Alternative Payment Models and Health IT Health DataPalooza Preconference May 8, 2016 Kelly Cronin, MS, MPH, Director, Office of Care Transformation, ONC/HHS
HHS Goals for Medicare Payment Reform In January 2015, the Department of Health and Human Services announced new goals for value-based payments and APMs in Medicare 2
Medicare Met the Goal of 30% of Payments in APMs 1 Year EARLY Major APM Categories 2014 2015 2016 2017 2018 Medicare Shared Savings Program ACO* Pioneer ACO* Bundled Payment for Care Improvement* Comprehensive Primary Care* Multi payer Advanced Primary Care Practice* Comprehensive ESRD Care Model Next Generation ACO Comprehensive Care for Joint Replacement Oncology Care Maryland All Payer Hospital Payments* ESRD Prospective Payment System* Model completion or expansion CMS will continue to test new models and will identify opportunities to expand existing models * MSSP started in 2012, Pioneer started in 2012, BPCI started in 2013, CPC started in 2012, MAPCP started in 2011, Maryland All Payer started in 2014 ESRD PPS started in 2011 3
Medicare Quality Payment Program Repeals the Sustainable Growth Rate (SGR) Formula Streamlines multiple quality reporting programs into the new Merit-based Incentive Payment System (MIPS) Provides incentive payments for participation in Advanced Alternative Payment Models (APMs) The Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) First step to a fresh start We re listening and help is available A better, smarter Medicare for healthier people Pay for what works to create a Medicare that is enduring Health information needs to be open, flexible, and user-centric 4
Most clinicians will be subject to MIPS. Subject to MIPS Not in APM In non-advanced APM QP in advanced APM In advanced APM, but not a QP Some people may be in advanced APMs but not have enough payments or patients through the advanced APM to be a QP. Note: Figure not to scale. 5
MIPS Performance Categories A single MIPS composite performance score will factor in performance in 4 weighted performance categories on a 0-100 point scale: Quality Resource use Clinical practice improvement activities Advancing care information MIPS Composite Performance Score (CPS) 6
Year 1 Performance Category Weights for MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITIES 15% COST 10% QUALITY 50% ADVANCING CARE INFORMATION 25% 7
How much can MIPS adjust payments? Based on a CPS, clinicians will receive +/- or neutral adjustments up to the percentages below. +/- Maximum Adjustments +4%+5% +7%+9% -4% - - 5% 7% - 9% 2019 2020 2021 2022 onward Merit-Based Incentive Payment System (MIPS) Adjusted Medicare Part B payment to clinician The potential maximum adjustment % will increase each year from 2019 to 2022 8
The Quality Payment Program provides additional rewards for participating in APMs. Potential financial rewards Not in APM In APM In Advanced APM MIPS adjustments MIPS adjustments + APM-specific rewards If you are a Qualifying APM Participant (QP) APM-specific rewards + 5% lump sum bonus 9
Advanced APMs meet certain criteria. As defined by MACRA, advanced APMs must meet the following criteria: The APM requires participants to use certified EHR technology. The APM bases payment on quality measures comparable to those in the MIPS quality performance category. The APM either: (1) requires APM Entities to bear more than nominal financial risk for monetary losses; OR (2) is a Medical Home Model expanded under CMMI authority. 10
NOTE: MACRA does NOT change how any particular APM functions or rewards value. Instead, it creates extra incentives for APM participation. 11
PROPOSED RULE Advanced APM Criterion 1: Requires use of Certified Health IT Certified EHR use Example: An Advanced APM has a provision in its participation agreement that at least 50% of an APM Entity s eligible clinicians must use Certified Health IT. APM Entity Eligible Clinicians An Advanced APM must require at least 50% of the eligible clinicians in each APM Entity to use Certified Health IT to document and communicate clinical care. The threshold will increase to 75% after the first year. For the Shared Savings Program only, the APM may apply a penalty or reward to APM entities based on the degree of Certified Health IT use among its eligible clinicians. 12
Proposed Rule Advanced APMs Based on the proposed criteria, which current APMs will be Advanced APMs in 2017? Shared Savings Program (Tracks 2 and 3) Next Generation ACO Model Comprehensive ESRD Care (CEC) (large dialysis organization arrangement) Comprehensive Primary Care Plus (CPC+) Oncology Care Model (OCM) (two-sided risk track available in 2018) 13
What about private payer or Medicaid APMs? Can they help me qualify to be a QP? Starting in 2021, some arrangements with other non-medicare payers can count toward becoming a QP. All-Payer Combination Option IF the Other Payer APMs meet criteria similar to those for Advanced APMs, CMS will consider them Other Payer Advanced APMs : Certified EHR use Quality Measures Financia l Risk 14
Putting it all together: 201 6 201 7 201 8 201 9 202 0 202 1 202 2 202 3 202 4 202 5 2026 & on Fee Schedule +0.5% each year No change +0.25% or 0.75% MIPS Max Adjustment (+/-) 4 5 7 9 9 9 9 QP in Advanced APM +5% bonus (excluded from MIPS) 15
Next Generation ACO Model builds upon successes from Pioneer and MSSP ACOs Designed for ACOs experienced coordinating care for patient populations 21 ACOs will assume higher levels of financial risk and reward than the Pioneer or MSSP ACOS Model will test how strong financial incentives for ACOs can improve health outcomes and reduce expenditures Greater opportunities to coordinate care (e.g., telehealth & skilled nursing facilities) Next Generation ACO Pioneer ACO 21 ACOs spread among 13 states 9 ACOs spread among 7 states Model Principles Prospective attribution Financial model for long term stability (smooth cash flow, improved investment capability) Reward quality Benefit enhancements that improve patient experience & protect freedom of choice Allow beneficiaries to choose alignment 16
Comprehensive Primary Care CMS convenes Medicaid and commercial payers to support primary care practice transformation through enhanced, non visit based payments, data feedback, and learning systems $14 or 2%* reduction part A and B expenditure in year 1 among all 7 CPC regions Reductions appear to be driven by initiative wide impacts on hospitalizations, ED visits, and unplanned 30 day readmissions 7 regions (AR, OR, NJ, CO, OK, OH/KY, NY) encompassing 31 payers, nearly 500 practices, and approximately 2.5 million multi payer patients CPC+ just announced could expand participation across 20 regions in the US with up to 5000 practices * Reductions relative to a matched comparison group and do not include the care management fees (~$20 pbpm) 17
Health IT Capabilities Expected in CPC+ Track 2 HIT Vendor Partnership with CMS and CPC practices vendors sign a MOU with CMS and will develop advanced HIT functionalities for practices in Track 2 Risk stratify the practice site patient population Empanel patients to the practice site care team Establish patient focused care plans to guide care management Screen for social and community support needs and link the identified need(s) to practice identified resources Produce and display ecqm results at the practice level to support continuous feedback Document and track patient reported outcomes Optional: Practice site care delivery and care touch documentation 18
Bundled Payments for Care Improvement is also growing rapidly The bundled payment model targets 48 conditions with a single payment for an episode of care Incentivizes providers to take accountability for both cost and quality of care Four Models Model 1: Retrospective acute care hospital stay only Model 2: Retrospective acute care hospital stay plus post acute care Model 3: Retrospective post acute care only Model 4: Prospective acute care hospital stay only 337 Awardees and 1237 Episode Initiators as of January 2016 Duration of model is scheduled for 3 years: Model 1: Awardees began Period of Performance in April 2013 Models 2, 3, 4: Awardees began Period of Performance in October 2013 19
Comprehensive Care for Joint Replacement (CJR) is testing a bundled payment model across a cross-section of hospitals The model tests bundled payment of lower extremity joint replacement (LEJR) episodes and includes approximately 20% of all Medicare LEJR procedures ~800 Inpatient Prospective Payment System Hospitals participating in 67 selected Metropolitan Statistical Areas (MSAs) where 30% U.S. population resides The model will have 5 performance years, first year started April 1, 2016 Participant hospitals that achieve spending and quality goals will be eligible to receive a reconciliation payment from Medicare or will be held accountable for spending above a pre determined target beginning in Year 2 Pay for performance methodology will include 2 required quality measures and voluntary submission of patient reported outcomes data 20
Medicare Payment Reform alone will not drive interoperability APMs offer a number of opportunities to reinforce the adoption of health information exchange capabilities and HIT tools that are instrumental to providers succeeding within these models. Advanced Medicare APMs will require use of certified health IT among eligible clinicians Multi-payer alignment of incentives or requirements for interoperability will drive provider behavior and uniform adoption of standards through certification. State policies will also reinforce interoperability through Medicaid waivers, State Plan Amendments (e.g., health home requirements), Managed Care Contract requirements, Medicaid matching fund policies, and other state driven mandates or incentives
HIT Capabilities for APMs where are the gaps? Based on an extensive literature review, interviews, and input from Technical Expert Panel participants, ONC has identified several market gaps around health IT capabilities, including: Up to date care plan in standardized format with patient goals and results accessible by providers & case managers Receive and incorporate notifications of referral status, including if appointment is not kept. Identify providers by specialty, commitment to care coordination, patient preference, patient s health plan network Ability to cross reference the organization s preferred providers to provider networks identified by the patient, health plan, or provider system.
HIT Modular Functions for Value Based Payment Providers & Data Sources Health Care Provider Systems Other Non- Health Care Provider Systems EHR Claims Data Clinical Data Information Analytics Services Notification Services Exchange Services Data Extraction Data Quality & Provenance ID Management Reporting Services Data Transport and Load Consumer Tools Provider Portal Patient Attribution Data Aggregation PD/Registry Various Reporting Formats Payers and Other VBP Stakeholders Private Purchasers CMS & Other Federal Agencies Medicaid & Other State Agencies ACOs MCOs - APMs Registries Security Consent Mngt Public Health Other Non- Provider Systems Governance Financing Policy/Legal Business Operations Other 23
Key Insights from States on Multi-Stakeholder Collaboration for APM Data Infrastructure Focus on 1-2 high value use cases valuable to providers and payers, i.e., improve measurement, reporting and performance Assess existing data assets statewide (APCD, HIEs, CDRs, Medicare QEs, etc.) to determine if they meet requirements Need a neutral convener and facilitator Starting with a multi-payer process with provider input has been effective Find the right committed partners at the right level in respective payer organizations (senior level clinician managers) State shouldn t necessarily lead but definitely be at the table and fully engaged Keep process nimble, flexible, informal initially Get front line clinician input into user design of reporting tools to ensure value and usability in practices CMS Data Use Agreement can permit access to Medicare data for APMs like CPC 5/8/2016 Office of the National Coordinator for Health Information Technology 24
Questions? Kelly.cronin@hhs.gov @ONC_HealthIT @HHSONC