MACRA, MIPS, and APMs Kate McIntosh MD FAAP Medical Director VITL - - PowerPoint PPT Presentation

Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data

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.

• Ends the Sustainable Growth Rate formula for determining Medicare

payments

• Changes payment to a value and quality based system
• Combines multiple existing federal programs in to a single program
• 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

• 0.5% annual

payment increase 2019-2024

• 0% annual

payment increase

• Introduction
• f MIPS
• Introduction
• f APM

2025+

• Strong push

to APMs

• Goal is 75%

participation in APM Models

Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data

Between now and the end of 2018

• Existing programs continue
• PCMH
• PQRS
• Value Modifier
• 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.

• MIPS is the minimum requirement
• Not all APMs will end up being Advanced APMs
• All Payer Waiver doesn’t exempt everyone from MIPS
• 2017 is the first evaluation year for MIPS with payment adjustments in

2019.

• 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

• f 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

Zero Adjustment Negative Adjustment Positive Adjustment Maximum Payment Reduction Additional positive Adjustment factor

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
• Total per costs capita for attributed beneficiaries
• Medicare Spending per Beneficiaries
• Clinical Practice Improvement Activity
• Patient Centered Medical Home or Patient Centered Specialty Practice

qualifies fully.

• 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)
• Model itself
• APM Entity
• An organization that participates in an APM through a direct agreement

with CMS or other non-Medicare payer.

• 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
• f financial risk OR be Medical Home Model that has been

expanded under Section 1115A of the Social Security Act

• Can be either:
• A Medicare Medical Home Payment Model
• A Combination All Payer and Medicare Model
• 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.

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/How_to_Get_Started.html

• Know your numbers
• Get a Quality and Resource Use Report from Medicare:
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html

• 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

Partner, Partner, Partner

• Care coordination, telemedicine, referral tracking, and patient

satisfaction are a few parts of MACRA and the push to Advanced APMs

• Look through the whole care-continuum for places to improve

care and utilization

• Readmission rates
• Non-compliant patients
• Socio-economic or housing issues that may be affecting your highest-cost

patients.

• UVM and Community Health Centers of Burlington partnered with

the Champlain Housing Trust and the Vermont Community Foundation to find housing for 95 patient with chronic homelessness and documented a savings of almost $1M in health care costs, along with a 42% reduction in ED visits and 68% fewer inpatient admissions.

Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data

MACRA latest update

• In response to feedback, CMS has modified the original roll-out
• f MACRA to a “Pick Your Pace” approach:
• Test the Quality Payment Program: submit some data in 2017 and

there will not be a negative payment adjustment in 2019.

• Participate for part the calendar year 2017 and and possibly get a

small positive payment adjustment in 2019.

• Participate for the whole calendar year 2017 and possibly qualify

for a modest positive payment adjustment in 2019.

• Participate in an Advanced Alternative Payment Model in 2017 and

possibly qualify for a 5% incentive payment in 2019.

• Final details on data requirements will be part of the final rule

Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data

VITL’s role in MACRA and the All Payer Model

• There will be an increasing need for high quality data from a

wide variety of health care organizations and sources.

• The All Payer Model may require VITL to supply additional, or

different, data from MACRA’s requirements.

• Multiple groups and organizations will need data for reporting
• n value and quality.
• Data reports will need to be provided to a variety of
• rganizations at both the state and federal levels.

Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data

The Brave New World of Preventive Care and Value Based Payment

• If you don’t put a code on it, you won’t get credit for it.
• For example, in Peds: well child codes:
• Z00.129 Well Child without abnormal findings
• Z00.121 Well Child with abnormal findings
• If a person has any chronic diagnoses at all, use the “with

abnormal findings” diagnosis.

• If a chronic diagnosis isn’t listed once in a calendar year, the

“system” forgets it.

• Document the complexity of your patients so you get credit

for the complexity of your thought processes and care.