panel session 3: do you make the grade? impact on … · 2020-01-30 · accreditation aagl is...

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AAGLAdvancing Minimally Invasive Gynecology Worldwide

Panel Session 3: Do You Make the Grade? Impact on

Reimbursement Changes

PROGRAM CHAIR

Craig J. Sobolewski, MD

Pam D’Apuzzo, BA Jon K. Hathaway, MD, PhDJin Hee (Jeannie) Kim, MD, MPH, MSCS Richard B. Rosenfield, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1

Disclosure ...................................................................................................................................................... 2

Understanding MACRA and Preparing for Its Impact P. D’Apuzzo .................................................................................................................................................. 3

MIPS and APMs: What You Need Know J.H. Kim ......................................................................................................................................................... 5

MACRA: So What’s Everyone Else Doing? J.K. Hathaway ............................................................................................................................................... 8 Bundles: The Future of GYN Surgical Payments R.B. Rosenfield ........................................................................................................................................... 10

Cultural and Linguistics Competency .......................................................................................................... 12

Panel Session 3: Do You Make the Grade? Impact on Reimbursement Changes

Craig J. Sobolewski, Chair

Faculty: Pam D’Apuzzo, Jon K. Hathaway, Jin Hee (Jeannie) Kim, Richard B. Rosenfield This session provides an insight into the impact that the Medicare Access and CHIP Reauthorization Act

(MACRA) and especially the Center for Medicare and Medicaid Services (CMS) MACRA Quality Payment

Program (QPP) will potentially have on GYNs practicing within the United States. Issues that are

important both now and in the future as we shift from volume-based to value-based health care will be

highlighted with a focus on the Merit-based Incentive Payment System (MIPS) and Alternative Payment

Models (APMs). Wading through this “alphabet soup” of acronyms can be difficult and confusing. This

session is a Panel Discussion designed to be interactive with a significant amount of time allotted to

audience and panelist discussion.

Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Appreciate the

changes that are underway between the past and future models of CMS reimbursement.

Course Outline

2:15 Welcome, Introductions and Course Overview C.J. Sobolewski

2:20 Understanding MACRA and Preparing for Its Impact P. D’Apuzzo

2:25 MIPS and APMs: What You Need Know J.H. Kim

2:30 MACRA: So What’s Everyone Else Doing? J.K. Hathaway

2:35 Bundles: The Future of GYN Surgical Payments R.B. Rosenfield

2:40 Panel Discussion All Faculty

3:15 Adjourn

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Craig J. Sobolewski Consultant: Covidien, Teleflex, TransEnterix Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Pam D’Apuzzo* Jon K. Hathaway* Jin Hee (Jeannie) Kim* Richard B. Rosenfield* Craig J. Sobolewski Consultant: Covidien, Teleflex, TransEnterix Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.

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RR|HSRR Health Strategies

© 2016 RRHS

Presented by Pam D’Apuzzo, CPC, ACS-EM, ACS-MS, CPMA

President of

Understanding MACRA and Preparing

for Its Impact

NOVEMBER 16, 2016

RR|HSRR Health Strategies1


© 2016 RRHS

Disclosure

I have no financial relationships to disclose.

2


© 2016 RRHS

Learning Objectives

• Provide overview of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

3


© 2016 RRHS

MACRA: Key Features

• Quality/Value-Based Care

• Patient Outcomes

• Goal: High Quality/Low Cost where Quality = Value

• Proposed Start Date: January 1, 2017

• Does not apply to Medicare payments to Hospitals, Medicaid or special Medicare programs (i.e., Medicare Advantage)

• Eligible Clinicians (EC)

• MD, DO, NP, PA, Nurse Anesthetist, and CNS (Clinical Nurse Specialist) for 1st year

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© 2016 RRHS

MACRAQuality Payment Program (QPP)

Two Different Reimbursement/Incentive Methods:

1. Merit-Based Incentive Payment System (MIPS)

• Solo practitioner is defined by NPI or TIN

• A “group” is 2 or more ECs defined by TIN (no “virtual groups”)

• NOT MIPS eligible if Medicare patient volume is < 101 patients AND charges are <$10,001.00 ANNUALLY

2. (Advanced) Alternative Payment Model (APM)

CMS picks threshold for payment/penalty

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© 2016 RRHS

MIPS4 Performance Categories (Additive Score of 4 Weighted Categories Determines Medicare Payment):

1. QUALITY (Replaces PQRS)

• 50% of total MPS score in 2019 – weighted amounts will vary over years.

• Must report a subset of 6 Quality measures to include 1 “cross-cutting” measure and 1 “outcome” measure in the QUALITY CATEGORY

• Clinicians will get to choose desired measure subsets from a CMS list

2. RESOURCE USE (Replaces VM)

• 10% of total MIPS score in 2019

• Measures cost savings from prudent use of resources (i.e. Labs/Hospital Admissions)

• No reporting required as CMS extracts information from Claims Data

• Focus is on COST of services

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3


© 2016 RRHS

3. ADVANCING CARE INFORMATION (ACI) (Replaces MU)

• 25% of total MIPS score in 2019

• Base and optional measurements

• Sub-categories resemble MU

4. CLINICAL PRACTICE IMPROVEMENT ACTIVITIES (CPIA) (New performance category)

• Worth 15% of total MIPS score in 2019

• Encourages same-day appointments, timely communication of test results, telemedicine, patient engagement and care plans for patients

• Provider to choose from 90 possible activities on CMS list

Vast majority of ECs will be in MIPS

MIPS

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© 2016 RRHS

MIPS

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© 2016 RRHS

Advanced Alternative Payment Model (APM)

• Currently, there is a short list of APMs:

• Track 2 & 3 ACOs, possibly “patient-centered medical homes” and a few other models*

• Most Providers are not in a qualifying shared risk structure, so they will go into MIPS

• APM participants should have an infrastructure, including EHR, staff who coordinate care and care transfers, and access to performance data

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© 2016 RRHS

Tips for Preparation:

1. Think “Quality = Value”

• Patient engagement, technology use, process improvement

2. Focus on aggregating lab and clinical data

3. Learn how to use data for quality improvement

4. Quality and Resource Use Report (QRUR – available from CMS)

5. Clinical improvements/outcomes/metrics, enhance patient engagement, use of EHR, contact Specialty Association or ACO for assistance

6. Choose 6 quality measures to report

7. Train Staff

Advanced Alternative Payment Model (APM)

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© 2016 RRHS

REFERENCES• AAPC

• http://www.aapc.com/

• CMS

• https://www.cms.gov

• “The New Physician Quality Reporting: Positioning Your Practice for MACRA’s Merit‐Based Incentive Payment System” –Webinar presented by: The Healthcare Intelligence Network and Eric Levin, DVD version July 14, 2016

• “Master MACRA To Keep Getting Paid” –Webinar presented by Jeanne J. Chamberlin, MA, FACMPE and “The Coding Leader” , July 12, 2016

• Medscape Business of Medicine: “MACRA For Busy Docs: 12 Things To Know” –Article published September 7, 2016

• The HealthmonixAdvisor: “Learn How MACRA Will Inflate Your Revenue” – Posted by Lauren Patrick on July 21, 2016

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© 2016 RRHS

Contact InformationPam D’Apuzzo

President of

102 Motor Parkway, Suite 520Hauppauge, NY 11788

631-231-0505Email: [email protected]

Website: www.rrhealthstrategies.com

Linked In: www.linkedin.com/pub/rr-health-strategies-llc/59/b43/865


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4

MIPS and APMs:What you need to know

MIPS: Merit-based Incentive Payment SystemAPM: Alternative Payment Model

Jin Hee (Jeannie) Kim, MD

Assistant Professor, Gynecologic Specialty SurgeryCo-Fellowship Director, Minimally Invasive Surgery

Columbia University Medical Center / NYPHPanel Session 3: Do you make the grade?

AAGL 2016

Disclosures

I have no financial relationship to disclose

2

Objectives

Recognize who participates in the quality payment program (MIPS vs APM)

Discuss the MIPS time line and adjustments

Explain what makes up the composite performance score

Discuss the next step for clinicians

3

How do I get out of this thing?

4

If not:

First year of participation in Medicare Part B (2017)

Qualify as an Advanced APM

Low volume exclusion<$10,000/yr from Medicare

≤100 Medicare patients/yr

Rural health clinics, federally qualified health centers exempt

Learn to accept it

What counts as an advanced APM?

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1. Certified EHR use

2. Quality Measures comparable to MIPS

3. Bear more than nominalfinancial risk for monetary loss

Must receive 25% of Medicare Part B revenue through Advanced APM entitiy

Must attribute at least 20% of eligible Medicare beneficiary

patients to an Advanced APM

Comprehensive End-Stage Renal Disease Care

Comprehensive Primary Care Plus

Medicare Shared Savings Program – Track 2

Medicare Shared Savings Program – Track 3

Next Generation ACO Model Oncology Care Model Certified Patient Centered Medical Homes (VQRC &

SCOPE)

5% Incentive payment 2019-2023

What counts as an advanced APM?

6

5% Incentive payment 2019-2023

5

MIPS Time Line and Max Adjustments

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9

MIPS Composite Performance Score

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50% 10% 15% 25% MAX SCORE 100 POINTS

30% 30%

2019

202215% 25%

(Physician Quality Reporting System)

6 (of 200+) quality measures (10pts)2-3 population measures (10pts)

TOTAL 80-90pts

(Cost component of Value Modifier Program)40+ episode-specific measures to account for specialty differences

Min 20-patient in each cost measure which is 10pts each

No reporting as score based on Medicare claimsNo score if lack volume

NEW! 90+ optionsHighly weighted 20ptNormal weighted 10pt

Care coordinationBeneficiary engagementPatient safetyAPM (half credit)Patient-centered medical home (full)

TOTAL 60 pts


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50% 10% 15% 25% MAX SCORE 100 POINTS

30% 30%

2019

202215% 25%

(Physician Quality Reporting System)

6 (of 200+) quality measures (10pts)2-3 population measures (10pts)

TOTAL 80-90pts

(“Meaningful Use” Medicare EHF Incentive Program)A. Base (50pts): 1. Protect patient health info (Y/N)2. Patient electronic access (N/D)3. Coordination of care through patient engagement (N/D)4. E-prescribe (N/D)5. Health info exchange (N/D)6. Public health & clinical data registry (Y/N)

B. Performance score (up to 80pts)1.Patient electronic access2. Coordination of care through patient engagement3. Health information exchange

C. Public health registry bonus (1pt)

TOTAL 100pts (Max 131pts)

(Cost component of Value Modifier Program)40+ episode-specific measures to account for specialty differences

Min 20-patient in each cost measure which is 10pts each

No reporting as score based on Medicare claimsNo score if lack volume

NEW! 90+ optionsHighly weighted 20ptNormal weighted 10pt

Care coordinationBeneficiary engagementPatient safetyAPM (half credit)Patient-centered medical home (full)

TOTAL 60 pts


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30% 202215% 25%

25%

6

Key Takeaways

Payment model is changing quickly

Commercial payers are moving to value payments (2021)

Collect! Report!

Engage with administration and IT to develop tracking and reporting tools/dashboards

Plan for ongoing monitoring and review of MIPS performance13

References

www.acc.org

www.columbiadoctors.org

www.aamc.org

www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf

www.acog.org

file:///C:/Users/jhk2146/Downloads/ACOG%20MACRA%20presentation%20(1).pdf

Manchikanti L et al. Merit-based incentive payment system (MIPS): Harsh choices for interventional pain management physicians. Pain Physician. 2016 Sep-Oct;19(7):E917-34

Carlson et al. SGO health policy and socioeconomic committee: current and future efforts of the future of physian payment reform taskforce and the legislative and regulatory affairs taskforce. Gynecol Oncol. 2016 Sept;142(3):385-7.

Dept of health and human services, CMS. 42 CFR Parts 414 and 495. April 27, 2016.

Hirsh JA et a. PQRS and MACRA: Value-based payments have moved from concept to reality. AJNR Am J Neuroradiol. 2016 Sep 22.

http://www.telligen.com/blog/breaking-down-clinical-practice-improvement-activities-cpia-category-mips

https://www.aledade.com/macra-part-1-what-are-advanced-alternative-payment-models/

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7

Alternative Payment Models

How are other specialties doing it?

APM’sDisclosures

I have no financial relationships to disclose

Objective

Discuss Alternative Payment Models (APM’s) used by various medical societies.

Medical Oncology Requires standard performance measures/programs

Standardizing planning, treatment and compliance

Developing software to measure/track

Cost Accountability

Appropriate Treatments

Feasible Risk (even for small practices)

Care Delivery Changes

Improve quality and outcomes

Decrease costs

How to factor in medications??

American College of Surgeons

Episode-based Payment Model

Build “Condition and Procedure Episodes”Includes “look back” period into the total time window

Construct Episode Clusters by Clinician Type

Construct Physician Service Groups with the Episodes

Establish PER PATIENT/PER CONDITION prices

American College of SurgeonsEpisodes Mock Retrospective Payment

Procedure X Expected Cost Actual Cost Variance

Patient 1 $12,000 $18,000 ($6,000)

Patient 2 $18,500 $14,000 $4,500

Patient 3 $15,000 $12,000 $2,000

Patient 4 $25,000 $23,500 $1,500

How would a small practice survive if they had one catastrophic patient?

Multiple payers and physicians would have to share data on what defines quality and outcomes based on those quality guidelines.

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AAGL

???

References

9

THE FUTURE OF SURGICAL REIMBURSEMENTS

BUNDLES

Richard Rosenfield MD Portland OR

DISCLOSURES

I have no financial relationships to disclose

OBJECTIVES

Explain Surgical Bundles

Provide an overview of why and how this is happening Self Funded Corporate America

ACA

ERISA

Discuss the Gynecology Vertical

Economics of Hysterectomy

Origins- Hospital Based Open Surgery

CMS sets rates for DRG 741 $6652.15 COST - JAMA/WSJ/Truven ($9-12k)

Uterine Adnexa Proc for Non-Ov/Adn mal w/o cc/mcc

AFFORDABLE CARE ACT We Must Reduce Cost ! Shift to Outpatient Surgery ASC – LSH/TLH $2900 Improve Process Increase volume to high volume surgeons = reduced complications (NSQIP)

Where is the Problem ? ASC contracts are priced based on these numbers

Obama Care – Friend or Foe ?

Let’s fix the system ? Higher Quality

Embrace Technology

Increase Access to Care

Reduce Cost

Who takes the Haircut ? Hospital Administrators ?

Medical Device Companies ?

Surgeons ?

Facilities ?

Everyone wants to preserve margins

How can we do this ? Improve Process

Reduce Complications

Restructure Pricing

Bundles Definition

CMS – Retrospective

Gyn – Prospective

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Where CMS went wrong…

Hospital Facility Fees DRG 741

CMS data

COST of surgery

Outpatient Surgery ACA pushing savings, venue must be addressed

ASC pricing is FLAWED at less than cost

BUNDLES set at 15-20% below current will change the market

The Future is now

Healthcare Economics Most Expensive Sector = Surgery

Largest Sector= Self funded corporations= 160 Million Lives

ERISA

HPN’s

We are not re-inventing the wheel

REFERENCES

HOW TO MAKE SURGERY SAFER, WALL STREET JOURNAL FEB 2015

MODERN HEALTHCARE FEB 2016

BECKERS ASC JAN 2016

BLOOMBERG MARCH 2014

COVIDIEN CMS PRICING GUIDE 2014

JAMA FEB 2014

US DEPT HEALTH&HUMAN SERVICES- H.CUPnet

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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