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2/27/2019

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March 7, 2019

MACRA: Quality Maximus Valorem

Agenda

• VBP Level-Set

• Understanding Digital Healthcare

• QPP for Groups, Solo & New Provider

• A Word to Interop

• Questions

© 2018. SS&C Technologies. Confidential

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I paid my copay – Now what?

Today

• Category 1 Payments

• Fee-for-Service (FFS)

• Medicare FFS frozen 2019 rates

• Productivity Revenue Model

• Transaction-based Payments


Result → Healthcare Spending State of the Union

Sources: CMS National Health Expenditure Data published Dec.2, 2017, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/index.html; Population related calculations based on U.S. Census Bureau data, https://www.census.gov/data/tables/time-series/demo/popest/pre-1980-national.html

U.S. Gov’t HealthcareProgram

Eligibility

U.S. Population / Enrollment

(1965)

Healthcare Cost as %

of GDP (1965)

Medicare American Age 65+

18.5 Million (9.5% of U.S. Population)

5.6% ($42 Billion or $210 per person)

Medicaid Low-income Americans

4 Million (2% of U.S.

Population)

CHIPLow-income, Non-Medicaid Children

0

U.S. Population / Enrollment

(2016)

57.1 Million (17.6% of U.S.

Population)

72.3 Million (22.3% of U.S.

Population)

6.7 Million (2% of U.S. Population)


of GDP (2016)

17.9%($3.3 Trillion or $10,180per person)

U.S. Population / Enrollment (2025/26)

74 Million (21.5% of US

Population

82 Million (23.8% of U.S.

Population)

TBD


of GDP (2026)

19.7%($5.7 Trillion or $16,460 per person)

11.5% 41.9% 47.3%


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Bipartisan Answer – Value-Based Payment

Tomorrow

• Categories 2- 4 Payments– Category 2 – Pay-for-Performance

– Categories 3 & 4 – Alternative Payment Models (APMs)

• MACRA Advanced- APMs

• Outcomes Revenue Model

• Analytic-based Payments


Individuals

CMS MACRA

U.S. Payment Trends 2015-2017


Lives% of

Market2016 2017

Medicare Advantage 20,711,961 70% 41% 49.5%

Medicare FFS ~37,000,000 100% 31% 38.3%

Commercial 135,532,277 63% 22% 28.3%

Medicaid 31,331,995 50% 18% 25.0%

Categories 3 & 4

Source: HHS Health Care Payment Learning & Action Network, Measuring Progress: APM Adoption, October, 2018, https://hcp-lan.org/2018-apm-measurement/

Payment Category 2015 2016 2017Category 1 62% 43% 41%

Category 2 15% 28% 25%

Categories 3 & 4 23% 29% 34%

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MACRA Three Policy Aims

Move Medicare to Value-Based Payment (VBP) by 2019 → MACRA

Ease Provider Burden and Abrasion• MACRA Proposed E&M Coding Redesign 99202-05

and 99212-15

Achieve Data Interoperability

MACRA = Medicare Access & CHIP Reauthorization Act of 2015;

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2

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Agenda

• VBP Level-Set

• Understanding Digital Healthcare



• Questions


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Digital Healthcare Evolution

1970s• Relational DB

• Microprocessor

• CT Scanner

1980s• HTML Prototype

• MS-DOS

• Digital Infusion Pumps

• PACs Systems

• DRGs

• Data Visualization

• Apple MAC

• DNA Sequencer

• T1 Data Lines

• Home Glucose Meter

• MRIs

1990s• Wrist BP cuff

• Nuclear Imaging

• HIPAA

• Personal Digital Assistants (PDAs)

• 2 Interop groups formed:

– CDISC

– IHE

2000s• Human Genome gets

mapped

• Software-as-a-Service

• iPhone

• “I’ve Got An App For That”

• Only eNew Drug Applications to FDA

• Google reports swine flu

• EHR penetration < 50%

• Fitbit

• ePrescribing


2010s• VC Digital Health

investments > $11 Billion

• 50% have Wearable Tech

• Meaningful Use

• EHR adoption > 85%

• Affordable Care Act

• MACRA

• Telemedicine

• Uber Health

• Artificial Intelligence

• Machine Learning

Disruptive Technology and Digital Healthcare

• Innovation can disrupt existing market

• Think “free” digital info– Radically changes humanity

(e.g., GPS v. Paper Maps)

– Quick, fast, in a hurry

• Self-Driving Cars – Disrupts parking,

– Law enforcement (tickets),

– Car insurance,

– Lawsuits,

– Auto repair/manufacturing, and

– Even hotels

• Futurist View:

• Apple watch → “BP is High”• Miri, “Go see your doctor”• Worried → Go to Amazon Hospital

• Medical Team + My Doctor connect through Telemedicine

• Apple Health App → Medical Records

• Rx written → drug produced & researched by Google

• PCP uses social media to engage patient and remotely monitors patient

• Expert is brought in for Telesurgery


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Digital Health Economics: Health Value Management

Managing “Healthcare”(Resource-Based)

Managing “Health” (Outcomes-Based)

Category 1 Category 2 Category 3 Category 4

Plan Risk Provider Risk

OLD NEW


MIPS A-APMs

Digital Economics and Data AnalyticsData Availability Claims EHR Clinical Records

Demographics Yes Yes

Race/ethnicity Limited Limited

Diagnosis Yes Yes

Procedures Yes Yes

Eligibility Yes Limited

Medications Medications dispensed Medications prescribed

Socioeconomic data Zip‐code derived Coded and zip‐code derived

Family history Not available Yes

Problem list Not available Yes

Procedure results Not available Yes

Laboratory results Not available Yes

Vital signs Not available Yes

Behavioral risk

factorsNot available Limited

Standardized

surveysLimited Limited

• Mile Wide, Inch Deep

• CPT, ICD Nomenclatures

• ANSI X12 Standards

• Inch Wide, Mile Deep

• CPT, ICD, LOINC, SNOMED, NDC Nomenclatures

• HL7 Standards (e.g., ADT, VXU, CDA, QRDA)

Categories 1 & 2Transaction-Oriented

PaymentCategories 3 & 4Analytics-Oriented

Payment


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Strategy #2 – Data, Data, Data

• Shifting from Transaction-based payment to Analytic-based payment

• U.S. Core Data for Interoperability (USCDI) List of data to define a common clinical data set

(CCDS) – initially for 2015 Certified EHR Technology (CEHRT)

21st Century Cures Act → Expanding data liquidity

3 ongoing data classes for annual expansion

Supported Data Classes

Candidate Data Classes

EmergingData Classes

USCDI Task Force: https://www.healthit.gov/hitac/committees/us-core-data-interoperability-task-force

MIPS – Composite Performance Score (CPS)

Performance Year /

Application YearQuality Measures

Resource Use or Cost

Improvement Activities

Promoting Interoperability

Programs

DescriptionReplaces CMS Physician Quality Reporting System (PQRS)

Replaces ACA Value‐based Payment Modifier

New category of measurement; Medical Homes and NCQA PCSR receive full credit; 113 activities available

Replaces CMS EHR Incentive Programs f/k/a Meaningful Use

Reporting Methods

Claims*, CSV, Web Interface (for group reporting), EHR, Qualified Clinical Data Registry (QCDR); QualifyingRegistry

ClaimsAttestation, QCDR, Qualified Registry, EHR Vendor

Attestation, QCDR, Qualified Registry, EHR Vendor, Web Interface (groups only)

2017 / 2019 60% 0% 15% 25%

2018 / 2020 50% 10% 15% 25%

2019 / 2021 45% 15% 15% 25%

* In Performance Year 2019, claims-based quality reporting is only available to small group providers (≤ 15 eligible clinicians)


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MIPS – Earning More Than Fee Schedule

0 – 100 Points

2017 Final CPS Score

2019 Year Payment

Adjustment

2018 Final CPS Score

2020 Year Payment

Adjustment

2019 CPS Final Score

2021 Payment Adjustment

≥ 70 Points

• Positive adjustment up to +5%

≥ 70 Points


≥ 75 Points


• Potential Performance Bonus → 0.5% minimum

• Potential Performance Bonus –0.5% minimum

• Potential Performance Bonus → 0.5% minimum

3.1‐69.9 Points

• Positive adjustment 15.1‐69.9 Points

• Positive adjustment 30.1‐74.9 Points

• Positive adjustment

• Ineligible for Performance Bonus



3 Points• Neutral – Fee Schedule Only 15 Points

• Neutral – Fee Schedule Only 30 Points

• Neutral – Fee Schedule Only

0‐2.9 Points• Negative adjustment up to ‐4% (Non‐participation)

0‐14.9 Points

• Negative adjustment up to ‐5% (Non‐participation)

0‐29.9 points

• Negative adjustment up to ‐7% (Non‐participation)

Earn same 2019 Fee Schedule

Earn Less than 2019 Fee Schedule

Earn More than Fee Schedule


2019 QPP Measures

DomainWeight of

CPSPerformance

PeriodOptimum Threshold

Quality Measures 45% Jan. 1 – Dec. 31

• 6 Measures or Specialty Measure Set (Including 1 outcomes measure)

• Groups of 16+ add All‐Cause Readmissions measures

Cost 15% Jan. 1 – Dec. 31

• Total Cost of Care measures

• 10 Measures

– Total Per Capita Cost

– Medicare Spending Per Beneficiary

– 5 Procedure Episode measures

– 3 Acute Inpatient Episode measures

Improvement Activities

15% 90‐days

• 2 High‐weighted activities

• 1 High‐weighted and 2 Medium‐weighted

• 4 Medium‐weighted activities

Promoting Interoperability

25% 90‐days

• 2015 Edition CEHRT & 3 Attestations

• Single measure set tied to 4 objectives

• 2 opioid bonus measures (5 bonus points each)


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Agenda

• VBP Level-Set

• Digital Healthcare



• Questions


Know the 5-Rights of Digital Data Redesign


• Right Information

• Right Person Capturing

• Right Data Format

• Right Technology Channel

• Right Time in the Patient Workflow

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• Providers reporting as individuals and/or as group• Benchmark performance data • Share performance data with providers • Identify potential constraints to success by

specialty, patient type, provider, workflow, etc.• Implement ongoing process improvement• Collaborate with other re: A‐APM positioning

QPP Decision Tree – The Group Practice

Other Payer MACRA Alignment

MIPS or A‐APM? A‐APM

• Identify QPP Quality & Value Measures• Harmonize measures across specialties, if able• Use 5‐Rights of digital data redesign• Determine measure reporting method• Confirm system can produce data• Educate, train staff and providers• Code claims with specificity

• Pinpoint Advantageous QPP Quality & Value Measures

• Use 5‐Rights of digital data redesign• Determine measure reporting method• Confirm EHR system 2015 cert. & abilities• Educate, train staff and providers• Code claims with specificity

OperationsRisk‐Bearing / Contracts

• Understand Value‐based Scoring Calculations• Reporting → Ongoing Performance,

Reconciliation, Appeals process• Population Health Management • Patient Attribution & Risk‐adjustment• System Integration & Payment• Supported through plan Benefit Design?

• Understand Payment Model Type• Recognize flow of risk/reward revenue

and corridors• Define Quality & Value Measures• Terms and Conditions• Negotiation, Execution & Renewal• Plan for Provider On‐boarding & Support

Are you a single or multi‐specialty group? MultiSingle

PlanPlan• Benchmark performance data • Share performance data with providers • Identify potential constraints to success by

patient type, provider, workflow, etc.• Implement ongoing process improvement• Collaborate with other re: A‐APM positioning• Register for Web Interface by June 30, if using

Operationalize

Performance Optimization

MIPS or A‐APM?

Operationalize

MIPS

Provider/Payer InitiationEligibility

• Payers initial first half of year prior to the Qualified Participant Performance Year

• Providers can initial thereafter• Provider qualified participation requires ≥

35% of patients or ≥ 50% of payments made through A‐APM

• APM Nominal Risk Standard Met?• Other Advanced APM (A‐APM)

Requirements Met:– Using certified EHR technology– MIPS‐like quality measures

Other Payers MACRA Alignment

Performance Optimization

MIPS


QPP Decision Tree – The Solo Practice

• Identify QPP Quality & Value Measures• Use 5‐Rights of digital data redesign• Determine measure reporting method• Confirm EHR system 2015 cert. and abilities• Educate, train staff and providers• Code claims with specificity

OperationsOther Payers & MACRA

• Understand Value‐based Scoring Calculations• Reporting → Ongoing Performance,

Reconciliation, Appeals process• Population Health Management • Patient Attribution & Risk‐adjustment• System Integration & Payment• Supported through plan Benefit Design?

• Align model with MACRA statutory, policy requirements

• File Payer/Provider initiated submission paperwork with CMS

• Harmonize measures across payers• Qualified providers require ≥ 35% of

patients or ≥ 50% of payments

Are you MIPS or APM? APMMIPS

Plan

• Benchmark performance data • Share performance data with providers • Identify potential constraints to success by

patient type, provider, workflow, etc.• Implement ongoing process improvement• Collaborate with other re: A‐APM positioning

Operationalize

Alignment & Optimization

Payer Alignment & Optimization

No

• Identify Provider Leaders, Outreach• Pinpoint Mutually Advantageous Quality

& Value Measures • Share Data with Providers, Patients and

Performance

Collaborate• List payer contracts in place today• Benchmark priority performance data

including new compliance data needs• Identify potential constraints to success by

payer type, culture, services patients, etc.

Plan

Plan & Operationalize

Collaborate & Plan Yes

Yes

• Models, Risk-Bearing Corridors• Measures and Provider Participation• Successes and Challenges• Contracting Entities & Terms (e.g., CMS)• Performance Data

Assess

• Culture Change, Internal & External• Identify Champions, Official & Unofficial• Recognize gaps in infrastructure• Open Provider and Payer Communications• Educate Staff and Providers

Modernize

Assess & Modernize

Is it Risk‐Bearing?

Do APMs exist in your market?

NoAre you Exempt?


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QPP Decision Tree – New Practice Providers

MIPS or A‐APM? A‐APMMIPS

No

Medicare enrolled in 2019 for first time?

Yes

Partial QP

TIN 1 duringPerformance Year, TIN 2 during Payment Year Qualifies as QP

Performance Year score will carry to Payment Year with related adjustments

to TIN 2.

MIPSExempt

Check QPP Participation StatusMultiple TINs duringPerformance Year

Low‐volume threshold in either/both TINs?

NoYes

MIPSExempt

MIPS ineligible, 5% bonus as QP + APM rewards

Voluntary Option to submit MIPS data and receive MIPS adjustments

Best Practice: Confirm status of all eligible clinicians using NPI and the CMS Look-up Tool at https://qpp.cms.gov/participation-lookup


Agenda

• VBP Level-Set

• Digital Healthcare



• Questions


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MyHealthEData and Blue Button

• MyHealthEData– Make data available through Blue Button

– Heightened in 21st Century Cures Act

• Blue Button – Branded Icon

– Introduced 2010 – DoD and VA

– Used today by Relay Health, Aetna, UHC and TriCare

– Moving to Blue Button 2.0

– Uses Application Programming Interface (API)


CMS & ONC Proposed Rules – Feb. 11, 2019

• CMS – Interop for Patient Access (~250 pgs.)

– Payers must support electronic exchange of data by 2020

– Working to “standardize data and technical approaches”

– Essence of Digital Healthcare

• ONC – EHR Certification, Interop (~750 pgs.)

– Fast Healthcare Interoperability Resources (FHIR)

– Enable third party software apps

– Digital information available for use by patients, providers, and health plans


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What is a Use Cases?

• Develop Interoperability Use Cases

– Create business model framework

– Identify the problem and the needs (e.g., care coordination, data capture, provider feedback)

– Who has the need? (Actors)

– Map the solution to meet the needs for each actor

– What technology is needed? (e.g., CCDA, Direct Messaging, FHIR)

– Determine financial/operational impact (initial & ongoing costs, workflows)


7 Identified Use Cases

Dual Eligible State‐Federal Data Updates

Daily update frequency

Electronic Notification of Hospital Use

Admissions, discharges, transfers

Provider Directory

In‐network patient navigation, transitions, care coordination

Trusted Exchange Framework

Verifies security and identity, IT agnostic, for nationwide exchange

Coordination Across Payers

• Patients moves from one plan to another

• Est. impact: 125M

Provider Digital Contact Info

• Added to NPPES• Public reporting of names July, 2020


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7th Use Case

• Pricing Transparency – Targets Hospitals

– Posting of Charge-masters

– Patient Cost Estimators

– Moving to make charges “machine-readable”

Facilitate informed decisions for patients

Allow consumers to “shop” for healthcare

• Concerns– Will data be in a format understood by patients?

– Charge-masters do not explain out-of-pocket

– Factors can influence actual services provided and change rates


The Da Vinci Project

• ONC and CMS collaborative with HL7 → Jan. 2018 (10 Payers, 3 EHRs, 6 Providers)

• Includes ONC’s Payer and Provider (P2) FHIR Task Force → Dec. 2017

• Top 3 Priority Use Cases: Coverage requirements discover (CRD), Alerting ADT (e.g., emergency room), and Prior Authorization

• Goal of Prior Authorization → Ease Provider Burden

Government Payers Providers Vendors OtherCMS, ONC Anthem, BCBSAL,

BCBSA, Cigna,

HCSC, Humana,

UnitedHealth

EnableCare, Boston

Children’s Hospital,

Aegis

Imprado,

Optum, Security

Risk Solutions

EHNAC,

HIMSS


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Prior Authorization and Reducing Burden

• Impacting delays and denials of treatment for patients

• Survey by the AMA in late 2017 showed:– Average 29 (14 Rx, 15 medical) prior authorizations/physician/week

– Average 15 hours in administrative labor per physician-clinician/week to complete

– 34% of physicians have a dedicated staff member exclusively administering PA

– 79% repeating PAs for Rx when patient is stabilized on treatment regimen for chronic condition

• Loss in revenue due to time/administration requirements

• Disparate PA types and processes (e.g., by payer)

• Lack of automation/technical solutions

• Use case would use FHIR-enabled algorithms


Emerging Technologies In Healthcare


Leading Edge

Bleeding Edge

Adopting too early

Quitting too early

Adopting too late

Hanging on too long

Source: Gartner Hype Cycle

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Emerging Technologies in Healthcare - Providers

Source: Craft, Jones, Gartner, “Hype Cycle for Healthcare Providers, 2018,” Jul. 2018 © 2018. SS&C Technologies. Confidential

Emerging Technologies in Healthcare - Payers

© 2018. SS&C Technologies. Confidential Source: Cole, Bishop, Cribbs, Gartner, “Hype Cycle for Healthcare Payers, 2018,” Jul. 2018

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Emerging Technologies in Healthcare - Consumers

© 2018. SS&C Technologies. Confidential Source: Cribbs, Gilbert, Gartner, “Hype Cycle for Consumer Engagement With Healthcare and Wellness, 2018,” Jul. 2018

Think Big!

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Adele Allison [email protected]

205.563.2210

@Adele_Allison | Adele Allison

macra: quality maximus valorem - amazon s3 · macra: quality maximus valorem agenda • vbp...

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