this session presented in partnership with konica minolta. · macra: how the new merit-based...

This session presented in partnership with Konica Minolta.

Imagination at work GE Healthcare Camden Group

MACRA: How the New Merit-Based Incentive Payment System Will Impact Physician Practices HIMSS/AHIMA Conference Coralville, Iowa

May 2, 2016

GE Healthcare Camden Group | May 2, 2016 | 3

Key forces driving change in healthcare

HIT costs and complexity

ACA and Health

Reform

Collaborate vs.

Compete

Volume-to-Value Payment Models Innovation and Technology

Consumerism

Competition

Pressure to reduce total cost of

care


Destination: Better Health. Better Care. Lower Cost.

Patient Safety and

Throughput

Hospitalist and Hospital-

Based

Physicians

Reduce Re-Admissions

Bundled Payment

Patient-Centered Medical Home

Transactions/Network

Development

ACO

Physician Relationships/Leadership

Development

Hospital Case

Management Improvement

Clinical Co-Management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

Moving from volume-to-value


Value-based payment models


Trends driving change

Customer/Patient Expectations

Payment Change

Market Opportunity

IT/ Biotech

Health Care Team

Health

Care

System

Change


Balancing the pace of change

Risks with Moving too Slow Risks with Moving too Fast

• Lost market share through tiered/narrow networks

• Reduced utilization driven by other organizations

• Inability to capture dollars for

reduced utilization • Limited leverage for aligning

other providers • Allows others to dictate your

future

• Reduced reimbursement

rates • Lower utilization driven by

own organization • Limited gains in market

share for being low- cost/high-quality relative to market

• Unnecessary infrastructure investment


CMS transitions to value-based reimbursement

2011

Historical Performance Goals

2014 2016 2018

Payments linked to alternative payment models

Fee-for-service (“FFS”) linked to quality

All Medicare FFS

30%

85%

50%

90%

~20%

>80%

0%

~70%

Source: The Center for Medicare & Medicaid Innovation (“CMMI”), Bundled Payment Summit, June 2015


Value-Based Programs


“Value-based programs reward healthcare providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how healthcare is delivered and paid for.”1

Value-based programs

1Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html

Better care for individuals

Better care for populations

Lower cost


MACRA*

Ends the sustainable growth rate (“SGR”) formula

Makes a new framework for rewarding providers for giving better care

Combines existing quality reporting programs

*Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”)


Value-based programs

Reporting begins in 2017


Categories: New healthcare payment models

1 2 3 4

FFS: no link to quality and value

FFS: link to quality and

value

Alternative payment

models built on FFS

architecture

Population-based

payment


Payments linked to quality

Target percentage of Medicare FFS payments linked to quality and alternative payment models in 2016 and 2018

2016 2018

Payments linked to alternative payment models (Categories 3-4)

FFS linked to quality (Categories 2-4)

All Medicare FFS (Categories 1-4)

30%

85%

50%

90%

Source: The Center for Medicare & Medicaid Innovation (“CMMI”), Bundled Payment Summit, June 2015, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html


MACRA

2015 2021

MIPS and APMs will go into effect over a timeline from 2015 through 2021 and beyond

MACRA

Merit-Based Incentive Payment

System (“MIPS”)

Alternative Payment Model

(“APM”)

• FFS system

• Innovative payment model


MIPS programs

MIPS

Value-based payment modifier (“VBPM”)

Physician quality

reporting system

(“PQRS”),

Meaningful use (“MU”)

*Merit-based incentive payment system (“MIPS”)

Clinical Practice

Improvement Activities (“CPIA”)


MIPs Eligible Professionals

Eligible Professionals (“EPs”) in 2017 and 2018 performance years

• Physicians

• Physicians assistants

• Nurse practitioners

• Clinical nurse specialists

• Nurse anesthetists

More EPs added in 2019 • Physical or occupational therapists

• Speech-language pathologists

• Audiologists

• Nurse midwives

• Clinical social workers

• Clinical psychologists

• Dietitians or nutrition professionals


Who is exempt in MIPs?

Exempt Physicians and Providers

1st year of Medicare Participation

MSSP ACO* providers and other participants in eligible alternative

payment models (“APM”) who qualify for the bonus

payment

Providers not meeting the “low volume threshold”

*Medicare Shared Savings Program (“MSSP”) Accountable Care Organization (“ACO”)


MIPS scoring

15%

25%

30%

30%

MIPS Composite Score 0 to 100

Clinical practice improvement activities

Meaningful use of certified electronic health record (“EHR”) technology

Resource use

Quality


MIPS: clinical practice improvement activities

Expanded Practice Access

Population Management

Care Coordination

Beneficiary Engagement

Patient Safety Practice

Assessment

Alternative Payment Models

• Same day appointments for urgent needs

• After hours clinician advise

• Monitoring health conditions and providing timely intervention

• Participation in a qualified clinical data registry

• Timely communication of test results

• Timely exchange of clinical information with patients AND providers

• Use of remote monitoring

• Use of telehealth

• Establishing care plans for complex patients

• Beneficiary self-management assessment and training

• Employing shared decision-making

• Use of clinical checklists

• Use of surgical checklists

• Assessments related to maintaining of certification

• Participation in an APM will also count for CPIA

Source: www.cms.gov


Eligible APMs

*Expanded under the Center for Medicare & Medicaid Innovation (“CMMI”), including Comprehensive Primary Care (“CPC”) initiative participants

Alternative Payment Model

(“APM”) APMs innovative payment model

MSSP ACO

Medicare healthcare quality demonstration program

Medicare acute care episode demonstration program

Or another demonstration program


Encourages expansion of APM options*, especially specialists

Bonus payments

Not subject to MIPS

*Sample models: Medicare ACOs, Patient-Centered Medical Home(“PCMH”), Physician Focused Payment Models (“PFPMs”)

APMs


MACRA timeline and payment impact

*Qualifying APM conversion factor, **Non-qualifying APM conversion factor

Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Timeline.PDF

MIPS Payment Adjustment (+/-)

Excluded from MIPS

Measurement/Report Period is typically 2

years earlier


MACRA implications

Receiving APM payments?

Payments are from eligible APMs?

In first year of Medicare or below low-volume threshold?

Receiving enough payment through eligible APMs?

Quality for APM track (if desired)

Exempt from MIPS

Subject from MIPS

Subject to MIPS, but … Get scoring advantage

May be exempt via “partial APM” pathway

YES NO

YES

YES

YES NO

NO


Proposed timeline for MIPS rulemaking process

2015 2016 2017

Jan: MIPS first performance year begins

Nov: Final 2017 MIPS rule

July: Proposed 2017 MIPS rule

Nov: RFI public comments

submitted to CMS

Oct: CMS released RFI seeking comments

April: MIPS legislation passed


The CMS bundled payments imperative

• Hip and knee replacements are the most common inpatient procedures among Medicare

beneficiaries, with more than 400,000 in 2014

• More than $7,000,000,000 in hospitalizations alone

• Wide variation in procedural costs across

geographies

• CMS goal: link 30 percent of all Medicare FFS

payments to alternative payment models by 2016,

and 50 percent by 2018

Source: CMS


• Lower extremity joint replacements (“LEJR”) (MS-DRGs 469 and 470)

• Commences April 1, 2016

• Mandatory 5-year program

• No downside risk in Year 1

Inpatient stay* *Facility and professional fees

Readmissions

Skilled Nursing Facility (“SNF”)

Inpatient Rehabilitation Facility (“IRF”)

Home Health Agency (“HHA”)

Long-Term Care Hospital (“LTCH”)

• 67 metropolitan statistical areas (“MSA”) affected

• Based on Bundled Payments for Care Improvement (“BPCI”) Model 2

• 90-day retrospective episode of care

• Annual reconciliation

• Payments tied to quality measures: complications and patient satisfaction

CJR overview

Source: Centers for Medicare & Medicaid Services (“CMS”)

90 days post-discharge*

Comprehensive Care for Joint Replacement (“CJR”)


Estimate of episode savings

Final rule announced

Nov 16 2015

Jan 2018

Program begins Year 1 No downside risk

Apr 2016

Year 3 Downside risk cap: 10%


Jan 2020

Q1 / Q2 2016

Anticipated data sets from CMS


Dec 2020

Program ends

Likely number of participant hospitals

Percent of national LEJR episodes in the program

CJR 5-year timeline

$343M 23% 794

Jan 2017


Jan 2019

Source: CMS


Composite quality score

CJR payments link to quality

• HCAHPS survey

• NQF #0166

Complication rates

[required]

• Hospital-level risk-standardized

complication rate (“RSCR”)

following elective primary total

hip arthroplasty (“THA”) and/or

total knee arthroplasty (“TKA”)

• National quality forum (“NQF”)

#1550

Patient satisfaction

[required]

50% 10% 40%

• THA/TKA PRO and limited risk

variable data: 4 unique patient

identifiers and 11 risk variable

data elements

Patient reported outcomes

(“PRO”) [voluntary]

Performance points Improvement points

Based on the performance percentile scale for

complications and HCAHPS and successful

submission of PRO

Points added if the hospital’s score on an individual

measure increases from the previous performance

year by at least 3 deciles

Source: CMS


Implications for Physician Practices


Population Health Management

Wellness/ Preventive

Care

Primary Care/ PCMH

Specialty Care

Community - Based

Services Pharmacies

Behavioral Health

Urgent Care

Emergency Services

Hospital Care

Post-Acute Care/

Home Care

End-of-Life Care

Seamless Patient Experience Across the Continuum

Patient-Focused

Technology and Tools

Patient-Directed

Access to Care

Effective Care

Teams and Care

Delivery


Value-based critical success factors

Strong Care Management Capabilities

Enabling Information Technology

Effective Care Teams

Larger Patient Population

Efficient Clinical Operations

Contracting Models Support Population Health

Physician Compensation Model that Aligns Incentives


Challenges for physicians

• Understanding the shift from volume-to-value

• Potential reduced reimbursement for services

• Tracking of quality and cost management

• Reimbursement based on performance

• Competing in the new world of value-based reimbursement

• Positioning for success under value-based (quality and

cost management ) reimbursement


Key MACRA considerations for medical groups

• Review the Quality and Resource Use Report (“QRUR”)

• Know if EPs received a penalty letter or any payment adjustments and calculate estimated incentives and penalties

• Know the deadlines related to PQRS/VBM, MU, and APMs

• Understand the MIPS scoring and how they may be impacted

• Be familiar with public reporting and the reputational impact of the EP/group

• Employ adequate resources and education opportunities to be successful

Medical groups must:


CMS Quality and Resource Use Report 2014 Annual Quality and Resource Use Report

• Made available September 9, 2015

• Enterprise Identity Management System (“EIDM”) account is required to access the report

• Access report on the CMS Enterprise Portal (https://portal.cms.gov)

• More information on www.cms.gov

https://portal.cms.gov/

http://www.cms.gov/


Sample QRUR


Publicly reported MIPs score

CMS Physician Compare website

Each MIPS-eligible professional's MIPS score and individual

category scores will be available on the Physician Compare

website, including the ranges of all such scores for eligible

professionals across the country.

https://www.medicare.gov/physiciancompare/search.html

https://www.medicare.gov/physiciancompare/search.html


Monitoring and performance improvement

Create Value

1 2 3 4

Define objectives

Select KPIs and

Measures

Activate plan Measure and evaluate consistently


Key performance indicators and measures

KPIs

Revenue Cycle

Operations

Cost/ Profitability

Production Quality and

Cost

Patient Access

Patient Experience

Charge lag Staffing ratios Cycle time and wait time EMR optimization

Days in AR , collection rates, AR aging, denial rate

POS collections, collected vs. collectable, cost to collect

Self-service payments

Operating margin Expense as percent of

revenue Cost per wRVU Net income/provider

Visits wRVUs Occupancy rate Panel size

Portal usage, on-line registration

First agent resolution Patient satisfaction Patient retention

Next appointment 3rd available

appointment Continuity of care

Clinical quality measures PCMH, HCC, RAF Cost of care, PMPM ICD-10 coding


Challenges to overcome

Focusing on the right

initiatives Ensuring correct

coding Tracking quality and

cost data


Real Value: operationalizing the data

Performance Reports (KPIs) Operational Impact

Average cost-of-care by member Identify specific care management programs by disease state

Average cost (PMPM) per chronic disease category

Monitor financial impact of clinical chronic disease programs

Domestic vs. non-domestic utilization Pinpoint utilization by disease category focusing on minimizing out-of-network leakage rate through care management

Projected month total spend during contract year

Evaluate success of programs and care management allowing for modifications as necessary

Member cost and utilization Identify high cost member outliers and establish proper level of care navigation

Top facilities, providers, and diagnosis by cost and encounter volume

Identify out-of-network providers for future contracting and/or steerage


10 steps to become the practice of the future

1

2

3

4

5

6

7

8

9

10

Create a profile of your

current and potential

patients.

Assess your market.

Examine your practice from

your patients’ perspective.

Create process excellence to

drive patient, provider, and

staff satisfaction.

Develop patient-directed,

convenient access points to

your practice.

Change your care delivery model

to facilitate population health

management.

Assess your current business

model based on what is

necessary to succeed in fee-for-

value world.

Optimize your use of data to

enhance care, ensure

accountability, and achieve your

goals.

Implement strategies to

foster patient “stickiness”

to your practice.

Optimize the use of technology.


Questions?

this session presented in partnership with konica minolta. · macra: how the new merit-based...

Documents