macra year 2 - hfma texas gulf coast€¦ · 2018, including implementation of the medicare access...

MACRA Year 2

Moving out of the Transition Period and Into RealityFebruary 16, 2018

Medicare Access and CHIP Reauthorization ActCopyright © 2018 Deloitte Development LLC. All rights reserved. 2

February 16, 2018: Where are we in MACRA implementation?

The 2018 performance year is underway. Cost will take effect for the first time, accounting for 10% of the MIPS performance score.

1Clinicians face a March deadline to report MIPS data for 2017.2

The President on February 9, 2018, signed into law a bill that includes targeted technical changes to MIPS.

3The first performance year under the All-Payer Combination Option will begin January 1, 2019.

4


With the repeal of the Sustainable Growth Rate (SGR) formula, MACRA sets updates to the Medicare physician fee schedule (PFS) for all years in the future. The Bipartisan Budget Act (BBA) of 2018 made one change.

Payment updates under MACRA

2016:0.5%

2017: 0.5%

2018: 0.5%

2019: 0.25%

2020: 0%

2021: 0%

2022: 0%

2023: 0%

2024: 0%

2025: 0%

2026+: 0.75%

2026+: 0.25%

PFSUpdates

Non-QPs

APMQPs

Source: Public Law 114-10 (April 16, 2015); Public Law 115-123 (February 9, 2018)

Under MACRA’s Quality Payment Program (QPP), clinicians have two distinct paths for payments under the PFS going forward:

Advanced Alternative Payment

Models (APMs)

• Risk-based, care coordination models

• For Qualifying Participants (QPs), temporary

bonuses from 2019-2024 (5% of Medicare PFS

payments)

• Increasing thresholds for QP status over time

• All-Payer Combination Option begins in

performance year 2019

• Consolidates Meaningful Use, Physician Quality

Reporting System (PQRS) and Value-based Modifier

• Budget-neutral payment adjustments based on

clinician performance

• +/-4% for 2019, progressively increasing to +/-

9% for 2021 and subsequent years

• For 2017, it is expected that approximately

85% of providers eligible for MACRA will have

participated in MIPS

Merit-based Incentive Payment

System (MIPS)

2019 fee schedule update reduced by BBA from 0.5% to 0.25%


The Centers for Medicare & Medicaid Services (CMS) estimates that MIPS payment adjustments for 2019 will be +/- $118 million, while APM incentives will be between $675 million and $900 million for the 2020 Payment Year. Leadership will play critical roles as organizations engage with clinicians with different incentives under the QPP.

The Quality Payment Program by the numbers

1,548,022

81,954540,347

70,732 17,694

621,700

All Medicareclinicians billing

Part B

Newly enrolledclinicians

Low-volumethresholdclinicians

APM QualifyingParticipants

(QPs)

Excludedclinicians who

previouslysubmitted

measures groupsunder 2016

PQRS

MIPS eligibleclinicians

Exempt from MIPS Reporting

Projected participation in the Quality Payment Program for the 2018 performance year

Note: CMS counts clinicians as unique combinations of Tax Identification Number (TIN) and National Provider Identifier (NPI).Source: Final Rule with Comment Period on Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive (November 16, 2017).


The Bipartisan Budget Act of 2018 gives the HHS Secretary until 2022 to increase the weight of the MIPS Cost measure from 10% to 30% of the overall MIPS composite score.

MIPS Scoring for Performance Years 2017–2021

25% 25% 25% 25% 25% 25%

15% 15% 15% 15% 15% 15%

10%At least

10%

At least

10%At least

10%

30%

60%50% 30% 30%

30% 30%

2017 2018 2019 2020 2021 2022

Components of MIPS Score in Performance Years 2017–2022

Advancing Care Information Improvement Activities Cost Quality

For 2019 through 2021, the HHS Secretary has the authority to set the weight of the Cost category

between 10% and 30%, and adjust the weight of the Quality category proportionately

Source: Public Law 114-10 (April 16, 2015); Public Law 115-123 (February 9, 2018)


The Bipartisan Budget Act of 2018 gives the HHS Secretary the option of setting the MIPS threshold score at less than the mathematic mean of MIPS performance scores through performance year 2021.

MIPS Performance Threshold for 2018

Source: Final Rule with Comment Period on Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive (November 16, 2017).

For 2018, CMS projects

that fewer than 3% of

MIPS eligible clinicians

will receive negative

payment adjustments

For 2018, CMS

projects that more

than 97% of MIPS

eligible clinicians

will receive positive

or neutral payment

adjustments, with

nearly 75%

qualifying for a

positive payment

adjustment with

exceptional payment

adjustment.


Requirements for Advanced APMs

Source: Public Law 114-10 (April 16, 2015), CMS, Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR), July 2016

Current qualifying Medicare Advanced APMs

1. Bundled Payments for Care Improvement-Advanced (BPCI-Advanced)

2. Medicare ACO Track 1+ [downside risk]

3. Medicare Shared Savings Program (MSSP) Track 2 [downside risk]

4. Medicare Shared Savings Program (MSSP) Track 3 [downside risk]

5. Next Generation Accountable Care Organization (ACO) Model

6. Comprehensive Primary Care Plus (CPC+)

7. Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) - Large Dialysis Organization (LDO) arrangement

8. Comprehensive ESRD Care Model (non-LDO arrangement)

9. Oncology Care Model (OCM) two-sided risk arrangement

10. Comprehensive Care for Joint Replacement (CJR)* Bundle

11. Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

Available for 2018


20%

35%

50%

10%

25%

35%

0%

20%

40%

60%

80%

100%

2017 2018 2019 2020 2021 2022

Performance year

QP Patient Count Thresholds

The threshold for QP status in advanced APMs increases dramatically in just 5 years. Many organizations are looking to the Other Payer Advanced APM option beginning in the 2019 performance year

Getting into the advanced APM track – and staying there

25%

50%

75%

20%

40%50%

0%

20%

40%

60%

80%

100%

2017 2018 2019 2020 2021 2022

Performance year

QP Payment Amount Thresholds

Source: Public Law 114-10 (April 16, 2015)

Qualifying participant (QP) Partial qualifying participant Other payer model begins


Qualifying Participant (QP) Determination Tree for Medicare, All Payer Combination Options

N

Is Medicare Threshold Score >= 75%?

QP


Is All-Payer Threshold Score >= 75%?


Is All-Payer Threshold Score >= 50% OR is Medicare Threshold Score >= 50%?

MIPS EP

QP

QP

MIPS EP

Y

N

Y

N

Y

N

Y

Y

N


QP


Is All-Payer Threshold Score >= 50%?


Is All-Payer Threshold Score >= 40% OR is Medicare Threshold Score >= 40%?

MIPS EP

QP

MIPS EP

Y

N

Y

N

Y

Y

N

Y

N

Partial QP

Performance years 2019–2020

Performance years 2023 and later


Is Threshold Score >= 25%?

QP

Y

N

Y

N Partial QP

MIPS EP

Performance years 2017–2018

All-Payer Combination Option

Medicare Option

N


CMS posts list of Other Payer APMs in Medicaid and MA for

2019 performance

year

Draft Medicare

Advantage Call Letter

Final Medicare

Advantage Call Letter

Beginning of first

performance year under All Payer

Combination Option

January 2018

February 2018

April 2018

May 2018

June 2018

September 2018

January 2019

Key Dates under the All-Payer Combination Option

April – June: Submission period for Medicare Advantage plans to be considered Other Payer AAPMs

January 1 - April 1:Submission period for states to submit Medicaid arrangements to CMS to be considered Other Payer AAPMs

// //

January – June:

First CMS Multi-payer Model submission period


Senior Manager | Regulatory Services, Life Sciences & Health Care

Daniel Esquibel

Profile

Daniel is a Deloitte Advisory Senior Manager at Deloitte & Touche LLP. Building off of more than 17 years of experience in the health care industry, Daniel works with health care providers, health plans, investors and other stakeholders to identify factors that will drive health care in the future. He helps stakeholders evaluate and plan for strategic risks and opportunities based on insights and analysis of government and private sector data; market trends; and political, legislative and regulatory issues affecting the health care industry.

Daniel is actively monitoring the legislative and regulatory agenda for health care and life sciences for 2018, including implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the 21st Century Cures Act, and the Tax Cuts and Jobs Act of 2017. In addition, Daniel is tracking regulatory changes to Medicaid, Medicare Advantage, the Program for All-Inclusive Care for the Elderly (PACE), as well as policies from the Center for Medicare and Medicaid Innovation (CMMI).

Prior to joining Deloitte Advisory, Daniel spent five years at a global professional services firm advising organizations on the implementation of the Affordable Care Act (ACA), including issues related to eligibility for premium tax credits and Medicaid, the employer mandate, and health insurance market reforms. He authored detailed analyses of the major ACA regulations from the Department of Health and Human Services, the Department of the Treasury, the Internal Revenue Service, and the Department of Labor. Daniel’s career in professional services builds off of 10 years of experience in strategic research and policy analysis at a research, technology, and consulting firm focused on the health care industry.

Daniel regularly speaks and writes on health care regulatory and legislative issues.

Education

▪ B.A., History - University of Pennsylvania

Daniel Esquibel

555 12th Street NW, Suite 400Washington, DC, 20004Phone: +1 202 578 0507Email: [email protected]

As used in this document, “Deloitte Advisory” means Deloitte & Touche LLP, which provides audit and enterprise risk services; Deloitte Financial Advisory Services LLP, which provides forensic, dispute, and other consulting services; and its affiliate, Deloitte Transactions and Business Analytics LLP, which provides a wide range of advisory and analytics services. Deloitte Transactions and Business Analytics LLP is not a certified public accounting firm. Please seewww.deloitte.com/us/about for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting.

http://www.deloitte.com/us/about

Copyright © 2017 Deloitte Development LLC. All rights reserved.

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