american health care after sgr - chop: coalition of...

© 2013 American Medical Association. All rights reserved.

American Health Care After SGR Coalition of Hematology Oncology Practices

Barbara McAneny MD


U.S. Health Care Spending

• More than $2 trillion • $7,681 per person • 16.2% of gross domestic

product

Each year the U.S. spends:


Global Growth in Spending


Medicare Expenditures


Medicare payment vs. practice cost inflation


AMA Strategy to Reduce Costs

1) Reduce burden of preventable disease

2) Make the delivery of care more efficient

3) Reduce nonclinical costs that don't contribute to patient care

4) Promote value-based decision-making at all levels

Goal: To get the most for our health care dollars, rather than reduce costs alone


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The problem

Yes

Source: NCPDP Prior Authorization Workflow-to-Transactions Task Group, 2005

Patient Visits Prescriber

Prescriber writes Rx for preferred drug

therapy

Patient takes Rx to pharmacy

Prescriber transmits Rx to

pharmacy or calls

Pharmacy enters Rx, claim filled with plan

Plan identifies drug as requiring PA, rejects claim & responds to pharmacy

or calls prescriber

Pharmacy contacts prescriber or submits

request if it has information

Prescriber contacts plan to obtain

correct form or looks up in book

New PA

Prescriber completes form, faxes to plan or provides info via

phone

Plan reviews PA request

Prescriber contacts

pharmacy with new Rx

Rx Dispensed

Prescriber contacts pharmacy indicating

PA request was approved, OK to

dispense

Plan contacts prescriber

approving PA

Plan contacts prescriber, asks for

more info

Does 2nd

drug require

PA?

Select 2nd drug?

Patient pays for all costs

No Rx therapy

Plan contacts prescriber denying

PA request

New PA

Are all PA questions

answered?

Approve PA Request?

Yes NoYes

No

NoNo

No

Yes

Yes


Reduce Preventable Disease • Train physicians on lifestyle

counseling • Expand insurance coverage for

prevention • Explore rewards-based

incentive programs • Promote public health

campaigns

of health care spending is on patients with chronic conditions

75%


Are you Prediabetic?

• Male 1 point

• Female 0 points

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Are you Prediabetic?

• Male 1 point

• Female 0 points

• Over 60? 3 points

• 50-60? 2 points

• 40-50? 1 point

12


Are you Prediabetic? • Male 1 point • Female 0 points

• Over 60? 3 points • 50-60? 2 points • 40-50? 1 point

• Not Physically active? 1 point

13




• Not Physically active? 1 point • Diabetes in family? 1 point

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• Not Physically active? 1 point • Diabetes in family? 1 point • Hypertension? 1 point

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Body Habitus

0 1 2 3

Opioid Abuse Prevention

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Ama-assn.org/go/endopioidabuse • 44 RX Opioid Deaths per day

• Use Prescription Drug Monitoring Programs

• Effective physician education on prescribing

• Reduce stigma of chronic pain

• Reduce stigma of substance abuse

• Expand use of naloxone for overdose

• Work with administration for treatment dollars

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Confronting the Opioid Epidemic

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January 2015

The MACRA Framework


MACRA overview

The Medicare Access and CHIP Reauthorization Act

of 2015 (MACRA)

Developed in bipartisan, bicameral process over 2+ years

Supported by over 750 national and

state-based physician organizations

Passed with overwhelming

bipartisan support

21


What MACRA does Permanently eliminates the SGR (and its annual physician payment cuts)

Establishes a path for alternative payment models (APMs)

Consolidates reporting programs

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Physicians will have choices

Fee-for-Service under a “Merit-based Incentive

Program” (MIPS)

Alternative Payment Models

• Statutory updates

• Consolidated reporting

• Reduced penalty risk

• Higher updates

• Exempt from MIPS

• Preferred treatment for medical homes

• Specialty models encouraged

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Annual payment updates

• 2015: 0.5% update provided July 1, in lieu of -21.2% cut on April 1

• 2016-2019: 0.5% update provided on Jan. 1 each year

• 2020-2025: 0% update • 2026 and beyond: 0.25%

annual updates in FFS; 0.75% annual updates for APMs

• There is no more SGR cliff

• Last short-term patch (PAMA) in 2014 set savings targets for revising misvalued codes – 0.5% savings per year, 2017-2020

• ABLE Act accelerated targets – 1.0% in 2016, 0.5% in 2017 and

2018

• Final 2016 fee schedule rule issued Oct. 30 announced -0.29% (10 cents) payment cut in 2016

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MACRA provisions Reality check

The Merit-based

Incentive Payment

System (MIPS)

25


Components of the Merit-based Incentive Payment

System (MIPS)

Quality Measurement (PQRS)

Resource Use (Value-based Modifier)

EHR Meaningful Use Clinical practice

improvement activities

MIPS

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Relative weights of MIPS components

2019 2020 2021 2022 onward

Quality

(PQRS)

50% 45% 30% 30%

Resource use

(VBM)

10% 15% 30% 30%

MU* 25% 25% 25% 25%

CPI 15% 15% 15% 15%

Penalty risk -4% -5% -7% -9%

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*MU weight may be reduced to 15% if 75% of EPs are successful


MIPS performance assessment

• CMS compares each EP’s or group’s performance to an annual “performance threshold,” calculates a “composite performance score,” and arrives at a percentage “adjustment factor.”

Adjustment factor

• MIPS measures and scoring must be adjusted for “an individual’s health status and other risk factors.”

Risk adjustment

• Annual threshold is based on median or mean composite scores of all EPs in a prior period. (Cannot be used as a standard of care for medical liability actions.)

Performance threshold

• At the threshold: no adjustment

• Above the threshold: bonus

• Below the threshold: penalty

Penalty or bonus

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MIPS performance assessment

• 2019: + 4%; 2020: + 5%; 2021: + 7%; 2022 and after: + 9%

• Bonuses may be adjusted (somewhat) so that total bonuses = total penalties

Range of adjustments

• Extra bonus up to 10%, $500 million per year, 2019-1025 for scoring in top 25% above threshold.

Exceptional performance bonus

• CMS can weight categories differently (even zero) if there are insufficient measures and activities for an EP type.

Flexible weight categories

• EP/group must be told their adjustment factor at least 30 days before next performance period (i.e., by Dec. 1). Notification

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Who must report under the MIPS?

MIPS eligible professionals (EPs) in 2019:

•Physicians, podiatrists, optometrists, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists & nurse anesthetists.

Starting 2021, MIPS EPs could include:

•Social workers, psychologists, dietitians, nutritionists, physical therapists, occupational therapists, speech pathologists & audiologists.

Who does not have to report under MIPS?

•EPs:

• In qualifying alternative payment models.

•W/Medicare claims or patients below “low volume threshold.”

• In 1st year of Medicare enrollment.

•Clinicians who are not EPs.

EPs who do not report:

•Get the maximum MIPS penalty:

• 4% in 2019

• 5% in 2020

• 7% in 2021;

• 9% in 2022 & after.

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2019 (first year) penalty risks compared

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Prior Law 2019

adjustments

PQRS -2%

MU -5%

VBM -4% or more*

Total penalty risk -11% or more*

Bonus potential (VBM

only)

Unknown (budget

neutral)*

MIPS factors 2019 scoring

Quality measurement 50% of score

MU 25% of score

Resource use 10% of score

Clinical improvement

activities

15% of score

Total penalty risk Max of -4%

Bonus potential Max of 4%, plus

potential 10% for high

performers *VBM was in effect for 3 years before MACRA

passed, and penalty risk was increased in each of

these years; there were no ceilings or floors on

penalties and bonuses, only a budget neutrality

requirement.


More on MIPS components

•Small practices (up to 10) may join “virtual groups”

•CMS may OK alternative measures and activities for those who do not see patients

•Reporting via EHRs and registries encouraged PQRS (30%)

•CMS to develop care episode, patient condition, and patient relationships categories for accurate calculations and attributions

•Charges to include Parts A and B, perhaps Part D drugs if feasible Resource use (30%)

•Acting CMS Administrator announced that MU in present form will end in 2016, to favor patient outcomes over reporting tasks

•Goal for achieving interoperability of EHRs set for 2018

Meaningful Use (25%)

•New category; options mentioned include: expanded practice access, population management, care coordination (e.g., remote monitoring, telehealth), beneficiary engagement, patient safety and practice assessment, participation in APMs.

Clinical improvement activities (15%)

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AMA Work on Meaningful Use

• Shortened the 2015 Reporting Period

• Reduced the measure threshold for the requirements for patients to

view, download or transmit their records

• Reduced the threshold for secure messaging requirement

• Secured passage of the Patient Access and Medicare Protection Act

– Allowed CMS to expedite exemptions from MU 2 Stage 2 for 2015

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Break the Red Tape: Meaningful Use

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Alternative payment

models (APMs)

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Alternative payment models (APMs) under MACRA

Incentives for APM

participation

• Better payment potential inherent in model design.

• 2019-2024: EPs get a 5% bonus for participation in qualifying APMs.

• 2026 & after: Annual payment update is 0.75% for EPs in APMs, 0.25% for others.

• No MIPS reporting.

Qualifying APMs

• MSSP accountable care organizations, CMMI initiatives (not Health Care Innovation awards) & certain demonstration programs.

• New APMs must require use of a certified EHRs & have quality measures.

• Must bear “more than nominal” financial risk, except CMMI medical homes.

36


Alternative payment models (APMs) under MACRA

Level of participation required for incentives

• APM revenue or patients must be at least 25% in 2019-20 – rising to 75% by 2023.

• EPs can qualify with non-Medicare APMs & “partially qualify” for getting close to thresholds.

• CMS can extrapolate from partial year revenue.

Advisory Committee &

CMS Study

• New Physician-focused Payment Model Technical Advisory Committee reviews proposals for new APMs & make recommendations.

• CMS must issue study by July 2016 of feasibility of integrating APMs into Medicare Advantage, adding a VBM & if it should be budget-neutral.

37


An AMA menu of physician-focused APMs

• Payments for high-value services

• Condition-based payment for a physician’s services

• Multi-physician bundled payment

• Physician-facility procedure bundle

• Warrantied payment for physician services

• Episode payment for a procedure

• Condition-based payment

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What’s next?

39


Milestone events

2016 •Proposed rule (March?) and final regulations (September?) issued for MIPS

2017

•First performance measurement year for MIPS

•APM criteria set, proposals accepted for review on an ongoing basis

2018

•First performance measurement year for APMs

•Separate PQRS, MU, and VBM programs/ adjustments sunset Dec. 31

•Deadline for achieving EHR interoperability Dec. 31

2019

•First MIPS payment adjustments implemented, maximum bonus/ penalty + 4% (phases up to + 9% in 2022)

•First APM performance assessed, 5% bonus payments made to “qualifying participants”

•HHS reports if EHR interoperability achieved, penalties and decertification criteria may be recommended

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AMA Plans

• Goal: To proactively shape MACRA implementation so that all

physicians can succeed under the practice model of their choice

• Work collaboratively with physician specialty organizations and state

medical societies (MACRA task force, MIPS and APM workgroups) to

promote common recommendations and physician engagement

• Conduct outreach to other influential stakeholders and find common

ground

• Secure needed external expertise

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Early consensus points for medicine

• It is important for MACRA to succeed

– Requires broad participation by medicine, constructive engagement with CMS

• MIPS must not simply combine current pay for performance/ reporting programs

– Programs need to be reformed, aligned, simplified

– Redirecting the Meaningful Use program is a top priority

• Diverse set of APMs needed, but common elements must be identified

– Don’t reinvent the wheel for each specialty

• Physicians need tools, resources, decision trees

42


Some important questions remain

• Will MIPS components be sufficiently improved?

• Will there be enough qualified APMs?

• Will “Physician-Focused Payment Models” qualify for the APM bonus

payments?

• How will “more than nominal risk” be identified?

• How frequently, in what format, and through what means will

performance feedback be provided to physicians?

• Does CMS have the necessary capabilities and bandwidth to implement

such a complex law?

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CMMI Oncology Care Model (OCM) Patient Population:

• The CMMI OCM Payment Model applies to all patients with a new chemotherapy start.

Episode Definition:

• 6 months following new chemotherapy start, repeatable.

Payments

• The OCM model will pay physicians in three ways:

– Normal FFS Payments

– $160 PBPM (per beneficiary per month)

– Shared Savings/Risk Sharing

Episode Price/Discount to Medicare

• 4% discount for practices participating in shared savings

• 2.75% discount for practices accepting full risk

The COME HOME Program – External Evaluation, Evolving Outcomes

January 2016

www.innovativeobs.com

http://www.comehomeprogram.com/

Methods

• Data collected from October 2012 – March 2015

• COME HOME patients compared to matched controls

• Analytic method: Difference in Differences (DID) analysis, which normalizes all utilization during the study period to normalization of those same patients before COME HOME

• Patient count: 3,663 Medicare FFS patients vs. matched controls


Quantitative Findings (quarterly)

• 10 ED Visits avoided per 1,000 patients**

• 3 acute care sensitive hospitalizations avoided per 1,000 patients*

• 4 readmissions avoided per 1,000 admissions*

• $673 reduction in total cost of care ($224 PMPM)**

*p<0.1

**p<0.05


What might the OCM look like for a community oncology practice?

($200,000.00)

($150,000.00)

($100,000.00)

($50,000.00)

$0.00

$50,000.00

$100,000.00

$150,000.00

$200,000.00

$250,000.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Qu

arte

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Ris

k B

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d P

aym

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Quarter

Shared Savings (Upside Only) Risk Based Payment (Full Risk)

AMA Advocacy in

Action

49


Blocking Health Insurer Consolidation

“The AMA believes patients are better served in a health care system that

promotes competition and choice. We have long cautioned about the

negative consequences of large health insurers pursuing merger strategies

to assume dominant positions in local markets. Recently proposed mergers

threaten to increase health insurer concentration, reduce competition and

decrease choice.”

Steven J. Stack, MD

President, American Medical Association

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http://www.ama-assn.org/ama/pub/about-ama/our-people/board-trustees/our-members/steven-stack.page


MARKET CONSOLIDATION:

5 PLANS NOW-----3 PLANS IN 2017?

• Competition in Health Insurance, 2015 AMA website

• Testimony before House Judiciary Committee

• Letter to Department of Justice to Block Mergers

• Engaged National Association of Attorneys General

• Collaboration with State and Specialty Medical Societies

• ama-assn.org/go/competition

• ama-assn.org/go/mergers

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Other AMA Advocacy Efforts

• Supporting Medical Education

– Undergraduate and GME

• Drug Pricing Task Force

– Address pharmaceutical prices

– Advocacy campaign for public attention

• Network Advocacy

– Regulatory oversight of networks

– Developing measures, including hospital based physicians

52


Effects of ACA so far

• 39 Million Americans used a preventative or screening service without

copay or coinsurance

• 9 Million annual Wellness Visits

• 10.7 Million Medicare patients received $20.8B on prescription drugs

• Closing the Donut Hole (by 2020) helps all seniors, now with a $250

rebate

• 9 Million fewer Uninsured

• Large deductibles are a predictable problem

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USP 800

• Punishing us to atone for New England Compounding

• Separate pressured rooms for “hazardous” and “non-hazardous” drugs

• Separate gowns and refrigerators and hoods

• Pressured receiving areas

• Planned for July 1 2018

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