hfma texas gulf coast chapter...macra • proposed rule published april 27, 2016 • cms solicited...

HFMA Texas Gulf Coast ChapterFederal & State Legislative Update:

MACRA!

Freddy WarnerVice President, Government Affairs

Memorial Hermann Health System

October 21, 2016

Presentation Outline

• Federal Healthcare Legislative Update:

– Focus on MACRA

– Lame Duck Congress

• Current Continuing Resolution Expires (12/09/16)

• Potential Impact of 2016 Election

Cycle

– Federal

– State

MACRA Disclaimer…

What is MACRA?

• The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

• President Obama signed into law April 16,

2015

• Permanently repeals Sustainable Growth Rate (SGR) formula for determining providers’

Medicare payments

• Creates a new framework for rewarding providers for providing better care, rather

than more care

• Combines existing quality reporting

programs into a new system

What is MACRA?

• CMS mandated a transition from “volume” to

“value” in 2015, directing that 30% of

traditional, fee-for-service, Medicare

payments must be tied to quality or value

through “alternative payment models,” such

as Accountable Care Organizations (ACOs) by

2016.

• CMS further mandated that 50% of

traditional, fee-for-service, Medicare

payments must be tied to these alternative

payment models by 2018.

What is MACRA?

• HHS mandated that 85% of traditional, fee-

for-service, Medicare payments must be tied

to quality or value by 2016, and that 90%

must be tied to quality or value by 2018,

through programs such as the Hospital Value-

Based Purchasing (VBP) and Hospital

Readmissions Reduction programs.

What is MACRA?

• MACRA contains Physician Fee Schedule

(PFS) updates

• Creates a new, Merit-Based Incentive

Payment System (MIPS)

• Creates a new, Technical Advisory Committee

for evaluating Physician-Focused Payment

Model (PFPM) proposals

• Creates incentive payments for participation

in Alternative Payment Models (APMs)

What is MACRA?

• Locks Medicare Part B reimbursement rates at near-zero

growth

– 2016-2019: Physician fees increase by 0.5% per year

– 2020-2025: Goal is to have physicians compensated for

value, rather than volume, utilizing “quality payment

programs”

– 2026 forward: 0.25% or 0.75% annual increase, depending

on track

• Establishes two replacement tracks for value-based

payments:

– Streamlines multiple quality programs under a new Merit-Based Incentive Payment System (MIPS)

– Provides bonus payments for participation in eligible

Advanced Alternative Payment Models (APMs)

MACRA

• Proposed Rule published April 27, 2016

• CMS solicited public comment through June 27,

2016

• Providers and physicians sought considerable

congressional input, CMS advocacy

• Final Rule issued October 14, 2016

• Program implementation date: January 1, 2019

• Proposed rule outlines reporting requirements for

Merit-Based Incentive Payment System (MIPS)

track

• Proposed rule lists payment models qualifying for

Alternative Payment Model (APM) track

MACRA Timeline

Measurement Period Begins

1/1/17

MACRA Law

Passed4/16/15

MACRA Proposed

Rule4/27/16

2016 2017 2018 2019

?

MACRA Final Rule10/14/16

Payment Adjustment

Begins 1/1/19

20202 year lag

2 year lag

• Physicians

• Physician Assistants (PAs)

• Nurse Practitioners (NPs)

• Clinical Nurse Specialists (CNSs)

• Certified Registered Nurse Anesthetists

(CRNAs)

• Possibly other clinician categories after

2021

MACRA: Who is Affected?

Provider Participation under MACRA

Merit-Based Incentive Payment

System

advanced Alternative

Payment Model

Who Chooses Which Track You Are In?

Merit-Based Incentive Payment

System

advanced Alternative

Payment Model

NPI + TIN

Answer:Your CMS

Payments Make the Choice for

You

NPI + TIN*

(*Qualified Provider)

Payment Differences between MIPS & aAPM

Note: MIPS “x” can scale up to 3, plus $500m will go to top decile performers

(X3 possible)

MACRA: MIPS

• Merit-Based Incentive Payment System (MIPS) changes how Medicare links performance to payment

• Streamlines current quality and value incentive programs for Medicare physicians and practitioners into a single system:

– Physician Quality Reporting Program (PQRS)

– Value-Based Payment Modifier (VM)

– Medicare Electronic Health Record (HER)

• Rolls existing quality programs into a single, budget-neutral, pay-for-performance program

• Evaluates clinicians across 4 categories, and provides a single score

• CMS evaluates clinicians’ scores to determine if they receive a fee increase, reduction, or have no change in reimbursement

• MIPS reduces number of measures physicians must report

MACRA: 4 MIPS Categories

• QUALITY (Measures):

– Majority of Quality Measures come from CMS Physician Quality Reporting System (PQRS)

– Clinicians choose to report 6 quality measures

– Each November, CMS will publish new list of quality measures for the following performance year• May be new, revised, or continued

– CMS will consider new measures based upon CMS Quality Development Plan• Population

• Inpatient facility measures

– CMS will provide feedback (report) to each MIPS-eligible clinician beginning July 2017

– Accounts for 50% of a clinician’s score in Year 1 (2019)


– Accounts for 30% of a clinician’s score in Year 3 and beyond (beginning in 2021)


• RESOURCE USE (COST) Measures:– CMS bases scores on Medicare claims; therefore, clinicians

have no reporting requirement– Measures include:

• Medicare Spend per Beneficiary (MSPB)

• Total Per Capita Costs

• Episode-based payment (virtual bundles)

– CMS established:• 46 distinct care episode groups

• Patient condition groups and codes

• Patient relationship categories and codes (attribution)

– Considers more than 40 episodic-specific measures



– Accounts for 30% of a clinician’s score in Year 3 and beyond (beginning in 2021)

– Beginning July 2018, CMS will provide reports to each participating provider, detailing items and services furnished to each patient by other providers.


• CLINICAL PRACTICE IMPROVEMENT ACTIVITIES (CPIAs): – Rewards physicians for clinical practice improvement

activities: Exs.• Care Coordination

• Beneficiary Engagement

• Patient Safety

– Clinicians may select from a list of 90 proposed activities; which will be grouped into “high” and “medium” categories

– Clinicians qualifying for Alternative payment Models (APMs) will automatically receive 50% of eligible points

– Qualifying Certified Medical Homes will receive 100% of eligible points

– Accounts for 15% of a clinician’s score beginning Year 1 (2019) and beyond

– Qualifying clinicians may be required to select different Clinical Practice Improvement Activities each year to demonstrate improvement


• ADVANCING CARE INFORMATION (New name for

“Meaningful Use”):

– Accounts for 25% of a clinician’s score beginning Year 1

(2019) and beyond

– Clinicians will report customizable measures,

demonstrating how they use Electronic Health Records

(EHR) in their practice

– No quarterly reporting

– Note that the score is calculated by base scores for 50

points, and a performance score for 80 points, with a cap

of 100 points

– If a clinician fails the Protecting Patient Health Information measure, the clinician receives a score of

ZERO for the entire category

MIPS Quality & Practice Measurements

(~300 Measures)

(~90 Activities)(Measured by

CMS)

(New name for Meaningful Use)Physician performance will be

published on the Physician Compare website on a 1-to-100

scale

MIPS Data Reporting

MIPS Data Reporting

Qualified Clinical Data Registry

(QCDR)

MACRA: MIPS

• Physicians will be scored on 4 weighted performance categories, and

payment adjustments allocated accordingly:

– Quality (50% in Year 1)

– EHR Use (25% in Year 1)

– Clinical Practice Improvement (15% in Year 1)

– Cost/Resource Use (10% in Year 1)

• MIPS allows flexibility for physicians to select measures to report, based on

the nature of their practice, and relevancy of the measures to their practice

• CMS will use 2017 as the performance period to determine a physician’s

payment track, and potential payment adjustment under the MIPS track

• Reporting and Data Collection occur in 2017, 2018

• MIPS adjustments become effective in 2019

• For Years 2019 through 2024, and additional payment adjustment will be given

to the highest MIPS performers for exceptional performance.

• Upward and downward maximum payment adjustments range:

– +/-4% (2019)

– +/-5% (2020)

– +/-7% (2021)

– +/-9% (2022)

Maximum Incentives for High MIPS Performers

MACRA: APMs

• Medicare Advanced Alternative Payment Models (APMs) are new Medicare payment methodologies incentivizing quality and value

• A Medicare Alternative Payment Model (APM) can be:– A CMS Center for Medicare & Medicaid Innovation

(CMMI) model under Section 1115A of the Social Security Act, established within the Affordable Care Act.

– Medicare Shared Savings Program (MSSP)

– Health Care Quality Demonstration Program project

– Any demonstration required by Federal law.

MACRA: APMs

• Advanced Alternative Payment Models (APMs)

are new Medicare payment methodologies

incentivizing quality and value

• APMs require significant share of revenue in

contracts where both parties have risk,

quality measurements, and EHR requirements

• APM track participants would be exempt from

MIPS payment adjustments, and qualify for a

5% Medicare incentive payment in 2019-2024

MACRA: APMs

• Eligible APMs are those meeting the following criteria:

– Base payment on quality measures (comparable to

those in MIPS)

– Require use of certified EHR

– Bear more than nominal financial risk, or

– Are Medical Home Models, expanded under Center for

Medicare and Medicaid Innovation (CMMI) authority

• APM-eligible payment models include:

– Medicare Shared Savings Program (MSSP) Tracks 2, 3

– Next Generation ACO Model

– Comprehensive End Stage Renal Disease Care Model

– Comprehensive Primary Care Plus (CPC+)

– Health Care Quality Demonstration Program

Alternative Payment Models (APM):

Eligible Payments

• Beginning in 2019, participants must have at least 25% of

their Medicare payments linked to performance

• Beginning in 2022, participants must have at least 75% of

their Medicare payments linked to performance

• CMS exempts Advanced APM providers from MIPS

adjustments; They receive a lump sum incentive payment instead, equal to 5% of the provider’s prior year’s

estimated aggregate expenditures under the fee schedule

• Physicians participating in the Advanced APM program

will receive an annual, across-the-board fee increase of

0.75% in 2026, which is higher than the 0.25% annual

increase scheduled for Merit-Based Incentive Payment

System (MIPS) participants

Alternative Payment Model (APM):

Additional Qualifying Models

• Next Generation ACO Model (Next Gen ACO)

• Pioneer ACO

• Medicare Shared Savings Program (Tracks 2 and 3)

• Comprehensive Primary Care Plus (CPC+)

• Comprehensive End-Stage Renal Disease Care Model

– Large Dialysis Organization (LDO) Arrangement

• Oncology Care Model (Double-Sided Risk Arrangement)

Advanced Alternative Payment Models: Which Ones Qualify?

*

\

{aAPM must} “bear more than a

nominal amount of risk for monetary

loses”

Payment Thresholds to receive aAPM Incentives

Next Generation ACO Model

(Next Gen ACO)

• Highest risk scenario

• CMS (prospectively) establishes a benchmark for how much an ACO should spend; considers:– Historical information

– Regional trends

– ACO population’s risk scores

• Evaluates ACO’s ability to assume almost all financial risk, by prescribing 2 risk arrangements:– A: ACO agrees to an 80% risk-sharing rate for years 1

through 3; and 85% for years 4 and 5

– B: ACO agrees to a 100% risk-Sharing rate

• Performance relative to the 2 models determine amount of savings or loss accruing to the Next Generation ACO

Next Generation ACO Model: Four

Payment Methodology Options

• Nominal Fee-for-Service (FFS) Payment:

– CMS reimburses for services through normal FFS

channels and at standard FFS payment levels

• Nominal Fee-for-Service (FFS) Payment +

Monthly Infrastructure Payment:

– CMS reimburses for services at a normal FFS rate,

PLUS and additional, per beneficiary, per month

payment to incentivize investment in infrastructure,

and to support ACO activities

– CMS infrastructure payment cannot exceed $6 per

beneficiary, per month



• Population-Based Payments (PBPs):

– A PBP is an estimate of the aggregate amount by

which a fee-for-service (FFS) payment will be

reduced for Medicare Parts A and B services

rendered by Next Generation ACO participants

agreeing to receive reduced FFS payments for vare

provided to aligned beneficiaries during the

subsequent performance year.



• All-Inclusive Population-Based Payments

(AIPBPs):

– Starting in 2017, AIPBPs will be determined by

estimating total annual expenditures for care

provided to beneficiaries by Next Generation ACO

participants who agree to participate in the AIPBP

program.

– CMS will pay the projected amount to the Next Gen

ACO in a per-beneficiary, per-month (PBPM)

payment

Oncology Care Model (Double-Sided Risk Arrangement)

• OCM participants must provide enhanced services: Exs.– Patient Navigation

– Care Plan – Containing 13 components of the Institute of Medicine Care management Plan contained in the Institute of

Medicine Report “Delivering High-Quality Cancer Care: Charting a

New Course for a System in Crisis”

– Patient Access - 24-Hour-a-Day, 7-Day-per-Week access to

appropriate clinical staff, with real-time access to the treating

medical practice’s medical records

– Treatment with therapies consistent with nationally-recognized,

clinical guidelines

Oncology Care Model (Double-Sided Risk Arrangement)

• OCM participants receive normal Medicare fee-for-

service payments throughout implementation of the

OCM model

• OCM fee-for-service payments utilize a two-part

payment methodology for participating oncology

practices

• The goal is to create incentives for these oncology

practices to improve the quality of care, and to provide

enhanced services for their patients undergoing

chemotherapy following a cancer diagnosis:

– Monthly, Enhanced Oncology Services Payment of $160 per-

patient, for delivery of OCM enhances services; and

– Performance-Based Payments for OCM episodes of care

MACRA: Technical Committee to

Evaluating Physician-Focused Payment

Model (PFPM) Proposals

• MACRA directs the establishment of a Technical Advisory Committee for assessing Physician-Focused Payment Models (PFPMs).

• MACRA does not define PFPM

• MACRA delegates to the HHS Secretary with establishing criteria for PFPMs, including models for physicians, which may be employed by the Technical Advisory Committee in making recommendations and rendering comments to CMS

• CMS must review recommendations from the technical advisory committee, and may choose to test modelsemanating from the committee

• CMS has no obligation to test or implement any recommendations made by the committee

UPDATE: September 2016

MACRA “Pick Your Pace” Options for 2017

Four Participation Options for 2017

Andy Slavitt

Acting CMS Administrator

1. Report any data to avoid a penalty

2. Submit data for less than a full yearto qualify for a small payment (i.e., tostart after Jan 1)

3. Submit MIPS data for entire year to potentially earn a higher payment

4. Participate in an advanced APM (aAPM)

2016 Election Cycle

• Presidential Election

– Trump v. Clinton

• US Senate (54/46 Republican Majority)

– Republicans defending 2/3 of seats

• US House (247/188 Republican Majority)

• Texas Legislature

– Texas Senate (20/11 Republican Majority)

– Texas House (99/51 Republican Majority)

2016 Elections: Federal

Impacts

• Trump nomination likely jeopardizes down-ballot Republicans

– Republicans lose Senate

– Republicans lose House seats; maintain majority

• Executive and Legislative branches likely remain split

• Reality of Obamacare “repeal and replace” rhetoric

– It’s a math problem…• Supreme Court Nominee, Succeeding Justice

Scalia: Senate Minority Leader Reid held up allbills authored by Republicans in contested elections

POLITICAL & LEGISLATIVE

DYNAMICS

• 2016 ELECTION CYCLE: Federal - ACA/Obamacare

remains deeply partisan, divisive issue at all levels of

government

– NATIONAL/Federal Election Impacts

• Presidential Election – New Administration is a

certainty

• The ACA is here to stay

• Impact of Supreme Court Justice Scalia’s death?

• US Senate

– Republicans defending twice as many seats: Can

Democrats take back Senate, capitalizing on large

presidential election turnout?

– Impossible for either party to reach 60-vote filibuster-

proof threshold

• US House

– Republicans should maintain House Majority

– Key House Committees (Ways & Means; Energy &

Commerce) will offer Obamacare alternatives

Federal Legislative Environment

• Continuing Resolution expires December 9, 2016

• No must-pass healthcare legislation in 2016

• Results of 2016 election will impact Lame Duck

– If Clinton wins, and Republicans lose Senate

– If Trump wins, and Republicans maintain Senate, House

• House v. Senate

– Schedule of House Ways and Means Hospital Proposals

• 1st Package: ASAP - “bipartisan, non-controversial

items”

• 2nd Package: Post-Acute, SNP, DSH, physician-owned

• 3rd Package: Political red meat: ACA-related proposals

– Senate Finance Committee taking different approaches

• Ex. No support for House Post-Acute, SNP proposals

• HOPD fixes

• MACRA

POLITICAL & LEGISLATIVE

DYNAMICS

• 2016 ELECTION CYCLE: STATE – 2017

Legislature will be more ideologically strident

than previous; healthcare will not be a priority

• No appetite for Medicaid/Coverageexpansion

• Low oil prices will impact biennial budget-

writing cycle: Exs., No new spending; Only

fund priorities, etc.)

• State Senate – Republicans will maintain 20-

11 Majority

• State House – Republicans should increase

99-51 Majority

State Dynamics: Major Issues

• Energy Tax Revenues: Impact on Rainy Day Fund

• HHS spending outpacing all other

• Revisiting Public Education Financing

• Article II v. Article III spending levels

• Refusal to accept Medicaid expansion funding

• Medicaid funding shortfall for balance of current

biennium

• $800M needed for Texas state psychiatric hospitals

• Child Protective Services (CPS)

• Legislature must direct HHSC to seek 1115 Waiver

continuation

Abbott, Patrick and Straus Joint Letter

to State Agencies: Cut budgets 4%

• Joint letter follows Speaker Straus’ April 19, 2016 letter toHouse Members - reinforces issues lawmakers must consider incrafting the 2018-19 biennial budget:

• LBB letter asking state agencies to prepare LAR’s with 10%budget cuts

– Impact of falling oil prices, slowing tax revenuestreams, on the Texas economy

– State foster care system is in crisis: Courts mayrequire the 2017 Texas Legislature to address

– Texas Supreme Court ruling in school financelawsuit

– Funding shortfall in Teacher Retirement System(TRS) health care program

– Rehabilitate aging Texas’ state psychiatric hospitals

QUESTIONS

FREDDY WARNERVice President

Government Affairs

MEMORIAL HERMANN HEALTH SYSTEM

[email protected]

(713)392-9750

mailto:[email protected]

hfma texas gulf coast chapter...macra • proposed rule published april 27, 2016 • cms solicited...

Documents