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Navigating the Valley between Volume and Value
Cathie Biga
Illinois ACC
1
MACRA Readiness
FACC
The Tipping Point at Altitude
3
Triple Aim in 2016
4
The march to value……..
The train has left the station, and it ain’t coming back
5
Triple Aim
Manage Population Health
Enhance the Experience of
Care
Reduce Per Capita Cost
Ideal Care System
6
HHS mandate followed by MACRA
7
The Basics of MACRA
• MACRA = Medicare Access & CHIP Reauthorization Act
• Eliminate SGR
• Effective 1/1/19 • BUT data collection begins 1/1/17
• Payment updates • 2016 was negated
• MACRA • APM
• MIPS
January 1, 2019
Rapid Pace of Change Continues
• MIPS changes
• APM changes
• Episodes of Care
• Attribution
10
Advancing Care Information: 25%
• 131 points (100 = 25% credit) • Removed all or nothing
approach • Customized set of measures • Base score + performance
Clinical Practice Improvement (15%) • 60 points • Weighted activities
• 10-20 points • 90 activities • APM’s = ½ credit
Quality/PQRS: 50%
• 80-90 points • 6 measures (1 cross
cutting) • OR • specialty measure set • Population measures
Resource Use: 10% • 10 points per
measure • Claims based • Total cost per capita • MSPB • Episode-based
measures
MIPS Composite Score
Quality 50%
Resource Use: 10%
EHR Meaningful
Clinical Practice Improvement: 15%
Quality Use: 50%
Allocation change announced: 4/8/16
What are we seeing in this proposal
• Reduce reporting burdens
• Adds flexibility
• Accountability
• Negative performance can NOT be > 4%
• Positive performance should be 4% with some bonuses
• If in a qualifying APM BUT don’t qualify for incentive – they can elect MIPS
• 1/1/17 – data collection begins
13
Summary
• Quality – 50% of total
• Replaces PQRS and quality component of VM
• Changes will allow for variances between specialties
• Groups 2-9: 2 claims based population measures
• Groups > 10: 3
• 80 or 90 possible points
14
Core Measure set
• Announced in April 2016 • Measure sets:
• Cardiology • Gastroenterology • HIV and Hepatitis C • Medical Oncology • Obstetrics and Gynecology • Orthopedics • ACO
• Measure Development Plan released yesterday
15
Summary
• Advancing Care Information aka MU • Replaces the Medicare EHR program
• New emphasis on interoperability and information exchange
• Eliminates the current all or nothing program
• Clinical Practice Improvement • New in MIPS
• 90 options – including participating in APM’s and pt. centered homes
16
Are your clinics ready?
Cost
• Each cost measure worth up to 10 points
• If 20 pt. sample not met – revert to average
• MSPB
• Total cost per beneficiary
• 40 episodes
BOTTOM LINE:
No Outcome…….No Income
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Transparency
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Physician Value Agenda
• Meaningful Use • PQRS • Value modifier
• QRUR report • Exhibits
• Supplemental QRUR • Drill Down exhibits
• Physician Compare
• Know the interaction amongst and between
these
Total at risk payments thru 2017
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QRUR……
Supplemental QRUR
MACRAeconomics
• Current PQRS report cards
• 43% of cardiology was Unsuccessful in ‘14
• Current MU report cards
• VM (5,477 providers were penalized – ’14 data)
• QRUR
• Supplemental QRUR
• Is physician comp tied to quality?
24
Are you MACRA ready?
• Organizational focus
• Currently successful in
• PQRS
• MU
• VM
• You have found your data
• You know your numbers
• Reducing variability is a priority
• Understanding cost per case and episodes of care
• Care coordination is an organizational priority
• Documentation is a focus – clinic & hosp.
25
What we don’t have time for
Risk Adjusted scores
• Your documentation matters
• It only counts if it is BILLED • What is your average number
Dx/claim
• It MUST have specificity • What are your top 10
diagnosis
Attribution
• Two step process • Total cost in QRUR
• Cost per the 4 index conditions
• MSPB • 3 days pre and 30 days post
• Condition Episodes
• Procedural Episodes
26
Stay tuned
Part 2:
Alternate payment models & other updates
27
ACO update
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• 477 ACO’s as of 1/31/16 (433 MSSP) • 8.9% of the population is in an ACO • Top states: Il, CA, FL, MA, TX, PA, NY
• ACO’s in 49 states
• MSSP welcomed 100 new ACOs, adding 15,000 more participating physicians, on January 1, 2016
• With the new group of ACOs, CMS will have 434 ACOs participating in the Shared Savings Program next year, serving more than 7.7 million beneficiaries
Alternative Payment Models
ACO’s
Pioneer model
• Medicare: 3 models MSSP model Next Generation model (proposed) • Medicaid
• Commercial
Where are we in 2016
447 ACO’s including MSSP, Pioneer, NG, ESRD 64 are in a Qualifying APM (22 in MSSP 2/3)
Distribution of ACO’s
BPCI NextGen
32
Advanced Alternative Payment Models
• Data year 2017 • Data year 2019 (2021) – private payer/Medicaid • Everyone will report MIPS yr. 1 • Qualifying APM’s:
• Comprehensive ESRD Care Model • Comprehensive Primary Care Plus (CPC+) • Medicare Shared Savings Program—Track 2 & 3 • Next Generation ACO Model • Oncology Care Model Two-Sided Risk Arrangement
(available in 2018)
33
Pulling it all together: Value Based Future
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DEGREE OF INTEGRATION
LEV
EL O
F FI
NA
NC
IAL
RIS
K
MIPS
Qualified APM
Performance-Based Contracts
Fee for Service
Global Payments
Shared Savings
Bundled/Episode Payments
*Potentially Qualified APM
APM
Shared Risk
* Must have more than nominal risk & threshold dependent – 2021 includes Non-Medicare population
Decision points
• Working/reporting individually vs as a group
• Attribution
• Documentation
• Risk scores
• CMI
• Episodes of care
• RFI completed
• Proposed ruling coming
35
Basic episode
36
Ortho to cardiac….
37
CAD Episode
• Goals: • Patient level: improve quality of life for CAD pts.
• Reduction in AMI
• System level: Increase rate of value services, reduce complications and inappropriate procedures
• Overarching Design = Nested episode • CAD – payment for 12 months of preventive care
• CAD procedures “nested” – sub-bundle payment • Within the course of the condition episode
38
Game changer?
• Did not want to repeat procedure episode
• Procedure within episode – incentivizes the use of low-resource tools (meds/life style) with the goal of avoiding the procedure
• Nested episode drives collaboration
39
What it might look like
40
The makeup of a “nested” episode
41
Variability of care…
42
43
Our Service Lines
• Continue to align CV care across the continuum
• Partnering in Value Programs
• Active in Episode calculations
• Same day discharges
• Radial approach
• 2 mid-night rule
• New Observation rules are here
• Moving from a wRVU comp model
44
45
CMS Hospital Quality Incentives and Penalties
CMS at risk dollars for Quality are 6.5% of Total Medicare Reimbursement in the current Fiscal Year, and will escalate to 11% over the next 5 years.
2011 2012 2013 2014 2015 2016 2017 2018 2019
Note: The above is the CMS Fiscal Year Payout Period.
The Performance Period is generally the Calendar Year Two Years
Prior.
45
Originally mandated by section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. this authorized CMS to pay hospitals that successfully report quality measures a higher annual update to their payment rates.
In addition to giving hospitals financial incentive to report the quality of services, the program provides CMS with data to help consumers make more informed decisions about their health.
This information is available on the Hospital compare website
Inpatient Quality Reporting (IQR) Program
46
Public Reporting and Our Hospitals
• 2005: TJC and CMS
• Hospital Compare • Payment & value for specific diagnosis
• Readmissions and mortality
• Timely and effective care
• Value Based Purchasing
• 5 – Star Ratings • Totally revised
• Soon to be released
47
Remember the Programs
• Hospital acquired conditions
• Hospital Readmission Reduction
• CABG joins the ranks of CHF and MI
• Hospital Inpatient Reporting (IQR)
• Cost of CHF
• Cost of MI
• MU
• Value Based Purchasing
48
CMS Value Based Purchasing
Clinical Process of
Care 20%
Outcomes 30%
Patient Experience
of Care 30%
Efficiency 20%
Payment Period FY 2015
49
CMS is rapidly changing the weighting of each Value Based Purchasing Domain as well as the content within each domain making systematic and proactive performance improvement more difficult.
FY 2014 FY 2015 FY 2016
49
2017
50
2018….change marches on
• New domains all equally weighted:
• Clinical Care
• Pt. and caregiver experience
• Safety
• Efficiency and Cost reduction
• And in the future
• Adding COPD mortality
• A 30 and 36 month outcome on Hip and Knee
51
Questions??
52