moving to vbp through macra and other policies · • physicians are risk averse; they value...

Cynthia Brown VP, Government Affairs

Moving to VBP through MACRA and Other Policies

May 18, 2017

© 2017 American Medical Association. All rights reserved.

Overview

• State of play for practices and payments

• Physicians’ perspective on today’s value-based payment systems

• MACRA improvements and challenges

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FFS is still the dominant payment method

83.6%

35.7% 25.1%

35.8% 16.7%

70.8%

6.5% 6.7% 8.8%

2.0% 0%

20%40%60%80%

100%

FFS P4P Capitation Bundledpayments

Shared savings

% of physicians in practices that receive positive revenue from that method

Average share of practice revenue from that method

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AMA Practice Benchmark Survey 2016

*Revenue shares don’t sum to 100 percent across the five payment methods because some physicians answered “don’t know” to one of more payment methods or shares.


Most physicians practice in single specialty groups (59.3%)

18.4% 17.1% 16.5%

45.5% 42.2% 42.8%

22.1% 24.7% 24.6%

5.6% 7.2% 7.4% 8.5% 8.8% 8.8%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Other practice type

Direct employee ofhospitalMulti-specialty group

Single specialty group

Solo practice

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About 58% in groups < 10 AMA Practice Benchmark Survey 2016


There were small increases in medical home and Medicare ACO participation between 2014 and 2016

23.7%

28.6% 25.7%

31.8%

0%5%

10%15%20%25%30%35%

Medical home Medicare ACO

Is your practice part of a medical home or Medicare ACO?

20142016

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Physician experience with P4P: incentives

• Stick vs. carrot approach

• Incentives built on penalty avoidance, or zero-sum game rewards

• Inadequate to support practice investment

• Tendency to reward high performers, not improvement

• Regulatory burdens often outweigh the rewards

• Perception of hurdles to “earn” full compensation

• Providing a health care service is no longer valued

• There aren’t enough hours in the day

• Physicians are risk averse; they value revenue predictability

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The Value of Income Stability and Fairness Few physicians reported dissatisfaction with their current levels of income. However, physicians reported that income stability was an important contributor to overall professional satisfaction. AMA/RAND study of factors affecting professional satisfaction, 2013


Physician experience with P4P: relevant measures • Professional satisfaction driven by providing high-quality care

• Physicians are diverse, many subspecialties and settings

• Drive for cross-cutting measures has not been successful

• Tension between developing measures relevant to physicians and workable for programs

• Frequent changes, limited education efforts, interactions between multiple P4P programs do not motivate

• Physicians do not perceive value for their patients

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Physician experience with P4P: need for simplicity & fairness

• Multiple, overlapping, conflicting performance measurement programs with different reporting streams and deadlines

• Practice management systems and EHRs failed to keep pace

• CMS systems fail to keep pace (e.g., incorporating ICD-10 updates into quality measures)

• MACRA offers some improvements

• Two-year time lag between performance period and incentives/ penalties

• No timely or actionable feedback to enable improvement • Failed once probably means failed twice

• Pass/ fail benchmarks do not reward improvement

• Risk adjustment, attribution methods

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AMA/ Dartmouth time and motion study

Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours are spend on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 or 2 hours of personal time each night doing additional computer and other clerical work

Sinsky, Annals of Internal Medicine, 2016

What this tells us:

• Cannot overestimate the impact regulatory and administrative burdens have on the willingness and capacity for physicians to change

• Ambitious data collection goals and auditing/ documentation requirements developed in a FFS system impede change

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MACRA and the QPP

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• MACRA was designed to offer physicians a choice between two payment pathways:

• A modified fee-for-service model (MIPS)

• New payment models that reduce costs of care and/or support high-value services not typically covered under the Medicare fee schedule (APMs)

• In the beginning, most are expected to participate in MIPS

MIPS

APMs


Preparedness for MACRA was low in September 2016 Has your practice made a pathway decision?

Yes 5.7%

Leaning in one direction 10.6%

No 21.7%

DK 12.5%

Had not heard of MACRA/no Medicare patients 49.4%

100%

MIPS 63.3%

APM 24.6%

Exempt 6.3%

DK 5.8%

Selected pathways of the 5.7% who said “yes”

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AMA survey consistent with others • 2016 Physicians Foundation survey (17,286): 20% say they are familiar with MACRA

• 2016 Deloitte survey (523): 50% have never heard of MACRA; 74% say performance reporting is burdensome

• 2016 Health Catalyst/Peer60 survey of hospital executives (187): 35% have a MACRA strategy

• Healthcare Informatics and SERMO survey 3/31/17 (2,045): 30% not at all prepared

• 2016 Advisory Board survey of employed medical groups (30): 70% were concerned or “totally freaked out”

• 2017 Black Book Research Survey (8,845 practices): 80% say they have not developed their MACRA strategy or plan to select turnkey software to catch up

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MIPS regulatory improvements over former P4P

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Quality (vs. PQRS)

•Measures reduced from 9 to 6

•Flexibility in measure choice

•Cross-cutting measures eliminated

•Bonus for electronic and registry reporting

ACI (vs. MU)

•Fewer measures •CPOE, CDC,

redundant clinical quality measures eliminated

•Base + performance scoring

•Bonus for registry reporting and use of CEHRT in IA

Cost (vs. VBM)

•Cost only; no double jeopardy for quality measures

•Moving to episode groups

• Interim feedback reports provided

•Weighted 0% for 2017

Improvement Activities

•New category •90+ options •Credit for both

practice transformation and other high-value activities

For all MIPS components: Pass/Fail approach eliminated


MIPS vs. P4P Improvements

• Better alignment of measures

• Less duplication, double-jeopardy

• Pass-fail approach largely eliminated

• Penalties less severe

• “Pick Your Pace” transition

• Helpful for those not participating in past P4P

• MIPS APMs can be accommodated

• Support transition to new delivery models

Challenges

• Still complex, burdensome • Daunting for small practices new to P4P

• Practice diversity remains

• 2-year time lag remains

• Feedback timeliness and usefulness TBD

• How will improvement be rewarded?

• EHR interoperability and data blocking problems

• CMS operational issues

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APM participation options under QPP

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Advanced APMs

Qualified Medical Homes

MIPS APMs

• “Advanced” APMs--have greatest risks and offer potential for greatest rewards

• Qualified Medical Homes have different risk structure but otherwise treated as Advanced APMs

• MIPS APMs receive favorable MIPS scoring

• Physician-focused APMs are under development

Physician-focused APMs

TBD


MACRA incentives for Advanced APM participation

Model design • APMs have shared savings, flexible payment bundles and other desirable features

Bonuses • In 2019-2024, 5% bonus payments made to physicians participating in Advanced APMs

Higher updates • Annual baseline payment updates will be higher (0.75%) for Advanced APM participants than for MIPS

participants (0.25%) starting 2026

MIPS exemption • Advanced APM participants do not have to participate in MIPS (models include their own EHR use and quality

reporting requirements)

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2017 Advanced APMs

Comprehensive ESRD Care Model (A portion of 13 ESCOs

will qualify)

Comprehensive Primary Care Plus (2,893 practices in 14

states/regions)

Medicare Shared Savings Track 2

(6 ACOs, 1% of total)

Medicare Shared Savings Track 3

(36 ACOs, 8% of total)

Next Generation ACO Model (Currently 45)

Oncology Care Model Track 2 (A portion of 190

practices will qualify)

Comprehensive Joint Replacement

(A portion of participants in 67 MSAs

qualify)

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MIPS APMs Criteria

• APM entity participates in a model under an agreement with CMS • Entity includes at least one MIPS eligible clinician on a participant list • Payment incentives based on performance on cost and quality measures (either on entity or individual clinician level)

2017 qualified models • MSSP Track 1 counts

Advanced APM benefits do not apply • Must participate in MIPS to receive any favorable payment adjustments • Do not qualify for 5% APM bonus payments 2019-2024 • Not eligible for higher baseline annual updates beginning 2026

Other benefits • 2017 MIPS APMs receive full Improvement Activities credit (could vary in future years) • Models have simplified MIPS reporting • APM-specific rewards (e.g., shared savings, guaranteed payments) • Eligible for annual MIPS bonuses, which continue indefinitely (vs. 6 years for 5% APM bonuses)

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MIPS APMs: all Advanced APMs below threshold PLUS

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ACO Track 1 (438, 91% of total)

Oncology Care Model Track 1

Comprehensive ESRD Care Model

1-sided risk

Medical Homes

Physician-focused payment model proposals • 11-member Physician-Focused Payment Model advisory committee (PTAC) created to

review stakeholder APM proposals, make recommendations to HHS Secretary

• To date, 5 proposals submitted to PTAC, with a dozen more in pipeline based on Letters of Intent

• Advanced Care Model (ACM) Service Delivery and Advanced Alternative Payment Model submitted by Coalition to Transform Advanced Care

• The Comprehensive Colonoscopy Advanced Alternative Payment Model for Colorectal Cancer Screening, Diagnosis and Surveillance submitted by Digestive Health Network

• The COPD and Asthma Monitoring Project submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group Inc. of Sacramento, California

• Project Sonar submitted by the Illinois Gastroenterology Group and SonarMD, LLC

• The ACS-Brandeis Advanced APM submitted by the American College of Surgeons

• PTAC plans to recommend two of these for pilots; prospects and timeline unclear

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https://aspe.hhs.gov/system/files/pdf/253406/ACM.pdf

https://aspe.hhs.gov/system/files/pdf/253406/ACM.pdf

https://aspe.hhs.gov/system/files/pdf/253406/PFPM.pdf

https://aspe.hhs.gov/system/files/pdf/253406/PFPM.pdf

https://aspe.hhs.gov/system/files/pdf/253406/TheCOPDandAsthmaMonitoringProject-PMA.pdf

https://aspe.hhs.gov/system/files/pdf/253406/ProjectSonarSonarMD.pdf

https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf

Examples of physician-focused APM pilots

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Project, MD leader, Payer Care Improvement Opportunity Barriers in Current Payment System Results from Payment Model

Frequent Emergency visits, Jennifer Wiler, MD, Univ. of Colorado, CMS Innovation Award

• Many patients with 3+ ED visits per year: are uninsured; have behavioral health problems; do not have a PCP

• No pay for pt education and care coordination in ED

• No pay for home visits post-ED • No coverage for non-medical

needs such as transportation

• 41% fewer ED visits • 49% fewer admissions • 80% now have PCP • 50% lower total spending

Crohn’s disease, Lawrence Kosinski, MD, Illinois Gastroenterology Group and SonarMD, Illinois BCBS

• Payer spends $11,000/yr for each Crohn’s patient

• >50% of $ for hospitals, mostly for complications

• <33% patients seen by MD w/i 30 days before admit

• No payment to support: o Nurse care managers o Clinical decision support tools o Proactive outreach to high-risk

patients

• Hospitalization rate cut >50% • Health plan spending cut 10% • Improved patient satisfaction due

to fewer complications, lower out-of-pocket costs

Total joint replacement, Stephen Zabinski, MD Shore Medical Center, Horizon BCBS of NJ

• Reduce risk factors for complications preoperatively

• Obtain lower implant prices • Use lower-cost settings for

surgery & rehab

• No support for pre- or post-op care coordination & risk reduction, ie, BMI, smoking, diabetes control, deconditioning

• Lack of data on facility costs to support better decision making

• Avg LOS reduced 1.5 days for knees, 1.3 days for hips

• Avg device cost cut 33% • Discharge to home: 34% 78% • Readmit rate: 3.2% 2.7%

Examples of physician-focused APMs being developed Condition Specialties Involved Opportunities to Improve Care and Reduce Spending

Epilepsy Headache

• Neurology

• Improve accuracy of diagnosis and appropriateness of diagnostic tests • Reduce frequency and severity of seizures and headaches, achieve better control • Reduce injuries and complications requiring emergency visits and hospitalizations • Prevent progression from episodic to chronic migraine and reduce opioid use

Cancer • Medical Oncology • Radiation Oncology • Gynecologic Oncology

• Improve cancer outcomes through accurate diagnosis and staging, more focus on appropriate use of treatments

• Coordinate treatment planning for each stage of cancer and type of treatment • Help patients manage psychological, physical, financial challenges of their disease • Reduce nausea, vomiting, pain, dehydration, other complications of cancer • Treat complications quickly without need for ED visits or hospital admissions • Prevent repeat operations and avoid unnecessary use of expensive radiation therapy

modalities, imaging, lab tests and drugs

Asthma • Allergy and Immunology

• Improve diagnostic accuracy, treatment planning, and medication adherence • Reduce work and school absenteeism and increase productivity • Reduce emergency visits and hospitalizations due to asthma exacerbations • Avoid unnecessary use of expensive tests and drugs

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MACRA APM observations • APM physicians generally “satisfied”

• High quality care, support for non face-to-face services, better use of staff

• Too few models currently available for specialists

• Likelihood of approval for new models unclear

• More opportunities for reduced regulatory burdens (e.g., prior authorization exemption)

• Risk criteria, attribution methods, risk adjustment need refinements

• Are MIPS APM advantages sufficient? Will they provide the needed glide path?

• Some specialties/ services may never neatly fit into an APM

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moving to vbp through macra and other policies · • physicians are risk averse; they value...

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