MACRA for Critical Access Hospitals. Tuesday, July 26, 2016 Webinar

MACRA for Critical Access Hospitals Tuesday, July 26, 2016 Webinar

MACRA presenters Harold D. Miller, President & CEO CHQPR Claudia Sanders, Sr. Vice President, Policy Development Andrew Busz, Policy Director, Finance Carol Wagner, Sr. Vice President, 8 Patient Safety

Based on what you know about MACRA so far, what is your impression of the likely impacts of MACRA on your organization?

MACRA Explanation and Implications Harold D. Miller, President & CEO Center for Healthcare Quality and Payment Reform (CHQPR)

What is MACRA? How Will It Affect Rural Hospitals? Harold D. Miller President and CEO Center for Healthcare Quality and Payment Reform www.chqpr.org

What is MACRA and Who Should Care About It? What is MACRA? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was approved on a bipartisan basis by Congress (House vote 392-37, Senate vote 92-8) and signed into law by the President on April 16, 2015 Who does it directly affect? Physicians and other clinicians who are paid under the Medicare Physician Fee Schedule (Part B payments) Hospitals and medical groups that bill for physician services under the Medicare Fee Schedule (including CAH Method II payments) Does NOT apply to physicians/clinicians in Rural Health Clinics who do not bill for services under the Medicare Physician Fee Schedule or physicians whose Part B billings fall below a minimum threshold 8

Topics Covered What the law (MACRA) says What the proposed regulations issued by CMS say (and where they might change) Proposed regulations were issued in April Comments closed on June 27, 2016 Final regulations required by November 1, 2016 The likely and potential implications for hospitals 10

Physicians Faced Significant Cuts Under Sustainable Growth Rate $ SGR Cut -21% Potential for Additional SGR Cuts in Future 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 11

Bipartisan Action to Repeal SGR $ Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Repealed Sustainable Growth Rate formula (SGR) SGR Cut -21% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 12

Bipartisan Action to Repeal SGR $ Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Repealed Sustainable Growth Rate formula (SGR) Stabilized physician fee levels for next decade Required new forms of value-based payment in Medicare SGR Cut -21% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 13

Bipartisan Action to Repeal SGR $ Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) SGR Cut -21% Repealed Sustainable Growth Rate formula (SGR) Stabilized physician fee levels for next decade Required new forms of value-based payment in Medicare Replaced existing MU, PQRS, and VM programs with a new Merit-Based Incentive Payment System (MIPS) Encouraged development and use of Alternative Payment Models (APMs) 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 14

Bipartisan Action to Repeal SGR $ Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) SGR Cut -21% Repealed Sustainable Growth Rate formula (SGR) Stabilized physician fee levels for next decade Required new forms of value-based payment in Medicare Replaced existing MU, PQRS, and VM programs with a new Merit-Based Incentive Payment System (MIPS) Encouraged development and use of Alternative Payment Models (APMs) Required new ways to code physician services Many other changes 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 15

Part 1: Stable Payments MACRA Repealed SGR & Stabilized Payment Rates $ 0.25% 0.5% 0.5% 0.5% 0.5% 0.25% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 16

Updates Will Be Very Small for the Next Decade Fees 2.3% Higher in 2025 Than 2014 $ 0.25% 0.5% 0.5% 0.5% 0.5% 0.25% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 17

MACRA Also Requires Value-Based Payment Part 1: Stable Payments Part 2: Value-Based Pmt $ 0.25% 0.5% 0.5% 0.5% 0.5% Value-Based Payment 0.25% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 18

$ 0.25% 0.5% Default: Merit-Based Incentive Part 1: Stable Payments Part 2: Value-Based Pmt a. MIPS Payment System (MIPS) 0.5% 0.5% +10% +10% +10% +10% +10% +10% +4x% 0.5% -4% +5x% -5% +7x% -7% +9x% -9% +9x% -9% +9x% -9% +9x% -9% +9x% 0.25% -9% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 19

$ MIPS Bonuses & Penalties Are Part 1: Stable Payments Part 2: Value-Based Pmt a. MIPS 0.25% 0.5% 0.5% Determined Annually 0.5% +10% +4x% 0.5% -5% Whether a physician gets a bonus/penalty, and the amount of that bonus/penalty, can vary from year to year -1% +2% -9% +3% 0.25% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 20

$ Congress Encouraged Use of Alternative Payment Models Part 1: Stable Payments Part 2: Value-Based Pmt a. MIPS or b. APMs 0.25% 0.5% 0.5% 0.5% +5% 0.5% +5% +5% +5% +5% +5% 0.75% 0.25% 25% APM APM 25% 50% APM APM 50% 75% APM 75% APM 75% APM 75% APM 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 21

Choice of Two Options For Payments in Future Years 22

$ Physicians Are Exempt from MIPS Whenever They Meet APM Criteria +10% +10% +10% +4x% +5x% +7x% 0.5% -4% 0.5% -5% -7% 0.5% 0.5% 0.25% MIPS APM +5% +5% +5% 0.75% 50% APM 75% APM 75% APM 75% APM 75% APM 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 23

Physician Returns to MIPS If APM Eligibility Is No Longer Met APM +10% +10% MIPS $ 0.25% 0.5% 0.5% 0.5% +5% 0.5% +5% +5% +5% 25% APM APM 25% 50% APM APM 50% +9x% +9x% +9x% +9x% 0.25% -9% -9% -9% -9% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 24

How MIPS Will Work

$ +x% -4.5% Value-Based Payment for Physicians Isn t New in Medicare +x% -6% +x% -9% +x% -10% 2015 2016 2017 2018 2017 Meaningful Use: 3% Penalties Physician Quality Reporting (PQRS): 2% Penalties Value-Based Modifier: 4% Penalties or Bonuses TOTAL Potential Penalties: 9% Penalty 2018 Meaningful Use: 4% Penalties Physician Quality Reporting (PQRS): 2% Penalties Value-Based Modifier: 4+% Penalties or Bonuses TOTAL Potential Penalties: 10+% Penalty 26

$ +x% -4.5% But Value Modifier Will First Hit Small Practices (<10) Next Year +x% -6% +x% -9% +x% -10% 2015 2016 2017 2018 100+ Docs 10-99 Docs 100+ Docs 1-9 Docs 10-99 Docs 100+ Docs NPs, PAs 1-9 Docs 10-99 Docs 100+ Docs 2015 2016 2017 2018 Chart Not Drawn to Scale 2017 Meaningful Use: 3% Penalties Physician Quality Reporting (PQRS): 2% Penalties Value-Based Modifier: 4% Penalties or Bonuses TOTAL Potential Penalties: 9% Penalty 2018 Meaningful Use: 4% Penalties Physician Quality Reporting (PQRS): 2% Penalties Value-Based Modifier: 4+% Penalties or Bonuses TOTAL Potential Penalties: 10+% Penalty Small Practices Start 2017 27

3 Existing P4P Programs Consolidated into 1 MIPS Program $ +x% -4.5% +x% -6% +x% -9% +x% -10% +10% +10% +10% +10% +10% +10% +4x% -4% +5x% -5% +7x% -7% +9x% -9% +9x% -9% +9x% -9% +9x% -9% +9x% -9% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 TODAY Meaningful Use (MU) Quality Reporting (PQRS) Value Modifier (VM) MIPS Advancing Care Information (EHR Use) Quality Performance Program Resource Use Clinical Practice Improvement 28

MIPS Penalties Lower and Bonuses Higher Than Current $ MU + PQRS + VM +x% -10% +10% +4x% -4% MIPS 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 TODAY Meaningful Use (MU) Quality Reporting (PQRS) Value Modifier (VM) MIPS Advancing Care Information (EHR Use) Quality Performance Program Resource Use Clinical Practice Improvement 29

10% Bonuses Are Capped and Temporary $ +10% +4x% -4% Only for practices with very high scores Limited to $500 million per year Only available from 2019 to 2024 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 30

What Does +4x% Mean? $ +10% +4x% -4% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 31

2019 Bonuses Could Range Between 0% and 12% (4%x3) $ +10% +4x% -4% +12% (4% x3) <1% (4% x 0) 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 32

2022 Bonuses Could Range Between 0% and 27% (9%x3) $ +10% +4x% -4% +12% (4% x3) <1% (4% x 0) +10% +9x% -9% +27% (9% x3) <1% (4% x 0) 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 33

Bonuses and Penalties Must Be Budget Neutral If many practices receive large penalties, then more money is available for bonuses If few practices qualify for bonuses, then the (large amount of) bonus money is divided among that small number of practices, generating large bonuses per practice. MACRA limits the bonus to 3 times the statutory amount. If few practices receive large penalties, then little money is available for bonuses If many practices qualify for bonuses, then the (small amount of) bonus money is divided among that large number of practices, generating small bonuses per practice. 35

Payment Adjustments Under PQRS & VM for 2016 No Quality Report Low Quality Average Quality High Quality Low Cost Average Cost High Cost No Quality Report 37

Many (Small) Physician Practices Were Penalized for Not Reporting No Quality Report Low Quality Average Quality High Quality Low Cost Average Cost High Cost No Quality Report -2% (5,418) 38

Most Physicians Who Did Report Were Average on Cost & Quality No Quality Report Low Quality Average Quality High Quality Low Cost 0% (6) Average Cost 0% (7,351) High Cost 0% (1) No Quality Report -2% (5,418) 39

Over 800 Practices Were Eligible for Penalties No Quality Report Low Quality Average Quality High Quality Low Cost Average Cost -1%* (644) 0% (7,351) High Cost -2%* (39) -1%* (226) 0% (1) No Quality Report -2% (5,418) *Penalties did not apply to 10-99 Clinician Practices in 2016 40

A Small Number of Practices Received Very Large Bonuses No Quality Report Low Quality Average Quality High Quality Low Cost 0% (6) 2x% = 31.84% (38) 1x% = 15.92% (35) 3x% = 47.76% (0) 2x% = 31.84% (0) Average Cost -1%* (644) 0% (7,351) 2x% = 31.84% (20) 1x% = 15.92% (35) High Cost -2%* (39) -1%* (226) 0% (1) No Quality Report -2% (5,418) *Penalties did not apply to 10-99 Clinician Practices in 2016 41

Bonuses Were High Because Many Practices Received Penalties Low Cost No Quality Report Low Quality Average Quality High Quality 128 Large Performance Bonuses Average Cost High Cost 909 Performance Penalties No Quality Report 5,418 Non-Reporting Penalties *Penalties did not apply to 10-99 Clinician Practices in 2016 42

Most Practices Received Neither Bonus Nor Penalty No Quality Report Low Quality Average Quality High Quality Low Cost 128 Performance Bonuses Average Cost 7,358 No Change in Payment High Cost 909 Performance Penalties No Quality Report 5,418 Non-Reporting Penalties *Penalties did not apply to 10-99 Clinician Practices in 2016 43

Size of Penalties is More Predictable Than Size of Bonuses $ +10% Summary: +4x% -4% Very Good Performance: 10-22% increases Good Performance: 0-12% increases Poor Performance: 0-4% cuts in pay 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 44

Current VBP Programs: All Part B Providers Required to Participate $ +x% +x% -4.5% +x% -6% +x% -9% -10% 2015 2016 2017 2018 100+ Docs 2015 2016 2017 2018 Chart Not Drawn to Scale 10-99 Docs 100+ Docs 1-9 Docs 10-99 Docs 100+ Docs NPs, PAs 1-9 Docs 10-99 Docs 100+ Docs 45

MIPS: Exemptions Based on Number of Patients & Revenues $ +x% -4.5% +x% -6% +x% -9% +x% -10% +10% +10% +10% +10% +10% +10% +4x% -4% +5x% -5% +7x% -7% +9x% -9% +9x% -9% +9x% -9% +9x% -9% +9x% -9% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 100+ Docs > $x &/or > y pts Low Volume Threshold & Other Exemptions > $x &/or > y pts > $x &/or > y pts > $x &/or > y pts > $x &/or > y pts > $x &/or > y pts > $x &/or > y pts > $x &/or > y pts 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 10-99 Docs 100+ Docs 1-9 Docs 10-99 Docs 100+ Docs NPs, PAs 1-9 Docs 10-99 Docs 100+ Docs 46

Exemptions from MIPS Payment Adjustments 47

Exemptions from MIPS Payment Adjustments What MACRA Says Below low volume threshold: # of beneficiaries treated # of services provided $ amount billed 48

Exemptions from MIPS Payment Adjustments What MACRA Says Below low volume threshold: # of beneficiaries treated # of services provided $ amount billed Providers with minimum level of participation in Alternative Payment Models 25%/50%/75% in APMs 20%/45%/70% in APMs # of patients in APMs First year of Medicare Part B participation 2019-2020: Other nonphysician providers PT/OT/Speech pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dieticians What Proposed Regs Say Low volume threshold: 100 Medicare patients/year $10,000 Medicare payments Qualified APM Participant (QPs): providers with minimum level of participation in Alternative Payment Models 25%/50%/75% in APMs 20%/35%/50% of patients in APMs Partially-Qualified APM Participant (Partial QPs): 20%/40%/50% in APMs 10%/25%/35% of patients in APMs First year of Medicare Part B participation 52

Pressure to Increase Thresholds for Exemption What MACRA Says Below low volume threshold: # of beneficiaries treated # of services provided $ amount billed Providers with minimum level of participation in Alternative Payment Models 25%/50%/75% in APMs 20%/45%/70% in APMs # of patients in APMs First year of Medicare Part B participation 2019-2020: Other nonphysician providers PT/OT/Speech pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dieticians What Proposed Regs Say Low volume threshold: 100 Medicare patients/year $10,000 Medicare payments Pressure to increase thresholds Qualified APM Participant (QPs): providers with minimum level of participation in Alternative Payment Models 25%/50%/75% in APMs 20%/35%/50% of patients in APMs Partially-Qualified APM Participant (Partial QPs): 20%/40%/50% in APMs 10%/25%/35% of patients in APMs First year of Medicare Part B participation 53

CMS Bases Penalties/Bonuses $ +x% -4.5% +x% -6% +x% -9% +x% -10% +10% +10% +10% +10% +10% +10% +4x% -4% +5x% -5% +7x% -7% +9x% -9% +9x% -9% +9x% -9% +9x% -9% +9x% -9% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 54

CMS Bases Penalties/Bonuses on Performance 2 Years Earlier $ +x% -4.5% +x% -6% +x% -9% +x% -10% +10% +10% +10% +10% +10% +10% +4x% -4% +5x% -5% +7x% -7% +9x% -9% +9x% -9% +9x% -9% +9x% -9% +9x% -9% 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Good Good Good Good Good Good Good Good Good Good Good Good Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Performance Measures 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Chart Not Drawn to Scale 55

2 Year Lag Means 2019 MIPS $ Will Be Based on Scores Next Year $ Under proposed CMS rules, performance measurement for 2019 MIPS and APMs starts in January 2017 +10% +4x% -4% 2017 2019 Good Bad Performance Measures 2017 56

Performance (Measurement) Year for MIPS Payment Adjustments What MACRA Says The Secretary shall establish a performance period (or periods) [to determine the MIPS payment adjustments that will be made in a particular year] Such performance period (or periods) shall begin and end prior to the beginning of such year and be as close as possible to such year. What Proposed Regs Say The performance period is the full calendar year that is two years prior to the year in which MIPS adjustments are made. Specifically, the first year of MIPS adjustments is 2019, so the performance year is Jan. 1, 2017 Dec. 31, 2017 58

What Are MIPS Bonuses/Penalties Based On? 2019 Quality Resource Use Clinical Practice Improvement Activities Advancing Care Information (EHR Use) 60

What Are MIPS Bonuses/Penalties Based On? 2019 Quality Resource Use Clinical Practice Improvement Activities Four Separate Measurement Silos, Not a Coordinated Measure of Value Advancing Care Information (EHR Use) 61

Resource Use Will Become Much More Important Over Time 2019 2021+ Quality 30% Quality 50% Resource Use 30% Resource Use Clinical Practice Improvement Activities 10% 15% Clinical Practice Improvement Activities 15% Advancing Care Information (EHR Use) 25% Advancing Care Information (EHR Use) 25% 62

Quality Measures 6 quality measures, selected from available measures (reduction from 9 measures in current PQRS/VM program) 1 cross-cutting measure, e.g. % of patients with advanced care plan Documentation of medications in medical record Tobacco cessation 1 outcome measure (or high-priority measure if outcome is unavailable), e.g., Readmissions Mortality Optimal asthma control 4 other measures Traditional primary care measures (process & outcome) Specialty specific measures (process & outcome) 63

Resource Use Performance Measures Average of all applicable resource use measures Total Per Capita Costs (total spending per patient per year) Dropped condition-specific groups currently used in Value Modifier Medicare Spending Per Beneficiary (spending in hospital + 30 days) ~41 episode measures, e.g., Spending during and after admission for exacerbation of heart failure Spending during surgery and rehabilitation for knee replacement Spending during treatment and rehabilitation for stroke Measures are calculated from claims data, attributed to physicians based on measure-specific attribution formulas, and used for MIPS if there are a minimum number of cases Total Per Capita Costs attributed to PCP with most office visits Medicare Spending Per Beneficiary (MSPB) attributed to hospital physician with most physician billings during hospital stay Episodes attributed based on physician who billed for trigger event 65

Most Spending on a Doctor s Patients Doesn t Go to the Doctor 66

Physicians Pay Will Be Affected by What Other Providers Do 67

Physicians Will Be Penalized if Hospital & Post-Acute $ Is High 68

Standardized Pricing Used in Resource Measures Admissions at Critical Access Hospitals are priced at the same rates as IPPS hospitals for the purposes of MIPS resource measures so physicians are not penalized if their patients are admitted to higher cost rural hospitals Swing bed stays at Critical Access Hospitals are priced at their actual Medicare payment amounts so physicians can be penalized if their patients are admitted to higher cost rural hospital swing beds for post acute care 69

Clinical Practice Improvement Activity (CPIA) Maximum credit achieved with 60 points (requires 1-6 activities) 60 points for certification as a patient-centered medical home 30 points for participation in an Alternative Payment Model (but not at a participation level which exempts physician from MIPS) 20 points for participation in high weight activities 10 points for participation in each medium weight activity 30 points for each activity of any type by small and rural practices Categories of Clinical Practice Improvement Activities Expanded practice access Beneficiary engagement Population management Patient safety and practice assessment Care coordination Achieving health equity Emergency preparedness and response Integrated behavioral and mental health 70

What Does a Clinical Practice Improvement Activity Look Like? 90 proposed options listed in proposed regulation Examples: Expanded Practice Access 20 points: 24/7 access for advice about urgent/emergent care 10 points: telehealth specialty consults Population Management 20 points: Anticoagulant management 10 points: Engaging rural health clinics in quality measurement Care Coordination 10 points: Partnering with hospital-based transitional care services 10 points: Care coordination agreements with consulting physicians Beneficiary Engagement 20 points: Collection and follow-up on patient experience data 10 points: Participation in a Qualified Clinical Data Registry Patient Safety and Practice Assessment 10 points: Use of tools such as Surgical Risk Calculator 71

Advancing Care Information (aka Meaningful EHR Use) 100 points needed for maximum credit in this category 50 point base score for participation on 6 things Protect patient health information ( yes required) Electronic prescribing (data submission only required) Patient electronic prescribing (data submission only required) Coordination of care through patient engagement (data submission only) Health Information Exchange (data submission only required) Public health and clinical data registry reporting ( yes required) 80 points for performance on measures from 3 categories Patient electronic access Coordination of care through patient engagement Health information exchange 73

Reporting Options 74

Reporting Options Report as individual If the physician is part of a multi-physician practice, the individual physician s bonus/penalty depends on how that individual physician scored on the quality and resource use measures Report as a group If the physician is part of a multi-physician practice, the individual physician s bonus/penalty depends on how the entire group of physicians scored on the quality and resource use measures Report as a virtual group (Authorized in MACRA, not defined in CMS proposed regs) If the physician is not part of a multi-physician practice or is part of a group of less than 10 physicians, the physician or practice can agree to report together with other independent physicians or small practices, and the individual physician s bonus/penalty then depends on how the entire virtual group scored on the quality and resource use measures 77

Reporting Options Report as individual If the physician is part of a multi-physician practice, the individual physician s bonus/penalty depends on how that individual physician scored on the quality and resource use measures Report as a group If the physician is part of a multi-physician practice, the individual physician s bonus/penalty depends on how the entire group of physicians scored on the quality and resource use measures Report as a virtual group (Authorized in MACRA, not defined in CMS proposed Virtual regs) Groups If the physician is not part of a multi-physician may represent practice an or opportunity is part of a group of less than 10 physicians, the physician for a hospital or practice to help can agree to report together with other independent physicians independent or small physicians practices, and the individual physician s bonus/penalty work then together depends without on how the entire virtual group scored on the quality the and need resource for the use hospital measures to employ the physicians 78

How is the MIPS Bonus/Penalty Determined?

Step 1: Performance Measurement in Each MIPS Category Quality Measurement Physician receives 1-10 points on each individual quality measure Number of points is based on which decile the physician falls into on the distribution of performance for all physicians during the prior year If performance is better than 90% of physicians, physician receives 10 points If 90% of physicians performed better, physician receives 1 point MACRA requires that credit be given to improvement, not just absolute performance, but proposed regs would not give improvement credit in Year 1 Resource Use Measurement Physician receives 1-10 points on each applicable resource use measure Number of points is based on which decile the physician falls into on the distribution of performance for all physicians during the current year (this requirement in CMS regulations may not meet statutory requirements) Clinical Practice Improvement Physician receives points for participation in each improvement initiative Not completely clear how participation will be defined/measured Advancing Care Information (EHR Use) 50 base points are all or nothing Additional points based on relative performance in individual categories 80

Multiple Episode Measures Averaged For Each Physician 81

Step 2: Composite Performance Measurement Scores in all four categories combined into a Composite Performance Score (CPS) from 0-100 using the weights for the categories A Performance Threshold is established based on how all physicians performed in the prior year on the CPS 82

Step 3: Performance Measurement Translated to Bonuses/Penalties Physician Composite Performance Score Relative to Performance Threshold CPS 25% of Performance Threshold CPS Below Performance Threshold CPS At or Slightly Above Threshold CPS Above Threshold CPS 75 th percentile of values above Performance Threshold MIPS Bonus/Penalty Maximum Penalty Penalty No Bonus or Penalty Bonus Additional bonus (up to 10%) 84

Implications for Hospitals Cost/Revenue Impacts on Hospitals for Employed Part B Physicians Potential losses of 9% of revenue Potential gains of 37% of revenue Costs of achieving high performance on measures 85

Implications for Hospitals Independent Physicians May Seek Hospital Help in Compliance Independent Physicians Will Focus on Ways to Reduce Use of Hospital Services and Post-Acute Care Total Per Capita Cost Measure and some episode measures will penalize physicians whose patients have: High rates of testing and imaging High rates of referrals to other physicians High rates of ED visits and hospitalizations High rates of readmissions and post-acute care costs Medicare Spending Per Beneficiary Measure and many episode measures will penalize physicians who manage inpatient admissions if there are: High use of other consultants High rates of readmissions High use of SNF beds or use of expensive SNF beds (e.g., CAHs) 87

Critical Access Hospitals Could Be Harmed by MIPS Quality Measures Small volumes of patients and safety net services could make quality measures for physicians look poor compared to those at other hospitals Resource Use Measures PCPs may be penalized for practicing in communities without the ability to provide care management and in-home services for patients with chronic disease Surgeons will be penalized if their patients use higher-cost post-acute care services delivered by Critical Access Hospitals 88

How APMs Will Work

MACRA Encourages Use of APMs Instead of MIPS Physicians are encouraged to participate in approved Alternative Payment Models (APMs) at a minimum level: They are exempt from MIPS They receive a 5% lump sum bonus They receive a higher annual update (increase) in their revenues They receive the benefits of participating in the APM 90

Why Should Hospitals Care About APMs? 91

Why Should Hospitals Care About APMs? For physicians they employ (and bill for under Part B): Avoids revenue uncertainty of bonuses/penalties under MIPS Avoids costs associated with complying with quality reporting, clinical practice improvement activities, and EHR use requirements Improves revenues via 5% bonuses and higher updates APMs could enable hospitals to redesign care delivery for higher margins without constraints of current fee-for-service system 92

Why Should Hospitals Care About APMs? Some physicians may not want to work in the community if they have to participate in MIPS or can t participate in Alternative Payment Models If physicians participate in APMs without the hospital as a partner, the hospital could lose significant revenue (the biggest opportunity for savings in many APMs will come from reducing ED visits, avoidable admissions, & unnecessary/unnecessarily-expensive post-acute care) APMs could enable hospitals to redesign care delivery for higher margins without constraints of current fee-for-service system 93

What Does MACRA Require for an APM? 94

What Does MACRA Require for an APM? Requirements for Physician 2019: 25% of Medicare payments from an alternative payment entity 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity 2023: 75% of Medicare or total payments from an alternative payment entity Option to count % of patients instead of % of payments Requirements for Alternative Payment Entity Participate in an Alternative Payment Model Bear financial risk for monetary losses under the APM in excess of a nominal amount OR be designated as a medical home expanded by the Innovation Center Requirements for an Alternative Payment Model Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration Require participants to use certified EHR technology Base payment on quality measures comparable to MIPS 97

What Exactly is an APM? Requirements for Physician 2019: 25% of Medicare payments from an alternative payment entity 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity 2023: 75% of Medicare or total payments from an alternative payment entity Option to count % of patients instead of % of payments Requirements for Alternative Payment Entity Participate in an Alternative Payment Model Bear financial risk for monetary losses under the APM in excess of a nominal amount OR be designated as a medical home expanded by the Innovation Center Requirements for an Alternative Payment Model Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration Require participants to use certified EHR technology Base payment on quality measures comparable to MIPS 98

Principal Focus of APMs is to Save Money Innovation Center The Secretary shall select models to be tested where there is evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures. The Secretary shall focus on models expected to reduce program costs while preserving or enhancing the quality of care. The Secretary shall terminate or modify the design and implementation of a model unless the Secretary determines that the model is expected to: (i) improve the quality of care without increasing spending; (ii) reduce spending without reducing the quality of care; or (iii) improve the quality of care and reduce spending. Shared Savings Program Payments to an ACO shall be established in a manner that does not result in spending more for such ACO for such beneficiaries than would otherwise be expended for such ACO for such beneficiaries for such year if the model were not implemented, as estimated by the Secretary. 99

Current CMS Alternative Payment Models Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Comprehensive ESRD Care Large Dialysis Organization Comprehensive ESRD Care Small Dialysis Organization Comprehensive Primary Care Plus Frontier Community Health Integration Program Home Health Value Based Purchasing Model Independence at Home Demonstration Medicare Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management Model Reducing Hospitalizations Among Nursing Home Residents Intravenous Immune Globulin Demonstration Maryland All-Payer Hospital Model Medicare Part B Drug Payment Model Medicare Care Choices Model Medicare Shared Savings Program (ACO) Track 1 Medicare Shared Savings Program (ACO) Track 2 Medicare Shared Savings Program (ACO) Track 3 Million Hearts Cardiovascular Risk Reduction Model Next Generation ACO Model Oncology Care Model Track 1 Oncology Care Model Track 2 100

Many APMs Focus Specifically on Reducing Spending on Hospitals Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Comprehensive ESRD Care Large Dialysis Organization Comprehensive ESRD Care Small Dialysis Organization Comprehensive Primary Care Plus Frontier Community Health Integration Program Home Health Value Based Purchasing Model Independence at Home Demonstration Medicare Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management Model Reducing Hospitalizations Among Nursing Home Residents Intravenous Immune Globulin Demonstration Maryland All-Payer Hospital Model Medicare Part B Drug Payment Model Medicare Care Choices Model Medicare Shared Savings Program (ACO) Track 1 Medicare Shared Savings Program (ACO) Track 2 Medicare Shared Savings Program (ACO) Track 3 Million Hearts Cardiovascular Risk Reduction Model Next Generation ACO Model Oncology Care Model Track 1 Oncology Care Model Track 2 101

Some APMs Focus Specifically on Reducing Post-Acute Spending Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Comprehensive ESRD Care Large Dialysis Organization Comprehensive ESRD Care Small Dialysis Organization Comprehensive Primary Care Plus Frontier Community Health Integration Program Home Health Value Based Purchasing Model Independence at Home Demonstration Medicare Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management Model Reducing Hospitalizations Among Nursing Home Residents Intravenous Immune Globulin Demonstration Maryland All-Payer Hospital Model Medicare Part B Drug Payment Model Medicare Care Choices Model Medicare Shared Savings Program (ACO) Track 1 Medicare Shared Savings Program (ACO) Track 2 Medicare Shared Savings Program (ACO) Track 3 Million Hearts Cardiovascular Risk Reduction Model Next Generation ACO Model Oncology Care Model Track 1 Oncology Care Model Track 2 102

Two APMs Have Components Focused on Rural Hospitals Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Comprehensive ESRD Care Large Dialysis Organization Comprehensive ESRD Care Small Dialysis Organization Comprehensive Primary Care Plus Frontier Community Health Integration Program Home Health Value Based Purchasing Model Independence at Home Demonstration Medicare Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management Model Reducing Hospitalizations Among Nursing Home Residents Intravenous Immune Globulin Demonstration Maryland All-Payer Hospital Model Medicare Part B Drug Payment Model Medicare Care Choices Model Medicare Shared Savings Program (ACO) Track 1 Medicare Shared Savings Program (ACO) Track 2 Medicare Shared Savings Program (ACO) Track 3 Million Hearts Cardiovascular Risk Reduction Model Next Generation ACO Model Oncology Care Model Track 1 Oncology Care Model Track 2 103

What Else Does MACRA Require for an APM to Replace MIPS? Requirements for Physician 2019: 25% of Medicare payments from an alternative payment entity 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity 2023: 75% of Medicare or total payments from an alternative payment entity Option to count % of patients instead of % of payments Requirements for Alternative Payment Entity Participate in an Alternative Payment Model Bear financial risk for monetary losses under the APM in excess of a nominal amount OR be designated as a medical home expanded by the Innovation Center Requirements for an Alternative Payment Model Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration Require participants to use certified EHR technology Base payment on quality measures comparable to MIPS 104

Requirements for APM Use of EHRs and Quality Measures What MACRA Says APM requires participants in such model to use certified EHR technology What Proposed Regs Say APM must require at least 50% of eligible clinicians in the APM entity to use Certified EHR Technology to document and communicate clinical care in 2019 At least 75% must do so in subsequent years 105

Requirements for APM Use of EHRs and Quality Measures What MACRA Says APM requires participants in such model to use certified EHR technology APM provides for payment for covered professional services based on quality measures comparable to measures under [MIPS What Proposed Regs Say APM must require at least 50% of eligible clinicians in the APM entity to use Certified EHR Technology to document and communicate clinical care in 2019 At least 75% must do so in subsequent years APM must base payment on quality measures comparable to MIPS No minimum number of measures, but must have at least one outcome measure if there is an appropriate outcome measure available 106

Requirements for Financial Risk What MACRA Says APM Entity must bear financial risk for monetary losses under such alternative payment model that are in excess of a nominal amount; or be a medical home expanded by the Innovation Center in APMs 108

Requirements for Financial Risk in APMs What MACRA Says APM Entity must bear financial risk for monetary losses under such alternative payment model that are in excess of a nominal amount; or be a medical home expanded by the Innovation Center What Proposed Regs Say The APM Entity is required to repay Medicare when spending on patients exceeds expected amounts, up to: 5% of the entity s total revenue, if the entity is a primary care practice with 50 or fewer clinicians (2.5% in 2017, 3% in 2018, 4% in 2019) 4% of total Medicare spending for all other physician practices or health systems 109

Widespread Opposition to CMS Definition of Nominal Risk 110

Only 16% of Medicare Spending Goes to Physicians Physicians: 16% 111

4% of Medicare Spending = Huge Risk for Average Physician 4% of Total Medicare Spending Physicians: 16% 25% of Physician Revenues 112

4% of Spending Could Be 100% of Physician s Revenue 113

CMS Calls APMs Meeting All These Criteria: Advanced APMs Requirements for Physician 2019: 25% of Medicare payments from an alternative payment entity 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity 2023: 75% of Medicare or total payments from an alternative payment entity Option to count % of patients instead of % of payments Requirements for Alternative Payment Entity Participate in an Alternative Payment Model Bear financial risk for monetary losses under the APM in excess of a nominal amount OR be designated as a medical home expanded by the Innovation Center Requirements for an Alternative Payment Model Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration Require participants to use certified EHR technology Base payment on quality measures comparable to MIPS 114

Few APMs Qualify as Advanced APMs Under Proposed Rule Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Comprehensive ESRD Care Large Dialysis Organization Comprehensive ESRD Care Small Dialysis Organization Comprehensive Primary Care Plus Frontier Community Health Integration Program Home Health Value Based Purchasing Model Independence at Home Demonstration Medicare Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management Model Reducing Hospitalizations Among Nursing Home Residents Intravenous Immune Globulin Demonstration Maryland All-Payer Hospital Model Medicare Part B Drug Payment Model Medicare Care Choices Model Medicare Shared Savings Program (ACO) Track 1 Medicare Shared Savings Program (ACO) Track 2 Medicare Shared Savings Program (ACO) Track 3 Million Hearts Cardiovascular Risk Reduction Model Next Generation ACO Model Oncology Care Model Track 1 Oncology Care Model Track 2 116

The APMs Most Physicians Are Participating In Don t Qualify Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Comprehensive ESRD Care Large Dialysis Organization Comprehensive ESRD Care Small Dialysis Organization Comprehensive Primary Care Plus Frontier Community Health Integration Program Home Health Value Based Purchasing Model Independence at Home Demonstration Medicare Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management Model Reducing Hospitalizations Among Nursing Home Residents Intravenous Immune Globulin Demonstration Maryland All-Payer Hospital Model Medicare Part B Drug Payment Model Medicare Care Choices Model Medicare Shared Savings Program (ACO) Track 1 Medicare Shared Savings Program (ACO) Track 2 Medicare Shared Savings Program (ACO) Track 3 Million Hearts Cardiovascular Risk Reduction Model Next Generation ACO Model Oncology Care Model Track 1 Oncology Care Model Track 2 117

CMS Defines Non-Advanced APMs as MIPS APMs Requirements for Physician 2019: 25% of Medicare payments from an alternative payment entity 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity 2023: 75% of Medicare or total payments from an alternative payment entity Option to count % of patients instead of % of payments Requirements for Alternative Payment Entity Participate in an Alternative Payment Model Bear financial risk for monetary losses under the APM in excess of a nominal amount OR be designated as a medical home expanded by the Innovation Center Requirements for an Alternative Payment Model Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration Require participants to use certified EHR technology Base payment on quality measures comparable to MIPS 118

What Good is a MIPS APM? Good: Exempt from regular MIPS requirements; follow the quality and resource use measures in the APM itself Bad: Physicians participating in a MIPS APM wouldn t qualify for the 5% bonus under MACRA or the higher payment update 119

Problems with APM Regulations Problems with Regulations But Also with CMS APMs Regulations set an excessively high bar for risk when Congress only required more than nominal financial risk Problems with CMS Alternative Payment Models Most CMS APMs are shared savings payment models that do not change the underlying payment system for providers and potentially encourage stinting on care to patients Most CMS APMs try to hold providers accountable for total cost of care whether they can control all costs or not Many CMS APMs do not adequately adjust payments for differences in patient needs 120

CMS Comprehensive Care for Joint Replacement EPISODE PAYMENT FOR SURGERIES PATIENT Hospital Costs for Surgery Readmits Post-Acute Care (IRF, SNF, HH) 121

Principal Goal of CMS Proposal Is Reducing Post-Acute Care Cost EPISODE PAYMENT FOR SURGERIES PATIENT Hospital Costs for Surgery Readmits Post-Acute Care (IRF, SNF, HH) Hospital Costs for Surgery Readmits Post-Acute Care SAVINGS 122

Proposed Structure Encourages Lower Spending, Not Better Care EPISODE PAYMENT FOR SURGERIES PATIENT Hospital Costs for Surgery Readmits Post-Acute Care (IRF, SNF, HH) Hospital Costs for Surgery Readmits Post-Acute Care SAVINGS No risk adjustment target spending amount is the same for high-risk, poor functional status patients as low-risk patients No flexibility to deliver different types of post-acute care or to be paid differently no change in current payment systems 123

Hospitals at Risk for Total Cost With Everyone Still Paid the Same EPISODE PAYMENT FOR SURGERIES PATIENT Hospital Costs for Surgery Readmits Post-Acute Care (IRF, SNF, HH) Hospital Costs for Surgery Readmits Post-Acute Care SAVINGS CMS No risk adjustment target spending amount is the same for high-risk, poor functional status patients as low-risk patients No flexibility to deliver different types of post-acute care or to be paid differently no change in current payment systems Hospital is at risk for higher post-acute care spending Hospital Physicians and Post-Acute Care 124

Over Time, CMS Keeps More of the Savings, If There Are Any EPISODE PAYMENT FOR SURGERIES PATIENT Hospital Costs for Surgery Readmits Post-Acute Care (IRF, SNF, HH) Hospital Costs for Surgery Readmits Post-Acute Care SAVINGS CMS No risk adjustment target spending amount is the same for high-risk, poor functional status patients as low-risk patients No flexibility to deliver different types of post-acute care or to be paid differently no change in current payment systems Hospital is at risk for higher post-acute care spending Target spending is reduced every year to match lower spending Hospital Physicians and Post-Acute Care 125

If There Are Fewer Surgeries, CMS Keeps ALL of the Savings EPISODE PAYMENT FOR SURGERIES PATIENT Hospital Costs for Surgery Readmits Post-Acute Care (IRF, SNF, HH) Hospital Costs for Surgery Readmits Post-Acute Care SAVINGS CMS Hospital Non-Surg. Treatment SAVINGS Physicians and Post-Acute Care 126

Critical Access Hospitals Could Be Harmed by CJR Hospitals will be penalized if their patients use higher-cost post-acute care services If CAH cost per SNF/swing day is higher than other hospitals, CJR hospitals could avoid using the CAH for post-acute care services 127

CMS Proposing Same Approach for AMI, CABG, and Hip Fracture 128

Innovation Center Authorized to Implement Other/Better APMs (i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, medical homes that address women s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment. (ii) Contracting directly with groups of providers of services and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payment or salary-based payment. (iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one of the following: (I) An inability to perform 2 or more activities of daily living. (II) Cognitive impairment, including dementia. (iv) Promote care coordination between providers of services and suppliers that transition health care providers away from fee-for-service based reimbursement and toward salary-based payment. (v) Supporting care coordination for chronically ill applicable individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology. (vi) Varying payment to physicians who order advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) according to the physician s adherence to appropriateness criteria for the ordering of such services, as determined in consultation with physician specialty groups and other relevant stakeholders. (vii) Utilizing medication therapy management services, such as those described in section 935 of the Public Health Service Act. (viii) Establishing community-based health teams to support small-practice medical homes by assisting the primary care practitioner in chronic care management, including patient selfmanagement, activities. (ix) Assisting applicable individuals in making informed health care choices by paying providers of services and suppliers for using patient decision-support tools, including tools that meet the standards developed and identified under section 936(c)(2)(A) of the Public Health Service Act, that improve applicable individual and caregiver understanding of medical treatment options. (x) Allowing States to test and evaluate fully integrating care for dual eligible individuals in the State, including the management and oversight of all funds under the applicable titles with respect to such individuals. (xi) Allowing States to test and evaluate systems of all-payer payment reform for the medical care of residents of the State, including dual eligible individuals. (xii) Aligning nationally recognized, evidence based guidelines of cancer care with payment incentives under title XVIII in the areas of treatment planning and follow-up care planning for applicable individuals described in clause (i) or (iii) of subsection (a)(4)(a) with cancer, including the identification of gaps in applicable quality measures. (xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or skilled nursing care during an inpatient stay and the 30 days immediately following discharge. (xiv) Funding home health providers who offer chronic care management services to applicable individuals in cooperation with interdisciplinary teams. (xv) Promoting improved quality and reduced cost by developing a collaborative of high-quality, low-cost health care institutions that is responsible for (I) developing, documenting, and disseminating best practices and proven care methods; (II) implementing such best practices and proven care methods within such institutions to demonstrate further improvements in quality and efficiency; and (III) providing assistance to other health care institutions on how best to employ such best practices and proven care methods to improve health care quality and lower costs. (xvi) Facilitate inpatient care, including intensive care, of hospitalized applicable individuals at their local hospital through the use of electronic monitoring by specialists, including intensivists and critical care specialists, based at integrated health systems. (xvii) Promoting greater efficiencies and timely access to outpatient services (such as outpatient physical therapy services) through models that do not require a physician or other health professional to refer the service or be involved in establishing the plan of care for the service, when such service is furnished by a health professional who has the authority to furnish the service under existing State law. (xviii) Establishing comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities, that, through their structure, operations, and joint-activity deliver a full spectrum of integrated and comprehensive health care services to applicable individuals while also incorporating innovative methods for the clinical training of future health care professionals. (xix) Utilizing, in particular in entities located in medically underserved areas and facilities of the Indian Health Service (whether operated by such Service or by an Indian tribe or tribal organization (as those terms are defined in section 4 of the Indian Health Care Improvement Act)), telehealth services (I) in treating behavioral health issues (such as post-traumatic stress disorder) and stroke; and (II) to improve the capacity of non-medical providers and non-specialized medical providers to provide health services for patients with chronic complex conditions. (xx) Utilizing a diverse network of providers of services and suppliers to improve care coordination for applicable individuals described in subsection (a)(4)(a)(i) with 2 or more chronic conditions and a history of prior-year hospitalization through interventions developed under the Medicare Coordinated Care Demonstration Project under section 4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b 1 note). (xxi) Focusing primarily on physicians services (as defined in section 1848(j)(3)) furnished by physicians who are not primary care practitioners (xxii) Focusing on practices of 15 or fewer professionals. (xxiii) Focusing on risk-based models for small physician practices which may involve two-sided risk and prospective patient assignment, and which examine risk-adjusted decreases in mortality rates, hospital readmissions rates, and other relevant and appropriate clinical measures. (xxiv) Focusing primarily on title XIX, working in conjunction with the Center for Medicaid and CHIP Services; 129

Good Ways and Bad Ways to Define Alternative Payment Models HOW PAYMENT REFORMS ARE DESIGNED TODAY Medicare and Health Plans Define Payment Systems Providers Have To Change Care to Align With Payment Systems Patients and Providers May Not Come Out Ahead THE RIGHT WAY TO DESIGN PAYMENT REFORMS Providers Redesign Care and Identify Payment Barriers Payers Change Payment to Support Redesigned Care Patients Get Better Care and Providers Stay Financially Viable 130

APMs Can Be Win-Win-Wins for Patients, Doctors, Hospitals, Payers APMs can be designed to protect hospital margins when admissions and services decrease APMs can be designed to ensure payments for physicians and hospitals are adequate for patients with higher needs APMs can be designed to facilitate and encourage collaboration between primary care physicians, specialists, hospitals, and skilled nursing facilities rather than pitting them against each other 131

MACRA Creates the PTAC to Encourage Provider-Driven APMs Physician-Focused Payment Model Technical Advisory Committee (PTAC) Eleven members appointed by the Comptroller General Reviews proposals for physician-focused payment models Makes recommendations to HHS/CMS on which to implement HHS is required to respond to recommendations, but it is not required to implement what the PTAC recommends PTAC and CMS are working to develop a joint set of criteria for approving alternative payment models that can be implemented quickly 132

Examples of Specialty Society Physician-Focused APM Concepts ASCO Patient-Centered Oncology Payment (PCOP) Basic model: New service codes in addition to E&M/infusion codes Option A: Bundled codes replacing E&M and infusion codes Option B: Bundled payment for medical oncology treatment AAN Patient-Centered Epilepsy and Headache Payment One-time or monthly bundled payment codes replacing E&M New service codes in addition to E&M for low-acuity patients Optional bundled payments for total treatment costs ASTRO Payment for Palliative Radiation Care for Bone Metastases and Radiation Treatment of Breast Cancer Bundle based on patient need instead of type/number of treatments ACC Payment for Testing/Treatment of Stable Angina (SMARTCare) Bundle based on patient risk instead of types of tests/interventions AGA Colonoscopy Bundled Payment Episode payment for procedure, anesthesia, facility, complications SGO/STS/ACS/ASA Surgical Episode Payments Bundled/episode payments for surgical procedures 133

Three Paths to Value-Based Payment Under MACRA MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) MACRA CMS-DESIGNED ALTERNATIVE PAYMENT MODELS (APMs) PROVIDER-DESIGNED ALTERNATIVE PAYMENT MODELS (APMs) 134

Other Parts of MACRA $20 million/year from 2016-2020 for technical assistance to small practices on MIPS and APMs Authority for Qualified Entities to use Medicare claims data to help physician practices and other providers develop APMs Development of improved ways of measuring resource use 135

Learn More About MACRA and Alternative Payment Models www.paymentreform.org 136

For More Information: Harold D. Miller President and CEO Center for Healthcare Quality and Payment Reform Miller.Harold@GMail.com (412) 803-3650 www.chqpr.org www.paymentreform.org

WSHA Resources

WSHA Advocacy Claudia Sanders, Sr. Vice President, Policy Development Andrew Busz, Policy Director, Finance 139

WSHA Advocacy MACRA comments to CMS- Concerns Need for alignment with hospital measures Barriers to EHR meaningful use in rural areas List of approved Alternative Payment Models too limited Limited capacity for small providers to accept significant downside risk Recognition of quality improvement already obtained due to Partnership for Patients and other efforts Advocating for reasonableness and alignment of quality measures between MACRA, Healthier Washington (including WHRAP and RHC APM-4), and commercial payors 140

MACRA IN ACTION Carol Wagner Senior Vice President Patient Safety

MACRA Principles - Washington Washington and Oregon physicians maximize their financial opportunities in MACRA. At the end of 2017 physicians will have an understanding, plan, and implementation process in progress. MACRA is delayed, but will be put into effect. Delay is part of refinement.

MACRA Principles - Washington MACRA is ultimately about patient care this should remain a focus. Mindset of what needs to happen versus what is happening. Leaning from best practices across the country. Linkage with Healthy Doctors, Healthier Patients.

Next Steps from WSHA and WSMA Understanding that MACRA is ultimately a clinical quality issue. This is about what physicians already care about. Pay for value based on outcomes not processes. Demonstrate value across membership.

Next Steps from WSHA and WSMA General education on MACRA Create a crosswalk of measures between: MACRA Choosing Wisely HCA Performance Measures WSHA Patient Safety Other State and Federal initiatives. Crosswalk the measures across multi-specialties based on national specialty associations.

Next Steps from WSHA and WSMA Synergistic measures list. Create a resource guide for measures. Create Improvement strategies best practices. Utilize best practice webinars? Survey meaningful use preparedness Based on findings create checklist for meeting.

Working Together Washington and Oregon WSHA and WSMA Qualis Healthier Washington

Please give us your rating from 1-10 on this informational MACRA session (1 is low and 10 is high)

Which aspect of MACRA would you like to know more about from WSHA?

Questions & Answers

Thank you for your participation Claudia Sanders claudias@wsha.org Carol Wagner carolw@wsha.org Andrew Busz andrewb@wsha.org