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©2015 RSM US LLP. All Rights Reserved. ©2015 RSM US LLP. All Rights Reserved.
©2015 RSM US LLP. All Rights Reserved. ©2015 RSM US LLP. All Rights Reserved.
HFMA GHALI
Medicare Access and CHIP Reauthorization Act of 2015 & Strategic Imperatives
May 22, 2017
©2015 RSM US LLP. All Rights Reserved.
Agenda/Overview
MACRA Overview & Political Landscape
MIPS Overview
APM Overview
Volume to Value Success Strategies
Phys Comp, Rev Integrity, Bundles
Q & A
Advanced Payment Models
Decline of strict wRVU productivity models
Transitioning from volume to value
Open discussion
Merit Based Incentive Payment System
Medicare Access and CHIP Re-authorization Act 2015
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Healthcare Roller Coaster……
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Political Change and Potential ACA Impact??
5
“Most agree, no changes to quality conversion
and potential focus on transparency”
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Industry Charge Variation
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Increasing Transparency Cost & Quality
7
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MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)
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2017 Transitional Year for Learning and Development“Pick Your Pace…”
9
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MIPS Incentive Categories
10
Formerly
PQRS
Formerly
VBMNew
Measure
Formerly
Meaningful
Use
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MIPS Incentive Weighting
11
Proposed Rule
Final Rule
Slight modifications to Final Rule with continued emphasis on resource use/cost
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MIPS: Applicability to CAHs and RHCs
12
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ADVANCED ALTERNATIVE PAYMENT MODELS (APMS)
13
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Alternative Payment Models
• What is an Alternative Payment Model?
− A payment approach offering incentives to clinicians to provide high quality cost efficient care
− Can apply to a specific care episode or population
• APMs may qualify under “MIPS APMs”
− Offer MIPs scoring advantages
• Advanced Alternative Payment Models are a subset of APMs offering added incentives
• Advanced APMs must meet criteria including nominal risk as defined by MACRA
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Advanced Alternative Payment Models (APMs) Overview
1. Advanced APM track
benefits
5% Lump sum
Bonus
Exclusion from
MIPS
Receive higher
fee schedule
update 2026
2. Must participate in an
Advanced APM as
defined by MACRA
3. Must meet criteria as
a Qualifying Participant
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MACRA & Alternative Payment Models
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• Significant threshold
criteria for QP/APM
participation
• 2017 – 20% patients
or 25% payments
• 2020 – 35% patients
or 50% payments
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VALUE VS VOLUME STRATEGIES
17
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Volume to Value and Consumer Driven Care
Bundled Payments
Shared Savings
Value Based PurchasingPhysician Compensation
Price Transparency
Population Health
Cost Accounting Technology/Big Data
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Organizational Readiness and Self Assessment
19
Organizational Readiness• Physician Compensation Model• Physician Leadership & Governance• Hospital Leadership
Risk Contracting Readiness• Alternative Payment Models (APMs)?• Bundled Payment Initiatives• Quality/Reporting Team• Coding & Severity of Illness• Professional Revenue Integrity
Cost and Quality• Revenue Integrity• Medical Home Certification• Dashboard Development• Quality Performance• HCCs & Episode Groupers
Technology• Advancing Care Information (MU)• Future ACO modeling • Business Analytics and Reporting Capabilities
Co
mp
lexity
/Org
an
iza
tion
al M
atu
rityLower
Higher
MIPS/APM
Readiness
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Physician and Provider Compensation
• Strict productivity models going extinct
• Introduce quality metrics
• Mirror MACRA – example performance year payment impact year
• Include some element of risk & reward
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Potential Quality Metrics
Medicare Quality Metrics
1. Breast Ca Screen
2. Colorectal Ca Screen
3. Influenza Immunization
4. Pneumonia Vaccination
5. Control high BP
6. Doc of current meds
7. IVD: use of aspirin
8. HgbA1C poor control
9. High Risk med in Elderly 1*
10. High Risk med in Elderly 2*
11. Imaging LBP*
* No Benchmark
Wellmark ACO Metrics
1. Breast Cancer Screen
2. Colorectal Cancer Screen
3. Well Child Infant
4. Well Child 3-6
5. Potential Preventable Admissions
6. Potential Preventable ED Visits
7. Physician Visits
8. Primary Care Physician Visits
9. Continuity of Care
10. Potential Preventable Readmissions
11. Discharge Follow-up
12. Chronic Care Visits
13. Qualified Provider*
14. Potentially Preventable Services*
15. Generic Prescribing*
Physicians may select any three metrics of poor performance listed in red
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Strategy Focus – MIPS & APMSStrategically Preparing for Entry to APMs
Comprehensive PCP+ FAQs
and
• Educated /coordinated staff
• Physician Leadership
• IT and data coordination
• Aligned physician incentives
• Coordinated coding/revenue
integrity
• Understanding of
hierarchical condition
categories
Key Success Drivers
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Hierarchical Conditional Categories (HCCs)
23
Fee For Service
ICD-10 CM
Medical Necessity
Demographics + Weighted ICD-10 CM x 12 months = HCC
HCC -> Drive Risk Adjustment -> Predict Future Healthcare Expenses
Comorbidities = Higher HCC = Sicker Patient Population -> Increased Expenses
Value Based
ICD-10 CM
Cost & Quality
MIPS/APMs
Risk Adjustment (HCCs)
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Documentation is Key
Document patient conditions were
monitored, evaluated, assessed and treated
Highest disease categories for each
condition
Complications or comorbidities (CCs)
and major complications or
comorbidities (MCCs)
HCCs must be captured every 12
months
Severity and stage of clinical conditions
Keep problem lists up to date
It’s critical to have dedicated resources and/or technology in place to assist in
the review and education of documentation and educate providers on what is
necessary to reach criteria to capture accurate HCCs.
Revenue Integrity
Operations
Finance
IT
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Bundled Payments
25
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What is Population Health Management?
Most fundamentally, Population Health
Management (PHM) or Value Based Care(VBC)
can be defined as an effort to provide the most
informed care for a patient population through a
comprehensive care delivery approach with a
goal if improving overall health care outcomes
in a cost-efficient manner.
26
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Strategy Essentials
27
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©2015 RSM US LLP. All Rights Reserved.
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© 2015 RSM US LLP. All Rights Reserved.
RSM US LLP
Dan Clark
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330-903-7905
www.rsmus.com
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