UPDATED WITH FINAL RULE NOVEMBER 11, 2016 G A M E C H A N G E R : Preparing for Success With MACRA
Overview The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) dramatically impacts the way Medicare payments will be made as the healthcare industry continues to shift from fee-for-service to value-based care. Here, we shed light on MACRA s key components and explore with CareSync s founder and CEO Travis Bond how establishing compliant, fullservice care coordination today can create success with MACRA tomorrow. Updated November 11, 2016 Table of contents 3 How did we get here? 6 Where are we now? 14 Where are we headed? Improved Care Through the Sharing of Health Information MACRA: A Law Paved With Good Intentions Connecting CCM, Care Coordination and MACRA GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 2
How did we get here? IMPROVED CARE THROUGH THE SHARING OF HEALTH INFORMATION In 2009, technology was improving productivity in ways we d never imagined. Mobile devices were becoming the norm, family and friends could video conference each other from continents away, and Facebook users had already been oversharing for three years. Software solutions were so prevalent that Apple trademarked the phrase, There s an app for that. It s amazing to think that while the most mundane details about personal lives were being shared electronically, the most important details that could save lives were not. In a very connected world, the healthcare industry was largely disconnected. Physician offices and even hospitals weren t adequately wired for the exchange of health information and creating a health IT infrastructure was a costly consideration. For many physicians, the act of shifting data from paper to paperless seemed too daunting a task, let alone finding a way to pay for it. And with patient information spread among so many different providers at once, it was hard for some in healthcare to get on board with a move toward electronic health records (EHRs) or even picture how it could be accomplished. However, as CareSync s Founder and Chief Executive Officer Travis Bond explains, It was becoming increasingly clear that sharing health information was vital to patient care and leveraging technology that added productivity and value to our personal lives could do the same for healthcare. To help prompt physicians out of paper silos and into EHRs, CMS did what had worked in the past: they dangled a carrot. Medicare EHR Incentive Programs The carrot came in the form of Medicare EHR Incentive Programs. These programs were launched in stages to help providers move from Stage 1, creating the information, to Stage 2, exchanging health information, to Stage 3, focusing on improved outcomes and using what we learned in Stage 2 to inform policy decisions for Stage 3. The first stage established the requirements for electronically capturing clinical data and providing patients with electronic copies of their health information. Referred to GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 3
EHR use as of April 2016 97% OF HOSPITALS 3/4 OF PHYSICIAN OFFICES as Meaningful Use, the programs encouraged the adoption of new technology and gave eligible providers and hospitals incentives for using certified EHR technology to: Improve healthcare quality, safety, and efficiency Reduce health disparities Engage patients and their family members Improve care coordination and public health Maintain the privacy and security of patient health information As we moved into Stage 2, focus shifted to patient engagement, interoperability and health information exchange. Measures were put in place to ensure that the meaningful use of EHRs supported national interests, such as: Achieving continuous quality improvement at the point of care Increasing interoperable health data sharing among providers Improving patient health outcomes and overall public health outcomes Providing structure to how health information is exchanged Increasing transparency and efficiency Empowering individuals and encouraging them to be active participants in their healthcare Providing more robust research data on health systems There were plenty of growing pains associated with adopting EHR technology and there will continue to be pain points as we move into Stage 3. However, since that pivotal point in 2009, we ve made a lot of progress. Now, more than 97 percent of all hospitals and three-quarters of physician offices use EHRs, according to the Center for Medicare and Medicaid Services (CMS). Increased use of EHRs has led to many benefits, including doctors getting a more accurate picture of a patient s overall health, the ability to swiftly and safely transmit prescriptions electronically to pharmacies, patients having direct access to their health information, and more. The next steps with EHR technology involve transitioning from the staged Meaningful Use phase to the new program as it will look under MACRA. GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 4
WHEN YOU READ THE LIST OF GOALS ASSOCIATED WITH THE MEANINGFUL USE OF EHR TECHNOLOGY, YOU CAN SEE HOW THEY ARE CLOSELY TIED TO PATIENT ENGAGEMENT, IMPROVED CARE, AND PUBLIC HEALTH OUTCOMES TRAVIS BOND When you read the list of goals associated with the meaningful use of EHR technology, you can see how they are closely tied to patient engagement, improved care, and public health outcomes, said Bond. These are all goals HHS has outlined for MACRA. Achieving the full potential of health IT is just one of those goals. According to the Office of the National Coordinator for Health Information Technology, Having the right information at the right time supports team-based care, strong care coordination, and effective patient and family engagement, which many provider communities have recognized are fundamental to an efficient and effective care delivery system. Widespread EHR adoption has, indeed, dramatically improved our ability to get the right information, into the right hands, at the right time. It has also paved the way for new programs, codes, and reimbursement models to be implemented, not the least of which are CPT Code 99490 for Chronic Care Management (CCM) and now MACRA. GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 5
Where are we now? MACRA: A LAW PAVED WITH GOOD INTENTIONS According to HHS, MACRA ended more than a decade of last-minute fixes and potential payment cliffs for Medicare doctors and clinicians, while making numerous improvements to America s healthcare system. At the heart of this bipartisan legislation is the desire to achieve truly patient-centered care by improving the relevancy and depth of Medicare s quality-based payments. Under the fee-for-service approach MACRA replaces, physicians would provide a service and get paid. The more services they provided, the more money they would make. Results of patient care, good or bad, were not a factor in payment as it was about quantity rather than quality. MACRA shifts the focus from volume to value. Physicians provide a service and their payment varies based on how well they meet certain quality measures and create value for their patients. MIPS APM 01.01.17 GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 6
MACRA FOCUS ON THREE KEY AREAS INCENTIVES CARE DELIVERY INFORMATION SHARING ACHIEVE THREE HEALTHCARE GOALS BETTER CARE SMARTER SPENDING HEALTHIER PEOPLE At CareSync, we think this shift represents the alignment of doing well by doing good There is legitimate concern that healthcare spending in the U.S. puts our national economy in jeopardy, said Bond. Currently, we spend 18 cents of every dollar on the delivery of healthcare and we re on track for that number to reach 34 cents by 2040 1. When you consider the impact of healthcare spend reaching 34 percent of GDP with 86 percent of that spend already going to the treatment of chronic conditions 2, it s clear the trajectory we re on can t possibly work and CMS is recognizing that. By emphasizing quality over quantity, the new system pays physicians for doing what they already want to do: provide the best possible care for their patients. Care becomes increasingly focused and individualized, health information is more easily shared (which supports the healthcare decisions of both doctors and patients), and patients get healthier and stay healthier longer. Additionally, Medicare pays for what works in the hope that we all benefit from a more enduring Medicare, and that we use the lessons we learn to turn the tide on healthcare spending. At CareSync, we think this shift represents the alignment of doing well by doing good, meaning that if a provider does the best thing in the interest of the patient doing good they ll also do financially well, said Bond. I think that s the essence and purpose of what CMS is doing here. 1 The Economic Case for Health Care Reform, Council of Economic Advisers, Executive Office of the President, 2009 2 Total U.S. Healthcare Spending by Number of Chronic Conditions in 2010, Agency for Healthcare Research and Quality, 2010 GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 7
The Quality Payment Program (QPP) Aligned with CMS effort to reward better care, smarter spending, and healthier people, MACRA repeals Medicare s flawed Sustainable Growth Rate (SGR) formula and replaces it with a new value-based reimbursement system called the Quality Payment Program (QPP). Additionally, it streamlines physician reporting and gives providers two paths to choose from for determining how the value and quality of their care will be measured. These two paths are the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients outcomes Reporting as an Advanced APM According to CMS, an APM is a In the case of reporting through the payment approach that gives added QPP as an Advanced APM, providers incentive payments to provide can earn a 5% incentive payment in high-quality and cost-efficient care. 2019 for Advanced APM participation APMs can apply to a specific clinical in 2017 if they receive 25% of their condition, a care episode, or a Medicare Part B payments through population. Advanced APMs are a an Advanced APM or see 20% of subset of APMs, and let practices their Medicare patients through an earn more for taking on some risk Advanced APM. related to their patients outcomes. Reporting through MIPS The term CMS uses for Medicare Part B providers subject to participation in MIPS is MIPS eligible clinicians. During the first performance year, this group includes physicians (MD/DO and DMD/DDS), physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. In future years, the HHS Secretary may expand the eligibility net to include other providers, such as physical or occupational therapists, speechlanguage pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dieticians and nutritional professionals. At least initially, most Medicare providers (CMS estimates between 592,000 and 642,000 for the first performance year) will participate in the QPP by reporting through MIPS. Eligible clinicians who do so can participate in MIPS as an individual or as a group billing through a common tax ID. If participating as a group, they would be assessed as a group practice across all four MIPS performance categories (three in 2017). GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 8
Reporting MIPS score as an individual: If you send MIPS data in as an individual, your payment adjustment will be based on your performance. An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number. You ll send your individual data for each of the MIPS categories through an electronic health record, registry, or a qualified clinical data registry. You may also send in quality data through your routine Medicare claims process. TO SUBMIT DATA THROUGH THE CMS WEB INTERFACE, YOU MUST REGISTER AS A GROUP BY JUNE 30, 2017 Reporting MIPS score as a group: If you send your MIPS data with a group, the group will get one payment adjustment based on the group s performance. A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site. Your group will send in group-level data for each of the MIPS categories through the CMS web interface or an electronic health record, registry, or a qualified clinical data registry. To submit data through the CMS web interface, you must register as a group by June 30, 2017. Some providers will be exempt from MIPS: Clinicians who are in their first year of participation in Medicare Part B Clinicians who fall under the low-volume threshold: Clinicians who see less than or equal to 100 Medicare patients in a year or accrue less than or equal to $30,000 in Medicare Part B allowed charges in a year Clinicians who are significantly participating in an Advanced Alternative Payment Model (APM), Qualifying APM Participants (QPs), and certain Partial Qualifying APM Participants (Partial QPs) GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 9
MIPS Performance Categories and Scores MIPS improves and consolidates the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) Program, and the Medicare EHR Incentive Program into one scoring system designed to measure the care given to Medicare patients. When reporting through MIPS, payments are determined by how well providers demonstrate success in four performance categories: Quality, Improvement Activities, Advancing Care Information, and Cost. These four categories are weighted to determine a provider s MIPS Composite Performance Score (CPS) of up to 100 points. This score will be used to measure a provider s overall care delivery and compute a positive, negative, or neutral adjustment to their future Medicare payments as appropriate. Payment Adjustments Based on MIPS Scores MIPS PAYMENT ADJUSTMENTS ARE APPLIED TO MEDICARE PART B PAYMENTS TWO YEARS AFTER THE PERFORMANCE YEAR MACRA requires MIPS to be budget neutral so total upward and downward adjustments will be balanced to make the average change equal 0%. The swing in percentage for those payment adjustments is based on the relationship between the provider s MIPS CPS and the MIPS performance threshold. If the CPS is below the performance threshold, the provider will see a negative payment adjustment, or proportional penalty. A CPS at the performance threshold will result in a neutral payment adjustment, or 0%. A CPS above the performance threshold will result in a positive payment adjustment, or incentive. The amount of adjustment will depend on how much the CPS exceeds the threshold and the overall CPS distribution. The MIPS performance threshold will be set annually by CMS. The threshold will be based on the mean or median of the MIPS scores from all MIPS-eligible providers during a prior period (as defined by CMS). In 2019, no historical MIPS scores will be available to determine the performance threshold. In 2020, historical MIPS scores will only reflect the first year of measurement, which may or may not be very representative of the norm. So in 2019 and 2020, the first two payment years, the plan is to base the performance threshold on historical data related to the previous reporting categories and any additional factors as determined by CMS. MIPS payment adjustments are applied to Medicare Part B payments GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 10
two years after the performance year. The first performance year will be 2017, with 2019 being the payment adjustment year. This means CMS will begin measuring a physician s performance and the care data they report through MIPS from January 1, 2017 to December 31, 2017, to determine their Medicare payments beginning in 2019. The stakes get higher each year after that as both positive and negative adjustments will increase as follows: 5 % IN 2020 7 % IN 2021 9 % IN 2022 In that first payment adjustment year, 2019, depending on the variation of MIPS scores, negative adjustments can be no more than -4 percent, and positive adjustments can be no more than +4 percent. Additionally, in the first five payment years of the program, the law allows for up to $500 million per year in an exceptional performance bonus to reward progressively high performers. CMS ESTIMATES THAT BETWEEN 592,000 AND 642,000 ELIGIBLE CLINICIANS WILL PARTICIPATE IN MIPS DURING THE FIRST PERFORMANCE YEAR GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 11
How MIPS Categories Will Be Weighted the First Performance Year THE QUALITY CATEGORY, WHICH REPLACES THE PQRS, WILL COUNT FOR 60% IN CALENDAR YEAR 2017 DURING THE FIRST PERFORMANCE YEAR, DESIGNATED A TRANSITION YEAR BY CMS, THE COST CATEGORY WILL BE EXCLUDED AND THE MIPS CATEGORIES WILL BE WEIGHTED AS FOLLOWS: Quality (60%) The Quality category, which replaces as few as one quality measure for the PQRS, will count for 60 percent in partial credit, or on six measures Calendar Year (CY) 2017. Depending or one speciality-specific set for full on how much the clinician wants credit if submitting quality data as an to participate, they can report on individual physician. Improvement Activities (15%) To receive full credit in Improvement eligible clinicians, CMS reduces the Activities, a new category, clinicians requirement for this category to only who report as an individual are two medium-weighted activities or required to complete four mediumweighted or two high-weighted one high-weighted activity. Because improving care often activities. involves deploying EHR technology, For small practices, rural practices, CMS has indicated it will designate or practices located in geographic some improvement activities as also health professional shortage areas qualifying for the Advancing Care (HPSAs), and non-patient facing MIPS Information score. Advancing Care Information (25%) For full participation in the Advancing Use, there are five required Care Information category, which measures. Reporting on other replaces the Medicare EHR Incentive measures is optional. Program also known as Meaningful GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 12
In 2017, clinicians can earn a bonus score for improvement activities that make use of certified electronic health record technology (CEHRT) and for reporting to public health or clinical data registries. CMS stated this reflects the belief that the Advancing Care Information performance category should align with the other performance categories to achieve the unified goal of quality improvement. Cost (0%) A note about the Cost category, which replaces the VBM: Beginning with performance year 2018, the Cost performance category s contribution to the final score will gradually increase from 0 to 30 percent by the third MIPS payment year of 2021, as required by MACRA, and the Quality category weight will decrease from 60 percent to 30 percent at the same time and by the same increments. Pick Your Pace Options for the First Performance Year Also during the first performance year, CMS is allowing clinicians to pick their pace for reporting through MIPS in an effort to ease the transition. The options include: Report nothing in 2017: Receive the full negative 4 percent adjustment. CLINICIANS COULD START COLLECTING PERFORMANCE DATA JANUARY 1, 2017 Report under MIPS for a full 90-day period or, ideally, the full year. This will maximize chances to qualify for a positive payment adjustment and the possibility to earn a bonus for exceptional performance (available for years 2019 through 2024, with $500 million allotted annually for this purpose). Clinicians could start collecting performance data January 1, 2017, but if they are not ready and plan to participate for at least part of the year, they can choose to start any time between January 1 and October 2, 2017. Whenever they choose to start, they will need to send in their performance data by March 31, 2018. Report under MIPS for less than the full year, but for at least a full 90- day period, and report more than one quality measure, more than one improvement activity, or more than the required measures under the Advancing Care Information category in order to avoid a negative MIPS payment adjustment and possibly receive a positive MIPS payment adjustment if reporting MIPS score as an individual. Report one quality measure, one improvement activity, or report the required measures of the Advancing Care Information category and avoid a negative MIPS payment adjustment if reporting MIPS score as an individual. Participate in an Advanced Alternative Payment Model (APM) and possibly qualify for a 5 percent bonus incentive payment in 2019. GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 13
Where are we headed? CONNECTING CCM, CARE COORDINATION AND MACRA What began with the adoption of EHR technology, boosted by incentivizing its meaningful use, and the adoption of CCM, boosted by creating reimbursement through CPT Code 99490, now brings us to the next evolution in patient care: MACRA. Moving into MACRA won t be easy, instant or an immediate fix for some of the frustrations that have been built along the way. Change is painful, acknowledged Bond. In fact, many practices are still in pain from the EHR implementation phase. But the good news is there are already programs in place that can help you compliantly bridge the gap between fee-for-service and value-based care. As we ve repeatedly seen in the healthcare industry, when new incentives, reimbursement models, or codes are announced, there is generally a bigger purpose behind such moves. If you get too focused on the protocols, you miss the purpose, said Bond. But when you truly understand the intention behind something, it s a lot easier to anticipate and appreciate the continued direction. Bond believes part of the reason CMS created CPT Code 99490 was to help ease providers out of the feefor-service environment they have been operating in their entire careers into the new outcomes-based environment of MACRA. The spirit of what CMS is trying to accomplish with MACRA is paying providers for the value and quality of care they provide to significantly improve the value and quality of care patients receive, said Bond. If that sounds like chronic care management or any other care coordination service, you re right. Consider any aspect of care coordination from creating a comprehensive care plan, implementing CCM in your practice or ensuring you ve got compliant, shareable EHR capabilities and you ll see it has the potential to impact all four MIPS performance categories. To that end, the following specifically illustrates how robust CCM and other care coordination services can be leveraged the first performance year. GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 14
How is the MIPS journey supported by CareSync? For a clinician reporting as an individual, CareSync can support you in the following ways: Quality Measures are 60% of MIPS score CareSync can help support your practice in 16 Quality Measures You only need 6 for full participation via the MIPS pathway Improvement Activities are 15% of MIPS score CareSync can help support 13 Medium-Weighted Activities and 1 High-Weighted Activity You only need 4 Medium or 2 High-Weighted Activities for full participation via the MIPS pathway Advancing Care Information is 25% of MIPS score (replaces Meaningful Use) CareSync can help support 3 out of 5 required measures Security Risk Analysis and e-prescribing are to be completed within the practice CareSync provides 4 additional measures which can be used for additional credit To implement your measures and activities Engage your patients to help achieve better results Notify you of measurement and activity progress Sustain the progress through ongoing CCM support If you are a group participating in MIPS or if you are participating in an Advanced APM, please contact us to learn how we can support you. GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 15
Conclusion Clearly, care coordination is at the core of MACRA. As a physician, you want to ask yourself if it s at the core of your practice. How you answer that question will speak volumes about whether or not you re prepared for what s to come next. Alternatively, providers who understand care coordination, embrace proactive between-visit care, and engage patients to become active participants in their health will be well-prepared for the changes and challenges ahead. Providers who delay participation in value-based care and are not prepared for the shift will face significant reductions in payment. And smaller practices, particularly those with single practitioners, could feel the biggest impact. If their low scores lead to low enough reimbursements, they could be forced to choose between joining larger groups or closing their doors. As Bond explained, We like to think of it this way: Making deposits in the bank of care coordination today will build equity for success with MACRA tomorrow. If you re looking for a smooth transition into MACRA, partnering with CareSync is a smart bet for the future. GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 16
Don t leave your Medicare reimbursments to chance Choose a trusted partner with the experience, resources and proven capabilities to deliver truly compliant chronic care management and other care coordination services to your patients. Leverage our expertise to give your organization a smooth and successful transition into CCM and MACRA. Contact us today to discuss your options and learn the many ways we can be of assistance to your practice. 800-587-5227 sales@caresync.com www.caresync.com Disclaimer At the time this white paper was published or uploaded to the web, the information, sources and links included were current. This white paper was written to provide you with a general summary of policy and is not intended to take the place of written laws or specific statutes as they evolve. CareSync encourages you to visit CareSync.com and CMS.gov for updates regarding MACRA. Note: Generally, we use the term providers or physicians in this white paper, but the terminology used in the legislation uses the phrase eligible clinicians. Originally published July 14, 2016. Last updated November 11, 2016. CareSync 2016. All Rights Reserved. GAME CHANGER: PREPARING FOR SUCCESS WITH MACRA I 17