macra –the financial & strategic impact for...

1 © 2017 PREMIER, INC.

MACRA – The Financial & Strategic Impact for 2018

Bryan F. Smith, [email protected]


OverviewObjectives:• Learn about key elements of the MACRA legislation• Understand the strategic choices before health systems and the financial ramifications

– MIPS– AAPM– MIPS – APM

• Determine the variables important to your organization

Themes:• MACRA is designed to move providers toward population health and will likely be successful• MACRA has strategic implications and the greatest impact may come from indirect

consequences, not assessed penalties or bonuses• Providers should explore all options and not assume they must default into a given strategic path• Every potential strategic direction, except doing nothing and accepting the maximum penalties,

requires a significant lift


Market Pressures1. Aging Population 2. Significant Spend Increase

15.5%16.0%16.5%17.0%17.5%18.0%18.5%19.0%19.5%20.0%20.5%

$0 $2,000 $4,000 $6,000 $8,000

$10,000 $12,000 $14,000 $16,000 $18,000

National Health Expenditures, per capita

3. Not Fiscally Sustainable 4. Chronic Conditions


Fee For Service Population Health Management

76.… 75.4%67.9%

64.8%61.7%

54.7% 51.3% 49.5%

23.6% 24.2% 25.6% 27.5% 29.1% 30.9% 32.5% 32.2%

0.0% 0.4%6.5% 7.7% 9.2%

14.4% 16.3% 18.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2010 2011 2012 2013 2014 2015 2016 2017

Perc

ent o

f Med

icar

e B

enef

icia

ries

Projection for 2017

TradMAACO

Sources:https://innovation.cms.gov/Files/fact-sheet/nextgenaco-fs.pdfhttp://www.markfarrah.com/healthcare-business-strategy/An-Analysis-of-2017-Medicare-Business-Competition.aspxFFS 2015#: 38 (http://www.cbo.gov/sites/default/files/cbofiles/attachments/44205-2015-03-Medicare.pdf) - 7.9M (the ACO population)= 30.1M ACO 2016 #: 8.9M (http://www.hhs.gov/about/news/2016/01/11/new-hospitals-and-health-care-providers-join-successful-cutting-edge-federal-initiative.html)MA 2015#: 17M (http://www.cbo.gov/sites/default/files/cbofiles/attachments/44205-2015-03-Medicare.pdf)


Better Care. Smarter Spending. Healthier People

Volume to ValueTrack 1:

Value-based payments2016

85% of all Medicare payments

201890% of all Medicare payments

Track 2:Alternative payment models* 30% of all Medicare payments 50% of all Medicare payments

FocusAreas

Incentives

Care Delivery

Information

Description§ Promote value-based payment systems

– Test new alternative payment models– Increase linkage of Medicaid, Medicare FFS, and other payments to value

§ Bring proven payment models to scale

§ Encourage the integration and coordination of clinical care services§ Improve population health§ Promote patient engagement through shared decision making

§ Create transparency on cost and quality information§ Bring electronic health information to the point of care for meaningful use


The MACRA Challenge

The MACRA legislation was made into law in 2015, Interim Final regulations were released in October of 2016 and thefirst performance periodbegan in January, 2017

The short time span between rulemaking and

implementation, and the lack of high quality data, means

providers must make decisions with less than

perfect information

“MACRA is the burning platform for progress in care delivery, just as the ACA was in health care coverage,”

- Andy Slavitt, former Acting Administrator of CMS


Health systems which build Advanced APMs may have some employed clinicians

remain in MIPS

Independent physicians, may feel threatened by MIPS

and drawn toward AAPMs, with or without hospital partners

MACRA & MIPS= incentive movement toward

population health; a carrot, not a stick

Simply understandingMIPS and successfully reporting

will be a major driver of performance in the early years

7

The AAPM bonus may not equal the total cost of

developing a two-sided risk ACO

Track 1+ contains lessrisk than Tracks 2 & 3, but has no more upside potential than

Track 1

consequence of lowering specialty physician participation

MACRA, by itself does not change the underlying economics of health system management but is a potential tool for physician alignment

AAPMs may have unintended

MACRA Readiness – Early Observations


MACRA Reform Timeline(Medicare Access And CHIP Reauthorization Act Of 2015)

*Pay for reporting will continue past 2018 for eligible professionals that are unable to participate in MIPS, however this group has yet to be defined.

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Permanent repeal of SGRUpdates in physician payments

MIP

S Tr

ack 2018

4%

2026

0.5% (7/2015-2019) 0% (2020-2025)

AA

PM

Trac

k

Measurement period

Measurement period

2017-3.0%

Advanced APM participating providers exempt from MIPS; receive annual 5% bonus (2019-2024)

Merit-Based Incentive Payment System (MIPS) adjustments 2019+/-4%

2020+/- 5%

2021+/- 7%

2022 & beyond+/- 9%

MIPS exceptional performance adjustment; ≤ 10% Medicare payment (2019-2024)

0.75% update

0.25% update

Measurement period Non-Advanced APM participating in MIPS with enhanced scoring and reporting; Potential to move to AAPM

0.25% update

MIP

S A

PM

Trac

k

PQRS Meaningful UseValue-based Payment Modifier


Thinking Strategically About MACRA

MIPSMIPS +

Non-QualifiedAlternative Payment

Model (APM)

Advanced Alternative

Payment Models(AAPM)

Providers who do not meetexclusion criteria and are not

part of an APM

Providers participating in a non-Advanced APM or partially qualified QPs

Providers participating in an Advanced APM and meet

volume thresholds

TOTAL MIPS TRACK TOTAL NON-QUALIFIEDAPM TRACK

TOTAL QUALIFIEDAPM TRACK

57% of organizations change the preliminary strategic direction after an assessment – with 75% deciding to take less risk than originally thought


MIPS TRACK

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Measurement period

Merit-Based Incentive Payment System (MIPS) adjustments

2019+/-4%

2020+/- 5%

2021+/- 7%

2022 & beyond+/- 9%


MIPS: Eligible Clinicians – Proposed 2018

§ Exclusions• New Medicare-enrolled eligible clinicians

• Enrolled during the performance year• Not previously part of a group or billing under a different TIN• Eligibility determined quarterly

• Clinicians below the low-volume threshold• $90,000 or less in charges OR• Provides care to 200 beneficiaries or fewer• Allow opt-in beginning in 2019• Seeking comments on a threshold based on items and

services provided (e.g. patient encounters or procedures)• Qualifying/ Partial Qualifying Advanced

APM Participants

• Non-Patient Facing MIPS ECs• Individuals: 100 or fewer patient-facing

encounters• Groups/Virtual Groups: More than 75% of NPIs in

TIN meet the individual threshold• Determination made in two-segment analysis

§ ASC/HHA/Hospice/HOPD: MIPS adjustment does not apply to facility payment

• CAHs: MIPS adjustment applies but not to facility payment

• RHC/FQHC: MIPS adjustment does not apply

Years 1 and 2

§ Physician, § Physician Assistants, § Nurse Practitioners, § Certified-Nurse Specialists, § Certified Registered Nurse Anesthetists

Years 3+ (potential)

§ Physical or occupational therapist, § Speech-language pathologists, § Audiologists, § Nurse midwives, § Clinical social workers, § Clinical psychologists, § Dieticians, § Nutritional professionals


60%

0%

15%

25%

Merit-based Incentive Payment System (Current Law)

50%

10%

15%

25%

2019

30%

30%15%

25%

Quality — PQRS Measures, PQIs (Acute and Chronic), Readmissions

Cost— MSPB, Total Per Capita Cost, Episode Payment

Advancing care information — Meaningful Use Objectives and Measures

Improvement activities — Expanded access, population management, care coordination, beneficiary engagement, patient safety, social and community involvement, health equity, emergency preparedness, behavioral and mental health integration and Alternative payment models.

• Sets performance targets in advance, when feasible

• Sets performance threshold at 3; median or mean in later years.

• Improvement scores in later years

Merit-Based Incentive Payment System (MIPS) adjustments 2019+/-4%

2020+/- 5%

2021+/- 7%

2022 & beyond+/- 9%

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

PerformancePeriod 1


2020 2021

Any continuous 90-days in CY 2017 is performance period

for CY 2019

CY 2018 is performance period

for CY 2020. Cost/quality- Full

year; ACI/Improvement-

any 90 days


Example of Health System MIPS Potential Impact:Asymmetrical Risk Corridor for 5 Years

Potential Penalty Potential Bonus

?


CMS Predictions on MACRA Impact (Pre-Revision)


MIPS Reporting Options for 2017

Do not submit data for 2017

• Automatic -4% payment adjustment

Submit minimal data for 2017

• 1 quality; 1 Improvement Activities (IA); or 4/5 required Advancing Care Information (ACI) measures

Submit partial data for 2017

• 1+ quality; 1+ IA; • or 5+ required ACI

measures• 90-day minimum• Possible + adjustment

Submit full data for 2017

• Full quality, IA, and ACI• Full 90 days, ideally full

year• Maximize + adjustment

Downward Payment

AdjustmentUpward Payment Adjustment

(based on performance)Zero

Payment Adjustment


MIPS Overview - Proposed 2018

60%

0%

15%

25%

60%

0%

15%

25% 30%

30%

15%

25%

2019 2020 2021

Quality — PQRS Measures, Readmissions

Cost — MSPB, Total Per Capita Cost, Episode-based spending measures

Advancing care information — Modified Meaningful Use Objectives & MeasuresImprovement activities — Expanded access, population management, care coordination, beneficiary engagement, patient safety, social and community involvement, health equity, emergency preparedness, behavioral and mental health integration and Alternative payment models

• Sets performance targets in advance, when feasible

• Sets performance threshold at 3; 15 in 2020 and median or mean in later years.

• Improvement scores for cost and quality in 2020 and beyond


Proliferation of Medicare ACOList of 69 ACOs on Following Pages

MSSPTrack1MSSPTrack3NGACO


Medicare ACOs on Map# on Map Name City State Track Start Date # Beneficiaries

1 Illinois Health Partners ACO, LLC Downers Grove IL 1 2014 66,8702 UCMCNACO, LLC Chicago IL 1 2017 2017 Starter3 Springfield Clinic ACO, LLC Springfield IL 1 2015 11,9614 AMITA Health Accountable Care Organization, LLC Arlington Heights IL 1 2013 40,4125 Advocate Physician Partners Accountable Care, Inc. Rolling Meadows IL 1 2012 149,6336 Independent Physicians' ACO of Chicago LLC Chicago IL 1 2013 15,0447 Medicare Value Partners Des Plaines IL 1 2013 35,8368 CHS ACO Westmont IL 1 2012 9,4339 HSHS ACO, L.L.C. Springfield IL 1 2016 2016 Starter10 CHWN ACO Crystal Lake IL 1 2015 12,69111 IL-RCCO Princeton IL 1 2015 14,19312 Northwestern Medicine Physician Partners ACO Oak Brook IL 1 2015 19,09513 Primaria ACO, LLC Chicago IL 1 2017 2017 Starter14 VillageMD New Hampshire ACO, LLC Chicago IL 1 2017 2017 Starter15 Christie Clinic Physician Services, LLC Champaign IL 1 2013 6,10716 Ingalls Care Network, LLC Harvey IL 1 2014 5,78517 Franciscan AHN ACO, LLC Mishawaka IN 1 2012 31,62218 Franciscan Union ACO Indianapolis IN 1 2013 15,47019 Franciscan Alliance ACO Indianapolis IN 1 2015 60,20320 Indiana Care Organization LLC Indianapolis IN 1 2013 9,71121 American Health Network of Ohio PC Indianapolis IN 1 2013 7,36222 Franciscan Riverview Health ACO Mishawaka IN 1 2015 5,54823 South Bend Clinic Accountable Care South Bend IN 1 2014 7,99324 Indiana Lakes ACO Goshen IN 1 2013 8,14125 Reliance ACO LLC Farmington Hills MI 1 2014 21,88126 POM ACO Ann Arbor MI 1 2013 135,45527 McLaren High Performance Network, LLC Auburn Hills MI 1 2017 2017 Starter28 USMM ACCOUNTABLE CARE PARTNERS, LLC Troy MI 1 2015 16,41129 Physician Direct Accountable Care Organization LLC Sylvan Lake MI 1 2014 8,60530 Prime Accountable care , LLC Southfield MI 1 2016 2016 Starter31 SEMAC Dearborn MI 1 2012 12,30932 Oakwood Accountable Care Organization, LLC Dearborn MI 1 2012 12,610

MSSPTrack1


# on Map Name City State Track Start Date # Beneficiaries33 The Accountable Care Organization, Ltd. Farmington Hills MI 1 2014 28,54334 GGC ACO, LLC Flint MI 1 2014 6,45635 Federation ACO, LLC Portage MI 1 2017 2017 Starter36 Genesys PHO, L.L.C. Flint MI 1 2015 16,56137 Northern Michigan Health Network Traverse City MI 1 2014 20,02138 PMC ACO Flint MI 1 2014 7,06039 UOP ACO, LLC Dearborn MI 1 2017 2017 Starter40 Trillium Health, LLC Traverse City MI 1 2017 2017 Starter41 Connected Care, LLC Port Huron MI 1 2015 8,61542 NewHealth Collaborative Akron Ohio 1 2012 27,20543 Integrated Health Collaborative, LLC Canton Ohio 1 2016 2016 Starter44 ProMedica Health Network, Inc. Toledo Ohio 1 2016 2016 Starter45 NOMS ACO, LLC Sandusky Ohio 1 2013 6,67546 Cleveland Clinic Medicare ACO, LLC Independence Ohio 1 2015 64,54147 University Hospitals Coordinated Care Organization Shaker Heights Ohio 1 2012 55,28248 Healthcare Solutions Network Cincinnati Ohio 1 2017 2017 Starter49 Adena Healthcare Collaborative, LLC Chillicothe Ohio 1 2015 8,58350 OICP Zanesville Ohio 1 2016 2016 Starter51 Cleveland Quality Healthnet Richmond Heights Ohio 1 2014 5,41652 Northwest Ohio ACO, LLC Toledo Ohio 1 2013 14,43753 Mercy Health Corporation Janesville WI 1 2014 11,31954 Marshfield Clinic, Inc. Marshfield WI 1 2013 31,54755 UW Health ACO, Inc. Madison WI 1 2013 29,280

Medicare ACOs on Map


# on Map Name City State Track Start Date # Beneficiaries1 OSF Healthcare System Peoria IL 3 2017 2017 Starter2 CHA ACO, LLC South Bend IN 3 2014 13,7033 Trinity Health Integrated Care Livonia MI 3 2017 2017 Starter4 Mercy Health Select, LLC Cincinnati OH 3 2012 74,2135 MetroHealth Care Partners Cleveland OH 3 2014 9,9256 Aurora Accountable Care Organization LLC Milwaukee WI 3 2017 2017 Starter

# on Map Name City State 1 Indiana University Health Indianapolis IN2 Trinity Health ACO Inc. Livonia MI3 Michigan Pioneer ACO, LLC Southfield MI4 Henry Ford Physician Accountable Care Organization Detroit MI5 Premier Health ACO of Ohio Dayton OH6 ProHealth Solutions, LLC Waukesha WI7 Bellin Health DBA Physician Partners, Ltd. (PPL) Green Bay WI8 ThedaCare ACO LLC Appleton WI

MSSPTrack3

NGACO

Medicare ACOs on Map


Advanced APM Tracks

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Measurement period APM participating providers exempt from MIPS; receive annual 5% bonus (2019-2024)

0.75% update(2026à)


Inclusion in Advanced APMs

triggers exclusion from MIPS.

Advanced APM participating providers exempt from MIPS; receive annual 5% bonus (2019-2024)

.75% update 2026 Tr

ack

2

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

1 | Use certified EHR technology,

2 | Pay based on MIPS comparable measures

• Total payments exclude payments made by the Secretaries of Defense/Veterans Affairs and Medicaid payments in states without medical home programs or Medicaid APMs.

* Minimum of 25% of Medicare payments must be in APM, unless partial qualifying at 20% with no 5% bonus and a choice of MIPS

Threshold of payments in an Advanced APM:

Measurement period

Greater update

vs. Track 1

program

3 | Bear more than “nominal” financial risk for losses

Advanced Alternative Payment Models (APM) Entities must:

Advanced APM Overview


What Qualifies for Advanced APM

Comprehensive ESRD Care (CEC)

Comprehensive Primary Care Plus (CPC +)

Medicare Shared Savings Program tracks 2 & 3*

Next Generation ACO Model

Oncology Care Model (OCM) two-sided risk arrangement

Proposed for 2018• Medicare Shared Savings Program track 1+*• Comprehensive Care for Joint Replacement• New voluntary bundled payments program

* Known to Have Upcoming Open Enrollment & Encompasses Majority of Medical Staff


POTENTIAL IMPACT OF MSSP – 2 SIDED RISK

Theoretical Best

Theoretical Worst

Market Average

HighMarket Average

Low

Beneficiary Years 40,045 40,045 40,045 40,045

Expenditure Target* 488,268,685$ 488,268,685$ 488,268,685$ 488,268,685$

Actual Expenditures 347,354,202$ 726,836,446$ 469,226,206$ 516,100,000$ % Savings / Loss (2%) 28.9% -48.9% 3.9% -5.7%

Savings / Losses 140,914,483$ (238,567,761)$ 19,042,479$ (27,831,315)$

Quality Scores** 92.4% 92.4% 92.4% 92.4%

Sharing Rate 69.3% 30.7% 69.3% 30.7%

Savings / Loss Due 97,653,737$ (73,240,303)$ 13,196,438$ (8,544,214)$ % of Target 20.0% -15.0% 2.7% -1.7%*Expenditure target = weighted average of CA ACO's; **National Average

Attachment Point* 5.8% 5.8% 5.8% 5.8%

Reinsurance Covers 0$ (44,920,719)$ 0$ 0$

ACO Responsibility 0$ (28,319,584)$ 0$ (8,544,214)$

Est. Rein. Premiums ($200K - $2M) ($200K - $2M) ($200K - $2M) ($200K - $2M)

Net Impact $97.5M - $95.7M ($28.5M - $30.3M) $13.0M - $11.2M ($8.7M - $10.5M)

*Based upon interviews with providers & insurance companies. Wide variation seen

Performance if Operating as MSSP Track 3


Example: ACO Performance in Arkansas

ServiceArea CountofACOs

EarnedSharedSavings

%AchievedSharedSavings

WeightedAverageSavings%

Arkansas 3 0 0.0% -1.540%ArkansasandOtherStates 6 0 0.0% -1.543%Combined 9 0 0.0% -1.543%

ACOName Savings% GeneratedSavings

EarnedSharedSavings

ArkansasHealthNetworkLLC 0.1% $189,813ArkansasAccountableCare,LLC -2.5%ArkansasHighPerformanceNetworkACOofCAH -4.3%

MultiStateServiceAreaMercyACO,LLC 0.3% $817,302AledadePrimaryCareACOLLC -0.3%CentralUSACO,LLC -0.3%ArkansasHIghPerformanceNetworkACO,LLC -1.4%MercyHealthACO,LLC -2.4%ArkansasHighPerformanceNetworkACOofFQHC,LLC -8.9%


Lift to Maintain AAPM Status

NumberofProviders

%ofMedicareFFSinACO

%Meeting2019Criteriaw/Medicare

MinimumCommercialRisk

NeededInternalMedicine 23 62% 70% 972,900$FamilyPractice 14 37% 29% 1,090,716$Cardiology 8 27% 38% 673,572$Orthopedics 6 16% 17% 1,587,144$GeneralSurgery 5 15% 20% 830,358$Pulmonology 5 15% 0% N/AOncology 4 30% 25% 923,572$Urology 3 22% 0% 605,358$Nephrology 3 35% 0% 1,355,358$InfectiousDisease 2 8% 0% N/ATotal 73 37.2% 36% 8,038,978$

It would require a disproportionate amount of commercial risk to help these 9 providers qualify for AAPM status – consider moving from Track 3 ACO


Conduct Contracting Assessment First

Artificially lowers benchmark; Need to be attributed or benchmark

raised

Convert to 3 year period

Too long a gap to engage providers

PopulationHealthManagementCollaborative

Pre-assessmenttermsrequest:

Topic Question PayerContract1 PayerContract2

BasicCharacteristics

Whichpayer/healthplanisthisagreementwith? XXXXXXX XXXXXXX

Whatwastheinitialstartdateofthisagreement? 1/1/17 6/1/15

Whendoesthisagreementexpire/renew? 1/1/20 Evergreen

Whatpopulationisthisagreementfor(i.e.MedicareAdvantage,Commercial,ManagedMedicaid)?

Commercial MedicareAdvantage

Howmanybeneficiariesarecovered/attributedunderthisagreement? 60,000 20,000

PopulationAttribution

Howarepatientsattributedtoyourproviders? PCPAttribution/Claims PCPattribution/Claims

IfaPPOproduct,howlongis“lookback”periodforpatientassignment? 24months 12months

Whathappensifanassignedmemberdoesnothaveanyclaimshistory? NoattributiontoACO NoattributiontoACO

PerformancePeriodReconciliationSavingsTermsandMethodology

Howlongisthe“runout”periodfollowingtheperformanceperiod?90days? 7months 8months

Howlongistheauditandfinaldistributionperiod? Notdefined Notdefined

Whatisthepercentagesplitbetweenthehealthplanandyourorganizationforanysavings?

40%ACO/60%XXXX-Qualityimpactssavings

50%ACO/50%XXXX–Qualityimpactsavings


MIPS – APM Track

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Measurement period

Merit-Based Incentive Payment System (MIPS) adjustments

2019+/-4%

2020+/- 5%

2021+/- 7%

2022 & beyond+/- 9%



CMS Preliminary Rule

The Intersection of MSSP and MIPS

Quality: 50%• Measures reported by APM• Shared Savings Program ACOs submit quality measures to the CMS Web Interface

on behalf of their MIPS eligible clinicians• The MIPS quality performance category requirements and benchmarks will be used to

determine the MIPS quality performance category score at the ACO level

Advancing Care Information: 30%• All MIPS eligible clinicians participating in the APM entity group submit through this category according to the

MIPS requirements• Their performance is assessed as the weighted average score for TINs, which will yield one ACO group score

Improvement Activities: 20%• All MIPS eligible clinicians participating in the APM entity group submit through this category according to the MIPS

requirements• They automatically receive half the points• Models awarded full points: Shared Savings, Next Gen, Comprehensive ESRD Care, Oncology Care Model, CPC+• Their performance is assessed as the weighted average score for TINs, which will yield one ACO group score

Cost: 0%• Not Assessed


Results from First 25 Assessments

MIPS12%

APM-MIPS56%

Advanced APM32%

40% of clients believe they have reached a conclusion before the assessment begins

Of those, 60% change course after seeing the numbers


Key Variables to Consider

• Ability to report and perform under MIPS• If referral sources can report and perform, and what they might do if not

• Financial impact of bonuses or penalties under MIPS and Advanced APMs• If those funds will flow to the individual providers or stay at the group level

• When will other payers move to Value Based Purchasing, including shared risk• Ability to succeed (or at least not lose money) in an Advanced APM• How the organization could use the federal waivers associated with some APM’s

to better align with providers• Where this aligns with the organization’s Medicare / population health strategy


Next Steps Depend Upon Strategy

• Educate all providers on MIPS• Monitor and enhance employed provider performance on MIPS• Provide or help with reporting solutions for independent providers• Begin work on performance of second tier of participating providers starting in year 3

MIPS

• Begin development of APM• Approach independent providers that may be interested in joining• Conduct market assessment to identify areas of high utilization• Join Premier’s Population Health Collaborative• Monitor and enhance performance on MIPS/ APM measures

MIPS-APM

• Select model & Conduct due diligence• Begin development of AAPM• Define network of providers• Consider development of additional MIPS-APM to create glide path for providers new to pop health• Determine organizational ability to assume risk and need for reinsurance• Identify all payer contracts that will help with AAPM qualification and develop action plan

Advanced APM

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QUESTIONS?


Bryan Smith, [email protected]

www.PremierInc.com


10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

10% 0.1% 0.2% 0.3% 0.4% 0.5% 0.5% 0.6% 0.7% 0.8% 0.9%

20% 0.2% 0.4% 0.5% 0.7% 0.9% 1.1% 1.3% 1.4% 1.6% 1.8%

30% 0.3% 0.5% 0.8% 1.1% 0.4% 0.6% 0.9% 2.2% 2.4% 2.7%

40% 0.4% 0.7% 1.1% 1.4% 1.8% 2.2% 2.5% 2.9% 3.2% 3.6%

50% 0.5% 0.9% 1.4% 1.8% 2.3% 2.7% 3.2% 3.6% 4.1% 4.5%

60% 0.5% 1.1% 1.6% 2.2% 2.7% 3.2% 3.8% 4.3% 4.9% 5.4%

70% 0.6% 1.3% 1.9% 2.5% 3.2% 3.8% 4.4% 5.0% 5.7% 6.3%

80% 0.7% 1.4% 2.2% 2.9% 3.6% 4.3% 5.0% 5.8% 6.5% 7.2%

90% 0.8% 1.6% 2.4% 3.2% 4.1% 4.9% 5.7% 6.5% 7.3% 8.1%

100% 0.9% 1.8% 2.7% 3.6% 4.5% 5.4% 6.3% 7.2% 8.1% 9.0%

% of Organization’s Total Revenues from Eligible Providers’ Fees%

of E

P’s

Rev

enue

from

FF

SM

edic

are

MIPS’ Maximum Penalty on Organization’s Total Revenues


• Exclusions from MIPS:• New Medicare-enrolled eligible clinicians

• Enrolled during the performance year• Not previously part of a group or billing

under a different TIN• Eligibility determined quarterly

• Clinicians below the low-volume threshold• Less than $30,000 in charges OR• Provides care for fewer than 100

beneficiaries• Determination is at reporting level

MIPS: Eligible Clinicians

• Physical or Occupational Therapist,

• Speech-Language Pathologists,

• Audiologists,

• Nurse Midwives,

• Clinical Social Workers,

• Clinical Psychologists,

• Dieticians & Nutritional Professionals

• Qualifying/Partial Qualifying Advanced APM Participants

• Non-Patient Facing MIPS ECs• Individuals: bill 100 or fewer patient-

facing encounters• Groups: More than 75% of NPIs under the

TIN meet the individual threshold• Practitioners at only RHCs or FQHCs

• Physician,• Physician Assistants,• Nurse Practitioners,• Certified-Nurse Specialists,• Certified Registered Nurse Anesthetists

Years 1 and 2 Years 3+


Retain Options & Create Time: MSSP & Track 1+

• If you do not submit a Notice of Intent to Apply by end of May, you will need to wait a full year to apply, reducing your options for 2018 reporting

• Completing the NOIA typically takes less than an hour of work

• Between May 1st and Noon ET on May 31st, go to the following website and click the link to the online NOIA (Notice of Intent to Apply):

– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Application.html

• Submitting the NOIA does not compel the organization to apply, but if a NOIA is not filed by the deadline, the organization will lose the option to start a MSSP or Track 1+ ACO for a full year

• There are additional requirements throughout the year to complete an application and organizations do not have to make a commitment until the contract is signed in December

Contact [email protected] with any questions about the application process


Medicare ACOs: 26% - 50% Success


Healthcare Implications

There is no new money

Increased strength of large physician groups

Continued growth of value-based payment models, including MACRA

Increased market competition for device and pharmaceuticals

Increased state control

Continued push toward consumer-driven healthcare

Growth in, and increased competition for, Medicare Advantage, private health plans

1

2

3

4

5

6

7


ACOs in Texas

Sources: 2017_Medicare_Shared_Savings_Program_Organizations; Next_Generation_ACO_Models; Definitive Healthcare; Google My Maps

MSSPTrack1MSSPTrack2MSSPTrack3NGACOESRDModel

• 46 Texas Medicare ACO’s in 2017:• 33 MSSP Track 1 (not Advanced APM)• 1 Track 2• 6 Track 3• 3 NextGen• 3 ESCO

• Of the 37 ACOs active in 2015, 14 (38%) generated $135 Million in shared savings payments for 2015;

• Of those an estimated 70% were formed by independent physician groups


List of ACOs on Map#onMap ACOName City #onMap ACOName City

5 AmarilloLegacyMedicalACO Amarillo 11 CHRISTUSHealthQualityCareAlliance(AKACPGQualityCareAlliance)Irving15 EssentialCarePartnersACO Austin 32 USMD-MedicalClinicofNorthTexas(MCNT) Irving17 IntegratedACO Austin 24 PrimeCareManagers Longview25 SetonAccountableCareOrganization Austin 2 CovenantACO Lubbock6 SunshineACO Brownsville 4 AlliedProvidersACO Lufkin27 StJosephHealthPartnersACO Bryan 5 RioGrandeValleyHealthAlliance McAllen22 PremierCareCommunity Carrollton 20 MHT-ACO(AKAACOProvidersofAustin) McKinney23 PremierPatientHealthcare Carrollton 14 EastTexasAccountableCareOrganization Nacogdoches7 BaylorScott&WhiteQualityAlliance Dallas 26 ShannonClinic SanAngelo19 MethodistPatientCenteredACO Dallas 6 BaptistIntegratedPhysicianPartners SanAntonio30 TXCIN Dallas 31 UPSAACO SanAntonio1 BaptistAccountableCare Dallas 1 FreseniusSeamlessCareofCentralTexas SanAntonio2 UTSouthwesternAccountableCareNetwork Dallas 16 GHNACO Seguin3 FreseniusSeamlessMedicalCareofDallasLLC Dallas 13 Collom&CarneyClinicACO Texarkana4 RGVACOHealthProviders Donna 2 ACOProviders TexasCity3 AllianceACO Gonzales 29 TrinityMotherFrancesCARECovenant(FKACareCompact)Tyler9 BuenaVidaySaludACO Harlingen 10 Care4Texans Waco33 VOPAccountableCare Harlingen 28 TexomaACO WichitaFalls1 AccountableCareCoalitionOfTexas Houston8 BaylorStLukesHealthNetworkACO Houston MSSPTrack112 ChrysalisMedicalServices Houston ESCO18 MemorialHermannAccountableCareOrganization Houston MSSPTrack221 PhysiciansACO Houston MSSPTrack31 AccountableCareCoalitionofNorthTexasLLC Houston NextGen3 HoustonMethodistCoordinatedCare Houston1 AccountableCareCoalitionofSoutheastTexasInc Houston3 AccountableCareCoalitionofChesapeake,LLC Houston2 FreseniusSeamlessCareofHouston Houston

macra –the financial & strategic impact for...

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