©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,

©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


Healthcare Roller Coaster……


Political Change and Potential ACA Impact??

5

“Most agree, no changes to quality conversion

and potential focus on transparency”


Industry Charge Variation


Increasing Transparency Cost & Quality

7


MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)


2017 Transitional Year for Learning and Development“Pick Your Pace…”

9


MIPS Incentive Categories

10

Formerly

PQRS

Formerly

VBMNew

Measure

Formerly

Meaningful

Use


MIPS Incentive Weighting

11

Proposed Rule

Final Rule

Slight modifications to Final Rule with continued emphasis on resource use/cost


MIPS: Applicability to CAHs and RHCs

12


ADVANCED ALTERNATIVE PAYMENT MODELS (APMS)

13


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

14


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


MACRA & Alternative Payment Models

16

• Significant threshold

criteria for QP/APM

participation

• 2017 – 20% patients

or 25% payments

• 2020 – 35% patients

or 50% payments


VALUE VS VOLUME STRATEGIES

17


Volume to Value and Consumer Driven Care

Bundled Payments

Shared Savings

Value Based PurchasingPhysician Compensation

Price Transparency

Population Health

Cost Accounting Technology/Big Data


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


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


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


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


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)


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


Bundled Payments

25


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


Strategy Essentials

27


28


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©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,