MACRA, MIPS, and APMs Kate McIntosh MD FAAP Medical Director VITL VITL Summit 2016 Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Initial Questions • How many of you have heard of MACRA , MIPS, or APMs? • How many of you have a working knowledge of MACRA and have developed a readiness plan? • How many of you are hoping that it just goes away? Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
What is MACRA? • MACRA is the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015. o Ends the Sustainable Growth Rate formula for determining Medicare payments o Changes payment to a value and quality based system o Combines multiple existing federal programs in to a single program o Has two arms: MIPS (Merit-based Incentive Payment System) AAPMs (Advanced Alternative Payment Models) • CMS will issue the final rule in November Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Agenda • Give you a working understanding of MACRA, MIPS, and APMs • Give you a road map for how to start thinking about these programs Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Learning Objectives • Understand the difference between the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) • Understand how to make a roadmap to prepare for MIPS or an advanced APM. Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Source: Neal Halfon: UCLA Center for Healthier Children, Families, and Communities Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
What happens with Medicare Part B payment? 2015-2018 2019-2024 2025+ • 0.5% annual • 0% annual • Strong push payment payment to APMs increase increase • Goal is 75% • Introduction participation of MIPS in APM Models • Introduction of APM Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Between now and the end of 2018 • Existing programs continue o PCMH o PQRS o Value Modifier o Meaningful Use • BUT- you will be judged on the quality of your data and your patient management. Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
The Arms of MACRA Merit Based Incentive Payment System (MIPS) MIPS Alternative Payment Model (APM) Advanced APM Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
The general consensus • Everyone has to be prepared for MIPS, even if they plan to participate in an advanced APM. o MIPS is the minimum requirement o Not all APMs will end up being Advanced APMs o All Payer Waiver doesn’t exempt everyone from MIPS o 2017 is the first evaluation year for MIPS with payment adjustments in 2019. o It is very unlikely that any change in politics at the federal level is going to change MIPS at this time. • Medicaid at-risk plans like AAPMs are coming and are also probably the way of the future. • At risk commercial plans are also coming. Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Merit Based Incentive Payment System (MIPS) • This system combines three things: Physician Quality Reporting System Value modifier (or Value-based Payment Modifier) Meaningful use (EHR Incentive Program) • These are combined into one single program based on quality, resource use, clinical practice improvement, and meaningful use of EHR technology Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Scoring of MIPS Source: Impact-Advisors.com Each is scored and the aggregate scoring is 100 points Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
How Performance affects Payment Performance Year Payment Year Adjustment +/- Maximum 2017 2019 4% 12% 2018 2020 5% 15% 2019 2021 7% 21% 2020 2022 9% 27% • Payment is relative to scoring and therefore participants have risk • Budget neutral- there will be winners and losers • Since you are scored relative to your peers, to get beyond 1 or 2 standard deviations will take a lot of work. • Benchmarks are set based on prior year performance so the pressure to improve continues Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Performance Threshold Maximum Payment Additional positive Reduction Negative Positive Adjustment factor Adjustment Adjustment Zero Adjustment Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Quality Reporting • Minimum of six measures • At least one cross-cutting measure for patient-facing providers • One outcome measure if available • If no outcome measure is available, can use a high priority measure (appropriate use, patient safety, efficiency, patient experience, care coordination measure). Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Resource Use, CPIA, and Meaningful Use • Resource Use o Total per costs capita for attributed beneficiaries o Medicare Spending per Beneficiaries • Clinical Practice Improvement Activity o Patient Centered Medical Home or Patient Centered Specialty Practice qualifies fully. o Emphasis on Practice Access Population Management Care Coordination Patient Engagement. • Advancing Care Information= Meaningful Use Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
APM terminology • APM (Advanced Payment Model) o Model itself • APM Entity o An organization that participates in an APM through a direct agreement with CMS or other non-Medicare payer. o APM Entities may be Accountable Care Organizations, Health Systems, Practice Associations, or other organized groups and they can participate in: Advanced APM Shared Savings Program MIPS APM Next Gen APM Other MIPS APM Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
What is an Advanced APM? • 50% of participants are required to use CEHRT. • The Advanced APM must bear more than a “nominal” amount of financial risk OR be Medical Home Model that has been expanded under Section 1115A of the Social Security Act • Can be either: o A Medicare Medical Home Payment Model o A Combination All Payer and Medicare Model o An Other Payer Alternative Payment Model • Performance-based pay • Revenue and patient thresholds that increase over time • 5% bonus from 2019-2024 then higher updates. • CMS goal is to push providers into AAPM models. Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
MACRA readiness- first steps • Begin to think about medical care in completely different way • Know your data • Be honest with yourselves • Create internal expertise • Partner, partner, partner Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Begin to think about medical care differently • Start thinking about Quality for a focused number of conditions • Start with measures that you already do well • Think beyond fee-for-service and ask how you can provide the highest quality using your care team • Where do you have flexibility? • Who is qualified to provide a service to a patient? • How do you increase patient buy-in and personal engagement? Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Know your data- data matters a lot • Know who is in your “attribution”. • Know how different metrics are being collected by your reporting agency, whether that is your EHR or an external source. • Understand how direct documentation in the chart is affecting your numbers. How do you increase accuracy? • Push for transparency and actionable information in internal and external reports. • Push toward the most reliable and highest quality data both internally and externally. Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Be honest with yourselves and get involved • Create a culture of introspection and improvement • Data is not judgment, but it is important and will eventually be a paycheck. • If you are not participating in incentive programs, you have to start. o https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/How_to_Get_Started.html • Know your numbers o Get a Quality and Resource Use Report from Medicare: https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html o Look at other comparison sites: http://www.whynotthebest.org https://www.medicare.gov/hospitalcompare/search.html https://www.medicare.gov/physiciancompare/search.html Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
Create internal expertise • Understand how the changes that are coming will impact your practice. • Customize your EHR as much as possible to streamline burdensome documentation guidelines. • Try to cut clicks as much as possible. • Be innovative if possible to give more time for clinical care. • Look for care variations in your practices and streamline • Perform a security risk analysis early in 2017. Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data
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