvement Activities Advancing Care Information Cost Improvement Activities Advancing Care Information Cost [SERIES NAME], [VALUE] Advancing Care Information Source: CMS

Plan for the Future, beginning in 2017 The focus on quality as the highest weighted category in 2017 will shift by 2019 The weight will shift to the Cost category The transition year allows for practice in the cost category without negative impact to your composite score

Hierarchical Condition Categories The CMS-HCC model was first introduced to pay Medicare Advantage plans Risk-adjustment model which calculates expected resource use of a patient or patient population Utilized to communicate expected and current cost and resource utilization at a patient level Source: CMS

HCC Scoring Diagnosis Codes Community or Institutional Gender HCC Dual Eligibility Reason for Enrollment Age

HCC Scoring 79 Categories 31 Hierarchies Disease Interactions

The Clean Slate January 1st Source: Conversation.com

Poor Coding Better Coding Complete Coding Example of HCC scoring 72 year old male, residing in Nursing Home, presents feeling short of breath. Complains of dyspnea, fatigue, and persistent coughing. Recently completed antibiotics for UTI. U/A done today is clear. Patient appears frail with mild malnutrition. Previously diagnosed COPD, stable on Flovent daily. Patient continues to smoke. After Radiologic exam, patient diagnosed with aspiration pneumonia and sepsis. Antibiotic prescribed twice daily for next seven days. Ensure twice daily on a continual basis. 72 yo institutionalized male:1.323 Pneumonia coded as J18.9: 0 Total HCC score: 1.323 Total Cost: $12,152.14 72 yo institutionalized male: 1.323 Aspiration Pneumonia J69.0:.067 Tobacco Use F17.210: 0 Total HCC score: 1.39 Total Cost: $12,767.55 72 yo institutionalized male: 1.323 Aspiration Pneumonia J69.0:.067 COPD J449:.305 Tobacco Use F17.210: 0 Sepsis A41.9:.346 Mild Malnutrition E44.1:.260 Disease Interaction COPD*Aspiration Pneumonia:.254 Disease Interaction Sepsis*Aspiration Pneumonia:.321 Total HCC score: 2.876 Total Cost: $26,416.89 57

How Can You Prepare for HCC Scoring Education of clinicians and coding team to understand impact of their roles Compliant and Complete Documentation MEAT (Monitor, Evaluate, Assess, Treat) Implement QA program to identify areas of opportunity and focus for additional education Explore technology options Not advocating for upcoding

New Required Modifiers and Codes Care Episode Groups Patient Condition Groups Patient Relationship Categories www.healthinformatics.wikispaces.com Source: CMS

Patient Relationship Categories Patient Relationship codes will be required to be submitted on all claims where a clinician has provided items or services Utilized to attribute patients, in part or in whole, to clinicians and conduct an analysis of resource use based on care episode and attributed clinician Source: CMS

Care Episode Groups MACRA requires a concurrent approach that enables physicians to determine, at the time a service is rendered, the care episode or episodes to which the service should be assigned based on the goal of the service and its relationship to other services that the patient is receiving define the types of procedures or services furnished for particular clinical conditions or diagnoses Enable better measures of the kinds of services and costs physicians can control or influence than the total cost of care and episode spending measures currently in use in Medicare programs Used to determine resource use by physician groups CMS must consider the patient s clinical problems at the time items and services are furnished during an episode of care, such as clinical conditions or diagnoses, whether or not hospitalization occurs, and the principal procedures or services furnished Source: CHQPR and CMS

Episode Groups Objectives of their use Describe or account for Medicare cost and utilization using categories that make sense to clinicians and others who are responsible for patient care and healthcare systems Estimate average Medicare payments for episodes, riskadjusted according to patient-level information and other factors as appropriate Frame spending patterns in ways that highlight opportunities for improvement Source: CMS

Patient Condition Groups CMS must consider the patient s clinical history at the time of a medical visit, such as the patient s combination of chronic conditions, current health status, and recent significant history (such as hospitalization and major surgery during a previous period) Source: CMS

Timeline April 2017 Final Patient Relationship Categories and Codes will be published December 14, 2017 Final Care Episode and Patient Condition Groups and Codes will be published January 1, 2018 Care Episode, Patient Condition and Patient Relationship Categories and Codes required on claims Source: CMS

Which Option MIPS or APM? Assess your readiness MIPS Options 1, 2, 3 or the APM Option Evaluate your current processes Determine your resources Assess your reporting capabilities 65

Do or do not. There is no try. Source: enwikipedia.org/wiki/yoda 66

Questions? This presentation is presented with the understanding that the information contained does not constitute legal, accounting or other professional advice. It is not intended to be responsive to any individual situation or concerns, as the contents of this presentation are intended for general informational purposes only. Viewers are urged not to act upon the information contained in this presentation without first consulting competent legal, accounting or other professional advice regarding implications of a particular factual situation. Questions and additional information can be submitted to your Eide Bailly representative, or to the presenter of this session. 67

Thank You! Adam Strom Health Care Consulting Manager astrom@eidebailly.com 612.253.6606 Dan Schletty ACO Program Manager / Health & Wellness Coach dschletty@riverwoodhealthcare.org 218.927.5168 68