5055 E. McKinley Ave, Fresno CA 95407 Tel: (559) 251 5038 Info@ CHIA PRESENTATION HANDOUT 2018 CHIA CONVENTION & EXHIBIT SAN DIEGO, CA MACRA and HIM Doing the Impossible Presented by: Moshe Starkman Presented on: Tuesday, June 05, 2018 Sponsored by:
Value-Based Care: Thriving in a Post-MACRA Payment Model Moshe Starkman Senior Value-Based Reimbursement Consultant nthrive mstarkman@nthrive.com 2017 California Health Information 2017 California Association Health Information Association About the Presenter Moshe Starkman Senior VBR Consultant nthrive MACRA subject matter expert (SME) with extensive technical savvy and communication skills. 20 years technical experience with software architecture, database administration, and hands-on software development. 15 years leadership experience and program development. Over 5 years experience with quality reporting, continuing medical education, and health care analytics. 1
Today s Agenda A Brief History of MACRA How Did We Get Into This Mess?! Merit-based Incentive Payment System The What And How Of Mips Advanced Alternative Payment Models A General Overview Of Apms The Untold Macra Story I'm From The Government And I'm Here To Help. Summary Putting Things In Perspective. Questions and Answers Please Feel Welcome To Ask Questions Throughout The Presentation. A Brief History of MACRA Universal health insurance is not as new an innovation as some people think! 2
The Medicare Marathon Began in 1965 the first broad point to keep in mind is that all of us who developed Medicare and fought for it had been advocates of universal national health insurance. We all saw insurance for the elderly as a fallback position, which we advocated solely because it seemed to have the best chance politically., we expected Medicare to be a first step toward universal national health insurance, perhaps with Kiddicare as another step - Robert M. Ball, Social Security Commissioner under Presidents Kennedy, Johnson, and Nixon, 1995 2017 nthrive, Inc. All rights reserved. The Medicare Marathon Began in 1965 Medicare was modeled on private insurance plans We proposed assuring the same level of care for the elderly as was then enjoyed by paying and insured patients; otherwise, we did not intend to disrupt the status quo. Had we advocated anything else, it never would have passed. (Ball, 1995) This allowed for 1 Faster implementation 2 Political acceptability 3
The Medicare Marathon Began in 1965 But the disadvantages of this approach included: 1 2 3 Payment methods that turned out to be inflationary prompting considerable legislative activity in subsequent years to control escalating costs Private insurance companies dictated policy Using private insurance companies to administer the program without allowing for their selection on a competitive basis hampered control of the program. Medicare benefits did not meet the specific needs of the elderly But Became a Sprint in the 21 st Century 16. Mexico $987 17. Turkey $794 4
In the 1990 s There Was a Significant Shift in Thinking The Balanced Budget Act of 1997 amended Section 1848(f) of the Social Security Act to replace the Medicare Volume Performance Standard (MVPS) with the Sustainable Growth Rate (SGR). and was then suspended or adjusted by Congress EVERY year. What we used to refer to as the doc fix. The government cannot afford Medicare Poor planning and program design created a very expensive, untenable U.S. health care reimbursement model. And they ve been trying to fix it ever since 5
What did MACRA change? MACRA has fundamentally and forever changed the relationship between government and clinicians caring for Medicare beneficiaries. Three Business Considerations Revenue: Fewer fee-for-volume payments in favor of managed costs and quality improvement through value-oriented reimbursement models. Technology: Mandates to increase secure information sharing and patient access through an emphasis on cloud-based technology and practice improvement. Reimbursements: i.e. shared risk! 6
Quality Payment Program 7 Seven Goals 1. Improve beneficiary outcomes and engage patients through patientcentered advanced APM and MIPS policies 2. Reduce the reporting burden on clinicians 3. Increase the adoption of advanced APMS 4. Maximize program participation 5. Improve data and information sharing 6. Ensure operational excellence in program implementation and ongoing development 7. Deliver it systems capabilities that meet the needs of users 2018 nthrive, Inc. All rights reserved. MACRA established the Quality Payment Program Merit-Based Incentive Payment System (MIPS) Streamlined reporting of known quality programs Four MIPS categories: Quality (PQRS) Cost/Resource Use (VM) Improvement Activities (NEW!) Advancing Care Information (MU) Advanced Alternative Payment Model (APM) Managed and coordinated care; moving towards population health management. Qualifying APMs Full Population Health Management Service Line Specific Primary Care A list of available APMs is on slide 18. 7
Quality Payment Program: MIPS Track 1 Merit-based Incentive Payment System (MIPS) The MIPS is the default payment track for eligible clinicians and practice groups; accounting for upwards of 75% of eligible clinicians. Eligible Clinicians: Physicians Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse Anesthetists Quality Payment Program: MIPS Categories Quality Improvement Activities Advancing Care Information Cost MIPS is a dynamic path with increasing risk and reward over time. 8
Quality Payment Program: APM Path 2 Advanced Alternative Payment Models (APMs) Qualifying APM Participants (QPs) providers who receive over 25% of their Medicare Part B payments or see over 20% of Medicare patients through an Advanced APM. Through 2024, QPs will receive a lump sum bonus payment of 5 percent of Medicare professional services payments based on the previous year. Advanced APMs must: Use Certified EHR Technology Tie payment to performance based on quality measures; and Be a Medical Home Model or bear more than nominal financial risk. For example, in some cases advanced APM participants must refund Medicare if their spending exceeds a projected amount. Quality Payment Program: APM Track 2: Advanced Alternative Payment Models (APMs) Full Population Health Management MSSP ACO Track 1+ New! MSSP ACO Track 2 MSSP ACO Track 3 Next Generation ACO Primary Care, Service Line Specific Comprehensive End-Stage Renal Disease Care (CEC) Oncology Care Model (OCM) Comprehensive Primary Care Plus (CPC+) Comprehensive Care for Joint Replacement Payment Model 9
Quality Payment Program: Year 2 Timeline Performance year opens January 1, 2018 and closes December 31, 2018. CMS provides performance feedback after the data is submitted. Clinicians will receive feedback before the start of the payment year. MIPS payment adjustments are prospectively applied to each claim beginning January 1, 2020. Submission Deadline Adjustment Baseline year Performance year Feedback available 2016 2018 March 31, 2019 2019 2020 15 Point Threshold to avoid a negative adjustment. What are the three primary business considerations that MACRA? Moving to value-oriented care Increasing technology utilization Shared risk reimbursements 10
Quality Payment Program: Payment Adjustments $199M + $500 Million $173M $1B $1.5B +_5% +_ 4% 7% +_ +_ 9% 201 7 201 8 2019 202 202 0 1 202 2 5% Advanced APMs have a fixed incentive rate / bonus of 5% for several years. Quality Payment Program: Real Numbers Non Participation Medicare Billings Negative Adjustment 2020 $50,000,000 x -5% = ($2,500,000) 2022 $50,000,000 x -9% = ($3,600,000) Full-Year Participation (9% x 3) + 10% Medicare Billings Positive Adjustment 2020 $50,000,000 x 5% = $2,500,000 2022 $50,000,000 x 9% = $4,500,000 2022 $50,000,000 x 37% = $18,500,000 Advanced APM Medicare Billings Positive Adjustment 2019 $50,000,000 x 5% = $2,500,000 2024 $50,000,000 x 5% = $2,500,000 11
Quality Payment Program: Real People Quality Payment Program: Payment Adjustments $199M + $500 Million $173M $1B $1.5B +_5% +_ 4% 7% +_ +_ 9% 2017 2018 2019 2020 2021 2022 5% Advanced APMs have a fixed incentive rate / bonus of 5% for several years. 12
MACRA Proposal: Table 64 On page 676 of the MACRA Practice Size Clinicians Physician Fee Schedule Allowed Charges (S Mil) Eligible Clinicians with Negative Adjustment Eligible Clinicians with Negative Adjustment Percent Eligible Clinicians with Positive Adjustment Clinicians with Positive Adjustment Clinicians with No Adjustment Solo 102,788 $12 458 87.0% 89,383 12.9% 13,302 103 2-9 eligible clinicians 10-24 eligible clinicians 25-99 eligible clinicians 100 or more eligible clinicians 123,695 $18 697 69.9% 86,519 29.8% 36,887 289 8,207 $9 934 59.4% 48,213 40.3% 32,737 257 147,976 $12 868 44.9% 66,515 54.5% 80,588 873 305,676 $18,648 18.3% 56,045 81.3% 248,626 1,005 Overall 761,342 $72,606 45.5% 346,675 54.1% 412,140 2,527 Who Is Excluded From MIPS? Advanced APM Newly-enrolled in Medicare Enrolled in Medicare for the first time during the performance period (exempt until following performance year) Below the low-volume threshold Medicare Part B allowed charges less than or equal to $30,000 $90,000 $10,000 a year AND OR See 100 200 or fewer Medicare Part B patients a year Significantly Participating in Advanced APMs Receive 25% of your Medicare payments OR See 20% or Medicare patients through an Advanced APM 2016 (proposed) 2017 (Year 1) 2018 (THIS YEAR) 13
MIPS Reporting Outcomes Don't Participate Submit Something Submit Minimal Data Submit a Full Dataset maximum penalty -% +% ++% Not participating If you don t send in sufficient data then you receive a full negative payment adjustment Unacceptable Scores If you submit a nominal amount of data, you can avoid a downward payment adjustment Acceptable Scores If you score above the minimum threshold you may earn a neutral or positive payment adjustment Top Scores If you submit a full data set and score above the exceptional performance threshold you may earn additional bonuses above your positive payment adjustment What is the Quality Payment Program? A paradigm shift away from being reimbursed for volume towards value-oriented population health management specific to a given beneficiary s preventative, acute, and long-term care needs. 14
Keep moving towards value! Answering the How does it work? of MACRA MACRA has fundamentally and forever changed the relationship between government and clinicians caring for Medicare Part B beneficiaries. 15
Quality Measure Determination TRUE or FALSE? Your best scoring quality measures are your best measures to submit to Medicare. 2018 nthrive, Inc. All rights reserved. Quality Measure Determination FALSE Your best scoring quality measures are your best measures to submit to Medicare. Your true best measures are the measures where you score considerably better than the measure benchmark, i.e. national average. Some measures are topped out. Meaning, some measures have an average score of about 100% so even a near perfect score will not earn you full credit. 16
Submission Method and Benchmarks Measure #128 Standard Measure If your performance score is a 90%... Claims reporting will get you 6.9 points EHR reporting will get you a full 10 points Registry/QCDR reporting will get you 9.3 points Submission Method and Benchmarks Measure #130 Topped out Measure If your performance score is a 90%... Claims reporting will get you 3 points (the minimum in 2017) EHR reporting will get you a full 4.7 points Registry/QCDR reporting will get you 4.9 points 17
Submission Method and Benchmarks Based on a 90% performance score! Measure #128 Measure #130 QPP Submission Methods Available to both individuals and Groups: 1. Administrative Claims, aka Claims 2. Electronic Health Record (EHR) Exclusive to Group Reporting: 1. CAHPS for MIPS Survey 2. CMS Web Interface 3. Qualified Clinical Data Registry (QCDR) 4. Qualified Registry, aka Registry 5. Attestation (IA and ACI only) 18
There s a lot to consider when it comes to MACRA success What to expect in QPP Year 2 What s different now from Year 1? 19
QPP year 2: Ten Key Takeaways 1 Fewer participants Approximately 63 percent of all Medicare clinicians will be exempt from MIPS in 2018. It is estimated that 134,000 clinicians will be added to the exemption list, raising the total to 926,000 ineligible MIPS clinicians. 2 Updated requirements Quality: Accounts for 50 percent of a physician s score in 2018. 12-month performance period for is required (up from 90 days.) Cost: Accounts for 10 percent of a physician s score in 2018. A minimum 12-month performance period for is still required. Improvement activities: 21 new activities added to the 2018 lineup; 27 existing activities have been modified. Advancing care information (ACI): See #3 (next slide) QPP year 2: Ten Key Takeaways 3 EHR requirements tweaked for MIPS not for APM! Eligible clinicians can use either 2014 or 2015 Edition certified EHRs (CEHRT) for the MIPS ACI category. However, a 10% ACI bonus will be awarded to those who use the 2015 Edition. APM participants, however, are required to use 2015 CEHRT for a full year beginning January 1, 2018. 4 Small practice opt-out options Practices with 15 or fewer clinicians can apply for a new hardship exception to shift the ACI scoring weight to 25% to the quality category, reweighting the ACI category to zero percent. 20
QPP year 2: Ten Key Takeaways 5 Bonus points complex patient care MIPS-eligible clinicians will be awarded five bonus points for the treatment of complex-care patients based on the Hierarchical Condition Categories (HCCs) definition and the number of complex patients treated by a practice. 6 Small practice bonus Small practices with 15 or fewer eligible clinicians will get five bonus points added to their MIPS composite score if the eligible physician or group submits data for at least one performance category in 2018. QPP year 2: Ten Key Takeaways 7 Relief for extreme and uncontrollable circumstances CMS is offering clinicians, who are providing care in areas deemed an emergency or disaster area by the Federal Emergency Management Agency, the opportunity to submit a hardship application that will be considered for reweighting of the ACI performance category. The application was due December 31, 2017. 8 Introduced Virtual Groups Eligible clinicians can participate as individuals, groups or as a virtual group. Solo practitioners or practices with 10 or fewer eligible clinicians can participate in MIPS by joining together as a virtual group. There are no restrictions on groups based on size, geography or specialty, however, it s important to note the election period ended December 2017. 21
QPP year 2: Ten Key Takeaways 9 Topped out measures are now capped at 7pts Topped out measures with measure benchmarks that have been topped out for at least 2 consecutive years will receive up to 7 points. A 7-point max score is in place for the 6 topped out measures identified for the 2018 performance year. 10 Important scoring changes Only 1 point is awarded (to large practices/ 3 points for small practices) for measures that were submitted, but do not meet data completeness criteria, regardless of whether they have a benchmark or meet the case minimum. The minimum score threshold is now 15 (up from 3)! A score lower than 15 will result in a negative payment adjustment. QPP year 2 is a significant step forward Achieving a successful score is more challenging in 2018 but accommodations have been made for the most disadvantaged practices. For example, bonus points are awarded for high-risk patient care and small practices. 22
Going forward Education and Technology are paramount Key Areas and Roles Affected by MACRA Clinical Chief Medical Officer Chief Medical Information Officer Vice President/Director of Physician Services Director of Quality Clinicians Financial Chief Executive Officer Chief Financial Officer VP, Revenue Cycle Director of HIM Technology Chief Technology Officer Chief Information Officer IT Director Director/Manager of Analytics 23
Health Care Leadership: Trustees / CEO Situation The transition from fee-for-service to value-based health care essentially repositions health care from a product model to a service model. This significantly changes the business metrics of hospital management for both short and long term practice operations. Action Trustees and hospital executives need to periodically weigh the financial risks and benefits of participating in MIPS vs. an Advanced APM. The decision on which path to take and at what level can significantly alter the eventual outcomes. Impact Whether in the form of an internal build, 3rd party outsourcing, or a blend thereof, value-driven health care compels finance leaders to invest in education, analytics, and consulting services. Challenges, Risks and Rewards The CMS Physician Compare website is designed to help consumers evaluate where to seek medical care. The quality performance scores of all Medicare Part B clinicians are included on the website and can be easily accessed by consumers. Physician Compare Website: https://www.medicare.gov/physiciancompare/ 24
Health Care Leadership: CFO Situation Value-based care will affect revenues. For example, consider the impact of expanded preventative care and or a reduction in preventable admissions (under MACRA providers will not be paid for preventable readmissions). Hospitals are further incentivized to reduce acute care costs, since hospital spending is included in the MIPS performance measures cost category and will account for between 10% and 30% of one s MIPS final score. Action As more care will shift to lower-cost settings, including ambulatory care and telehealth services, to keep patients out of hospitals or other costly settings, your organization must take steps to identify shifting revenue sources while mitigating or reducing avoidable operating costs. Impact Whether in the form of an internal build, 3rd party outsourcing, or a blend thereof, value-driven health care compels finance leaders to invest in education, analytics, and consulting services. Health Care Leadership: Dir. Phys. Services Situation Enabling your hospitals to compete with traditionally lower-cost alternatives is going to be key to physician recruitment and improved overall performance scores under the Quality Payment Program. Action As group reporting and Alternative Payment Models become the norm, it is increasingly important that every member of the team understands and complies with your QPP goals and practice adjustments. Impact It may be necessary or advisable to setup an incentive and rewards program to further encourage learning and compliance on the part of the practitioners. 25
Health Care Leadership: CTO Situation Technology is a central component of valuable health care and increased patient engagement. The Advancing Care Information category of MIPS, for example, is specifically designed to encourage EHR upgrades and promote technology utilization and patient access. Action Almost equal in scope to the paradigm shift from fee-for-service to fee-forvalue is the shift from HIT as a solution to HIT as a service. Technology leaders are going to have to go beyond training internal staff and begin to consider how best to engage patient populations and define the vehicles for stronger provider-and-patient relationships Impact In an age of increasingly digital health care, the technology employed by a health system is almost as important as the staff that use it. Health Care Leadership: CIO Situation The widespread adoption of electronic medical records has repositioned the focus of health data away from how do I capture this information? to what more can I do with it? Additionally, the IoT (Internet of Things) has ushered in an era of unparalleled data collection and supplemental patient information. Action VBR will drive analytics leaders to consider not only how practice changes will impact internal performance scores but how those scores compare to national trends as well. Position your health system to see beyond descriptive data through predictive data analytics and intelligence augmenting solutions. 26
Summary Review Leadership Considerations & Participant Questions 2017 nthrive, Inc. All rights reserved. The Medicare Fixing Marathon Continues The Affordable Care Act revolutionized how Medicare reimbursements are determined and has irrevocably shifted the Fee-for-Service (FFS) paradigm and payer-to-provider relationship. This new reality compels successful health systems to understand the impact of these regulatory changes to each role in a health care organization. In other words, without a comprehensive approach to value-driven health care, health networks will not be positioned to successfully compete for positive incentives and may, at worst, see a reduction in both payment reimbursements and patient loyalty. 27
Leadership Considerations Objectives Advancing quality care Reducing operational costs Reducing resource use costs Performance excellence? Shared financial risks? Operational eligibility Practice volume Technology utilization (CEHRT) Advanced APM financial model How much risk can we take? What s the required reserve if performance is negative? Will participants be held accountable for downside risk (providers)? If an entity will pay for downside penalties, which entity? Success and Rewards Organizational alignment Leadership and providers goals and objectives alignment Collective risk tolerance Questions? You can also email Moshe at mstarkman@nthrive.com 28