Current State Over Volume Silos of Utilization over Care Value - - PowerPoint PPT Presentation

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Current State Over Volume Silos of Utilization over Care Value - - PowerPoint PPT Presentation

Jan 10, 2024 114 likes •611 views

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

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SLIDE 1
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SLIDE 2

Current State

Over Utilization Volume

  • ver

Value Silos of Care

2

Fee for Service

Materials herein reflect public law 114-10 dated April 16, 2015 2

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SLIDE 3

Push Toward Value & Quality

  • Medicare payments tied to quality
  • r value by end of 2016
  • Of those through alternative

payment models (APMs) by end of 2016

  • Private payer business through

value-based arrangements by 2020

75%

Materials herein reflect public law 114-10 dated April 16, 2015 3

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SLIDE 4

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 dated April 16, 2015 4

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SLIDE 5

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

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SLIDE 6

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 dated April 16, 2015 6

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SLIDE 7

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 dated April 16, 2015 7

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SLIDE 8

Payment Pathways

  • Consolidates quality programs

Merit-Based Incentive Payment System (MIPS)

  • Potential for bonus payment for participation

Advanced Alternative Payment Models (AAPM)

Materials herein reflect public law 114-10 dated April 16, 2015

8

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SLIDE 9

Alternative Payment Model

  • Defined by CMS
  • Participate in MIPS

Advanced Alternative Payment Model

  • Defined by CMS
  • Meet additional eligibility

requirements

  • Do not participate in

MIPS

Alternative Payment Model vs. Advanced Alternative Payment Model

Materials herein reflect public law 114-10 dated April 16, 2015

9

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SLIDE 10

Merit-Based Incentive Payment System

(MIPS)

Materials herein reflect public law 114-10 dated April 16, 2015

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SLIDE 11

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 dated April 16, 2015 11

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SLIDE 12

Consolidates Quality & Value Programs

  • Physician Quality

Reporting System

  • Value Based Payment

Modifier

  • Meaningful Use

MIPS

MU VBPM PQRS

Materials herein reflect public law 114-10 dated April 16, 2015 12

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SLIDE 13

Establish Composite Performance Score

Quality Resource Use Clinical Practice Improvement Activities Advancing Care Information

Materials herein reflect public law 114-10 dated April 16, 2015 13

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SLIDE 14

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 dated April 16, 2015 14

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SLIDE 15

Weighting by Category

Materials herein reflect public law 114-10 dated April 16, 2015

CPIA 15% Cost 10% Quality 50% Advancing Care Information 25%

15

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SLIDE 16

Weighting by Category

2019 2020 2021 Quality 50% 45% 30% Resource Use 10% 15% 30% Advancing Care Information 25% 25% 25% CPIA1 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 dated April 16, 2015 16

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SLIDE 17

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 dated April 16, 2015 17

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SLIDE 18

Adjust Payments

  • 4%-5%
  • 7% -9%

4% 5% 7% 9%

2019 2020 2021 2022 onward

“With respect to positive MIPS adjustment factors…the Secretary shall increase or decrease such adjustment factors by a scaling factor in

  • rder to ensure that the budget

neutrality requirement…is met”

Materials herein reflect public law 114-10 dated April 16, 2015 18

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SLIDE 19

Adjust Payments

  • 4%-5%
  • 7% -9%

4% 5% 7% 9%

2019 2020 2021 2022 onward

Materials herein reflect public law 114-10 dated April 16, 2015

Maximum Adjustments

*Potential for

3X

adjustment

1 9

Adjustment to provider’s base rate of Medicare Part B payment

19 Materials herein reflect public law 114-10 dated April 16, 2015

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SLIDE 20

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 dated April 16, 2015 20

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SLIDE 21

Adjustment Summary

Performance Score Payment Adjustment 25th Percentile or below = Maximum negative adjustment At threshold = Stable Payment

“Exceptional Performers” eligible for up to 10% positive adjustment

Materials herein reflect public law 114-10 dated April 16, 2015 21

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SLIDE 22

MACRA Timeline

2017 2018 2019 2020 2021

2022-2024

2025 2026

Medicare Part B Baseline Payment Updates

+0.5% +0.5% +0.5%

0% 0% 0%

+0.25%* +0.75%**

*Non-Qualifying APM Conversion Factor **Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)

PQRS, Value-based Modifier, & Meaningful Use Quality, Resource Use, Meaningful Use, & Clinical Practice Improvement Activities

  • 9%
  • 9%?

+/-4% +/-5% +/-7%

+0% +/-9%

Materials herein reflect public law 114-10 dated April 16, 2015 22

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SLIDE 23

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 dated April 16, 2015 23

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SLIDE 24

Alternative Payment Models

(APMs)

Materials herein reflect public law 114-10 dated April 16, 2015

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SLIDE 25

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 dated April 16, 2015

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SLIDE 26

Qualifying APMs

  • MSSP (Medicare Shares Savings

Program)

  • Expanded under CMS Innovation

Center Model*

  • Demonstration under Medicare

Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration

  • “Demonstration required by Federal

Law”

Qualifying APMs

Materials herein reflect public law 114-10 dated April 16, 2015 26

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SLIDE 27

Advanced APM Eligibility

  • Quality measures

comparable to MIPS

  • Use of certified EHR

technology

  • More than nominal risk

OR Medical Home model under CMMI authority

Qualifying APMs Advanced APMs

Materials herein reflect public law 114-10 dated April 16, 2015 27

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SLIDE 28

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 dated April 16, 2015 28

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SLIDE 29

Qualifying APM Participant

  • Percentage of

patients or payments thru eligible APM

  • In 2019, the

threshold is 25% of Medicare payments

  • r 20% of patients.
  • Can be a group or

individual percentage

Qualifying APMs Advanced APMs

Qualifying APM Participant

Materials herein reflect public law 114-10 dated April 16, 2015 29

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SLIDE 30

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 dated April 16, 2015 30

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SLIDE 31

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 dated April 16, 2015 31

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SLIDE 32

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10 dated April 16, 2015 32

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SLIDE 33

Yes No

Am I in a Qualifying APM?

Yes No

Am I in an Advanced APM?

Materials herein reflect public law 114-10 dated April 16, 2015 33

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SLIDE 34

Yes No

Am I in a Qualifying APM?

Yes No

Am I in an Advanced APM? Enough payments or patients?

Yes No

Materials herein reflect public law 114-10 dated April 16, 2015 34

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SLIDE 35

Yes No

Am I in a Qualifying APM?

Yes No

Am I in an Advanced APM? 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 dated April 16, 2015 35

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SLIDE 36

Yes No

Am I in a Qualifying APM?

Yes No

Am I in an Advanced APM? Enough payments or patients?

Yes No

Subject to MIPS Favorable MIPS scoring APM-specific rewards

Materials herein reflect public law 114-10 dated April 16, 2015 36

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SLIDE 37

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10 dated April 16, 2015 37

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SLIDE 38

Yes No

Am I in a Qualifying APM?

1st year in Medicare OR below low-volume threshold?

Yes No

Not subject to MIPS

Materials herein reflect public law 114-10 dated April 16, 2015 38

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SLIDE 39

Yes No

Am I in a Qualifying APM?

1st year in Medicare OR below low-volume threshold?

Yes No

Not subject to MIPS - FFS Subject to MIPS

Materials herein reflect public law 114-10 dated April 16, 2015 39

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SLIDE 40

Yes No

Am I in a Qualifying APM?

1st year in Medicare OR below low-volume threshold?

Yes No

Not subject to MIPS - FFS Subject to MIPS

Yes No Yes No

Am I in an Advanced APM? Enough payments or patients?

Qualifying APM Participant 5% bonus payment 2019-2024 Higher fee schedule 2026+ APM-specific rewards Excluded from MIPS

Subject to MIPS Favorable MIPS scoring APM-specific rewards

Materials herein reflect public law 114-10 dated April 16, 2015 40

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SLIDE 41

MACRA Timeline

2017 2018 2019 2020 2021

2022- 2024

2025 2026

Medicare Part B Baseline Payment Updates

+0.5% +0.5% +0.5%

0% 0% 0%

+0.25%* +0.75%**

*Non-qualifying APM Conversion Factor **Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)

PQRS, Value-based Modifier, & Meaningful Use Quality, Resource Use, Meaningful Use, & Clinical Practice Improvement Activities

  • 9%
  • 9%?

+/-4% +/-5% +/-7%

Qualifying APM Participant

5% Incentive payment Excluded from MIPS

+0% +/-9%

Materials herein reflect public law 114-10 dated April 16, 2015 41

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SLIDE 42

Payment Reform Is Here

  • Final regulations in 2016
  • 2017 likely performance year for MIPS and APMs
  • Help is available

Materials herein reflect public law 114-10 dated April 16, 2015 42

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SLIDE 43

Themes of MACRA

  • Aggregate data
  • Integrate & Collaborate
  • Treat the individual – evaluate the population
  • Identify and progress towards an Advanced APM

43 Materials herein reflect public law 114-10 dated April 16, 2015

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SLIDE 44

What Can I Do Right Now?

  • 1. Take a really deep

breath

  • 2. Evaluate your

practice

– Are you submitting PQRS? – Have you reviewed your QRUR? – Attested for Meaningful Use?

Materials herein reflect public law 114-10 dated April 16, 2015 44

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SLIDE 45

What Can I Do Right Now?

  • 3. Develop a quality

plan.

  • 4. Learn how to

evaluate resource use

  • 5. Create a glidepath

towards an Advanced APM

Materials herein reflect public law 114-10 dated April 16, 2015 45

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SLIDE 46

Post MACRA alternatives for physicians

  • Retire before 2019 or de-participate from the Medicare

program

  • Join a larger physician group practice with capabilities to

provide MACRA support

  • Become employed by an organization with capabilities to

provide MACRA support

  • Remain independent an join a Clinically Integrated

Network(that can provide MACRA support)

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SLIDE 47

RESPONSE TO MACRA

KHN

  • Partnering with the Advisory Board Company to provide

education for MACRA and payment innovation

  • Education Dates to follow that will include PHA/KPP

membership KPP (align with KHN strategy)

  • Working to Identify several companies to assist with
  • Readiness Assessment’s
  • Consulting Services for quality, care management,
  • ffice practice operations
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SLIDE 48
  • R. Shawn Martin

Senior Vice President Advocacy, Practice Advancement, & Policy

smartin@aafp.org @rshawnm

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