the future of healthcare provider reimbursement amanda r ......mips payment explained fee for...
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The Future of Healthcare Provider Reimbursement
Amanda R. Attaway
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MACRA Quality Payment Programs
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MACRA Routes for Incentives/Penalties Creates two routes for incentive payments/penalty
adjustments
Merit-based Incentive Payment System (MIPS)
Alternative Payment Model/Structure (APM/APS)
Penalties associated with MIPS and APM
MIPS = penalty % of allowable charges
APM = risk (potential shared savings) based on quality improvement and cost containment
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Changed to $30,000
.
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MIPS versus APMs
MIPS Payment Explained Fee for Service (FFS) maintained
Adds incentives/penalties to FFS
Provides base payment stability through 2019 Jan. 2015 – June 2015, rates stable June 2015 – Dec. 2015, 0.5% update Jan. 2016 – Dec. 2019, 0.5% update annually Jan. 2020 – Dec. 2025, 2019 payment rates
Scaling factor bonus potential (3x): +12% in 2019 to +27% in 2022) Careful, benchmark movement The better you perform the more the benchmark moves (i.e. norm-setting)
Exceptional Performance Bonus: up to +10%
RVU changes can still occur as a part of the annual Medicare fee schedule review process.
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MIPS Incentive/Penalty Adjustment Caps
Maximum incentives/penalties:
4% for 2019
5% for 2020
7% for 2021
9% for 2022 and beyond
Providers may also not earn an incentive or penalty, but remain at average for region and group or specialty. This would mean that they’d receive the base FFS payment.
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Incentives/Penalties Associated with MIPS CMS sets Mean Composite Score for all eligible professionals (year
prior), resets every year. Composite score also issued for group
Eligible professionals may achieve: Incentive payments
Eligible professional’s composite score is above mean May earn 4-9% in incentive payments based on Medicare allowable charges
No incentive/penalty Eligible professional’s composite score is equivalent to the mean
Penalty adjustments Eligible professional’s composite score below the mean The farther the deviation from the mean the higher the penalty
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Individual Reporting Option for MIPS Eligible individual provider submits 6 measures
1 high priority
1 outcome
1 appropriate use
1 patient safety
1 efficiency
1 care coordination or patient experience
Plus 3 population measures from claims 1 acute composite
1 chronic composite
1 readmissions
Must meet Meaningful Use
Can earn extra points for submitting additional measures
Submitted via registry or web interface
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Group Reporting Option for MIPS Data abstracted and extracted and reported to Medicare
Group Reporting Option
20 total measures required for reporting Three population-based measures
Must report on all Web Interface measures
Proposed 17 measures
Reporting via Web Interface (anticipated to initially be the same as 2016 PQRS measures)
CAHPS®-related measures no longer required with groups of 100 or more providers, but can earn extra points for electing to report.
Pathologists included in MIPS under individual reporting, but GRPO does not report specifically for laboratory physicians (i.e. pathologists). Therefore, MIPS group reporting, in current state, will not directly reflect laboratory services.
Merit-based Incentive Payment System
Consolidates Meaningful Use (MU), Physician Quality Reporting System (PQRS, PQRS-GPRO), and Value Based Payment Modifier (VBM) into one program
Performance improvement
Four categories
1. Quality
2. Resource Use
3. Clinical Practice Improvement
4. Meaningful Use of ONC-certified electronic health record technology
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Performance & Scoring
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Final Rule MIPS Composite Performance ScorePerformance threshold will be established based on the mean or median of the composite performance scores during a prior period.
Performance Categories Year 1 (2019) Year 2 (2020) 2021 - Forward
Quality 60% 50% 30%
Resource Use 0% 10% 30%
Clinical Practice Improvement Activities15% 15% 15%
Meaningful Use of EHR 25% 25% 25%
Quality (60%) Weight increases/time
Group reporting option Similar to PQRS-GPRO Web Interface Clinical data registries
Based on National QualityForum (NQF) measures
Focus on cross cutting measures Commercial payers
following government lead
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Resource Use (0% for 2017) Weight increases/time
Measures currently in VBP program Clinical condition Treatment episodes
Typically links type of provider to patient Example: cardiology, hem/oncology, nephrology, transplant
specialties et al. will have higher costs of care
Algorithms identify condition and comorbidities of patients Chronically-ill Risk adjusted for sicker patients
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Clinical Practice Improvement (15%)
Expanded access (same day appointments)
Population health management
Care coordination (telehealth)
Beneficiary engagement (shared-decision making, self-management training)
Patient safety/practice safety (checklists, problem lists, medication reconciliation)
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Advancing Care Information or MU Category: Electronic Health Record (25%)
Multi-user data repository
Interoperability (ETA 2018)
State/national health information exchanges
Data integrity
Reputational risks to patient and provider?
Auditability/discoverability
Emphasis on getting the data correct!
Exemptions expected for some organizations
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MU: Electronic Health Record
All ONCHIT-certified EHRs must be fully interoperable by 2018
Send, query, and receive
Clinical summaries, problem lists
Structured data standardized data
Is data consistent across multiple practices and health systems?
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Example of Reimbursement Scenario
Input Solo to Small Physician Practice Larger Health System
Medicare Part B Allowables $2,000,000 $20,000,000
Number of Eligible NPIs 4 400
Incentives at 4% for 2019 1 provider at $500,000 4% = $20,000
200 providers at $10,000,0004% = $400,000
Penalties at 4% for 2019 3 providers at $60,000$40,000 net penalty
4% = $400,000 = neutrality
Net Medicare Part B Allowables $1,960,000 $20,000,000
Worst Case Scenario (2019) 4% = 80,000 4% = $800,000
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Alternative Payment Model Second route to incentive payments
Majority of programs = risk-based
Examples of APMs Patient Centered Medical Home (PCMH)
CMS Innovations Center
Medicare Shared Savings Program (MSSP) or Accountable Care Organization (ACO)
Million Hearts Cardiovascular Program
Oncology Care Model
Medicare Demonstration Projects
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Advanced APMs
The APM requires participants to use certified EHR technology.
The APM bases payment on quality measures comparable to those in the MIPS quality performance category.
The APM either: (1) requires APM entities to bear more than nominal financial risk for monetary losses; OR (2) is a Medical Home Model expanded under CMMI authority
MACRA does NOT change how any particular APM functions or rewards value. Instead, it creates extra incentives for APM participation
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Alternative Payment Model (APM)
Physicians in alternative payment models (APMs) receive a lump-sum equal to 5% of total Medicare reimbursement in 2019-2024
Must receive 25% of Medicare revenue under an APM in 2019, 50% in 2020-2021 and 75% in 2023 and beyond
Technical Advisory Committee to be established to develop / approve new APM programs
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Potential Affects on Reputation
Physician Compare®
Five Star Rating System
CMS Virtual Research Data Center (VRDC) Data.Medicare.gov
Information sold to external entities (2015)
National Provider Data Bank (HRSA)
Hospitals, professional societies, health plans, liability companies, QICs, federal agencies, state licensing and disciplinary authorities, DEA, OIG et al.
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Key Considerations Data Integrity
Healthcare Consumer Heavy risk adjustment
Socioeconomic considerations
Limitations to engagement/interactivity
Site workgroups forming to perform gap analysis and identify needs Work with providers and practices going forward
Assure data integrity, appropriate coding, and assignment of beneficiary and metrics to correct provider
Analyze denominator sets against patient populations
Looping back to practices with performance data with a focus on “how” to institute improvements
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NEW: MACRA FINAL RULE RELEASED
Emphasizes evolution/time
Broadens abilities for specialties and small practices to participate
Changes minimal threshold to bill more than $30,000 year or care for more than 100 Medicare patients per year
Providers can choose to start anytime between January 1 and October 2, 2017 through one of any MIPS reporting routes: Avoid downward payment adjustment in 2019 by submitting minimal
amount of data
Submit 90 days of data to remain neutral or earn small upward adjustment
Full year of data may earn moderate upward adjustment
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MIPS Final Rule
Low volume thresholds were revised:
Physicians and related professionals who accrue “less than or equal to $30,000 in Medicare Part B allowed charges or see 100 Medicare patients or less are exempt from MIPS requirements
Per CMS this represents 32.5 percent of Medicare clinicians but only five percent Medicare Part B spending
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MIPS Final Rule
CMS estimates that in 2017 approximately:
600,000 clinicians will fall under MIPS
100,000 will fall under APMs
380,000 clinicians will meet exceptions from MIPS
By 2019, 90 percent of eligible clinicians will participate in MIPS and adjustments will be evenly balanced between cuts and bonuses of the same amount
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MIPS Final Rule Clinicians who achieve a final score of 70 or higher will be eligible for the
exceptional performance adjustment, funded from a pool of $500 million
$20 million each year for five years will be provided to train and educate Medicare clinicians in small practices of 15 clinicians or less and providers working
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MIPS Final Rule
The "Advancing Care Information" section of MIPS replaces the Meaningful Use program. CMS reduced the total number of required measures from 11 in the proposed rule to five in the final rule:
Security risk analysis;
E-prescribing;
Provide patient access;
Send summary of care; and
Request/accept summary of care.
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Implications of MACRA across organizations
Financial
Clinical
Strategic
Physician Partnership
Affects future Medicare reimbursement for all paid on Physician Fee Schedule
Requires clinicians to change / assess and improve clinical quality outcomes
Prioritizes strategic physician acquisition / growth decisions
Evolve arrangements to attract, retain, evaluate and optimize
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Implications of MACRA across Organizations
Operational
Technological
Reputational
Patient Engagement
Requires organization-wide coordination of eligibility, multiple impacts and regulatory requirements
Requires robust clinical data capabilities (data governance, capture, collection, validation and reporting)
MIPS program performance results will be made public by physician
Coordination of care and two-sided risk requires providers to foster closer ties with patients to actively manage their health
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