Using Patient-Centered Care to Maximize Clinician Payments Under MACRA

Using Patient-Centered Care to Maximize Clinician Payments Under MACRA Michael Barr, MD, MBA, MACP Executive Vice President Quality Measurement & Research Group NCQA

Disclosure Statement No relevant financial relationships to disclose other than employment by NCQA. 2

PCMH, PCSP and QPP Oh My! 3

Learning Objectives 1.Outline the key tenets of the Patient-Centered Medical Home (PCMH) as it relates to current health care policy. 2.Describe the synergy between PCMH and the recognition of specialty practices (PCSP). 3.Highlight key changes to the NCQA PCMH program and alignment with the CMS Quality Payment Program (QPP). 4

Access Quality Cost Desired Future

New 2-track Quality Payment Program MERIT-BASED INCENTIVE PAYMENT SYSTEM MIPS ALTERNATIVE PAYMENT MODELS APMS +4% +5% +7% +9% FFS + performance bonuses/penalties for: 1) Quality 2) Cost 3) Improvement Activities 4) Advancing Care Information (ACI) Automatic 5% bonus for either: 2-sided risk, performance-based pay, use of Certified EHRs & revenue/ patient thresholds OR expanded CMMI demonstrations CPS Threshold -4% 201 9-5% 202 0-7% 202 1-9% 2022 Onward 6

MACRA MIPS (Merit-based Incentive Performance System) CMS predicts up to 95% of clinicians will be in MIPS path in 2019 Who s in? All clinicians not in a MIPS APM All clinicians not participating in an Advanced APM or not meeting threshold of patient/payment volume in an Advanced APM How are they paid? Scores in 4 categories generate Composite Performance Score (CPS) Receive +/- payments based on how CPS compares to threshold score Special MIPS scoring under APM Scoring Standard Bonuses/penalties range from 4% in 2019 to 9% in 2022+ 7

MACRA APMs (Alternative Payment Models) Who s in? Clinicians who participate in a MIPS APM Clinicians who meet threshold for percentage of patients they treat/payments they receive through approved Advanced APM How are they paid? Scores in 4 categories (MIPS APMs) Annual 5% automatic bonus based on previous year s fees begins 2019 (Advanced APMs) Per CMS: Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients' outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM. 8

Weighting of MIPS performance categories 2017 Performance determines 2019 pay Improvement Activities 15% Resource Use/Cost 0 % in 2019 10% in 2020 30% in 2021+ Advancing Care Information 25% Quality 60% in 2019 50% in 2020 30% 2021+ 9

PCMH/PCSP & MACRA Auto-credit for Improvement Activities (MIPS) and support for APMs NCQA PCMH & PCSP IA auto-credit Largest PCMH program to qualify No other PCSP programs qualify Others must be national programs or state/commercial programs with at least 500 practices meeting specific criteria 100% automatic credit for IA PCMH/PCSPs within non-qualified APMs bring auto credit and boost overall scores PCMHs/PCSPs also should have: Higher quality scores Lower resource use Higher ACI scores PCMH/PCSP are solid foundations for (A)APMs 10

Most Clinicians Will Be in MIPS And at least one analysis (Brookings) suggests it might not be so bad https://www.brookings.edu/research/how-the-money-flows-under-macra/ 11

Approved Advanced APMs for 2017 Resources from CMS Quality Payment Program Website: https://qpp.cms.gov/ Comprehensive ESRD Care (CEC) - Two-Sided Risk Comprehensive Primary Care Plus (CPC+) Next Generation ACO Model Shared Savings Program - Track 2 Shared Savings Program - Track 3 Oncology Care Model (OCM) - Two-Sided Risk Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT) Chart of all APMs (Advanced and MIPS APMs) 12

Pick Your Pace Options for 2017 Affecting 2019 Payment Year Mirror Under the Nose Test Any reporting prevents penalties No reporting Full 4% penalty Partial Year Reporting Full reporting in one 90-day period qualifies for small bonus Full Reporting in 2018 on Quality & Cost - Full reporting in all categories required in 2019 Participate in APM 5% bonus if meet patient/revenue thresholds CMS expects 90% to get bonus or no penalty for 2017 performance / 2019 payment year 13

Direction is Clear CMS Quality Payment Program is Designed to Drive Changes in Behavior Incentives for value Discourages fee-for-service Puts more teeth into quality, cost and utilization measurement Advances HIT through the Advancing Care Information (ACI) Performance category 14

Top Priority: Helping clinicians move to APMs Goal to encourage clinicians to join together in APMs and maximize improvement potential Clinicians, practices and health systems need guidance & help to succeed! 15

Current Medical Neighborhood Landscape

Growth of PCMH 2008-2016 60,000 50,000 PCMH Sites and Clinicians 60,024 45,855 40,000 30,000 20,000 10,000 11,974 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 PCMH Unique Physicians PCMH Clinicians PCMH Sites Data current as of 1/1/17 17

Growth of PCSP 2013-2016 1,400 1,200 PCSP Sites and Clinicians 1,289 1,000 800 600 400 200 190 0 2013 2014 2015 2016 PCSP Sites PCSP Clinicians Data current as of 1/1/17 18

1 in 6 Doctors practice in an NCQA- Recognized PCMH 19

NCQA Medical Neighborhood Recognitions Closing the Loop Between PCPs, Specialists & Other Sites of Care Primary Care (PCMH) Sites WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK TX MN IA MO AR LA WI IL MS MI IN TN AL KY OH GA WV PA SC VA NC NY VT NH ME RI CT NJ DE MD MA Connected Care (PCCC) Sites 1-4 Sites AK HI Specialty (PCSP) Sites 1-9 Sites FL 5+Sites PR 10-20 Sites 21+ Sites

Patient-Centered Medical Home 62% $265 of total lower spending per NCQA PCMH Medicare beneficiary was attributable to reductions in payments to acute care hospitals Lower average annual total Medicare spend per beneficiary for patients in NCQA recognized practices Van Hasselt, M., McCall, N., Keyes, V., Wensky, S. G., & Smith, K. W. (2014). Total Cost of Care Lower among 21 Medicare Fee-for-Service Beneficiaries Receiving Care from Patient-Centered Medical Homes. Health Services Research.

Patient-Centered Care Lower risk-adjusted ED use and hospitalizations for adult patients treated within NCQA recognized PCMH. 11% Lower riskadjusted use of ED services 12% Fewer hospitalizations 15% Lower PMPM costs for patients in a PCMH DeVries, A, Chia-Hsuan W, Sridhar G, Hummel J, Breidbart S., Barron J. (2012) Impact of Medical Homes on Quality Healthcare Utilization and Costs. The American Journal of Managed Care. http://www.ajmc.com/publications/issue/2012/2012-9-vol18-n9/impact-of-medical-homes-on-quality- HealthcareUtilization-and-Costs#sthash.vuXFYJRA.dpuf 4

NCQA Recognition Programs Cover the Medical Home Neighborhood

PCMH 2017 Standards

Evolution of the PCMH Standards Continue to Move Practices Closer to Achieving the Triple Aim 2011 2014 2017 Emphasizes relationship with/expectations of specialists Integrates behaviors affecting health, language, CLAS Enhances evaluation of patient experience Underscores importance of system cost-savings Enhances use of clinical performance measure results Further incorporates behavioral health Additional emphasis on team-based care Focuses on care management of high need populations Higher bar, alignment of QI activities with triple aim Addition of Annual reporting requirements Further integrates social determinants & community connections Further integrates behavioral health Shift from focus on structure to focus on outcomes 25

2017 Standards Scoring Core Criteria Elective Criteria 26

2017 PCMH Standards Concepts Team-Based Care and Practice Organization Knowing and Managing Your Patients Patient-Centered Access and Continuity Care Management and Support Care Coordination and Care Transitions Performance Measurement & Quality Improvement 27

2017 PCMH Standards Concepts Team-Based Care and Practice Organization Practice leadership Care team responsibilities Orientation of patient/families/car egivers Knowing and Managing Your Patients Data collection Medication reconciliation Evidence-based clinical decision support Connection with community resources Patient-Centered Access and Continuity Access to practice and clinical advice Care continuity Empanelment 28

2017 PCMH Standards Concepts Care Management and Support Identifying patients for care management Person-centered care plan development Care Coordination and Care Transitions Management of lab/imaging results Tracking and managing patient referrals Care transitions Performance Measurement & Quality Improvement Collecting and analyzing performance data Setting goals Improving practice performance Sharing practice performance data 29

2017 PCMH Distinction Modules Practice Opportunities to Show Excellence Distinction in Patient Experience Reporting Distinction in Behavioral Health Integration Distinction in Electronic Measure Reporting 30

PCMH Redesign

2017 Standards Changes Level 1 Level 2 Level 3 32

NCQA PCMH redesign Self-guide to recognition Previously through PCMH 2014 Submit documents all at once Cumbersome survey tool Recognition is a 3-year cycle, has 3 levels NCQA representative to guide you PCMH 2017 (and PCSP 2018) Gradual submissions, steady feedback More intuitive tool, with user tips Yearly check-ins, more frequent help, no levels 33

Three Parts to the new system NCQA PCMH Recognition redesign Commit Practice completes an online guided assessment. Practice works with an NCQA representative to develop an evaluation schedule. Practice works with NCQA representative to identify support and education for transformation. Transform Practice submits initial documentation and checks in with its evaluator Practice submits additional documentation and checks in with its Evaluator. Practice submits final documentation to complete submission and begin NCQA evaluation process. Succeed Practice is prepared for new payment environment (value-based payment, MACRA MIPS/APMs). Practice demonstrates continued readiness and high quality performance through annual check-ins with NCQA. New NCQA PCMH online education resources support the transformation process. Practice earns NCQA Recognition. 34

Sustaining Recognition Engage practices in an annual check-in providing confirmation of continuing commitment and performance Each practice demonstrates that changes made during the initial recognition effort are part of their culture, and practice is becoming more patient-centered 33

Why Create a Specialty Recognition Program? Closely related; synergistic; two sides of the same coin 36

Why Create a Program for Specialists? Every year, the average Medicare beneficiary PCP Specialist(s) Pharmacy Consumer Caregiver/ Family Sees 7 physicians Fills 20+ prescriptions Has 2 referrals Hospital Other Care Sites

Gaps in Care Coordination Primary care and specialists: No information sent to Peds specialist 49% of time; no feedback to primary care 55% of time Emergency Department 30% of adults indicated regular physician not informed about visit Hospital 33% of adults with chronic condition did not have follow-up plans post hospital discharge 3% of primary care physicians discussed discharge plans with hospital physicians 66% of time primary care follow-up post discharge was done without a hospital discharge summary Bodenheimer, T: Coordinating Care A Perilous Journey through the Health Care System. NEJM 2008;358:10 38

Even if individual organizations deliver high quality care, effective patient-centered systems (neighborhoods) require coordination Specialty Care Primary Care Inpatient Care? Behavioral Health Long-term Services and Supports X 39

The Burden of Uncoordinated Care Pain Lack of Care Coordination Can Lead to Complications 1 Medical Errors Unnecessary Procedures Wasteful Spending The National Academies Health and Medicine Division (aka IOM) has estimated that care coordination initiatives addressing these complications could result in $240 billion in healthcare savings. Foy, R., Hempel, S., Rubenstein, L., Suttorp, M., Seelig, M., Shanman, R., Shekelle, P.G. (2010). Metaanalysis: effect of interactive communication between collaborating primary care physicians and specialists. Annals of Internal Medicine, 152 (4), 247-258

Teams Wikipedia definition: A team comprises a group of people linked in a common purpose. Teams are especially appropriate for conducting tasks that are high in complexity and have many interdependent subtasks. Interdependent team: No significant task can be accomplished without the help of any of the members; Within that team members typically specialize in different tasks, and The success of every individual is inextricably bound to the success of the whole team. No football player, no matter how talented, has ever won a game by playing alone. Adapted from: http://en.wikipedia.org/wiki/team 41

But Health Care is Often Delivered Like 6-year Old Kids Playing Baseball 42

The PCSP Design Accommodates the range of relationships between PCP and specialist Based on a typology developed by Dr. Christopher Forrest (2009) Consulting on patients Evaluating and treating patients Co-managing patients Providing temporary/permanent care management for some patients Practices are likely to have patients in each relationship category Archives of Internal Med, June 2009

How is the PCSP program organized? PCSP 1: Working with Primary Care and Other Referring Clinicians PCSP 2: Provide Access & Communication PCSP 3: Identify and Coordinate Patient Populations PCSP 4: Plan and Manage Care PCSP 5: Track and Coordinate Care PCSP 6: Measure and Improve Performance 18

Key Aims of the Program 1. Patient access (timely appointments and advice) 2. Agreements with PCP to coordinate care 3. Timely information exchange with PCP 4. Timely referral summary to referring clinician 5. Care plan coordination with PCP 6. Communication with patient and PCP 7. Reduced duplication of tests 8. Measure performance 9. Align with Meaningful Use Requirements

PCSP Standards Based on ACP & AHRQ Medical Neighborhoods 1. Track and Coordinate Referrals A. *Referral Process and Agreements B. Referral Content. C. *Referral Response 2. Provide Access and Communication A. Access B. Electronic Access C. Specialty Practice Responsibilities D. Culturally and Linguistically Appropriate Services (CLAS) E. *The Practice Team 3. Identify and Coordinate Patient Populations Patient Information A. Clinical Data *Must Pass B. Coordinate Patient Populations 4. Plan and Manage Care A. Care Planning and Support Self-Care B. *Medication Management C. Use Electronic Prescribing 5. Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up C. Coordinate Care Transitions 6. Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. *Implement and Demonstrate Continuous Quality Improvement D. Report Performance E. Use Certified EHR Technology 46

What is PCSP Recognition? PCSP acknowledges specialty practices that demonstrate the highest level of care coordination, including: Referral Tracking Streamlined referral processes Care Management Timely patient and caregiverfocused care management Quality Improvement Continuous clinical quality improvement 47

Growth in Specialties Treating Patients with Chronic/High Cost Conditions PCSP Program Growth Creates Many Opportunities Top Ten States by Number of PCSP Sites As of March 9 th, 2017 1 OBGYN/Family Planning 82 2 Oncology 37 3 Cardiology 33 4 Endocrinology 8 5 Surgery 7 6 Multi-Specialty 7 7 Gastroenterology 6 8 Nephrology 6 9 Rheumatology, Behavioral Health, Neurology, Ophthalmology, Orthopedics, Pulmonology 10 Infectious Disease 3 6 Build robust referral networks Better manage care for shared patient populations Increase operational efficiency & reduce overhead 48

Maintenance of Certification Credit American Board of Family Medicine American Board of Internal Medicine American Board of Pediatrics Eligible Programs: PCMH 2011, PCMH 2014, & DRP/HSRP Cycle: Initial & Renewal Type of Credit: Performance Improvement Points: PMCH = 40 points DRP/HSRP = 20 points Eligible Programs: PCMH 2014, PCSP 2013 & PCSP 2016 Cycle: Initial & Renewal Type of Credit: Performance Assessment Points: 20 points Eligible Programs: PCMH 2011, PCMH 2014, PCSP 2013 & PCSP 2016 Cycle: Initial & Renewal Type of Credit: Part IV; Meets patient safety requirement Points: 40 points (each) 49

Measure Proliferation and Medical Taylorism * *Frederick Taylor Father of Scientific Management

Five Objectives to Achieve Meaningful Quality Measurement at the Practice Level Now 1 Develop/modify & align measures across health plans, clinically integrated networks, and practices. 2 Leverage data generated at the point of care. 3 Reduce the work associated with reporting quality measures. 4 Establish data connections in support of measurement and analysis of the healthcare system. 5 Incorporate more measures in NCQA accreditation and recognition programs. 51

Moving Forward Let s Continue to Grow the Patient- Centered Medical Neighborhood! 2017+ PCMH 2017 and Q-PASS launched April 3rd Bringing PCSP and other recognition programs into new process (2018+) Moving forward with NCQA emeasure Certification of vendors and evolving Distinction for Electronic Measure Reporting for practices 52

Future Considerations 1. Collect/report patient-reported outcome measures 2. Reflection of accurate, valid performance measure reporting and utilization at the practice, network and plan level 3. Develop quality benchmarks for the practice and network levels 53

Questions Michael S. Barr, MD, MBA, MACP EVP, Quality Measurement & Research NCQA barr@ncqa.org Twitter: @barrms 202-955-5139