CMS: Delivery System Reform

CMS: Delivery System Reform Session #6, February 20, 2017 Pierre Yong, Director, Quality Measurement and Value-Based Incentives Group, Centers for Clinical Standards and Quality, Centers for Medicare & Medicaid Services Monica Kay, Director, Division of Program Management, Office of Enterprise Information, Centers for Medicare & Medicaid Services 1

Conflict of Interest Pierre Yong, MD, MPH, MS Monica N. Kay, D.B.A., PMP Have no real or apparent conflicts of interest to report. 2

Agenda Delivery System Reform Goals Medicare Access and CHIP Reauthorization Act (MACRA) Social Security Number Removal Initiative (SSNRI) 3

Learning Objectives Describe the current state of Quality programs at CMS Illustrate how CMS is aligning with the private sector and states to drive delivery system reform Discuss what to expect during the transition year of the Quality Payment Program in 2017 Discuss the Social Security Number Removal Initiative (SSNRI) goals and implementation 4

Delivery System Reform Requires Focusing on the Way We Pay Providers, Deliver Care, and Distribute Information { Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system. } FOCUS AREAS Pay Providers Deliver Care Distribute Information Source: Burwell SM. Setting Value-Based Payment Goals HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first. 5

CMS Has Adopted a Framework That Categorizes Payments to Providers Description Category 1: Fee for Service No Link to Value Payments are based on volume of services and not linked to quality or efficiency Category 2: Fee for Service Link to Quality At least a portion of payments vary based on the quality or efficiency of health care delivery Category 3: Alternative Payment Models Built on Fee-for-Service Architecture Some payment is linked to the effective management of a population or an episode of care Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Category 4: Population-Based Payment Payment is not directly triggered by service delivery so volume is not linked to payment Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., 1 year) Medicare Fee-for- Service examples Limited in Medicare fee-forservice Majority of Medicare payments now are linked to quality Hospital valuebased purchasing Physician Value Modifier Readmissions / Hospital Acquired Condition Reduction Program Accountable Care Organizations Medical homes Bundled payments Comprehensive Primary Care initiative Comprehensive ESRD Medicare-Medicaid Financial Alignment Initiative Fee-For- Service Model Eligible Pioneer Accountable Care Organizations in years 3-5 Maryland hospitals 6 Source: Rajkumar R, Conway PH, Tavenner M. CMS engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

CMS is aligning with private sector and states to drive delivery system reform CMS Strategies for Aligning with Private Sector Convening Stakeholders Convened payers in 7 markets in CPCI Convening payers, providers, employers, consumers, and public partners for the Health Care Payment Learning and Action Network Incentivizing Providers In Pioneer ACOs, agreements required Pioneers to have 50% of business in valuebased contracts by the end of the second program year Partnering with States The State Innovation Model Initiative funds testing awards and model design awards for states implementing comprehensive delivery system reform The Maryland All-Payer Model tests the effectiveness of an all-payer rate system for hospital payments 7

Partnership for Patients contributes to quality improvements Data shows a 17% reduction in hospital acquired conditions across all measures from 2010 2013 50,000 lives saved 1.3 million patient harm events avoided $12 billion in savings Many areas of harm dropping dramatically patient safety improving Ventilator- Associated Pneumonia Early Elective Delivery Central Line- Associated Blood Stream Infections Venous thromboembolic complications Readmissions 62.4% 70.4% 12.3% 14.2% 7.3% 8

Readmission Rate Medicare all-cause, 30-day hospital readmission rate is declining Legend: CL: control limit; UCL: upper control limit; LCL: lower control limit 9

Beneficiaries move to MA plans with high quality scores Medicare Advantage (MA) Enrollment Rating Distribution 5-star 4-star 3-star 2-star % 4 or 5 star % 2 or 3 star 9% 9% 9% 2012 2013 2014 29% 37% 55% 71% 63% 45% 10 Sent prompt to beneficiaries enrolled in plans with 2.5 star rating or lower Letters only sent to beneficiaries in consistently low-rated plans Switch rate 44% (prompt) v. 21% (no prompt)

The 21st Century Cures Act Impacts the EHR Incentive Program and MIPS Ambulatory Surgical Center (ASC) Decertification- Hardship We will issue rulemaking and guidance in the he future. Stay tuned! 11

Hospital Reporting of Electronic Clinical Quality Measures (ecqms) Requires hospitals to report four quarters of data on an annual bases for eight of the available ecqms included in the Hospital IQR Program measure set for the FY 2019 and FY 2020 payment determination in order to align with the Medicare and Medicaid EHR Incentive Programs; Requires several related technical ecqm submission requirements beginning with the FY 2019 payment determination; and Expands the current validation process to include the validation of ecqm data beginning in the spring of CY 2018 for the FY 202 payment determination. 12

The Quality Payment Program 13

Medicare Payment Prior to MACRA Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. The Sustainable Growth Rate (SGR) Established in 1997 to control the cost of Medicare payments to physicians IF Overall physician costs > Target Medicare expenditures Physician payments cut across the board Each year, Congress passed temporary doc fixes to avert cuts (no fix in 2015 would have meant a 21% cut in Medicare payments to clinicians) 14

The Quality Payment Program The Quality Payment Program policy will: Reform Medicare Part B payments for Medicare clinicians Improve care across the entire health care delivery system Clinicians have two tracks to choose from: The Merit-based Incentive Payment System (MIPS) If you decide to participate in traditional Medicare, you may earn a performance-based payment adjustment through MIPS. OR Advanced Alternative Payment Models (APMs) If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model. 15

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) 16

What is the Merit-Based Incentive Payment System? Combines legacy programs into single, improved reporting program PQRS VM EHR Legacy Program Phase Out Last Performance Period PQRS Payment End 2016 2018 17

What is the Merit-based Incentive Payment System? Performance Categories Quality Cost Improvement Activities Advancing Care Information Moves Medicare Part B clinicians to a performance-based payment system Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice Reporting standards align with Advanced APMs wherever possible 18

Who Will Participate in MIPS? Clinicians billing more than $30,000 a year in Medicare Part B allowed charges AND providing care for more than 100 Medicare patients a year. 19

Who Will NOT Participate in MIPS? Clinicians who are: 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 a year OR See 100 or fewer Medicare Part B patients a year Significantly participating in Advanced APMs Receive 25% of your Medicare payments OR See 20% of your Medicare patients through an Advanced APM 20

Category Requirements MIPS Performance Category: Quality - Replaces PQRS and Quality Portion of the Value Modifier - So what? Provides for an easier transition due to familiarity 60% of final score Select 6 of about 300 quality measures (minimum of 90 days to be eligible for maximum payment adjustment); 1 must be: Outcome measure OR High-priority measure defined as outcome measure, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination Different requirements for groups reporting CMS Web Interface or those in MIPS APMs May also select specialtyspecific set of measures 21

MIPS Performance Category: Cost No reporting requirement; 0% of final score in 2017 Clinicians assessed on Medicare claims data CMS will still provide feedback on how you performed in this category in 2017, but it will not affect your 2019 payments. Keep in mind: Uses measures previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR) Only the scoring is different 22

MIPS Performance Category: Improvement Activities Attest to participation in activities that improve clinical practice - Examples: Shared decision making, patient safety, coordinating care, increasing access Clinicians choose from 90+ activities under 9 subcategories: 1. Expanded Practice Access 2. Population Management 3. Care Coordination 4. Beneficiary Engagement 7. Achieving Health Equity 5. Patient Safety and Practice Assessment 8. Integrating Behavioral and Mental Health 6. Participation in an APM 9. Emergency Preparedness and Response 23

MIPS Performance Category: Advancing Care Information Promotes patient engagement and the electronic exchange of information using certified EHR technology Ends and replaces the Medicare EHR Incentive Program (also known as Medicare Meaningful Use) Greater flexibility in choosing measures In 2017, there are 2 measure sets for reporting based on EHR edition: Advancing Care Information Objectives and Measures 2017 Advancing Care Information Transition Objectives and Measures 24

Alternative Payment Models (APMs) 25

What is an Alternative Payment Model (APM)? Alternative Payment Models (APMs) are new approaches to paying for medical care through Medicare that incentivize quality and value. The CMS Innovation Center develops new payment and service delivery models. Additionally, Congress has defined both through the Affordable Care Act and other legislation a number of demonstrations that CMS conducts. As defined by MACRA, APMs include: CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award) MSSP (Medicare Shared Savings Program) Demonstration under the Health Care Quality Demonstration Program Demonstration required by federal law 26

Advanced APMs Meet Certain Criteria To be an Advanced APM, the following three requirements must be met. The APM: 27

PFPM Technical Advisory Committee (PTAC) PFPM = Physician-Focused Payment Model Goal to encourage new APM options for Medicare clinicians Submission of model proposals by Stakeholders Technical Advisory Committee Secretary comments on CMS website, CMS considers testing proposed models Models with favorable response go to CMS Innovation Center 11 appointed care delivery experts that review proposals, submit recommendations to HHS Secretary 28

Note: Most Practitioners Will Be Subject to MIPS Goals MIPS APMs are a Subset of APMs Reduce eligible clinician reporting burden. Maintain focus on the goals and objectives of APMs. How does it work? Streamlined MIPS reporting and scoring for eligible clinicians in certain APMs. Aggregates eligible clinician MIPS scores to the APM Entity level. APMs MIPS APMs All eligible clinicians in an APM Entity receive the same MIPS final score. Uses APM-related performance to the extent practicable. 29

MIPS Adjustments and APM Incentive Payment Will Begin in 2019 Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements) Performance Year 2017 2018 2019 2020 2021 2022 and later Percentage of Payments through an Advanced APM Percentage of Patients through an Advanced APM 30

How do Eligible Clinicians Participate in the Merit-based Incentive Payment System 31

Pick Your Pace for Participation for the Transition Year Participate in an Advanced Alternative Payment Model MIPS Test Partial Year Full Year Some practices may choose to participate in an Advanced Alternative Payment Model in 2017 Submit some data after January 1, 2017 Neutral or small payment adjustment Report for 90-day period after January 1, 2017 Small positive payment adjustment Fully participate starting January 1, 2017 Modest positive payment adjustment Not participating in the Quality Payment Program for the Transition Year will result in a negative 4% payment adjustment. 32

MIPS: Choosing to Test for 2017 Submit minimum amount of 2017 data to Medicare Avoid a downward adjustment You Have Asked: What is a minimum amount of data? 1 Quality Measure OR 1 Improvement Activity OR 4 or 5 Required Advancing Care Information Measures 33

MIPS: Partial Participation for 2017 Submit 90 days of 2017 data to Medicare May earn a positive payment adjustment So what? - If you re not ready on January 1, you can start anytime between January 1 and October 2 34

MIPS: Full Participation for 2017 Submit a full year of 2017 data to Medicare May earn a positive payment adjustment Best way to earn largest payment adjustment is to submit data on all MIPS performance categories Key Takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted. 35

Advanced Alternative Payment Models: Option 4 Clinicians and practices can: Receive greater rewards for taking on some risk related to patient outcomes. Advanced APMs + Advanced APM- specific rewards 5% lump sum incentive So what? - It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs. 36

What can you do? Eliminate patient harm Focus on better health, better care, and lower costs for the patient population you serve Engage in accountable care and other alternative contracts that move away from fee-for-service to model based on achieving better outcomes at lower cost Invest in the quality infrastructure necessary to improve Focus on data and performance transparency Help us develop specialty physician payment and service delivery models Test new innovations and scale successes rapidly Relentlessly pursue improved health outcomes 37

Additional Information Additional information can be obtained from our websiteat: https://qpp.cms.gov/ Please submit any additional questions to: QPP@cms.hhs.gov 38

Social Security Number Removal Initiative (SSNRI) Healthcare Information and Management System Society Conference 02/19/17 02/23/17 39

Background The Health Insurance Claim Number (HICN) is a Medicare beneficiary s identification number, used for paying claims and for determining eligibility for services across multiple entities (e.g. Social Security Administration (SSA), Railroad Retirement Board (RRB), States, Medicare providers and health plans, etc.) The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 mandates the removal of the Social Security Number (SSN)-based HICN from Medicare cards to address current risk of beneficiary medical identity theft The legislation requires that CMS mail out new Medicare cards with a new Medicare Beneficiary Identifier (MBI) by April 2019 40

SSNRI Program Goals Primary goal: To decrease Medicare Beneficiary vulnerability to identity theft by removing the SSN-based HICN from their Medicareidentification cards and replacing the HICN with a new Medicare Beneficiary Identifier (MBI) In achieving this goal CMS seeksto: Minimize burdens for beneficiaries Minimize burdens for providers Minimize disruption to Medicare operations Provide a solution to our business partners that allows usage ofhicn and/or MBI for business critical data exchanges Manage the cost, scope, and schedule for theproject 41

Complex IT Systems affecting Providers, Partners, and Beneficiaries Along with our partners, CMS will address complex systems changesfor over 75 systems, conduct extensive outreach & education activities and analyze the many changes that will be needed to systems and business processes Affected stakeholders include: Federal partners, States, Beneficiaries, Providers, and Plans Other key stakeholders, such as billing agencies, advocacy groups,data warehouses, etc. CMS has been working closely with partners and stakeholdersto implement the SSN Removal Initiative 42

Implementation of SSNRI 43

Solution Concept: Medicare Beneficiary Identifier (MBI) The solution for SSNRI must provide the following capabilities: 1. Generate MBIs for all beneficiaries: Includes existing (currentlyactive and deceased or archived) and new beneficiaries 2. Issue new, redesigned Medicare cards: New cards containing the MBI to existing and new beneficiaries 3. Modify systems and business processes: Required updates to accommodate receipt, transmission, display, and processing of the MBI CMS will use a MBI generatorto: Assign 150 million MBIs in the initial enumeration (60 million active and 90 million deceased/archived) and generate a unique MBI for each new Medicare beneficiary Generate a new unique MBI for a Medicare beneficiary whose identityhas been compromised 44

MBI Characteristics The Medicare Beneficiary Identifier will have the following characteristics: The same number of characters as the current HICN (11), but will be visibly distinguishable from the HICN Contain uppercase alphabetic and numeric characters throughout the 11 digit identifier Occupy the same field as the HICN on transactions Be unique to each beneficiary (e.g. husband and wife will have their own MBI) Be easy to read and limit the possibility of letters being interpreted as numbers (e.g. Alphabetic characters are upper case only and will exclude S, L, O, I, B, Z) Not contain any embedded intelligence or special characters Not contain inappropriate combinations of numbers or strings that may be offensive CMS anticipates that the MBI will not be changed for an individual unless the MBI is compromised or other limited circumstances still undergoing review 45

HICN and MBI Number Health Insurance Claim Number(HICN) Primary Beneficiary Account Holder Social Security Number (SSN) plus Beneficiary Identification Code (BIC) 9-byte SSN plus 1 or 2-byteBIC Key positions 1-9 are numeric Medicare Beneficiary Identifier(MBI) New Non-Intelligent Unique Identifier 11 bytes Key positions 2, 5, 8, and 9 will alwaysbe alphabetic Note: Identifiers are fictitious and dashes for display purposes only; they are not stored in the database nor used in file formats 46

MBI Generation and Transition Period 47

SSNRI Transition Periods CMS will complete its system and process updates to be ready toaccept and return the MBI on April 1,2018 All stakeholders who submit or receive transactions containing the HICN must modify their processes and systems to be ready to submit or exchange the MBI by April 1, 2018. Stakeholders may submit either the MBI or HICN during the transitionperiod CMS will accept, use for processing and return to stakeholders either the MBI or HICN, whichever is submitted, during the transitionperiod In addition, beginning October 2018 through the end of the transition period, when a HICN is submitted on Medicare fee-for-service claims both the HICN and the MBI will be returned on the remittanceadvice The transition period will run from April 2018 through December 31,2019 48

SSNRI Card Issuance CMS will begin issuing new Medicare cards for existing beneficiaries after the initial enumeration of MBIs; roughly 60 million beneficiaries The gender and signature line will be removed from the new Medicare cards The Railroad Retirement Board who will issue their new cards to RRB beneficiaries We will work with states that currently include the HICN on Medicaid cards to remove the Medicare ID or replace it with a MBI CMS will conduct intensive education and outreach to allmedicare beneficiaries and their agents to help prepare for thischange 49

Outreach and Education CMS will provide outreach and education to: Approximately 60 million beneficiaries, their agents, advocacy groups and caregivers Health Plans The provider community (1.5M providers) States andterritories Key stakeholders, vendors & other partners CMS will ensure that we involve all stakeholders in our outreach and education efforts through their existing vehicles for communication(e.g. Open Door Forums, HPMS notices, etc.) 50

Final Thoughts Thank you for participating in this discussiontoday Additional information can be obtained from our websiteat: http://go.cms.gov/ssnri Please submit any additional information to the SSNRI team mailboxat: SSNRemoval@cms.hhs.gov 51

Questions Pierre Yong Pierre.Yong@cms.hhs.gov Monica Kay Monica.Kay@cms.hhs.gov 52

Additional CMS Education Sessions Tuesday, February 21 CMS Quality Payment Program Overview 10:00-11:00 a.m. Room 230A MIPS: Advancing Care Information and Improvement Activities 1:00-2:00 p.m. Room 230A Wednesday, February 22 MIPS: Quality and Cost 8:30-9:30 a.m. Room 230A Overview of MIPS for Small, Rural, and Underserved Practices 11:30 a.m.-12:30 p.m. Room 230A 53

CMS Office Hours Schedule All Office Hours will be held in Booth #229 Monday, February 20 o Office Hours: MIPS/QPP, 11:30 a.m.-12:30 p.m. o Office Hours: Advancing Care Information, 12:30-1:30 p.m. o Office Hours: MIPS/QPP, 1:30-2:30 p.m. o Office Hours: Social Security Number Removal Initiative, 2:30-4:30 p.m. o Office Hours: APMs, 4:30-6:00 p.m. Tuesday, February 21 o Office Hours: Social Security Number Removal Initiative, 9:30-11:00 a.m. o Office Hours: MIPS, 11:00 a.m.-12:00 p.m. o Office Hours: Improvement Activities, 12:00-1:00 p.m. o Office Hours: APMs, 1:00-2:00 p.m. o Office Hours: QPP, 2:00-3:00 p.m. o Office Hours: MIPS, 5:00-6:00 p.m. Wednesday, February 22 o Office Hours: Advancing Care Information, 9:30-10:15 a.m. o Office Hours: Quality and Cost, 10:15-11:00 a.m. o Office Hours: Medicaid, 11:00 a.m.-12:00 p.m. o Office Hours: Improvement Activities, 12:00-1:30 p.m. o Office Hours: MIPS, 1:30-2:30 p.m. o Office Hours: Quality and Cost, 2:30-4:00 p.m. 54