making sense of macra

Making Sense of MACRAMay 10, 2016

How ready are you to participate in MACRA?

1. Not at all – 12.36%

2. Somewhat – 22.53%

3. Unsure – 55.77%

4. Ready – 8.24%

5. Very ready – 1.10%

Poll Question #1

364 Total Responses

Who reads 962 pages of regulations?

Remember all these slides reflect PROPOSED regulations

Question

Purpose of HR Bill 02

Physician Fix Passed in April 2015

• Offer multiple pathways for risk/reward

• Minimize additional reporting burdens

• Streamline multiple programs

• Reward clinicians for value over volume

• MACRA – Medicare Access and CHIP Reauthorization Act of 2015

• SGR – Sustainable Growth Rate (replaced by MACRA)

• MIPS – Merit-based Incentive Payment System

• APM – Alternative Payment Models (Advanced)

• EP – Eligible professional becomes EC Eligible clinician

Acronyms

Goals of CMS• Overall goal – 90% of

Medicare payments shifted to quality or value by 2018

• In 2014, 22% of Medicare payments (approximately $138B) for physicians

• Invite private sector to match/exceed goal

Better care

Smarter spending

Healthier people

Goals of CMS

Via focusedIncentives

Care delivery

Information sharing

“Most profound change to physician compensation in more than 25 years. There is going to be a lot of anger and frustration.”

Steven Stack, M.D., President of AMA

“Make policies simple, flexible to allow providers to make choices to meet their needs and outcomes-oriented.”

Patrick Conway, M.D., Chief Medical Officer, CMS

“Feedback mechanisms are too removed from the performance year.” Anders Gilberg, Senior Vice President of Government Affairs, MGMA

“Quite frankly, the rank-and-file physicians aren’t paying attention.” Chet Speed, JD, LLM, Vice President of Public Policy, AMGA

Reactions

2017Performance Year

• $100M of technical assistance for small practices (under 15 professionals)

• $75M for physician groups to improve quality measure development

Additional Aspects

Two Tracks of MACRA``

.5% annual update thru 2019

Combine MU, PQRS, VBM

Value Based participation bonus 5%

APM QP2019

Performance year

Base year

+/- 5%+/-4% +/- 7% +/- 9% Up to +/- or neutral + Bonus

Performance year

20232021 2022 2024

20202018 20192017 20232021 2022 2024

MIPS participants who participate in APMs would receive credit toward scores in the Clinical Practice Improvement Activities category.

Certain Advanced APMs participants, who fall short of the payment or patient participation requirements for the incentive payment can choose whether they would like to receive the MIPS payment adjustment.

The proposed rule aligns standards between the two parts of the Quality Payment Program in order to make it easy for clinicians to move between programs.

Cross Over Between the Tracks

Public commentary until June 27, 2016

Final regulations published in November 2016

Comments may be submitted electronically to CMS:

Source: http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking

Proposed Rulemaking

Reporting period will be annual - only see your results once a year

• First feedback report – July 2017

• Second feedback report – July 2018

All data will be made available on Physician Compare

Reporting

MIPSMerit-based

Incentive Payment System

EligibilityYear 1, 2 Medicare Part B clinicians:

• Physicians• Physician assistants• Nurse practitioners• Clinical nurse specialist • Certified registered nurse

anesthetists

Hospitals are not part of program

Year three expansion: • Physical or occupational

therapists• Speech-language pathologists,

Audiologists• Nurse midwives• Clinical social workers, Clinical

psychologists• Dietitians / Nutritional

professionals

• First year of Medicare participation

• Low volume threshold

• Participants in advanced APM

Exceptions for MIPS

Composite Performance Score (CPS)

Measurement

Area Weight in 2019 (Changes by year)

Quality 50%Cost (Resource use) 10%Clinical practice improvement activities (CPIA) 15%Advancing care information (Meaningful use of certified EHR technology)

• Six measures with no domain required – select from over 300 measures (last 200 pages of regulation)

• One cross-cutting and one outcome measure required

Cross cutting measure exampleCare Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed.

Outcome measure example- CMS definesCataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Quality – Weighted 50%

Stakeholders

Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf

Clinical Care• Measures incorporating patient preference and shared decision-

making

• Cross cutting measures (more than one specialty)

• Outcome measures

• Focused measures for specialties that have clear gaps

Safety• Measures of diagnostic accuracy

• Medication safety related to important drug classes

Initial Priorities for Measure Development

Care coordination• Assessing team-based care (timely exchange of data)

• Effective use of new technology such as telehealth

Patient and caregiver experience• PROMs (Patient-reported outcome measures)

• Additional topics important to patient/family/caregivers

Affordable care• Overuse measures

Continued- Initial Priorities

Population Health and Prevention• Developing or adapting outcome measures at

population levels to assess effectiveness of promotion and preventative services

• IOM Vital Signs topics

• Detection or prevention of chronic disease

Continued – Initial Priorities

• Compare resources used to treat similar care episodes and clinical condition groups across practices

• Can be risk-adjusted to reflect external factors

• CMS will calculate from claims

Resource – Weighted 10%

Medicare Spend per Beneficiary Jan to Dec 2014Period Claim Type Hospital State Nation

1 to 3 days Prior to Index Hospital AdmissionHome Health Agency 11$ 13$ 13$ 1 to 3 days Prior to Index Hospital AdmissionInpatient 12$ 4$ 5$ 1 to 3 days Prior to Index Hospital AdmissionOutpatient 117$ 70$ 117$ 1 to 3 days Prior to Index Hospital AdmissionDurable Medical Equipment 12$ 9$ 9$ 1 to 3 days Prior to Index Hospital AdmissionCarrier 456$ 535$ 532$ During Index Hospital AdmissionInpatient 13,433$ 9,456$ 9,108$ During Index Hospital AdmissionDurable Medical Equipment 33$ 21$ 24$ During Index Hospital AdmissionCarrier 2,216$ 1,617$ 1,514$ 1 through 30 days After Discharge from Index Hospital AdmissionHome Health Agency 846$ 785$ 771$ 1 through 30 days After Discharge from Index Hospital AdmissionHospice 96$ 108$ 118$ 1 through 30 days After Discharge from Index Hospital AdmissionInpatient 1,810$ 2,545$ 2,665$ 1 through 30 days After Discharge from Index Hospital AdmissionOutpatient 1,103$ 656$ 710$ 1 through 30 days After Discharge from Index Hospital AdmissionSkilled Nursing Facility 2,576$ 3,571$ 3,251$ 1 through 30 days After Discharge from Index Hospital AdmissionDurable Medical Equipment 150$ 94$ 101$ 1 through 30 days After Discharge from Index Hospital AdmissionCarrier 901$ 1,184$ 1,083$ Complete Episode Total 23,775$ 20,669$ 20,025$

Source: CMS Public Information

Areas: (Not yet defined in detail but there will be 90+ activities and selection of one)

• Expanded practice access

• Population management

• Care coordination

• Beneficiary engagement

• Patient safety and practice assessment

• Participation in an APM

Clinical Practice Improvement Activity (CPIA) – Weighted 15%

• Former Meaningful Use

• Use of certified electronic health record (EHR) technology in day-to-day practice

• Emphasis on interoperability and information exchange.

• Not all-or-nothing EHR measurement and no quarterly reporting.

• Removes reporting for CPOE(Computerized Provider Order Entry) and Clinical Decision Support

Advancing Care Information – Weighted 25%

Tweet from Andy Slavitt:

In 2016, MU as it has existed—with MACRA—will now be effectively over and replaced with something better #JPM16

Slavitt said: ‘The focus will move away from rewarding providers for the use of technology and towards the outcome they achieve with their patients.’

Meaningful Use

1. Protect patient health information

2. Patient electronic access

3. Electronic prescribing

4. Coordination of care through patient engagement

5. Health information exchange

6. Public health and clinical data registry

Six Objectives of Advancing Care Information

For period of January 2017 to December 2017

1. Use 2014 or 2015 edition certified EHR

2. Report eight Stage 2 or six Stage 3 advancing care information measures/objectives

3. Attest that clinicians have cooperated with the surveillance of certified EHR technology under the ONC Health IT Certification Program

4. Attest to statements related to health information exchange and information blocking

Technology

Each of the four areas will have a scoring calculation and points

Example for Advancing Care Information

Scoring

BaseScore\ 60 pts

PerformanceScore\10 pts

BonusScore

Composite Score

Area Maximum Points ScoringQuality 80-90 Each measure 1-10 compare

to benchmark, bonusCost (Resource use) Average score of cost Same as quality

Clinical practice improvement activities

60 Each activity=10pt,double for high, compare to a target

Advancing care information 100 Base + performance and bonus potential

• Converts measures/activities to points

• Eligible Clinicians will know in advance what they need to do to achieve top performance, targets will be communicated

• Partial credit available

• MIPS composite performance score in 4 weighted performance categories on a 100-point scale

• Option to do as a group

More about scoring

The CPS will be compared to the MIPS performance threshold to determine the adjustment percentage the eligible clinician will receive

In the first five payment years $500 million in an additional performance bonus that is exempt from budget neutrality for exceptional performance.

Scoring

Quality Resource Use

Composite Performance Score

Clinical Practice

Improvement

Advancing Care

Information

Payment adjustment

Performance below

Negative payment adjustment

Performance above

Neutral or positive payment adjustment

Potential for bonus not to exceed 10%

Adjustment % based on relationship between their CPS and MIPS threshold- budget neutral program

APMAlternative

Payment Model

MACRA does not change any existing APM programs or incentives

• Comprehensive ESRD Care Model (Large Dialysis organization)- 12 participants

• Medicare Shared Savings Program—Track 2 and Track 3 – 24 participants

• Next Generation ACO Model -21 participants

• Comprehensive Primary Care Plus (CPC+) Currently regional with payers, available in 2017

• Oncology Care Model Two-Sided Risk Arrangement (available in 2018)

Models that Qualify for Advanced APM

Criteria to meet:

• Payment based on quality (measures similar/comparable to MIPS)

• Use of certified EHR technology- at least 50% of providers

• Bear financial risk and risk must be at certain magnitude or be part of Medical home model expanded under CMMI

It WILL be difficult to qualify for Advanced APM

Advanced APM Eligible Programs

Not only do you need to be part of an advanced APM, but you also need to be a QP (Qualified Provider)

• Based on advanced APM entity scoring and done for payment year

• % of payment and patients under advanced APM-based on 2017

Expanded Criteria

CMS Calculates Threshold Score

Payment amount formula for Threshold score %

$ for Part B professional to attributed beneficiaries divided by $ for Part B professional to attribution-eligible beneficiaries

Patient Count formula for Threshold score %

# of attributed beneficiaries given Part B professional services divided by # of attributed-eligible beneficiaries given Part B professional services

** Partial QP can choose MIPS

Use most favorable score

2019 QP 25%

2019 Partial QP 20%

2019 QP 20%

2019 Partial QP 10%

Now QP in advanced APM

• Do not participate in MIPS

• Get 5% increase in fee schedule

Met all criteria

CMS estimates 30,000 to 90,000 clinicians in advanced APM.

The costs for implementation and complying with the advancing care information performance category requirements could potentially lead to higher operational expenses. However, we believe that the combination of payment adjustments and long-term overall gains in efficiency will likely offset the initial expenditures.

CMS believes that the proposed changes will have a positive impact and improve the quality and value of care provided to Medicare beneficiaries.

Calculation for internal medicine –$1,100 to a positive of $1,900.

Impact Projected by CMS

Readiness

How optimistic are you that the April 27th proposed regulations will produce the results that CMS is expecting from MACRA?

1. Not at all – 20.28%

2. Somewhat – 38%

3. Optimistic – 12.59%

4. Very optimistic – 0%

Poll Question #2

429 Total Responses

• Set predictable updates for physician fee schedules

• Encourage physicians to participate in new payment models• Both cost and quality

• Adopt interoperable electronic health record

Is this encouraging consolidation?

This is not cheap or simple.

Joseph J. Fifer, FHFMA, CPA, President HFMA

HFMA Comments

May push independent physicians to a breaking point

Reaction

“I am going to predict that more physicians will seek employment and figure that it is the health system problem to deal with the %s and give me the infrastructure to be successful”.

Lee Sacks, M.D., Chief Medical OfficerAdvocate Health

Take Medicare Part B revenue and annualize – adjust for volume and fee schedule increase of .5%

• What is impact of 4% reduction under MIPS?

• What investments do I need to participate?

• What is impact of 5% under APM?

• Have we explored these options and know investments?

$25M of revenue has potential for negative impact of ($1M) – adjust for point scoring on MIPS

Financial Impact

Outline a strategy

• Do I know which track I want?

• What is impact on my practice?

• What do I need to do?

• What happens if I do nothing?

• What are we doing to move to value-based models?

Deadline of Q3 2016 for outline.To Do #1

Current strategy of organization, MACRA may help decision

Applications due for ACO

Next generation Letter of intent May 20, 2016

Application May 25, 2016

MSSP Notice of intent May 31, 2016

Application July 29, 2016

Link with Value Based

Educate and communicate• Provide clinicians with

summarized documents.

• Use webinars.

• Make time in current meeting structure for education on topic.

• Staying informed will ease stress.

To Do #2

Connect locally and use their websites

AMA – http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-physician-payment-reform.page

AHA – http://www.aha.org/advocacy-issues/physician/index.shtml

AAFP – http://www.aafp.org/practice-management/payment/medicare-payment.html

Use professional societies

MACRA READY program

To Do #3

Identify thought leaders and discussTo Do #4

• Who has been your thought leader?

• Can be someone in healthcare or can you explain to someone outside of healthcare to get feedback?

Look inward, know your strengths• What do you think you do well?

• Where do you have data that shows you do well?

• Which measures show how well your practice performs?

• Do you have an performance plan in place to improve?

• Who has accountability for performance?

Source: Bobbi Brown Art

To Do #5

Review your QRUR and Meaningful Use Submission• Talk with the individuals that

completed the work in PQRS and MU.

• What can you learn?

• What applies to MIPS?

To Do #6

QRUR Report

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/QRUR-Quick-Ref-Guide.pdf

Evaluate readiness/ExecuteYou now have a plan and can do a quick check on reality based on your practice. You know where you have penalties and where you need to change.

You need data, best practices and an adoption methodology to succeed.

Source: Health Catalyst

To Do #6

Questions

Bobbi BrownBobbi.brown@healthcatalyst.com

Bryan T. Oshiro, M.D.Chief Medical Officerbryanoshiro@healthcatalyst.com

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