W20.8XXA The Future of Medicare: A Move Toward Value Driven Healthcare Emily L. Graham, RHIA, CCS-P VP, Regulatory Affairs, Hart Health Strategies Consultant, Coalition of State Rheumatology Organizations Other cause of strike by thrown, projected or falling object, initial encounter Medicare Access and CHIP Reauthorization Act of 2015 () Passed the House: March 26, 2015 Passed the Senate: April 14, 2015 Signed into law: April 16, 2015 Immediately repeals the Sustainable Growth Rate (SGR) formula From the Congress: A New Medicare Payment System Provides short-term phase-in to new payment system (2015-2019) 0.5% base update July 1, 2015 December 31, 2015 0.5% base update each year (CY 2016-2019) Current CMS Quality Improvement Programs continue Physician Quality Reporting System (PQRS) Value Based Modifier (VM) Electronic Health Record (EHR) Incentive Program ( Meaningful Use ) Separate application of payment adjustments under PQRS, VM, and EHR-MU will sunset December 31, 2018 New value-based payment models begin January 1, 2019 Merit-Based Incentive Payment System (MIPS) Alternative Payment Models (APMs) Physicians can choose to participate in MIPS or meet requirements to be a qualifying APM participant No automatic payment updates (CY 2020-2025) Base payment update: 0% 1
Consolidates existing Medicare quality improvement programs (PQRS, VBM, EHR/MU) Creates composite performance score (0-100) to inform physician payment based on four weighted categories*: Quality (30%) (PQRS) Resource Use (30%) (VBM) Meaningful Use (25%) (EHR)** Clinical Practice Improvement Activities (15%)*** * Weights may be adjusted if there are not sufficient measures and activities applicable for each type of eligible professional (EP), including assigning a scoring weight of 0 for a performance category ** EHR weighting can be decreased and shifted to other categories if the Secretary estimates the proportion of physicians who are meaningful EHR users is 75% or greater (statutory floor for EHR weight is 15%) *** Secretary currently soliciting suggestions from stakeholders on activities Examples of potential Clinical Practice Improvement Activities Expanded Practice Access Same day appointments for urgent needs; After hours clinician advice Population Management Monitoring health conditions & providing timely intervention; Participation in a qualified clinical data registry (QCDR) Care Coordination Timely communication of test results; Timely exchange of clinical information with patients and providers; Remote monitoring; Telehealth Beneficiary Engagement Care plans for complex patients; Beneficiary self-management, assessment and training; Shared decision making Patient safety and practice assessment Clinical or surgical checklists, practice assessments related to maintaining certification Participation in an APM APMs: The Basics The composite performance score will be used to determine and apply a MIPS payment adjustment factor for 2019 onward MIPS participants can receive positive, negative or zero payment adjustment EPs receive a positive adjustment factor if score is above the performance threshold and a negative adjustment factor if score is below threshold. MIPS applicable percent (positive or negative): CY Potential Adjustments 2019-4%; up to +12% 2020-5%; up to +15% 2021-7%; up to +21% 2022 & Beyond -9%; up to +27% Negative adjustment capped each year Positive adjustment can be up to 3X the amount, plus additional bonus of up to 10% (2019-2024) for exceptional performers Alternative Payment Models (APMs): Physicians receiving a significant share of their revenues through an APM that involves financial risk and quality measurement APMs are defined as A CMMI demo (not Health Care Innovation awards) Medicare Shared Savings Program (i.e., Medicare ACO) Certain other demonstration programs APMs must also Bear more than nominal financial risk (except CMMI medical homes) Require participants to use certified EHR technology Report on MIPS-like quality measures APMs: The Basics : Next Steps Participating in an APM offers A 5% participation bonus (lump sum) 2019-2024 A higher baseline update in 2026 and beyond (0.75% vs. 0.25%) Technical assistance to help small practices participate, and help poor performers improve Emphasis on APMs tested for medical specialties, small practices, and private payer incentives July 2015: CY 2016 MPFS Proposed Rule Preliminary questions on MIPS/APMs October 2015: Request for Information on MIPS/APMs Detailed questions on MIPS/APMs November 2015: CY 2016 MPFS Final Rule Additional information on MIPS/APMS July 2016: CY 2017 MPFS Proposed Rule Proposed policies for MIPS November 2016: CY 2017 MPFS Final Rule Finalized policies for MIPS January 2017 Beginning of first performance period for MIPS 2
[W]e have a responsibility to help align the way providers are paid as a key step toward better care, smarter spending, and healthier people From the Secretary: Advancing Value-Driven Health Care - Secretary Sylvia M. Burwell Secretary s Timeline Payment Taxonomy Framework HCPLAN HHS launched the Health Care Payment Learning and Action Network ( The LAN ) to accelerate the transition to alternative payment models Serve as a convening body to facilitate joint implementation of new models of payment and care delivery, Identify areas of agreement around movement toward alternative payment models and how best to analyze data and report on these new payment models, Collaborate to generate evidence, share approaches, and remove barriers, Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, quality and performance measurement, risk adjustment, and other topics raised for discussion, and Create implementation guides for payers, purchasers, providers, and consumers. Private Sector on VBP Health Care Transformation Task Force Coalition of private payers, purchasers, health systems, patients Committed to moving 75% of payments to value-based arrangements by 2020 3
Proposed rule released on July 7, 2015; Includes multiple proposals that would modify how physicians are paid under the Medicare program Highlights from quality provisions in the proposed rule: Changes to existing quality improvement programs (i.e., PQRS, VM, Physician Compare) CSRO: Make apples-to-apples comparisons; Take into account Part D drugs in VM calculation Merit-Based Incentive Payment System (MIPS) /Alternative Payment Models (APMs) CSRO: Consider multiple activities towards clinical practice improvement category; ensure flexibility by adopting fundamental elements for APMs Regulatory Update Multiple issues for rheumatology practices CSRO Submitted comments on September 8, 2015 25 CSRO Member Organization signed on in support of the 2016 MPFS proposed rule comments Potentially Misvalued Code Initiative CSRO: Remove chemotherapy administration/therapeutic drug codes from and add E/M codes to the list of potentially misvalued codes Target/Phase-In for Misvalued Codes CSRO: Remove Advance Care Planning (ACP) services from the calculation; Adopt a 50% phase-in for significant RVU reductions Improving Payment Accuracy for Primary Care/Care Management CSRO: Conduct robust study of E/M services; Adopt and implement chronic disease management codes Payment for ACP services CSRO: Finalize ACP services for payment Changes to Incident To Billing CSRO: Clarify that direct personal physician supervision may be the responsibility of several physicians Biosimilars CSRO: Establish unique J codes /separate payment amounts for each biosimilar product Meaning Use CMS issued Stage 3 meaningful use proposed rule, and Stage 1 & 2 modifications rule in Spring 2015; ONC simultaneously issued Stage 3 certification criteria Final rules delivered to the Office of Management and Budget (OMB) for review on September 3, 2015 Medical community urging the Secretary to delay Stage 3 and associated certification criteria, but release the Stage 1 & 2 modifications rule Legislative effort to delay Stage 3 Flexibility in HIT Reporting and Advancing Interoperability Act ( Flex-IT 2 Act ) (HR 3309) Introduced by Rep. Renee Ellmers (R-NC-2) 4
ICD-10 Implementation ICD-10 Implementation ICD-10 will replace ICD-9 on October 1, 2015 AMA/CMS announced a one-year grace period (Applies to Medicare fee-for-service ONLY!) CMS will not deny/audit claims based solely on the specificity of the ICD-10 diagnosis code, as long as the physician used a valid code from the correct family CMS will not subject physicians to penalties for ICD-10 coding specificity errors as part of CMS quality programs CMS will establish an ICD-10 Ombudsman to triage physician issues during implementation Medicare Administrative Contractors (MACs) are authorized to make advanced payment to physicians if contractors are unable to process claims within established time limits https://www.cms.gov/medicare/coding/icd10/clarifying-questions-and-answers-related-tothe-july-6-2015-cms-ama-joint-announcement.pdf Questions? 5