Current State Over Volume Silos of Utilization over Care Value Fee for Service 2 Materials herein reflect public law 114-10 dated April 16, 2015 2
Push Toward Value & Quality • Medicare payments tied to quality or value by end of 2016 • Of those through alternative payment models (APMs ) by end of 2016 75 % • Private payer business through value-based arrangements by 2020 Materials herein reflect public law 114-10 3 dated April 16, 2015
Medicare Access & CHIP Reauthorization Act (MACRA) “To repeal the Medicare SGR and strengthen Medicare access by improving physician payments…” Photo Courtesy of Amy Mullins, MD Materials herein reflect public law 114-10 4 dated April 16, 2015
What is MACRA?: Quality Payment Program • Signed into law April 16, 2015 • Passed 392 to 37 in the House and 92 to 8 in the Senate Materials herein reflect public law 114-10 dated April 16, 2015 5
What Does MACRA Do? • Repeals the Sustainable Growth Rate (SGR) • Extends Children’s Health Insurance Program (CHIP) funding for 2 years • Creates 2 payment pathways • Provides Annual Baseline Fee Schedule Updates 2016-2018 Materials herein reflect public law 114-10 6 dated April 16, 2015
MACRA Timeline • MACRA enacted: April 16, 2015 • Request For Information: October 2015 • Proposed Rule released: April 27, 2016 – 60-day comment period • Final Rule anticipated: September/October 2016 *Medicare physician fee schedule published separately Materials herein reflect public law 114-10 7 dated April 16, 2015
Payment Pathways Merit-Based Incentive Payment System (MIPS) • Consolidates quality programs Advanced Alternative Payment Models (AAPM) • Potential for bonus payment for participation Materials herein reflect public law 114-10 8 dated April 16, 2015
Alternative Payment Model vs. Advanced Alternative Payment Model Alternative Payment Advanced Alternative Model Payment Model • Defined by CMS • Defined by CMS • Participate in MIPS • Meet additional eligibility requirements • Do not participate in MIPS Materials herein reflect public law 114-10 dated 9 April 16, 2015
Merit-Based Incentive Payment System (MIPS) Materials herein reflect public law 114-10 dated April 16, 2015
MIPS Highlights Consolidates existing quality and value programs • Adds a category for Clinical Practice Improvement Activities Establishes a Composite Performance Score (CPS) • Weighted scoring by category Provides opportunity for payment adjustments • Both positive and negative Materials herein reflect public law 114-10 11 dated April 16, 2015
Consolidates Quality & Value Programs • Physician Quality PQRS Reporting System VBPM • Value Based Payment MU Modifier MIPS • Meaningful Use Materials herein reflect public law 114-10 12 dated April 16, 2015
Establish Composite Performance Score Resource Quality Advancing Clinical Use Care Practice Information Improvement Activities Materials herein reflect public law 114-10 13 dated April 16, 2015
Clinical Practice Improvement Activities (CPIA) • Access • Population Management • Care Coordination • Beneficiary Engagement • Patient Safety • Participation in an Alternative Payment Model Materials herein reflect public law 114-10 14 dated April 16, 2015
Weighting by Category Cost 10% Quality 50% CPIA 15% Advancing Care Information 25% Materials herein reflect public law 114-10 15 dated April 16, 2015
Weighting by Category 2019 2020 2021 Quality 50% 45% 30% Resource Use 10% 15% 30% Advancing Care Information 25% 25% 25% CPIA 1 15% 15% 15% 1 - “Certified” patient -centered medical home will receive the full 15 points for CPIA MIPS APM Participants will get half credit Materials herein reflect public law 114-10 16 dated April 16, 2015
Annual Performance Threshold • Established by Secretary years 1 and 2 • Mean or median of previous year’s MIPS scores • Below = negative payment adjustments • Above = positive payment adjustments Materials herein reflect public law 114-10 17 dated April 16, 2015
Adjust Payments 7% 9% 4% 5% “With respect to positive MIPS adjustment factors…the Secretary shall increase or 2019 2020 2021 2022 onward decrease such adjustment factors by a scaling factor in -4%-5% order to ensure that the budget -7% -9% neutrality requirement…is met” Materials herein reflect public law 114-10 18 dated April 16, 2015
Adjust Payments 4% 5% 7% 9% *Potential for 3X Maximum Adjustments adjustment 2019 2020 2021 2022 onward -4%-5% -7% -9% Adjustment to provider’s base rate of Medicare Part B 1 payment Materials herein reflect public law 114-10 dated April 16, 2015 9 Materials herein reflect public law 114-10 19 dated April 16, 2015
Exemptions • Year 1 Medicare • Eligible APMs with Bonus • Below low volume threshold – Less than or equal to $10,000 Medicare payments; AND less than or equal to 100 Medicare beneficiaries Materials herein reflect public law 114-10 20 dated April 16, 2015
Adjustment Summary Performance Score Payment Adjustment 25 th Percentile or Maximum negative = below adjustment At threshold = Stable Payment “Exceptional Performers” eligible for up to 10% positive adjustment Materials herein reflect public law 114-10 21 dated April 16, 2015
MACRA Timeline 2017 2018 2019 2020 2021 2025 2026 2022-2024 Medicare Part B Baseline Payment Updates +0.25 % * + 0.5 % + 0.5 % + 0.5 % 0% 0% 0% +0% +0.75 % ** *Non-Qualifying APM Conversion Factor **Qualifying APM Conversion Factor Merit-Based Incentive Payment System (MIPS) PQRS, Value-based Modifier, & Meaningful Quality, Resource Use, Meaningful Use, & Clinical Practice Improvement Activities Use +/-9% -9% -9%? +/- 4% +/- 5% +/- 7% Materials herein reflect public law 114-10 22 dated April 16, 2015
MIPS Summary Composite Performance Score • Consolidates existing quality reporting programs in Medicare Part B with Clinical Practice Improvement Activities Positive payment adjustments • Includes the potential for adjustments for “Exceptional Performers” Risk of payment penalty • Risk of negative payment adjustment if performance below threshold Materials herein reflect public law 114-10 23 dated April 16, 2015
Alternative Payment Models (APMs) Materials herein reflect public law 114-10 dated April 16, 2015
Definitions Qualifying APM • Based on existing payment models Advanced APM • Based on criteria of the payment model Qualifying APM Participant • Based on individual physician payment or patient volume Materials herein reflect public law 114-10 25 dated April 16, 2015
Qualifying APMs • MSSP (Medicare Shares Savings Program) • Expanded under CMS Innovation Center Model* Qualifying • Demonstration under Medicare APMs Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration • “Demonstration required by Federal Law” Materials herein reflect public law 114-10 26 dated April 16, 2015
Advanced APM Eligibility Qualifying • Quality measures APMs comparable to MIPS • Use of certified EHR technology Advanced APMs • More than nominal risk OR Medical Home model under CMMI authority Materials herein reflect public law 114-10 27 dated April 16, 2015
Advanced APMs • Shared Savings Program (all tracks) • Next Generation ACO Model • Comprehensive ESRD Care (CEC) (large dialysis organization arrangement) • Comprehensive Primary Care Plus (CPC+) • Oncology Care Model (OCM) • All other APMs that meet criteria for the APM scoring standard Materials herein reflect public law 114-10 28 dated April 16, 2015
Qualifying APM Participant Qualifying • Percentage of APMs patients or payments thru eligible APM Advanced APMs • In 2019, the threshold is 25% of Medicare payments Qualifying or 20% of patients. APM Participant • Can be a group or individual percentage Materials herein reflect public law 114-10 29 dated April 16, 2015
Additional Rewards for Qualifying Participants • Not subject to MIPS • 5% bonus 2019-2024 • Higher fee schedule update 2026 QP Advanced APM Materials herein reflect public law 114-10 30 dated April 16, 2015
Summary of APMs Qualifying APMs • As defined by the law Advanced APMs • Must meet further criteria Qualifying APM Participants • Potentially more financial certainty with a 5% annual bonus (and no potential for penalty) Materials herein reflect public law 114-10 31 dated April 16, 2015
Am I in a Qualifying APM? Yes No Materials herein reflect public law 114-10 32 dated April 16, 2015
Am I in a Qualifying APM? Yes No Am I in an Advanced APM? Yes No Materials herein reflect public law 114-10 33 dated April 16, 2015
Am I in a Qualifying APM? Yes No Am I in an Advanced APM? Yes No Enough payments or patients ? Yes No Materials herein reflect public law 114-10 34 dated April 16, 2015
Am I in a Qualifying APM? Yes No Am I in an Advanced APM? Yes No Enough payments or patients ? Yes No Qualifying APM Participant 5% bonus payment 2019-2024 Higher fee schedule 2026+ APM-specific rewards Excluded from MIPS Materials herein reflect public law 114-10 35 dated April 16, 2015
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