macra for critical access hospitals...(macra) was approved on a bipartisan basis by congress (house...
TRANSCRIPT
MACRA for Critical Access Hospitals
Tuesday, July 26, 2016
Webinar
MACRA presenters
8Carol Wagner, Sr. Vice President,
Patient Safety
Claudia Sanders, Sr. Vice President,Policy Development
Harold D. Miller, President & CEOCHQPR
Andrew Busz, Policy Director,Finance
Based on what you know about MACRA so far, what is your impression of the likely impacts of MACRA on your organization?
MACRA
Explanation and Implications
Harold D. Miller, President & CEO – Center for Healthcare Quality
and Payment Reform (CHQPR)
What is MACRA?
How Will It Affect Rural Hospitals?
Harold D. MillerPresident and CEO
Center for Healthcare Quality and Payment Reform
www.CHQPR.org
2© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What is MACRA and
Who Should Care About It?• What is MACRA?
– The Medicare Access and CHIP Reauthorization Act of 2015(MACRA) was approved on a bipartisan basis by Congress (House vote 392-37, Senate vote 92-8) and signed into law by the President on April 16, 2015
3© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What is MACRA and
Who Should Care About It?• What is MACRA?
– The Medicare Access and CHIP Reauthorization Act of 2015(MACRA) was approved on a bipartisan basis by Congress (House vote 392-37, Senate vote 92-8) and signed into law by the President on April 16, 2015
• Who does it directly affect?– Physicians and other clinicians who are paid under the Medicare
Physician Fee Schedule (Part B payments)
– Hospitals and medical groups that bill for physician services under the Medicare Fee Schedule (including CAH Method II payments)
4© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What is MACRA and
Who Should Care About It?• What is MACRA?
– The Medicare Access and CHIP Reauthorization Act of 2015(MACRA) was approved on a bipartisan basis by Congress (House vote 392-37, Senate vote 92-8) and signed into law by the President on April 16, 2015
• Who does it directly affect?– Physicians and other clinicians who are paid under the Medicare
Physician Fee Schedule (Part B payments)
– Hospitals and medical groups that bill for physician services under the Medicare Fee Schedule (including CAH Method II payments)
– Does NOT apply to physicians/clinicians in Rural Health Clinics who do not bill for services under the Medicare Physician Fee Schedule or physicians whose Part B billings fall below a minimum threshold
5© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What is MACRA and
Who Should Care About It?• What is MACRA?
– The Medicare Access and CHIP Reauthorization Act of 2015(MACRA) was approved on a bipartisan basis by Congress (House vote 392-37, Senate vote 92-8) and signed into law by the President on April 16, 2015
• Who does it directly affect?– Physicians and other clinicians who are paid under the Medicare
Physician Fee Schedule (Part B payments)
– Hospitals and medical groups that bill for physician services under the Medicare Fee Schedule (including CAH Method II payments)
– Does NOT apply to physicians/clinicians in Rural Health Clinics who do not bill for services under the Medicare Physician Fee Schedule or physicians whose Part B billings fall below a minimum threshold
• Who can it indirectly affect?– Hospitals, skilled nursing facilities, or other healthcare providers that
deliver services to Medicare beneficiaries who are treated by a physician paid through the Medicare Physician Fee Schedule
6© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Topics Covered
• What the law (MACRA) says
• What the proposed regulations issued by CMS say (and where they might change)
– Proposed regulations were issued in April
– Comments closed on June 27, 2016
– Final regulations required by November 1, 2016
• The likely and potential implications for hospitals
7© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Physicians Faced Significant Cuts
Under “Sustainable Growth Rate”
FFS
$
FFS FFS FFS FFS FFS FFS FFSFFS FFS FFS
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
SGRCut
-21%
Potential for Additional SGR Cuts in Future
8© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bipartisan Action to Repeal SGR
FFS
$
FFS FFS FFS FFS FFS FFS FFSFFS FFS FFS
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
SGRCut
-21%
Medicare Access and CHIP Reauthorization Act of 2015(MACRA)
• Repealed Sustainable Growth Rate formula (SGR)
9© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bipartisan Action to Repeal SGR
FFS
$
FFS FFS FFS FFS FFS FFS FFSFFS FFS FFS
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
SGRCut
-21%
• Repealed Sustainable Growth Rate formula (SGR)
• Stabilized physician fee levels for next decade
• Required new forms of “value-based payment” in Medicare
Medicare Access and CHIP Reauthorization Act of 2015(MACRA)
10© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bipartisan Action to Repeal SGR
FFS
$
FFS FFS FFS FFS FFS FFS FFSFFS FFS FFS
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
SGRCut
-21%
• Repealed Sustainable Growth Rate formula (SGR)
• Stabilized physician fee levels for next decade
• Required new forms of “value-based payment” in Medicare
• Replaced existing MU, PQRS, and VM programswith a new “Merit-Based Incentive Payment System” (MIPS)
• Encouraged development and use of “Alternative Payment Models” (APMs)
Medicare Access and CHIP Reauthorization Act of 2015(MACRA)
11© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bipartisan Action to Repeal SGR
FFS
$
FFS FFS FFS FFS FFS FFS FFSFFS FFS FFS
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
SGRCut
-21%
• Repealed Sustainable Growth Rate formula (SGR)
• Stabilized physician fee levels for next decade
• Required new forms of “value-based payment” in Medicare
• Replaced existing MU, PQRS, and VM programswith a new “Merit-Based Incentive Payment System” (MIPS)
• Encouraged development and use of “Alternative Payment Models” (APMs)
• Required new ways to code physician services
• Many other changes
Medicare Access and CHIP Reauthorization Act of 2015(MACRA)
12© Center for Healthcare Quality and Payment Reform www.CHQPR.org
MACRA Repealed SGR &
Stabilized Payment Rates
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS FFS FFS FFSFFS FFS FFS
0.25%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
Part 1: Stable Payments
13© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Updates Will Be Very Small
for the Next Decade
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS FFS FFS FFSFFS FFS FFS
0.25%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
Fees 2.3% Higher in 2025 Than 2014
14© Center for Healthcare Quality and Payment Reform www.CHQPR.org
MACRA Also Requires
“Value-Based Payment”
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS FFS FFS FFSFFS FFS FFS
0.25%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
Part 1: Stable Payments
Part 2: Value-Based Pmt
Value-Based Payment
15© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Default: Merit-Based Incentive
Payment System (MIPS)
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS FFS FFS FFSFFS FFS FFS
0.25%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
-4%
+4x%
-5%
+5x%
-9%
+9x%
-9%
+9x%
-9%
+9x%
-7%
+7x%
-9%
+9x%
-9%
+9x%+10% +10% +10% +10% +10% +10%
Part 1: Stable Payments
Part 2: Value-Based Pmt
a. MIPS
16© Center for Healthcare Quality and Payment Reform www.CHQPR.org
MIPS Bonuses & Penalties Are
Determined Annually
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS FFS FFS FFSFFS FFS FFS
0.25%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
+4x%
-5%
+2%-1%
+3%
+10%
Part 1: Stable Payments
Part 2: Value-Based Pmt
a. MIPS
Whether a physician gets a bonus/penalty,and the amount of that bonus/penalty,
can vary from year to year
-9%
17© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Congress Encouraged Use of
“Alternative Payment Models”
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS
FFS
FFS FFS
FFS
FFS FFS
0.75%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
+5% +5% +5% +5% +5%
25%APM
25%APM
50%APM
50%APM
75%APM
75%APM
75%APM
75%APM
Part 1: Stable Payments
Part 2: Value-Based Pmt
a. MIPS
or
b. APMs
+5%0.25%
18© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Choice of Two Options
For Payments in Future Years
19© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Physicians Are Exempt from MIPS
Whenever They Meet APM Criteria
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS FFS
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
-4%
+4x%
-5%
+5x%
-7%
+7x%
+10% +10% +10%
FFS
FFS FFS FFS FFS
0.75%+5% +5% +5%
50%APM
75%APM
75%APM
75%APM
75%APM
MIPS APM
20© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Physician Returns to MIPS
If APM Eligibility Is No Longer Met
FFS
$
0.25%0.5%
FFS
0.5%
FFS
0.5%
FFS
0.5%
FFS
FFSFFS
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FFS
Chart Not Drawn to Scale
+5% +5% +5%
25%APM
25%APM
50%APM
50%APM
+5%
FFS FFS FFS FFS
0.25%
-9%
+9x%
-9%
+9x%
-9%
+9x%
-9%
+9x%
+10% +10%
APM MIPS
How MIPS Will Work
22© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Value-Based Payment for
Physicians Isn’t New in Medicare
FFS
$
-4.5%
+x%
FFS
-6%
+x%
FFS
-9%
+x%
FFS
-10%
+x%
2015 2016 2017 2018
2017Meaningful Use: 3% Penalties
Physician Quality Reporting (PQRS): 2% Penalties
Value-Based Modifier: 4% Penalties or Bonuses
TOTAL Potential Penalties: 9% Penalty
2018Meaningful Use: 4% Penalties
Physician Quality Reporting (PQRS): 2% Penalties
Value-Based Modifier: 4+% Penalties or Bonuses
TOTAL Potential Penalties: 10+% Penalty
23© Center for Healthcare Quality and Payment Reform www.CHQPR.org
But Value Modifier Will First Hit
Small Practices (<10) Next Year
FFS
$
-4.5%
+x%
FFS
-6%
+x%
FFS
-9%
+x%
FFS
-10%
+x%
2015 2016 2017 2018
2015 2016 2017 2018
100+Docs
100+Docs
10-99Docs
100+Docs
10-99Docs
1-9Docs
100+Docs
10-99Docs
1-9Docs
Chart Not Drawn to Scale
2017Meaningful Use: 3% Penalties
Physician Quality Reporting (PQRS): 2% Penalties
Value-Based Modifier: 4% Penalties or Bonuses
TOTAL Potential Penalties: 9% Penalty
2018Meaningful Use: 4% Penalties
Physician Quality Reporting (PQRS): 2% Penalties
Value-Based Modifier: 4+% Penalties or Bonuses
TOTAL Potential Penalties: 10+% Penalty
Small
Practices
Start 2017
NPs,PAs
24© Center for Healthcare Quality and Payment Reform www.CHQPR.org
3 Existing P4P Programs
Consolidated into 1 MIPS Program
FFS
$
-4.5%
+x%
FFS
-6%
+x%
FFS
-9%
+x%
FFS
-10%
+x%
FFS
-4%
+4x%
FFS
-5%
+5x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-7%
+7x%
FFS
-9%
+9x%
FFS
-9%
+9x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10% +10% +10% +10% +10% +10%
TODAY• Meaningful Use (MU)
• Quality Reporting (PQRS)
• Value Modifier (VM)
MIPS• “Advancing Care Information” (EHR Use)
• Quality Performance Program
• Resource Use
• Clinical Practice Improvement
25© Center for Healthcare Quality and Payment Reform www.CHQPR.org
MIPS Penalties Lower and
Bonuses Higher Than Current
$
FFS
-10%
+x%
FFS
-4%
+4x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10%
TODAY• Meaningful Use (MU)
• Quality Reporting (PQRS)
• Value Modifier (VM)
MIPS• “Advancing Care Information” (EHR Use)
• Quality Performance Program
• Resource Use
• Clinical Practice Improvement
MIPSMU+
PQRS+
VM
26© Center for Healthcare Quality and Payment Reform www.CHQPR.org
10% Bonuses
Are Capped and Temporary
$
FFS
-4%
+4x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10%
• Only for practices with very high scores
• Limited to $500 million per year
• Only available from 2019 to 2024
27© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Does “+4x%” Mean?
$
FFS
-4%
+4x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10%
28© Center for Healthcare Quality and Payment Reform www.CHQPR.org
2019 Bonuses Could Range
Between 0% and 12% (4%x3)
$
FFS
-4%
+4x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10%+12% (4% x3)
<1% (4% x 0)
29© Center for Healthcare Quality and Payment Reform www.CHQPR.org
2022 Bonuses Could Range
Between 0% and 27% (9%x3)
$
FFS
-4%
+4x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10%+12% (4% x3)
<1% (4% x 0)
FFS
-9%
+9x%
+10%
+27% (9% x3)
<1% (4% x 0)
30© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bonuses and Penalties
Must Be Budget Neutral
• If many practices receive large penalties, then more money is available for bonuses
• If few practices qualify for bonuses, then the (large amount of) bonus money is divided among that small number of practices, generating large bonuses per practice. MACRA limits the bonus to 3 times the statutory amount.
31© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bonuses and Penalties
Must Be Budget Neutral
• If many practices receive large penalties, then more money is available for bonuses
• If few practices qualify for bonuses, then the (large amount of) bonus money is divided among that small number of practices, generating large bonuses per practice. MACRA limits the bonus to 3 times the statutory amount.
• If few practices receive large penalties, then little money is available for bonuses
• If many practices qualify for bonuses, then the (small amount of) bonus money is divided among that large number of practices, generating small bonuses per practice.
32© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bonuses and Penalties
Must Be Budget Neutral
• If many practices receive large penalties, then more money is available for bonuses
• If few practices qualify for bonuses, then the (large amount of) bonus money is divided among that small number of practices, generating large bonuses per practice. MACRA limits the bonus to 3 times the statutory amount.
• If few practices receive large penalties, then little money is available for bonuses
• If many practices qualify for bonuses, then the (small amount of) bonus money is divided among that large number of practices, generating small bonuses per practice.
• The size of the rewards to high performing physician practices depends not on good they are, but on how many poor quality practices there are
33© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Payment Adjustments Under
PQRS & VM for 2016No Quality
Report Low Quality Average Quality High Quality
Low Cost
Average
Cost
High Cost
No Quality
Report
34© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Many (Small) Physician Practices
Were Penalized for Not ReportingNo Quality
Report Low Quality Average Quality High Quality
Low Cost
Average
Cost
High Cost
No Quality
Report
-2%
(5,418)
35© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Most Physicians Who Did Report
Were “Average” on Cost & QualityNo Quality
Report Low Quality Average Quality High Quality
Low Cost0%
(6)
Average
Cost
0%
(7,351)
High Cost0%
(1)
No Quality
Report
-2%
(5,418)
36© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Over 800 Practices Were Eligible
for PenaltiesNo Quality
Report Low Quality Average Quality High Quality
Low Cost
Average
Cost
-1%*
(644)
0%
(7,351)
High Cost-2%*
(39)
-1%*
(226)
0%
(1)
No Quality
Report
-2%
(5,418)
*Penalties did not apply to 10-99 Clinician Practices in 2016
37© Center for Healthcare Quality and Payment Reform www.CHQPR.org
A Small Number of Practices
Received Very Large BonusesNo Quality
Report Low Quality Average Quality High Quality
Low Cost0%
(6)
2x% = 31.84%
(38)
1x% = 15.92%
(35)
3x% = 47.76%
(0)
2x% = 31.84%
(0)
Average
Cost
-1%*
(644)
0%
(7,351)
2x% = 31.84%
(20)
1x% = 15.92%
(35)
High Cost-2%*
(39)
-1%*
(226)
0%
(1)
No Quality
Report
-2%
(5,418)
*Penalties did not apply to 10-99 Clinician Practices in 2016
38© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Bonuses Were High Because
Many Practices Received PenaltiesNo Quality
Report Low Quality Average Quality High Quality
Low Cost
128Large
PerformanceBonuses
Average
Cost
High Cost
909Performance
Penalties
No Quality
Report
5,418Non-Reporting
Penalties
*Penalties did not apply to 10-99 Clinician Practices in 2016
39© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Most Practices Received
Neither Bonus Nor PenaltyNo Quality
Report Low Quality Average Quality High Quality
Low Cost
128Performance
Bonuses
Average
Cost
7,358No Changein Payment
High Cost
909Performance
Penalties
No Quality
Report
5,418Non-Reporting
Penalties
*Penalties did not apply to 10-99 Clinician Practices in 2016
40© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Size of Penalties is More
Predictable Than Size of Bonuses
$
FFS
-4%
+4x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10%Summary:
• Very Good Performance: 10-22% increases
• Good Performance: 0-12% increases
• Poor Performance: 0-4% cuts in pay
41© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Current VBP Programs: All Part B
Providers Required to Participate
FFS
$
-4.5%
+x%
FFS
-6%
+x%
FFS
-9%
+x%
FFS
-10%
+x%
2015 2016 2017 2018
2015 2016 2017 2018Chart Not Drawn to Scale
2015 2016 2017 2018
100+Docs
100+Docs
10-99Docs
100+Docs
10-99Docs
1-9Docs
100+Docs
10-99Docs
1-9Docs
NPs,PAs
42© Center for Healthcare Quality and Payment Reform www.CHQPR.org
MIPS: Exemptions Based on
Number of Patients & Revenues
FFS
$
-4.5%
+x%
FFS
-6%
+x%
FFS
-9%
+x%
FFS
-10%
+x%
FFS
-4%
+4x%
FFS
-5%
+5x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-7%
+7x%
FFS
-9%
+9x%
FFS
-9%
+9x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10% +10% +10% +10% +10% +10%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
>$x
&/or>
y pts
>$x
&/or >
y pts
>$x
&/or>
y pts
>$x
&/or>
y pts
>$x
&/or >
y pts
>$x
&/or>
y pts
>$x
&/or>
y pts
>$x
&/or >
y pts
Low Volume Threshold & Other Exemptions
Chart Not Drawn to Scale
100+Docs
100+Docs
10-99Docs
100+Docs
10-99Docs
1-9Docs
100+Docs
10-99Docs
1-9Docs
NPs,PAs
43© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Exemptions from
MIPS Payment Adjustments
44© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Exemptions from
MIPS Payment Adjustments
What MACRA Says
• Below low volume threshold:– # of beneficiaries treated
– # of services provided
– $ amount billed
45© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Exemptions from
MIPS Payment Adjustments
What MACRA Says
• Below low volume threshold:– # of beneficiaries treated
– # of services provided
– $ amount billed
• Providers with minimumlevel of participation in Alternative Payment Models
– 25%/50%/75% in APMs
– 20%/45%/70% in APMs
– # of patients in APMs
46© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Exemptions from
MIPS Payment Adjustments
What MACRA Says
• Below low volume threshold:– # of beneficiaries treated
– # of services provided
– $ amount billed
• Providers with minimumlevel of participation in Alternative Payment Models
– 25%/50%/75% in APMs
– 20%/45%/70% in APMs
– # of patients in APMs
• First year of MedicarePart B participation
47© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Exemptions from
MIPS Payment Adjustments
What MACRA Says
• Below low volume threshold:– # of beneficiaries treated
– # of services provided
– $ amount billed
• Providers with minimumlevel of participation in Alternative Payment Models
– 25%/50%/75% in APMs
– 20%/45%/70% in APMs
– # of patients in APMs
• First year of MedicarePart B participation
• 2019-2020: Other non-physician providers
– PT/OT/Speech pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dieticians
48© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Exemptions from
MIPS Payment Adjustments
What MACRA Says
• Below low volume threshold:– # of beneficiaries treated
– # of services provided
– $ amount billed
• Providers with minimumlevel of participation in Alternative Payment Models
– 25%/50%/75% in APMs
– 20%/45%/70% in APMs
– # of patients in APMs
• First year of MedicarePart B participation
• 2019-2020: Other non-physician providers
– PT/OT/Speech pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dieticians
What Proposed Regs Say
• Low volume threshold:– ≤100 Medicare patients/year
– $10,000 Medicare payments
• Qualified APM Participant (QPs):providers with minimumlevel of participation in Alternative Payment Models
– 25%/50%/75% in APMs
– 20%/35%/50% of patients in APMs
• Partially-Qualified APM Participant (Partial QPs):
– 20%/40%/50% in APMs
– 10%/25%/35% of patients in APMs
• First year of MedicarePart B participation
49© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Pressure to Increase Thresholds
for Exemption
What MACRA Says
• Below low volume threshold:– # of beneficiaries treated
– # of services provided
– $ amount billed
• Providers with minimumlevel of participation in Alternative Payment Models
– 25%/50%/75% in APMs
– 20%/45%/70% in APMs
– # of patients in APMs
• First year of MedicarePart B participation
• 2019-2020: Other non-physician providers
– PT/OT/Speech pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dieticians
What Proposed Regs Say
• Low volume threshold:– ≤100 Medicare patients/year
– $10,000 Medicare payments
Pressure to increase thresholds
• Qualified APM Participant (QPs):providers with minimumlevel of participation in Alternative Payment Models
– 25%/50%/75% in APMs
– 20%/35%/50% of patients in APMs
• Partially-Qualified APM Participant (Partial QPs):
– 20%/40%/50% in APMs
– 10%/25%/35% of patients in APMs
• First year of MedicarePart B participation
50© Center for Healthcare Quality and Payment Reform www.CHQPR.org
CMS Bases Penalties/Bonuses…
FFS
$
-4.5%
+x%
FFS
-6%
+x%
FFS
-9%
+x%
FFS
-10%
+x%
FFS
-4%
+4x%
FFS
-5%
+5x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-7%
+7x%
FFS
-9%
+9x%
FFS
-9%
+9x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10% +10% +10% +10% +10% +10%
51© Center for Healthcare Quality and Payment Reform www.CHQPR.org
CMS Bases Penalties/Bonuses…
…on Performance 2 Years Earlier
FFS
$
-4.5%
+x%
FFS
-6%
+x%
FFS
-9%
+x%
FFS
-10%
+x%
FFS
-4%
+4x%
FFS
-5%
+5x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-9%
+9x%
FFS
-7%
+7x%
FFS
-9%
+9x%
FFS
-9%
+9x%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
+10% +10% +10% +10% +10% +10%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026Chart Not Drawn to Scale
Bad
Good
Bad
Good
Bad
Good
Bad
Good
Bad
Good
Bad
Good
Performance Measures
Bad
Good
Bad
Good
Bad
Good
Bad
Good
Bad
Good
Bad
Good
52© Center for Healthcare Quality and Payment Reform www.CHQPR.org
2 Year Lag Means 2019 MIPS $
Will Be Based on Scores Next Year
$
FFS
-4%
+4x%
2017 2019
+10%
2017
Bad
Good
Performance Measures
Underproposed
CMS rules,performancemeasurementfor 2019 MIPS
and APMsstarts in
January 2017
53© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Performance (Measurement) Year
for MIPS Payment Adjustments
What MACRA Says• “The Secretary shall establish
a performance period (or periods) [to determine the MIPS payment adjustments that will be made in a particular year]…Such performance period (or periods) shall begin and end prior to the beginning of such year and be as close as possible to such year.”
54© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Performance (Measurement) Year
for MIPS Payment Adjustments
What MACRA Says• “The Secretary shall establish
a performance period (or periods) [to determine the MIPS payment adjustments that will be made in a particular year]…Such performance period (or periods) shall begin and end prior to the beginning of such year and be as close as possible to such year.”
What Proposed Regs Say• The performance period is the
full calendar year that is two years prior to the year in which MIPS adjustments are made.
• Specifically, the first year of MIPS adjustments is 2019, so the performance year is Jan. 1, 2017 – Dec. 31, 2017
55© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Performance (Measurement) Year
for MIPS Payment Adjustments
What MACRA Says• “The Secretary shall establish
a performance period (or periods) [to determine the MIPS payment adjustments that will be made in a particular year]…Such performance period (or periods) shall begin and end prior to the beginning of such year and be as close as possible to such year.”
What Proposed Regs Say• The performance period is the
full calendar year that is two years prior to the year in which MIPS adjustments are made.
• Specifically, the first year of MIPS adjustments is 2019, so the performance year is Jan. 1, 2017 – Dec. 31, 2017
There is a lot of pressure to:
• delay the start date of the program to July 1, 2017 or January 1, 2018
• move the performance period closer to the payment year
• use performance periods shorter than one year
56© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Are MIPS
Bonuses/Penalties Based On?
Quality
Resource Use
“Clinical Practice Improvement
Activities”
“Advancing Care
Information”
(EHR Use)
2019
57© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Are MIPS
Bonuses/Penalties Based On?
Quality
Resource Use
“Clinical Practice Improvement
Activities”
“Advancing Care
Information”
(EHR Use)
2019
Four Separate
Measurement Silos,
Not a Coordinated
Measure of Value
58© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Resource Use Will Become Much
More Important Over Time
Quality
Resource Use
“Clinical Practice Improvement
Activities”
“Advancing Care
Information”
(EHR Use)
50%
10%
25%
15%
Quality
Resource Use
“Clinical Practice Improvement
Activities”
“Advancing Care
Information”
(EHR Use)
30%
30%
25%
15%
2019 2021+
59© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Quality Measures
• 6 quality measures, selected from available measures(reduction from 9 measures in current PQRS/VM program)
– 1 cross-cutting measure, e.g.• % of patients with advanced care plan
• Documentation of medications in medical record
• Tobacco cessation
– 1 outcome measure
(or high-priority measure if outcome is unavailable), e.g.,• Readmissions
• Mortality
• Optimal asthma control
– 4 other measures• Traditional primary care measures (process & outcome)
• Specialty specific measures (process & outcome)
60© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Resource Use
Performance Measures• Average of all applicable resource use measures
– Total Per Capita Costs (total spending per patient per year)• Dropped condition-specific groups currently used in Value Modifier
– Medicare Spending Per Beneficiary (spending in hospital + 30 days)
– ~41 episode measures, e.g.,• Spending during and after admission for exacerbation of heart failure
• Spending during surgery and rehabilitation for knee replacement
• Spending during treatment and rehabilitation for stroke
61© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Resource Use
Performance Measures• Average of all applicable resource use measures
– Total Per Capita Costs (total spending per patient per year)• Dropped condition-specific groups currently used in Value Modifier
– Medicare Spending Per Beneficiary (spending in hospital + 30 days)
– ~41 episode measures, e.g.,• Spending during and after admission for exacerbation of heart failure
• Spending during surgery and rehabilitation for knee replacement
• Spending during treatment and rehabilitation for stroke
• Measures are calculated from claims data, attributed to physicians based on measure-specific attribution formulas, and used for MIPS if there are a minimum number of cases– Total Per Capita Costs attributed to PCP with most office visits
– Medicare Spending Per Beneficiary (MSPB) attributed to hospital physician with most physician billings during hospital stay
– Episodes attributed based on physician who billed for trigger event
62© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Most Spending on a Doctor’s
Patients Doesn’t Go to the Doctor
63© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Physicians’ Pay Will Be Affected
by What Other Providers Do
64© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Physicians Will Be Penalized if
Hospital & Post-Acute $ Is High
65© Center for Healthcare Quality and Payment Reform www.CHQPR.org
“Standardized Pricing” Used
in Resource Measures
• Admissions at Critical Access Hospitals are “priced” at the same rates as IPPS hospitals for the purposes of MIPS resource measures – so physicians are not penalized if their patients are admitted to higher cost rural hospitals
• Swing bed stays at Critical Access Hospitals are “priced” at their actual Medicare payment amounts – so physicians can be penalized if their patients are admitted to higher cost rural hospital swing beds for post acute care
66© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Clinical Practice
Improvement Activity (CPIA)
• Maximum credit achieved with 60 points (requires 1-6 activities)– 60 points for certification as a patient-centered medical home
– 30 points for participation in an Alternative Payment Model(but not at a participation level which exempts physician from MIPS)
– 20 points for participation in “high weight” activities
– 10 points for participation in each “medium weight” activity
– 30 points for each activity of any type by small and rural practices
• Categories of Clinical Practice Improvement Activities– Expanded practice access
– Beneficiary engagement
– Population management
– Patient safety and practice assessment
– Care coordination
– Achieving health equity
– Emergency preparedness and response
– Integrated behavioral and mental health
67© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Does a “Clinical Practice
Improvement Activity” Look Like?• 90 proposed options listed in proposed regulation
• Examples:
– Expanded Practice Access• 20 points: 24/7 access for advice about urgent/emergent care
• 10 points: telehealth specialty consults
– Population Management• 20 points: Anticoagulant management
• 10 points: Engaging rural health clinics in quality measurement
– Care Coordination• 10 points: Partnering with hospital-based transitional care services
• 10 points: Care coordination agreements with consulting physicians
– Beneficiary Engagement• 20 points: Collection and follow-up on patient experience data
• 10 points: Participation in a Qualified Clinical Data Registry
– Patient Safety and Practice Assessment• 10 points: Use of tools such as Surgical Risk Calculator
68© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Does a “Clinical Practice
Improvement Activity” Look Like?• 90 proposed options listed in proposed regulation
• Examples:
– Expanded Practice Access• 20 points: 24/7 access for advice about urgent/emergent care
• 10 points: telehealth specialty consults
– Population Management• 20 points: Anticoagulant management
• 10 points: Engaging rural health clinics in quality measurement
– Care Coordination• 10 points: Partnering with hospital-based transitional care services
• 10 points: Care coordination agreements with consulting physicians
– Beneficiary Engagement• 20 points: Collection and follow-up on patient experience data
• 10 points: Participation in a Qualified Clinical Data Registry
– Patient Safety and Practice Assessment• 10 points: Use of tools such as Surgical Risk Calculator
Clinical Practice
Improvement Activities
could represent
opportunities for
physicians to benefit
from initiatives that
could also benefit
the hospital
69© Center for Healthcare Quality and Payment Reform www.CHQPR.org
“Advancing Care Information”
(aka Meaningful EHR Use)
• 100 points needed for maximum credit in this category
• 50 point “base score” for participation on 6 things– Protect patient health information (“yes” required)
– Electronic prescribing (data submission only required)
– Patient electronic prescribing (data submission only required)
– Coordination of care through patient engagement (data submission
only)
– Health Information Exchange (data submission only required)
– Public health and clinical data registry reporting (“yes” required)
• 80 points for performance on measures from 3 categories– Patient electronic access
– Coordination of care through patient engagement
– Health information exchange
70© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Reporting Options
71© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Reporting Options
• Report as individual– If the physician is part of a multi-physician practice, the individual
physician’s bonus/penalty depends on how that individual physician scored on the quality and resource use measures
72© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Reporting Options
• Report as individual– If the physician is part of a multi-physician practice, the individual
physician’s bonus/penalty depends on how that individual physician scored on the quality and resource use measures
• Report as a group– If the physician is part of a multi-physician practice, the individual
physician’s bonus/penalty depends on how the entire group of physicians scored on the quality and resource use measures
73© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Reporting Options
• Report as individual– If the physician is part of a multi-physician practice, the individual
physician’s bonus/penalty depends on how that individual physician scored on the quality and resource use measures
• Report as a group– If the physician is part of a multi-physician practice, the individual
physician’s bonus/penalty depends on how the entire group of physicians scored on the quality and resource use measures
• Report as a “virtual group”(Authorized in MACRA, not defined in CMS proposed regs)– If the physician is not part of a multi-physician practice or is part of a
group of less than 10 physicians, the physician or practice can agree to report together with other independent physicians or small practices, and the individual physician’s bonus/penalty then depends on how the entire virtual group scored on the quality and resource use measures
74© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Reporting Options
• Report as individual– If the physician is part of a multi-physician practice, the individual
physician’s bonus/penalty depends on how that individual physician scored on the quality and resource use measures
• Report as a group– If the physician is part of a multi-physician practice, the individual
physician’s bonus/penalty depends on how the entire group of physicians scored on the quality and resource use measures
• Report as a “virtual group”(Authorized in MACRA, not defined in CMS proposed regs)– If the physician is not part of a multi-physician practice or is part of a
group of less than 10 physicians, the physician or practice can agree to report together with other independent physicians or small practices, and the individual physician’s bonus/penalty then depends on how the entire virtual group scored on the quality and resource use measures
Virtual Groupsmay represent an opportunity
for a hospital to help independent physicianswork together without
the need for the hospitalto employ the physicians
How is the MIPS
Bonus/Penalty
Determined?
76© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Step 1: Performance Measurement
in Each MIPS Category• Quality Measurement
– Physician receives 1-10 points on each individual quality measure– Number of points is based on which decile the physician falls into on the
distribution of performance for all physicians during the prior year
• If performance is better than 90% of physicians, physician receives 10 points
• If 90% of physicians performed better, physician receives 1 point– MACRA requires that credit be given to improvement, not just absolute
performance, but proposed regs would not give improvement credit in Year 1
• Resource Use Measurement– Physician receives 1-10 points on each applicable resource use measure
– Number of points is based on which decile the physician falls into on the distribution of performance for all physicians during the current year (this requirement in CMS regulations may not meet statutory requirements)
• Clinical Practice Improvement– Physician receives points for participation in each improvement initiative
– Not completely clear how “participation” will be defined/measured
• Advancing Care Information (EHR Use)– 50 “base points” are all or nothing
– Additional points based on relative performance in individual categories
77© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Multiple Episode Measures
Averaged For Each Physician
78© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Step 2: Composite
Performance Measurement• Scores in all four categories combined into a Composite Performance
Score (CPS) from 0-100 using the weights for the categories
• A Performance Threshold is established based on how all physicians performed in the prior year on the CPS
79© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Step 2: Composite
Performance Measurement• Scores in all four categories combined into a Composite Performance
Score (CPS) from 0-100 using the weights for the categories
• A Performance Threshold is established based on how all physicians performed in the prior year on the CPS
80© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Step 3: Performance Measurement
Translated to Bonuses/Penalties
Physician Composite Performance Score
Relative to Performance Threshold
MIPS Bonus/Penalty
CPS ≤ 25% of Performance Threshold Maximum Penalty
CPS Below Performance Threshold Penalty
CPS At or Slightly Above Threshold No Bonus or Penalty
CPS Above Threshold Bonus
CPS ≥ 75th percentile of values above
Performance Threshold
Additional bonus (up to 10%)
81© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Implications for Hospitals
• Independent Physicians May Seek Hospital Help in Compliance
• Independent Physicians Will Focus on Ways to Reduce Use of Hospital Services and Post-Acute Care
– Total Per Capita Cost Measure and some episode measures will penalize physicians whose patients have:
• High rates of testing and imaging• High rates of referrals to other physicians• High rates of ED visits and hospitalizations• High rates of readmissions and post-acute care costs
– Medicare Spending Per Beneficiary Measure and many episode measures will penalize physicians who manage inpatient admissions if there are:
• High use of other consultants• High rates of readmissions• High use of SNF beds or use of expensive SNF beds (e.g., CAHs)
82© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Critical Access Hospitals
Could Be Harmed by MIPS
• Quality Measures– Small volumes of patients and safety net services could make
quality measures for physicians look poor compared to those at other hospitals
• Resource Use Measures– PCPs may be penalized for practicing in communities without the ability
to provide care management and in-home services for patients with chronic disease
– Surgeons will be penalized if their patients use higher-cost post-acute care services delivered by Critical Access Hospitals
How APMs Will Work
84© Center for Healthcare Quality and Payment Reform www.CHQPR.org
MACRA Encourages
Use of APMs Instead of MIPS
• Physicians are encouraged to participate in approved Alternative Payment Models (APMs) at a minimum level:– They are exempt from MIPS
– They receive a 5% lump sum bonus
– They receive a higher annual update (increase) in their FFS revenues
– They receive the benefits of participating in the APM
85© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Why Should Hospitals Care
About APMs?• For physicians they employ or bill for under Part B:
– Avoids revenue uncertainty of bonuses/penalties under MIPS
– Avoids costs associated with complying with quality reporting, clinical practice improvement activities, and EHR use requirements
– Improves revenues via 5% bonuses and higher updates
– APMs could enable hospitals to redesign care delivery for higher margins without constraints of current fee-for-service system
• For other physicians:– Some physicians may not want to work in the community if they have to
participate in MIPS or can’t participate in Alternative Payment Models
– If physicians participate in APMs without the hospital as a partner, the hospital could lose significant revenue (the biggest opportunity for savings in many APMs will come from reducing ED visits, avoidable admissions, & unnecessary/unnecessarily-expensive post-acute care)
– APMs could enable hospitals to redesign care delivery for higher margins without constraints of current fee-for-service system
86© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Does MACRA Require
for an APM?
87© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Does MACRA Require
for an APM?• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
88© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Does MACRA Require
for an APM?• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under the APM“in excess of a nominal amount” ORbe designated as a medical home expanded by the Innovation Center
89© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Does MACRA Require
for an APM?• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under the APM“in excess of a nominal amount” ORbe designated as a medical home expanded by the Innovation Center
• Requirements for an Alternative Payment Model
– Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration
– Require participants to use certified EHR technology
– Base payment on quality measures “comparable” to MIPS
90© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Exactly is an “APM?”
• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under the APM“in excess of a nominal amount” ORbe designated as a medical home expanded by the Innovation Center
• Requirements for an Alternative Payment Model
– Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration
– Require participants to use certified EHR technology
– Base payment on quality measures “comparable” to MIPS
91© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Principal Focus of APMs
is to Save Money
• Innovation Center– The Secretary shall select models to be tested where there is evidence that the
model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures. The Secretary shall focus on models expected to reduce program costs while preserving or enhancing the quality of care.
– The Secretary shall terminate or modify the design and implementation of a model unless the Secretary determines that the model is expected to: (i) improve the quality of care without increasing spending; (ii) reduce spending without reducing the quality of care; or (iii) improve the quality of care and reduce spending.
• Shared Savings Program– Payments to an ACO shall be established in a manner that does not result
in spending more for such ACO for such beneficiaries than would otherwise be expended for such ACO for such beneficiaries for such year if the model were not implemented, as estimated by the Secretary.
92© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Current CMS
Alternative Payment Models• Bundled Payments for Care Improvement (BPCI)• Comprehensive Care for Joint Replacement (CJR)• Comprehensive ESRD Care – Large Dialysis Organization• Comprehensive ESRD Care – Small Dialysis Organization• Comprehensive Primary Care Plus• Frontier Community Health Integration Program• Home Health Value Based Purchasing Model• Independence at Home Demonstration• Medicare Value-Based Insurance Design Model• Part D Enhanced Medication Therapy Management Model• Reducing Hospitalizations Among Nursing Home Residents• Intravenous Immune Globulin Demonstration• Maryland All-Payer Hospital Model• Medicare Part B Drug Payment Model• Medicare Care Choices Model• Medicare Shared Savings Program (ACO) – Track 1• Medicare Shared Savings Program (ACO) – Track 2• Medicare Shared Savings Program (ACO) – Track 3• Million Hearts Cardiovascular Risk Reduction Model• Next Generation ACO Model• Oncology Care Model – Track 1• Oncology Care Model – Track 2
93© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Many APMs Focus Specifically
on Reducing Spending on Hospitals• Bundled Payments for Care Improvement (BPCI)• Comprehensive Care for Joint Replacement (CJR)• Comprehensive ESRD Care – Large Dialysis Organization• Comprehensive ESRD Care – Small Dialysis Organization• Comprehensive Primary Care Plus• Frontier Community Health Integration Program• Home Health Value Based Purchasing Model• Independence at Home Demonstration• Medicare Value-Based Insurance Design Model• Part D Enhanced Medication Therapy Management Model• Reducing Hospitalizations Among Nursing Home Residents• Intravenous Immune Globulin Demonstration• Maryland All-Payer Hospital Model• Medicare Part B Drug Payment Model• Medicare Care Choices Model• Medicare Shared Savings Program (ACO) – Track 1• Medicare Shared Savings Program (ACO) – Track 2• Medicare Shared Savings Program (ACO) – Track 3• Million Hearts Cardiovascular Risk Reduction Model• Next Generation ACO Model• Oncology Care Model – Track 1• Oncology Care Model – Track 2
94© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Some APMs Focus Specifically
on Reducing Post-Acute Spending• Bundled Payments for Care Improvement (BPCI)• Comprehensive Care for Joint Replacement (CJR)• Comprehensive ESRD Care – Large Dialysis Organization• Comprehensive ESRD Care – Small Dialysis Organization• Comprehensive Primary Care Plus• Frontier Community Health Integration Program• Home Health Value Based Purchasing Model• Independence at Home Demonstration• Medicare Value-Based Insurance Design Model• Part D Enhanced Medication Therapy Management Model• Reducing Hospitalizations Among Nursing Home Residents• Intravenous Immune Globulin Demonstration• Maryland All-Payer Hospital Model• Medicare Part B Drug Payment Model• Medicare Care Choices Model• Medicare Shared Savings Program (ACO) – Track 1• Medicare Shared Savings Program (ACO) – Track 2• Medicare Shared Savings Program (ACO) – Track 3• Million Hearts Cardiovascular Risk Reduction Model• Next Generation ACO Model• Oncology Care Model – Track 1• Oncology Care Model – Track 2
95© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Two APMs Have Components
Focused on Rural Hospitals• Bundled Payments for Care Improvement (BPCI)• Comprehensive Care for Joint Replacement (CJR)• Comprehensive ESRD Care – Large Dialysis Organization• Comprehensive ESRD Care – Small Dialysis Organization• Comprehensive Primary Care Plus• Frontier Community Health Integration Program• Home Health Value Based Purchasing Model• Independence at Home Demonstration• Medicare Value-Based Insurance Design Model• Part D Enhanced Medication Therapy Management Model• Reducing Hospitalizations Among Nursing Home Residents• Intravenous Immune Globulin Demonstration• Maryland All-Payer Hospital Model• Medicare Part B Drug Payment Model• Medicare Care Choices Model• Medicare Shared Savings Program (ACO) – Track 1• Medicare Shared Savings Program (ACO) – Track 2• Medicare Shared Savings Program (ACO) – Track 3• Million Hearts Cardiovascular Risk Reduction Model• Next Generation ACO Model• Oncology Care Model – Track 1• Oncology Care Model – Track 2
96© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Else Does MACRA Require
for an APM to Replace MIPS?• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under the APM“in excess of a nominal amount” ORbe designated as a medical home expanded by the Innovation Center
• Requirements for an Alternative Payment Model
– Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration
– Require participants to use certified EHR technology
– Base payment on quality measures “comparable” to MIPS
97© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Requirements for APM Use of
EHRs and Quality Measures
What MACRA Says• APM “requires participants in
such model to use certified EHR technology”
What Proposed Regs Say• APM must require at least 50%
of eligible clinicians in the APM entity to use Certified EHR Technology to document and communicate clinical care in 2019
• At least 75% must do so in subsequent years
98© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Requirements for APM Use of
EHRs and Quality Measures
What MACRA Says• APM “requires participants in
such model to use certified EHR technology”
• APM “provides for payment for covered professional services based on quality measures comparable to measures under [MIPS”
What Proposed Regs Say• APM must require at least 50%
of eligible clinicians in the APM entity to use Certified EHR Technology to document and communicate clinical care in 2019
• At least 75% must do so in subsequent years
• APM must base payment on quality measures comparable to MIPS
• No minimum number of measures, but must have at least one outcome measure if there is an appropriate outcome measure available
99© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Else Does MACRA Require
for an APM to Replace MIPS?• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under the APM“in excess of a nominal amount” ORbe designated as a medical home expanded by the Innovation Center
• Requirements for an Alternative Payment Model
– Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration
– Require participants to use certified EHR technology
– Base payment on quality measures “comparable” to MIPS
100© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Requirements for Financial Risk
in APMs
What MACRA Says
• APM Entity must
– “bear financial risk for
monetary losses under
such alternative payment
model that are in excess of
a nominal amount;” or
– be a medical home
expanded by the
Innovation Center
101© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Requirements for Financial Risk
in APMs
What MACRA Says
• APM Entity must
– “bear financial risk for
monetary losses under
such alternative payment
model that are in excess of
a nominal amount;” or
– be a medical home
expanded by the
Innovation Center
What Proposed Regs Say• The APM Entity is required to
repay Medicare when spending on patients exceeds expected amounts, up to:
• 5% of the entity’s total revenue, if the entity is a primary care practice with 50 or fewer clinicians (2.5% in 2017, 3% in 2018, 4% in 2019)
• 4% of total Medicare spendingfor all other physician practices or health systems
102© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Widespread Opposition to CMS
Definition of “Nominal Risk”
103© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Only 16% of Medicare Spending
Goes to Physicians
Physicians:16%
104© Center for Healthcare Quality and Payment Reform www.CHQPR.org
4% of Medicare Spending =
Huge Risk for Average Physician
Physicians:16%
4% of Total Medicare Spending
25% ofPhysicianRevenues
105© Center for Healthcare Quality and Payment Reform www.CHQPR.org
4% of Spending Could Be
100% of Physician’s Revenue
106© Center for Healthcare Quality and Payment Reform www.CHQPR.org
CMS Calls APMs Meeting All These
Criteria: “Advanced APMs”• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under the APM“in excess of a nominal amount” ORbe designated as a medical home expanded by the Innovation Center
• Requirements for an Alternative Payment Model
– Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration
– Require participants to use certified EHR technology
– Base payment on quality measures “comparable” to MIPS
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Current CMS
Alternative Payment Models• Bundled Payments for Care Improvement (BPCI)• Comprehensive Care for Joint Replacement (CJR)• Comprehensive ESRD Care – Large Dialysis Organization• Comprehensive ESRD Care – Small Dialysis Organization• Comprehensive Primary Care Plus• Frontier Community Health Integration Program• Home Health Value Based Purchasing Model• Independence at Home Demonstration• Medicare Value-Based Insurance Design Model• Part D Enhanced Medication Therapy Management Model• Reducing Hospitalizations Among Nursing Home Residents• Intravenous Immune Globulin Demonstration• Maryland All-Payer Hospital Model• Medicare Part B Drug Payment Model• Medicare Care Choices Model• Medicare Shared Savings Program (ACO) – Track 1• Medicare Shared Savings Program (ACO) – Track 2• Medicare Shared Savings Program (ACO) – Track 3• Million Hearts Cardiovascular Risk Reduction Model• Next Generation ACO Model• Oncology Care Model – Track 1• Oncology Care Model – Track 2
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Few APMs Qualify as “Advanced”
APMs Under Proposed Rule• Bundled Payments for Care Improvement (BPCI)• Comprehensive Care for Joint Replacement (CJR)• Comprehensive ESRD Care – Large Dialysis Organization• Comprehensive ESRD Care – Small Dialysis Organization• Comprehensive Primary Care Plus• Frontier Community Health Integration Program• Home Health Value Based Purchasing Model• Independence at Home Demonstration• Medicare Value-Based Insurance Design Model• Part D Enhanced Medication Therapy Management Model• Reducing Hospitalizations Among Nursing Home Residents• Intravenous Immune Globulin Demonstration• Maryland All-Payer Hospital Model• Medicare Part B Drug Payment Model• Medicare Care Choices Model• Medicare Shared Savings Program (ACO) – Track 1• Medicare Shared Savings Program (ACO) – Track 2• Medicare Shared Savings Program (ACO) – Track 3• Million Hearts Cardiovascular Risk Reduction Model• Next Generation ACO Model• Oncology Care Model – Track 1• Oncology Care Model – Track 2
109© Center for Healthcare Quality and Payment Reform www.CHQPR.org
The APMs Most Physicians Are
Participating In Don’t Qualify• Bundled Payments for Care Improvement (BPCI)• Comprehensive Care for Joint Replacement (CJR)• Comprehensive ESRD Care – Large Dialysis Organization• Comprehensive ESRD Care – Small Dialysis Organization• Comprehensive Primary Care Plus• Frontier Community Health Integration Program• Home Health Value Based Purchasing Model• Independence at Home Demonstration• Medicare Value-Based Insurance Design Model• Part D Enhanced Medication Therapy Management Model• Reducing Hospitalizations Among Nursing Home Residents• Intravenous Immune Globulin Demonstration• Maryland All-Payer Hospital Model• Medicare Part B Drug Payment Model• Medicare Care Choices Model• Medicare Shared Savings Program (ACO) – Track 1• Medicare Shared Savings Program (ACO) – Track 2• Medicare Shared Savings Program (ACO) – Track 3• Million Hearts Cardiovascular Risk Reduction Model• Next Generation ACO Model• Oncology Care Model – Track 1• Oncology Care Model – Track 2
110© Center for Healthcare Quality and Payment Reform www.CHQPR.org
CMS Defines Non-Advanced APMs
as “MIPS APMs”• Requirements for Physician
– 2019: 25% of Medicare payments from an “alternative payment entity”
– 2021: [50% of Medicare payments] or [25% Medicare & 50% of total payments] from an alternative payment entity
– 2023: 75% of Medicare or total payments from an alternative payment entity
– Option to count % of patients instead of % of payments
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under the APM“in excess of a nominal amount” ORbe designated as a medical home expanded by the Innovation Center
• Requirements for an Alternative Payment Model
– Be a model defined in the Innovation Center language under ACA, be part of the shared savings (ACO) program, or be a Medicare demonstration
– Require participants to use certified EHR technology
– Base payment on quality measures “comparable” to MIPS
111© Center for Healthcare Quality and Payment Reform www.CHQPR.org
What Good is a MIPS APM?
• Good: Exempt from “regular” MIPS requirements; follow the
quality and resource use measures in the APM itself
• Bad: Physicians participating in a MIPS APM wouldn’t qualify
for the 5% bonus under MACRA or the higher payment update
112© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Problems with APM Regulations
But Also with CMS APMs
• Problems with Regulations
– Regulations set an excessively high bar for risk when Congress only required “more than nominal financial risk”
• Problems with CMS Alternative Payment Models
– Most CMS APMs are “shared savings” payment models that do not change the underlying payment system for providers and potentially encourage stinting on care to patients
– Most CMS APMs try to hold providers accountable for total cost of care whether they can control all costs or not
– Many CMS APMs do not adequately adjust payments for differences in patient needs
113© Center for Healthcare Quality and Payment Reform www.CHQPR.org
CMS “Comprehensive
Care for Joint Replacement”
PATIENTHospital Costs
for SurgeryPost-Acute Care(IRF, SNF, HH)Readmits
EPISODE PAYMENT FOR SURGERIES
114© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Principal Goal of CMS Proposal
Is Reducing Post-Acute Care Cost
PATIENTHospital Costs
for SurgeryPost-Acute Care(IRF, SNF, HH)Readmits
Hospital Costsfor Surgery
Post-Acute CareReadmits SAVINGS
EPISODE PAYMENT FOR SURGERIES
115© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Proposed Structure Encourages
Lower Spending, Not Better Care
PATIENTHospital Costs
for SurgeryPost-Acute Care(IRF, SNF, HH)Readmits
Hospital Costsfor Surgery
Post-Acute CareReadmits SAVINGS
EPISODE PAYMENT FOR SURGERIES
• No risk adjustment – target spending amount is the same for high-risk, poor functional status patients as low-risk patients
• No flexibility to deliver different types of post-acute care orto be paid differently – no change in current payment systems
116© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Hospitals at Risk for Total Cost
With Everyone Still Paid the Same
PATIENTHospital Costs
for SurgeryPost-Acute Care(IRF, SNF, HH)Readmits
CMS
Hospital
Physiciansand
Post-AcuteCare
Hospital Costsfor Surgery
Post-Acute CareReadmits SAVINGS
EPISODE PAYMENT FOR SURGERIES
• No risk adjustment – target spending amount is the same for high-risk, poor functional status patients as low-risk patients
• No flexibility to deliver different types of post-acute care orto be paid differently – no change in current payment systems
• Hospital is at risk for higher post-acute care spending
117© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Over Time, CMS Keeps More of
the Savings, If There Are Any
PATIENTHospital Costs
for SurgeryPost-Acute Care(IRF, SNF, HH)Readmits
Hospital Costsfor Surgery
Post-Acute CareReadmits SAVINGS
EPISODE PAYMENT FOR SURGERIES
CMS
Hospital
• No risk adjustment – target spending amount is the same for high-risk, poor functional status patients as low-risk patients
• No flexibility to deliver different types of post-acute care orto be paid differently – no change in current payment systems
• Hospital is at risk for higher post-acute care spending
• Target spending is reduced every year to match lower FFS spending
Physiciansand
Post-AcuteCare
118© Center for Healthcare Quality and Payment Reform www.CHQPR.org
If There Are Fewer Surgeries,
CMS Keeps ALL of the Savings
PATIENTHospital Costs
for SurgeryPost-Acute Care(IRF, SNF, HH)Readmits
Hospital Costsfor Surgery
Post-Acute CareReadmits SAVINGS
EPISODE PAYMENT FOR SURGERIES
CMS
Hospital
Non-Surg.Treatment SAVINGS
Physiciansand
Post-AcuteCare
119© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Critical Access Hospitals
Could Be Harmed by CJR
• Hospitals will be penalized if their patients use higher-cost
post-acute care services
• If CAH cost per SNF/swing day is higher than other hospitals,
CJR hospitals could avoid using the CAH for post-acute care
services
120© Center for Healthcare Quality and Payment Reform www.CHQPR.org
CMS Proposing Same Approach for
AMI, CABG, and Hip Fracture
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Innovation Center Authorized to
Implement Other/Better APMs(i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, medical homes that address women’s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment.(ii) Contracting directly with groups of providers of services and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payment or salary-based payment.(iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one of the following:
(I) An inability to perform 2 or more activities of daily living.(II) Cognitive impairment, including dementia.
(iv) Promote care coordination between providers of services and suppliers that transition health care providers away from fee-for-service based reimbursement and toward salary-based payment.(v) Supporting care coordination for chronically ill applicable individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology.(vi) Varying payment to physicians who order advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) according to the physician’s adherence to appropriateness criteria for the ordering of such services, as determined in consultation with physician specialty groups and other relevant stakeholders.(vii) Utilizing medication therapy management services, such as those described in section 935 of the Public Health Service Act.(viii) Establishing community-based health teams to support small-practice medical homes by assisting the primary care practitioner in chronic care management, including patient self-management, activities.(ix) Assisting applicable individuals in making informed health care choices by paying providers of services and suppliers for using patient decision-support tools, including tools that meet the standards developed and identified under section 936(c)(2)(A) of the Public Health Service Act, that improve applicable individual and caregiver understanding of medical treatment options.(x) Allowing States to test and evaluate fully integrating care for dual eligible individuals in the State, including the management and oversight of all funds under the applicable titles with respect to such individuals.(xi) Allowing States to test and evaluate systems of all-payer payment reform for the medical care of residents of the State, including dual eligible individuals.(xii) Aligning nationally recognized, evidence based guidelines of cancer care with payment incentives under title XVIII in the areas of treatment planning and follow-up care planning for applicable individuals described in clause (i) or (iii) of subsection (a)(4)(A) with cancer, including the identification of gaps in applicable quality measures.(xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or skilled nursing care during an inpatient stay and the 30 days immediately following discharge.(xiv) Funding home health providers who offer chronic care management services to applicable individuals in cooperation with interdisciplinary teams.(xv) Promoting improved quality and reduced cost by developing a collaborative of high-quality, low-cost health care institutions that is responsible for—
(I) developing, documenting, and disseminating best practices and proven care methods;(II) implementing such best practices and proven care methods within such institutions to demonstrate further improvements in quality and efficiency; and(III) providing assistance to other health care institutions on how best to employ such best practices and proven care methods to improve health care quality and lower costs.
(xvi) Facilitate inpatient care, including intensive care, of hospitalized applicable individuals at their local hospital through the use of electronic monitoring by specialists, including intensivists and critical care specialists, based at integrated health systems.(xvii) Promoting greater efficiencies and timely access to outpatient services (such as outpatient physical therapy services) through models that do not require a physician or other health professional to refer the service or be involved in establishing the plan of care for the service, when such service is furnished by a health professional who has the authority to furnish the service under existing State law.(xviii) Establishing comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities, that, through their structure, operations, and joint-activity deliver a full spectrum of integrated and comprehensive health care services to applicable individuals while also incorporating innovative methods for the clinical training of future health care professionals.(xix) Utilizing, in particular in entities located in medically underserved areas and facilities of the Indian Health Service (whether operated by such Service or by an Indian tribe or tribal organization (as those terms are defined in section 4 of the Indian Health Care Improvement Act)), telehealth services—
(I) in treating behavioral health issues (such as post-traumatic stress disorder) and stroke; and(II) to improve the capacity of non-medical providers and non-specialized medical providers to provide health services for patients with chronic complex conditions.
(xx) Utilizing a diverse network of providers of services and suppliers to improve care coordination for applicable individuals described in subsection (a)(4)(A)(i) with 2 or more chronic conditions and a history of prior-year hospitalization through interventions developed under the Medicare Coordinated Care Demonstration Project under section 4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b–1 note).(xxi) Focusing primarily on physicians’ services (as defined in section 1848(j)(3)) furnished by physicians who are not primary care practitioners(xxii) Focusing on practices of 15 or fewer professionals.(xxiii) Focusing on risk-based models for small physician practices which may involve two-sided risk and prospective patient assignment, and which examine risk-adjusted decreases in mortality rates, hospital readmissions rates, and other relevant and appropriate clinical measures.(xxiv) Focusing primarily on title XIX, working in conjunction with the Center for Medicaid and CHIP Services;
122© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Good Ways and Bad Ways to
Define Alternative Payment Models
Medicare and
Health Plans
Define
Payment Systems
Providers Have
To Change Care
to Align With
Payment Systems
Patients and
Providers
May Not
Come Out Ahead
Providers
Redesign Care
and Identify
Payment Barriers
Payers Change
Payment to
Support
Redesigned Care
Patients Get
Better Care and
Providers Stay
Financially Viable
THE RIGHT WAY TO DESIGN PAYMENT REFORMS
HOW PAYMENT REFORMS ARE DESIGNED TODAY
123© Center for Healthcare Quality and Payment Reform www.CHQPR.org
APMs Can Be Win-Win-Wins for
Patients, Doctors, Hospitals, Payers
• APMs can be designed to protect hospital margins when admissions and services decrease
• APMs can be designed to ensure payments for physicians and hospitals are adequate for patients with higher needs
• APMs can be designed to facilitate and encourage collaboration between primary care physicians, specialists, hospitals, and skilled nursing facilities rather than pitting them against each other
124© Center for Healthcare Quality and Payment Reform www.CHQPR.org
MACRA Creates the “PTAC” to
Encourage Provider-Driven APMs
• Physician-Focused Payment Model Technical Advisory
Committee (PTAC)
– Eleven members appointed by the Comptroller General
– Reviews proposals for “physician-focused payment models”
– Makes recommendations to HHS/CMS on which to implement
– HHS is required to respond to recommendations,
but it is not required to implement what the PTAC recommends
– PTAC and CMS are working to develop a joint set of criteria for
approving alternative payment models that can be implemented quickly
125© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Examples of Specialty Society
Physician-Focused APM Concepts• ASCO Patient-Centered Oncology Payment (PCOP)
– Basic model: New service codes in addition to E&M/infusion codes– Option A: Bundled codes replacing E&M and infusion codes– Option B: Bundled payment for medical oncology treatment
• AAN Patient-Centered Epilepsy and Headache Payment– One-time or monthly bundled payment codes replacing E&M– New service codes in addition to E&M for low-acuity patients– Optional bundled payments for total treatment costs
• ASTRO Payment for Palliative Radiation Care for Bone Metastases and Radiation Treatment of Breast Cancer– Bundle based on patient need instead of type/number of treatments
• ACC Payment for Testing/Treatment of Stable Angina (SMARTCare)– Bundle based on patient risk instead of types of tests/interventions
• AGA Colonoscopy Bundled Payment– Episode payment for procedure, anesthesia, facility, complications
• SGO/STS/ACS/ASA Surgical Episode Payments– Bundled/episode payments for surgical procedures
126© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Three Paths to Value-Based
Payment Under MACRA
CMS-DESIGNEDALTERNATIVE
PAYMENT MODELS (APMs)
MERIT-BASED INCENTIVE
PAYMENT SYSTEM (MIPS)
PROVIDER-DESIGNEDALTERNATIVE
PAYMENT MODELS (APMs)
MACRA
127© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Other Parts of MACRA
• $20 million/year from 2016-2020 for technical assistance to small practices on MIPS and APMs
• Authority for “Qualified Entities” to use Medicare claims data to help physician practices and other providers develop APMs
• Development of improved ways of measuring resource use
128© Center for Healthcare Quality and Payment Reform www.CHQPR.org
Learn More About MACRA and
Alternative Payment Modelswww.PaymentReform.org
For More Information:
Harold D. MillerPresident and CEO
Center for Healthcare Quality and Payment Reform
(412) 803-3650
www.CHQPR.org
www.PaymentReform.org
WSHA Resources
Claudia Sanders, Sr. Vice President, Policy Development
Andrew Busz, Policy Director, Finance
WSHA Advocacy
139
MACRA comments to CMS- Concerns
• Need for alignment with hospital measures
• Barriers to EHR meaningful use in rural areas
• List of approved Alternative Payment Models too limited
• Limited capacity for small providers to accept significant downside risk
• Recognition of quality improvement already obtained due to Partnership for Patients and other efforts
Advocating for reasonableness and alignment of quality measures
between MACRA, Healthier Washington (including WHRAP and RHC
APM-4), and commercial payors
WSHA Advocacy
140
MACRA IN ACTIONCarol Wagner
Senior Vice President Patient Safety
MACRA Principles - Washington
• Washington and Oregon physicians maximize their financial opportunities in MACRA.
• At the end of 2017 physicians will have an understanding, plan, and implementation process in progress.
• MACRA is delayed, but will be put into effect. Delay is part of refinement.
MACRA Principles - Washington
• MACRA is ultimately about patient care – this should remain a focus.
• Mindset of what needs to happen versus what is happening.
• Leaning from best practices across the country.
• Linkage with Healthy Doctors, Healthier Patients.
Next Steps from WSHA and WSMA
• Understanding that MACRA is ultimately a clinical quality issue.• This is about what physicians already care about.
• Pay for value based on outcomes not processes.
• Demonstrate value across membership.
Next Steps from WSHA and WSMA
• General education on MACRA
• Create a crosswalk of measures between:• MACRA
• Choosing Wisely
• HCA Performance Measures
• WSHA Patient Safety
• Other State and Federal initiatives.
• Crosswalk the measures across multi-specialties based on national specialtyassociations.
Next Steps from WSHA and WSMA
• Synergistic measures list.• Create a resource guide for measures.
• Create Improvement strategies best practices.
• Utilize best practice webinars?
• Survey meaningful use preparedness• Based on findings create checklist for meeting.
Working Together
• Washington and Oregon
• WSHA and WSMA
• Qualis
• Healthier Washington
Please give us your rating from 1-10 on this informational MACRA session
(1 is low and 10 is high)
Which aspect of MACRA would you like to know more about from WSHA?
Questions & Answers
Thank you for your participation
Claudia Sanders – [email protected] Wagner – [email protected] Busz – [email protected]