Adele Allison, Director of Provider Innovation Strategies ... Spring Conference/Adele Allison... · Adele Allison, Director of Provider ... • Data Collection →Purchases, Demographics,

4/3/2018

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IMPACT MACRA: ESSENTIAL STRATEGIESPart I: Foundations – Trends, Data & EconomicsAdele Allison, Director of Provider Innovation StrategiesApril 11, 2018

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AGENDA

• Evolution of Reimbursement

• Overview of Value-Based Payment

• Perspective on Data

• Your Data is Your Voice

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EVOLUTION OF U.S. HEALTHCARE

• 20th Century Emerges – 1 Specialty → The Family Doctor

• 1929 – Texas Hospital Assoc. → “prepaid health” → Blue Cross

• 1930 – Ratio of generalists to specialists 80/20

• 1934‐1939 – Great Depression → Roosevelt enacts SSA as part of the “New Deal”

• 1939 – CA Medical Assoc. → Blue Shield

• 1945 – Blue Cross serves 59% of health insurance market

• 1954 – IRS solidifies “prepaid” insurance → tax deduction

• 1961 – Ratio of generalists to specialists 50/50

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EVOLUTION OF U.S. HEALTHCARE

• 1965 - Medicare / Medicaid established – Pres. Johnson− Life Expectancy – 68.2

− U.S. Population age 65+ – 18.5M

− Cost of Care as a % of GDP – 5.6% → $42BN or $210/person

• Today – Medicare (58 M) and Medicaid/CHIP (72.3 M)

− Life Expectancy – 78.74 (UK – 81.6; Canada 82.2)

− U.S. Population age 65+ – 46.2M

− Cost of Care as a % of GDP – 17.9% → $3.3 Trillion, $10,348/person

• Congressional Budget Office – Medicare Part A insolvency by 2028• Projected spending – $5.7 Trillion, 19.7% of GDP by 2026• Cannot be sustained!

Source: CMS National Health Expenditure Data published Dec.2, 2017, https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/NationalHealthExpendData/index.html

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CLAIMS PAID ON HIAA / MDR

CPT Code: 99213Zip Codes: Nashville, AR

100%

50%

$100

$89$87

$85

$82

$79

$75

$73$70

$98

$95

$92

85% $85 = UCR

Issues:• Fees are Charge Driven• Unscientific / Arbitrary

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CALCULATING FEE SCHEDULES• Claims paid by RBRVS – Resource-Based Relative Value Scale

o 1985 – Secretary commissions Harvard School of Public Health

o 1988 – Phase 1 RBRVS issued to Health Care Financing Administration (HCFA)

o 1989 – Omnibus Budget Reconciliation Act → Create Medicare RBRVS Fee Schedule

o 1992 – RBRVS Medicare Fee Schedule Implemented

• RBRVS uses weighted, 3-part formula:o Physician Work (skill, time, effort, and stress) = 50.9%

o Physician Expense (E.g. supplies, Rx, devices, etc.) = 44.8%

o Malpractice Risk (e.g. Office Visit vs. Brain Surgery) = 4.3%

o RVUs are adjusted → Geographic Practice Cost Index (GPCI)

• Medicare Fee Schedule → RBRVS x Conversion Factor (CF)

• 2017 Medicare CF = $35.89; 2018 CF = $35.99

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CALCULATING FEE SCHEDULES

Math Components

Work RVU x GPCI

+ Expense RVU x GPCI

+ Malpractice RVU x GPCI

= Total RVU

X CY2018 Conversion Factor

= Medicare Payment

The Equation Nashville, TN – 99213Item Values

Work 0.97 x 0.976 = 0.95

+ Expense 1.02 x 0.901 = 0.92

+ Malprac. 0.07 x 0.526 = 0.036

Total RVUs 1.906 RVUs

X CF $35.99/RVU

= Payment $68.60

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AGENDA





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Claims Data

Voluntary Clinical Reporting

Pay-for-Reporting

Pay for Higher “Value” Value = f (Quality + Efficiency)

MACRA – 2 Payment PathsAlternative Payment Model or MIPS

FEDERAL REFORM

Reform Paradigm Shifts• Delivery → Prevention, Health and Patient-

Centeredness

• Payment → Redesign Compensated

• Data → Distribute and Move Information

Affordable Quality Health Care

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HIPAAMIPPATRCHAARRAPPACAMACRA Era

HHS Healthcare

Reform Factory

Status QuoPay-for-Service

Providers CEHRTData

Comparative Effectiveness Research

Guidelines

Educate Pop. HealthMeasures

Advance HITProviders

PerformanceData

New Status QuoPay-for-Value

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HIPAAMIPPATRCHAARRAPPACAMACRA Era

HHS Healthcare

Reform Factory

Status QuoPay-for-Service

Providers CEHRTData

Comparative Effectiveness Research

Guidelines

Educate Pop. HealthMeasures

Advance HITProviders

PerformanceData

New Status QuoPay-for-Value

MIPPA – eRx and QRUR

ARRA – Meaningful Use

TRHCA –PQRS

PPACA – Define “Value”

MACRA – APMs or MIPS

HIPAA – ICD-10

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1. Condition-Specific Population-Based Payment

2. Comprehensive Population-Based Payment

3. Integrated Finance & Delivery System

1. Alternative Payment Models (APMs) with Upside Gainsharing

2. APM with Upside Sharing & Downside Risk

1. Pay for Infrastructure & Operations

2. Pay-for-Reporting

3. Pay-for-Performance

4. Performance Rewards and Penalties

4 CATEGORIES OF VALUE-BASED PAYMENT (VBP)

Category 4Population-Based Payment (PBP)

Category 3Alternative Payment Built on FFS Architecture

Category 2FFS Linked to Quality & Value

Category 1FFS No Link to Quality & Value

Starting Point

Advancing Provider Alignment Creates Data and Operational ComplexitiesSource: HHS Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework White Paper, July 11, 2017

Non-Risk-Bearing Risk-Bearing

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CMS Risk-BearingAlternative Payment Models

• Advanced-APMs• Includes CPC+ and

Oncology Care Model (OCM)

• 5% Lump Sum Bonus

• No MIPS

CMS Risk-BearingAlternative Payment Models

• Advanced-APMs• Includes ACOs and

CJR Bundles• Must be a

Qualified Participant (QP)

• 5% Lump Sum Bonus

• No MIPS

Merit-Based Incentive Payment System (MIPS)

• Budget Neutral Differential FFS Payment

• Earn > MPFS by comparative performance

• ~ 621,700 Cliniciansimpacted

Medicare Physician Fee Schedule (MPFS)

• Frozen CY2019• ~ 23% of Medicare

Provider Total Revenue

• Traditional MPFS obsolete

MEDICARE ACCESS & CHIP REAUTHORIZATION ACT (MACRA)

Category 4Population-Based Payment (PBP)

Category 3Alternative Payment Built on FFS Architecture

Category 2FFS Linked to Quality & Value

Category 1FFS No Link to Quality & Value

Tra

ditio

nal M

edic

are

Pay

men

t C

Y 2

019

Category 4Category 3

CMS → 185,000 – 250,000 QPs in 2018 (More than 2x 2017 estimates)

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• Private Cat. 1 = 4% ↓

• Private Cat. 2 = 1% ↓

• Private Cat. 3-4 = 5% ↑

• $354.5 Billion

• ACOs Q1 2016 to Q1 2017 grew by 92 (Total 923)

U.S. PAYMENT TRENDS 2015-2016• 2017 Public and Private National Health Plan Survey• Participants → > 245.4 million Americans, ~ 84% of Market

− Represents ~ 84% of the total covered population− Data collected from 78 plans, 3 managed FFS Medicaid states, and FFS Medicare

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HEALTH-VALUE MANAGEMENT

Managing “Healthcare”(Resource-Based)

Managing “Health” (Outcomes-Based)

Category 1 Category 2 Category 3 Category 4

Plan Risk Provider Risk

OLD NEW

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4 Owned Business Capabilities• Intelligent health value administration and application (“Advanced Analytics”)

• Provider Alignment

• Purchaser Alignment

• Alternative Payment Model Administration

3 Shared Business Capabilities• Population Health Management

• Consumer Engagement Management

• Data Interoperability

HEALTH-VALUE MANAGEMENT

Source: Adapted from Bryan Cole, Gartner, “Introducing Provider/Partner Alignment: U.S. Healthcare Payer CIOs’ Transformative Relationship Model,” Feb. 1, 2017

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AGENDA





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BITS, NIBBLES AND BYTES

• Bit = 1 or 0 (on / off) → Binary Digit

• Nibble = 4 Bits of Data

• Byte = 8 Bits of Data

• Kilobyte (KB) = 1,024 Bytes

• Megabyte (MB) = 1,048,576 Bytes or 1,024 KB

• 1 MB = 873 Pages of Plain Text (1,200 characters)

• 800 MB = Human Genome (2001) → (700,000 pages of data)

Source: doi:10.1093/bioinformatics/btn582

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GIGABYTES (GB) AND TERABYTES (TB)

• 1 GB = 1,024 Megabytes

− 1 GB = 7 Minutes HD‐TV Video

− 2 GB = 20 Yards of Books on a Shelf

• 1 TB = 1,024 GBs

− 1 TB = All X‐rays in large hospital

− 7 TB = Amount of Tweets/Day

− 10 TB = All Printed Materials of U.S.

Library of Congress

− 45 TB = Data Amassed by Hubble

Telescope first 20 years (launched 1990)

Source: www.mozy.com

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PETABYTE (PB)• 1 PB = 1,024 TB

• 1 PB = 20 Million, 4‐drawer filing cabinets of text

• 1 PB = DNA of U.S. population

• 1.5 PB = Size of Facebook photos → 10 Billion

• 20 PB = Data processed by Google EVERY DAY!

• 50 PB = ALL Mankind’s written works from Beginning of Recorded

History (All Languages)

• 100 PB = Facebook data storage before IPO (2.1.2012)

• 300 PB = Facebook data today (600 TB/day)!

Sources: www.mozy.com and Computer Weekly

‐ and then clone them 2x

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FACTS ABOUT TECHNOLOGY

• Rate of Advancement → Double capabilities & information every 12-18 months, known as the “Doubling Rate”

• Law of Accelerating Returns → 18-20 years out = 100,000’s-Millions of times more advanced

• 40 Years Out → Technology will be a trillion times more advanced

• Humans cannot conceive of these advances− What industries are headed for oblivion right now?− Do you have foresight to understand relevance in the next 3-5 years?

Example:Today: Regenerative medicine in trial

20 Years Later: Grow a new arm

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EXAMPLE → SPACE TRAVEL

• Apollo 11 (1969) → 2K of Memory• Guidance Computer

− Nouns + Verbs for commands− Less advanced electronics than modern toaster

• IBM communications computer− 3,500 IBM employees to build− Huntsville, AL

• Today → iPhone 8 has 64-256 GBs

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DISRUPTIVE TECHNOLOGY

• Innovation creates new market/value that disrupts existing market/value

• Started with “free,” constant digital info− Radically changes humanity− Quick, fast and in a hurry

• Some of today’s disrupters:− Personal guidance− Desktop fabricators− Accident-free, autonomous transportation− Cybernetic/bionic senses, organs, limbs− Computer-brain interfaces− Manipulation of molecules/atoms

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THINK BIG!

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AGENDA





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ROLE OF HEALTH IT

PrescriptiveHow can we make it happen?

PredictiveWhat will happen?

DiagnosticWhy did it happen?

DescriptiveWhat happened?

Val

ue a

nd D

iffic

ulty

Con

tinuu

m

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WHO’S USING DATA?• Guest ID Number → Every Customer

− Credit Card

− Name

− Email Address

• Data Collection → Purchases, Demographics,

Other Data Sources

• Comparative Analysis to Baby Registries− Unscented Lotion

− Large Purse and Bright Blue Rug

− Zinc and Magnesium

• “Pregnancy Prediction” Score

• 87 Percent Accuracy!NY Times, “How Companies Learn Your Secrets,” Feb. 16, 2012,

http://www.nytimes.com/2012/02/19/magazine/shopping‐habits.html?_r=0

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IMPACT OF DOCUMENTATION & CODING

Source: BCBSAL, Complete Picture of Health Documentation and Coding Improvement Initiative

Diagnosis DescriptionEstimated

Cost of Care

E11.8 – E11.9 Type 2 Diabetes w/ no complications $1,400

E11.311 – E11.39Diabetes with Ophthalmic

Manifestations$2,239

E11.40 – E11.49Diabetes w/ neurological

complications$3,527

E11.21 – E11.29

E11.51 – E11.59

Diabetes with renal or peripheral

circulatory complications$4,391

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CLINICALLY-DRIVEN FINANCIALS

• Patient Presents with a broke forearm

• Where on the forearm?

• Which arm?

• What kind of fracture?• First encounter? Subsequent Routine Healing? Subsequent Delayed Healing? Sequela?

• S52

• Lower end of the radius – S52.5

• The right – S52.52

• Torus – S52.521• Subsequent

encounter with delayed healing –S52.521G

Documentation Coding

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CLINICAL DOCUMENTATION IMPROVEMENT

↑ Documentation = ↑ Performance

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THANK YOU!Adele Allison | [email protected] | 205.563.2210

@Adele_Allison | Adele Allison

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IMPACT MACRA: ESSENTIAL STRATEGIESPart II: MPH – Rethinking Your ProcessAdele Allison, Director of Provider Innovation StrategiesApril 11, 2018

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3 CAMPS OF TRANSFORMATION

Pragmatist Collaborator Innovator• 60% Aim for Minimum

• Only Core Processes for admin./compliance

• Last Minute Adoption

• Penalties may occur

• Aiming for Average = High Potential Risk

• 20-25% Aim for Opportunity

• Improve Processes• Advanced Analytics,

Process Improvement• Incentives Attained• Aiming for Improvement =

Potential Value for Costs

• 15-20% Aim for Transformation

• Complete Change Agent• Training, Outcomes Mgmt.

Incentives Attained• Aiming for Excellence =

Competitive Advantage & Strategic Positioning

Adapted from Deloitte, ICD‐10 Turning Regulatory Compliance into Strategic Advantage, 2009.

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HIPAAMIPPATRCHAARRAPPACAMARCA ERA!

AnxietyChangeChaossClutterComplexityComplicationDistasteDisorderDoubtFearfulJumbleMessMuckSnafuPickleNightmarePredicamentMuddl

Healthcare is overwhelming!

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INFORMATION OVERLOAD

We have to move to

Value-BasedPayment

I don’t understand

my condition

Our CEO says the future is in documenting

with structured data (?)

We need a new

server

We don’t like the word

“Bundled” We must contain costs

Quality Reports

are almost due

I can’t afford my

meds

I’m not hitting my

performance measuresThe

Internet is down

We need to issue the regs by

November

The Federal Marketplace is imploding!

I can’t afford

coverage!

Our Hospital revenues

are declining

We cannot sustain

Medicare

Why are my claims

are rejecting?

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DEALING WITH THE COMPLEXITIES

Ready,

Set,

HOW?

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LEADERSHIP MAKES A DIFFERENCE

Being a Leader/Champion vs. Management

Management Leaders

Administer Innovate

Maintain Develop

Control Inspire

Short‐Term View Long‐Term View

Ask, “How” and “When” Ask, “What” and “Why”

Initiate Originate

Accept Status Quo Change Status Quo

Do Things Right Do Right Things

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COMMIT TO STAYING INFORMED

• Professional Associations, Societies & Organizations (MGMA, HFMA, AHIMA, CHIME, HIMSS, etc.)

• Vendor → Training, Upgrades, etc.• Federal Tools

– CMS Quality Payment Program (QPP) Website– Health Care Payment Learning & Action Network

(HCPLAN)– AFMC → Arkansas Quality Improvement

Organization

• Payers → Training, Portals, Reps, etc.

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HOW DO YOU EAT AN ELEPHANT?!

• One bite at a time → Iterative Design Process• Remember, cultural changes take time• Pursue active interventions through “coaching” formal / informal

leaders• Provide techniques to mark and encourage progress• Celebrate your Success!

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ONE BITE AT A TIME … KEY POINTS

• Knowledge is gained through testing (vs. planning, brainstorming)• Tests should be small, rapid, sequential• Developing a theory and prediction before each test and reviewing in

comparison to test results is essential• Learning from other teams can accelerate learning and

understanding• Measurement does not have to be hard and should aid learning

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PLAN, DO, STUDY, ACT (PDSA)

• Developed by the Institute for Healthcare Improvement (IHI)

• PDSA → Documenting a test of change

• Think:– What are we trying to accomplish?– How will we know that change is an

improvement?– What changes can we make that will result in

improvement?

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10-MINUTE BREAK

4/3/2018

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IMPACT MACRA: ESSENTIAL STRATEGIESPart III: MACRA Essential StrategiesAdele Allison, Director of Provider Innovation StrategiesApril 11, 2018

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AGENDA

• MACRA 2018

• Data-Driven Operations

• Community-Level Population Health

• Essential Strategies

• Questions / Wrap-Up

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MACRA BY THE NUMBERS

• 95 – Pages long

• 8 – Meaningful Use

• 18 – Risk

• 19 – Resource Use or Efficiency

• 31 – “Reasonable Cost Reimbursement”

• 27 – EHR or Technology to Manage, Measure and Report

• 38 – Quality Measures

• 171 – “Measures” or “Measurement”

• 103 – Data

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2018 – SOLO & SMALL GROUP MIPS PROTECTIONS

• Solo practitioners up to groups ≤ 15 clinicians

• MIPS Exemption Volume Thresholds

− ≤ $90,000 in billable Part B allowables (up from $30,000 in 2017), or

− ≤ 200 Part B patients (up from 100 in 2017)

• Automatic +5 bonus point if not exempt

• Form or join Virtual Groups (made up of ≤ 10 clinicians groups)

• Quality performance +3 points when measures do not meeting data completeness criteria

• Hardship exception for Advancing Care Information

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MERIT-BASED INCENTIVE PAYMENT SYSTEM

MIPSCategory 2Payments

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MIPS – GET YOUR DUCKS IN A ROW

Will you submit as an individual or part of a group?• Individual → submit by NPI/TIN; Group → submit by group TIN

How will you submit your data?• Choices → Registry, EHR, Claims, CMS Web Interface; verify capabilities

Can your system create the data for the time periods you need?• Contact your EHR or registry vendor to validate

Choose your path and measures.

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PICKING MEASURES & LEARNING MORE

CMS QPPURL: https://qpp.cms.gov/

CMS ResourcesURL: https://www.cms.gov/Medicare/Quality‐Payment‐Program/Resource‐Library/Resource‐

library.html

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MIPS COMPOSITE PERFORMANCE SCORE (CPS)

CMS, Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Final Rule, Released to Office of Federal Register, Oct. 14, 2016; Interim Final Rule released to Office of Federal Register Nov. 2, 2017.

Performance Year /

Application Year

Quality MeasuresResource Use

or CostImprovement Activities

Advancing Care Information

DescriptionReplaces CMS Physician Quality Reporting System (PQRS)

Replaces ACA Value‐based Payment Modifier

New category of measurement; Medical Homes and NCQA PCSR receive full credit; 112 activities available

Replaces CMS EHR Incentive Programs f/k/a Meaningful Use

Reporting Methods

Claims, CSV, Web Interface (for group reporting), EHR, Qualified Clinical Data Registry (QCDR); QualifyingRegistry

ClaimsAttestation, QCDR, Qualified Registry, EHR Vendor

Attestation, QCDR, Qualified Registry, EHR Vendor, Web Interface (groups only)

2017 / 2019 60% 0%* 15% 25%

2018 / 2020 50% 10% 15% 25%

2019 / 2021 30% 30% 15% 25%*Measured for feedback only in 2017

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2017-2018 MIPS CHANGES

• Solo/Small practice bonus available in 2018 → +5 Points

• Complex Patient bonus available in 2018 → +5 Points

• Performance Periods:

Year Quality CostImprovement Activities

Advancing Care

Information

2017 90‐day minimum 12‐months 90‐day minimum 90‐day minimum

2018 12 months 12‐months 90‐day minimum 90‐day minimum

2017/18Exception

Measures thru CMS Web Interface, CAHPS,and readmissions are for 12 months

NoneMeasures thru CMS Web Interface, CAHPS, and readmissions are for 12 months

None

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Fee 2019 Schedule

Earn Less than 2019 Fee Schedule 0 – 100 Points

MIPS – CPS PAYMENT ADJUSTMENTS2017 Final

ScoreTransition Year Payment

Adjustment2018 Final

Score2018 Proposed Payment

Adjustment

≥ 70 Points

• Positive adjustment up to +4%

• Potential Performance Bonus → 0.5% minimum

≥ 70 Points

• Positive adjustment up to +5%

• Potential Performance Bonus → 0.5% minimum

4-69 Points

• Positive adjustment • Ineligible for Performance

Bonus

16-69 Points

• Positive adjustment• Ineligible for Performance

Bonus

3 Points • Neutral – Fee Schedule Only 15 Points • Neutral – Fee Schedule

Only

0 Points • Negative adjustment of -4% (Non-participation) 0 points • Negative adjustment of -

5% (Non-participation)

Earn More than Fee Schedule


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MERIT-BASED INCENTIVE PAYMENT SYSTEM

Advanced APMsCategories 3 & 4

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CMS APM vs. A-APM

CMS Alternative Payment Model (APM)

CMS Advanced Alternative Payment Model (A‐APM)

There is a difference!

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3-PART QUALIFIER FOR A-APMs

APM Nominal Amount of Risk Standard

Additional APM MACRA Statutory Req.

2017 2018

• Marginal Risk ≥ 30%;

• Minimum Loss Ratio capped at 4%; and,

• Total Risk ≥ 3% of expected APM expenditures

• Adds revenue-based nominal standard for total risk of 8% for APM under revenue models (through Performance Year 2020)

• Quality Measures align with MIPS

• Using certified EHR Technology (CEHRT) –currently requiring 2014 Edition certification

• Is a CMS expanded medical home (Optional to Nominal Risk Standard of 3%)


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3-PART QUALIFIER FOR A-APMs

Eligible ClinicianVolume Threshold

2017 2018

• Volume ≥ 25% of Part B payments; or,

• Volume ≥ 20% of Medicare patients

• No Change


32019

• Adds the CMS All-Payer Combination Option

• Incorporates Other Payers into a threshold calculation

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ALTERNATIVE PAYMENT ADMINISTRATION

Shared-Savings Population-BasedEpisode Payment

• Upside Only

• Downside Financial Risk

• Total Cost of Care

• Member-Patient Attribution

• Risk-Adjustment

• Quality Measures

• Retrospective

• Prospective

• Target Spend

• Inclusions & Exclusions


• Inclusion & Exclusions

• Performance Period

• Risk-Adjustment

• Stop Loss


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AGENDA

• MACRA 2018





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THE BASICS OF RISK

Attributed Population’s

Inherent Risk

Control

Exposure

Options: Accept Risk or Take Action

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VBP AND ADVANCED ANALYTICSData Availability Claims EHR Clinical Records

Demographics Yes Yes

Race/ethnicity Limited Limited

Diagnosis(a) Yes Yes

Procedures Yes Yes

Eligibility Yes Limited

Medications Medications dispensed Medications prescribed

Socioeconomic data Zip‐code derived Coded and zip‐code derived

Family history Not available Yes

Problem list Not available Yes

Procedure results Not available Yes

Laboratory results Not available Yes

Vital signs Not available Yes

Behavioral risk

factorsNot available Limited

Standardized

surveysLimited Limited

• Mile Wide, Inch Deep

• CPT, ICD Nomenclatures

• ANSI X12 Standards

• Inch Wide, Mile Deep

• CPT, ICD, LOINC, SNOMED, NDC Nomenclatures

• HL7 Standards (e.g., ADT, VXU)

Categories 1 & 2 Transaction-Oriented Categories 3 & 4Analytics-Oriented

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CLAIMS SUBMISSION = DATA REPORTING

Claims Data Reporting

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ITS ALL ABOUT THE DATA

• Provider Demographics• Provider-Patient Relationships• Provider Performance

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MACRA EXPANDED CODING – 2018

• MACRA → CMS required to define 3 new code sets

• Patient Relationship Codes → 2018 Medicare PFS Proposed Rule

– Purpose → Attribution of Patients & Episodes to 1+ physicians/clinicians; Plurality of care to pinpoint resource use

– Reported through claims using Level II HCPCS Modifiers

– “Voluntary” to start → Not a condition of payment

• Today → Traditional Medicare Only

• Tomorrow → Mainstream for VBP

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MACRA EXPANDED CODING – 2018 Continuous/broad

i. Provides ongoing principal care

ii. E.g., PCPs and Primary care specialists

Continuous/focusedi. Provides ongoing

management of chronic condition

ii. E.g., Rheumatologist

Episodic/broadi. Provides broad

responsibility during a brief defined period of time

ii. E.g., Hospitalist

Episodic/focusedi. Provides time‐limited

treatment or intervention

ii. E.g., Ortho performing knee replacement

Ordered by Anotheri. Provides care only as

ordered by another clinician

ii. E.g., Radiologist

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4 5

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AGENDA

• MACRA 2018





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CMS – 6 NAT’L QUALITY STRATEGY DOMAINS Domain Description

Efficiency and Cost

Reduction

Annual spending measures per capita, episodic care costs and quality‐to‐

cost metrics

Care CoordinationMeasuring successful transitions of care, admissions and readmission

rates and provider communication

SafetyPatient and Provider safety, including healthcare acquired infections and

conditions

Clinical Care Acute, Chronic, Preventive and Clinically Effective

Person‐ and Caregiver‐

Centered

Experience and Outcomes reported by patients and caregivers and

functional outcomes

Population and

Community Health

Measuring health behaviors, access, social / economic factors, physical

environ., disparities

Lower Costs

Better Care

Better Health

TRIPLE A

IM

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Low/No Risk

Moderate Risk

High

Risk

BUILDING PHM PROGRAMS

Attributed Population

Health Assessment

Intervention

Risk Stratification

Incr

easi

ng In

tens

ity

Who?

What? How?

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UNDER FFS, WHO HOLDS THE “RISK” BAG TODAY?

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COMMUNITY LEVEL RISK

Health Plans have been in Community Level Risk Management for Years

… but not care delivery

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ANSWERING THE “WHO,” “WHAT” AND “WHERE”

CMS Risk Adjustment Payment Transfer Formula

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MANAGING RISK FOR HEALTH PLANS

Analytics

• Benefits & Plan Design• Enrollment Data• Prevalence / Utilization Data• Burden of Disease

• Network Adequacy• Performance Data• Conditions by Specialty• Patient Capacity

• Administration• Compliance by Business Line• Provider Reimbursement Rates• Patient Out‐of‐Pocket• Inbound Revenue (e.g., premium)

Members

Providers Plan Operations

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E.G. #1 – RISK MANAGEMENTJOHNS HOPKINS ACGS – POPULATION DECISION TREE

The Whole Population

Non‐Users Single Morbidity (either acute or

chronic)

Commonly occurring morbidity

combinations

Complex morbidity

combinations

PregnantWomen

Infants (<12 months of age)

• No utilization, No or Invalid diagnoses

• Invalid Age

• Acute Minor• Acute Major• Likely to Recur• Asthma• Chronic Medical• Chronic Specialty• Eye• Dental• Psycho‐social• Preventive/

Administrative

• Acute: Minor and Acute: Major

• Acute: Minor and Likely to Recur

• Acute: Minor and Chronic Medical: Stable

• Acute: Minor and Eye/Dental

• Acute: Minor and Psychosocial

• Acute: Major and Likely to Recur

• 2‐3 morbidities• 4‐5 morbidities• 6‐9 morbidities• 10+ morbidities

• Further differentiated by age, sex and major morbidities

• 0‐1 morbidities• 2‐3 morbidities• 4‐5 morbidities• 6+ morbidities

• Further differentiated by major morbidities and delivery status

• 0‐5 morbidities• 6+ morbidities

• Further differentiated by major morbidities and low birthweight

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E.G. #1 – RISK MANAGEMENTIndividual Population Health Intervention

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AGENDA

• MACRA 2018





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Category 2 Category 3 – Bundle Payment/ACOCategory 4 – Global PBP

Category 1

PAYER A-APM ALIGNMENT – WHY CARE?Productivity-Based

PaymentPopulation-Based

Payment

Category 1 or 2

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• Payer ABC – Hospital Performance-based Fee-for-Service

• Goals → Come to us! “Low wait-times for our Emergency Room”

• Payer ABC – Per Member Per Month (PMPM)

• Goals → Reduced ER and hospital admissions during chemo episode

PAYER A-APM ALIGNMENT – WHY CARE?

Category 2 Category 4 – Oncology Care Model

Utilization

Utilization

ER ~$1,233Per Visit

UC ~$155Per Visit

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• Payer ABC – Hospital Performance-based Fee-for-Service

• Goals → Come to us! “Low wait-times for our Emergency Room”

• Payer ABC – Per Member Per Month (PMPM)

• Goals → Reduced ER and hospital admissions during chemo episode

PAYER A-APM ALIGNMENT – WHY CARE?

Category 2 Category 4 – Oncology Care Model

Episodic Care available now for your pain (short‐term)

Care Plan so pain is always well controlled (long‐term)

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IT’S HARD TO HAVE A FOOT ON BOTH PATHS!

Productivity-Based Payment

Population-Based Payment

4/3/2018

14

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ALL-PAYERS, MULTI-PAYERS, & OTHER PAYERS


• MACRA expands into additional payers beginning performance year 2019

− All-Payer Combination Option includes Medicare Advantage, and Medicaid Medical Homes

− Other-Payer Advanced APMs are those non-Part B payers that have similar payment arrangements as the Medicare Option

− Multi-Payer Models includes APMs under the CMS Innovation Center

• Enables clinicians to join the A-APM track by aligning payers and meeting volume thresholds – SMART!

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A-APM ALIGNMENT


• VOLUNTARY → Strong positioning to align A-APMs

• CMS Other Payer Advanced APMs qualification vetted annually in year prior to the applicable performance year

• Qualification can be initiated by Payer or Eligible Clinician

TIMELINES FORPAYER INITIATED

MedicaidCMS Multi-Payer

ModelsMedicare Health Plan

Other Payer A-APMs (Starting in 2019)

Description Title XIXInnovation Center

model with other payersMedicare Advantage

Commercial & other payers not in the other

groups

Annual Submission Period

Jan. 1 – Apr. 1 Jan. 1 – Jun. 30

Opens when bid package is sent in Apr. & closes

with bid deadline (1 Mon. of June)

TBD

Approval By Sept. Sept. Sept. TBD

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ELIGIBLE CLINICIAN A-APM ALL-PAYER VOLUME


TIMELINES FORELIGIBLE CLINICIANS

MedicaidCMS Multi-Payer

ModelsMedicare Health

PlanOther Payer A-APMs

(Starting in 2019)

Description Title XIXInnovation Center model

with other payersMedicare Advantage

Commercial & other payers not in the other

groups

Annual Submission Period

Sept. 2018 – Nov. 30 2018; annually

thereafter

Aug. 2019 – Dec. 2019; annually thereafter

Aug. 2019 – Dec. 2019; annually

thereafter

Aug. 2019 – Dec. 2019; annually thereafter

Approval By Dec. 2018; annually Dec. 2019; annually Dec. 2019; annually Dec. 2019; annually

• Qualification can be initiated by Eligible Clinician subsequent to Payer timeline

4/3/2018

15

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FUTURE OF FINANCIAL REWARDS

• Non-advanced APM or MIPS APM− APM-specific Rewards

− MIPS Opt-In – Collective Scoring

• Clinicians Scored Individually• Scores averaged across APM• Average score applied to all APM clinicians subject to MIPS

− MIPS Opt-Out – No Scoring

• Advanced APM− APM-specific Rewards− Lump sum incentive of 5% of Medicare payments− Qualified Participants (QPs) not subject to MIPS

• Not in APM− MIPS Rewards (or penalties)

Earning more than

fee schedule

1

2

3

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ESSENTIAL STRATEGIES

• #1 Assess → Payers & Patient Health Status

• #2 Recognize → Majority Revenue Source

• #3 Identify → Essential Data Points

• #4 Communicate → Remember Claims = Reporting Data

• #5 Document → Clinical Documentation Improvement (CDI)

• #6 Redesign → Use “5-Rights” for Strong Data Capture

• #7 Align → Payers, Provider Community, Patients

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AND REMEMBER …

We’re all in this together –by ourselves!

‐ Lily Tomlin

4/3/2018

16

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Documents

Adele Allison, Director of Provider Innovation Strategies ... Spring Conference/Adele Allison... · Adele Allison, Director of Provider ... • Data Collection →Purchases, Demographics,