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Making Sense of MACRAMay 10, 2016
© 2016 Health CatalystProprietary and Confidential
How ready are you to participate in MACRA?
1. Not at all – 12.36%
2. Somewhat – 22.53%
3. Unsure – 55.77%
4. Ready – 8.24%
5. Very ready – 1.10%
Poll Question #1
364 Total Responses
© 2016 Health CatalystProprietary and Confidential3
Who reads 962 pages of regulations?
Remember all these slides reflect PROPOSED regulations
Question
© 2016 Health CatalystProprietary and Confidential4
Purpose of HR Bill 02
Physician Fix Passed in April 2015
• Offer multiple pathways for risk/reward
• Minimize additional reporting burdens
• Streamline multiple programs
• Reward clinicians for value over volume
© 2016 Health CatalystProprietary and Confidential5
• MACRA – Medicare Access and CHIP Reauthorization Act of 2015
• SGR – Sustainable Growth Rate (replaced by MACRA)
• MIPS – Merit-based Incentive Payment System
• APM – Alternative Payment Models (Advanced)
• EP – Eligible professional becomes EC Eligible clinician
Acronyms
© 2016 Health CatalystProprietary and Confidential6
Goals of CMS• Overall goal – 90% of
Medicare payments shifted to quality or value by 2018
• In 2014, 22% of Medicare payments (approximately $138B) for physicians
• Invite private sector to match/exceed goal
© 2016 Health CatalystProprietary and Confidential7
Better care
Smarter spending
Healthier people
Goals of CMS
Via focusedIncentives
Care delivery
Information sharing
© 2016 Health CatalystProprietary and Confidential8
“Most profound change to physician compensation in more than 25 years. There is going to be a lot of anger and frustration.”
Steven Stack, M.D., President of AMA
“Make policies simple, flexible to allow providers to make choices to meet their needs and outcomes-oriented.”
Patrick Conway, M.D., Chief Medical Officer, CMS
“Feedback mechanisms are too removed from the performance year.” Anders Gilberg, Senior Vice President of Government Affairs, MGMA
“Quite frankly, the rank-and-file physicians aren’t paying attention.” Chet Speed, JD, LLM, Vice President of Public Policy, AMGA
Reactions
© 2016 Health CatalystProprietary and Confidential9
2017Performance Year
© 2016 Health CatalystProprietary and Confidential10
• $100M of technical assistance for small practices (under 15 professionals)
• $75M for physician groups to improve quality measure development
Additional Aspects
© 2016 Health CatalystProprietary and Confidential11
Two Tracks of MACRA``
2020
.5% annual update thru 2019
Combine MU, PQRS, VBM
Value Based participation bonus 5%
2018
MIPS
APM QP2019
Performance year
Base year
+/- 5%+/-4% +/- 7% +/- 9% Up to +/- or neutral + Bonus
2017
Performance year
20232021 2022 2024
20202018 20192017 20232021 2022 2024
© 2016 Health CatalystProprietary and Confidential12
MIPS participants who participate in APMs would receive credit toward scores in the Clinical Practice Improvement Activities category.
Certain Advanced APMs participants, who fall short of the payment or patient participation requirements for the incentive payment can choose whether they would like to receive the MIPS payment adjustment.
The proposed rule aligns standards between the two parts of the Quality Payment Program in order to make it easy for clinicians to move between programs.
Cross Over Between the Tracks
© 2016 Health CatalystProprietary and Confidential13
Public commentary until June 27, 2016
Final regulations published in November 2016
Comments may be submitted electronically to CMS:
Source: http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking
Proposed Rulemaking
© 2016 Health CatalystProprietary and Confidential14
Reporting period will be annual - only see your results once a year
• First feedback report – July 2017
• Second feedback report – July 2018
All data will be made available on Physician Compare
Reporting
MIPSMerit-based
Incentive Payment System
© 2016 Health CatalystProprietary and Confidential16
EligibilityYear 1, 2 Medicare Part B clinicians:
• Physicians• Physician assistants• Nurse practitioners• Clinical nurse specialist • Certified registered nurse
anesthetists
Hospitals are not part of program
Year three expansion: • Physical or occupational
therapists• Speech-language pathologists,
Audiologists• Nurse midwives• Clinical social workers, Clinical
psychologists• Dietitians / Nutritional
professionals
© 2016 Health CatalystProprietary and Confidential17
• First year of Medicare participation
• Low volume threshold
• Participants in advanced APM
Exceptions for MIPS
© 2016 Health CatalystProprietary and Confidential18
Composite Performance Score (CPS)
Measurement
Area Weight in 2019 (Changes by year)
Quality 50%Cost (Resource use) 10%Clinical practice improvement activities (CPIA) 15%Advancing care information (Meaningful use of certified EHR technology)
25%
© 2016 Health CatalystProprietary and Confidential19
• Six measures with no domain required – select from over 300 measures (last 200 pages of regulation)
• One cross-cutting and one outcome measure required
Cross cutting measure exampleCare Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed.
Outcome measure example- CMS definesCataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Quality – Weighted 50%
© 2016 Health CatalystProprietary and Confidential20
Stakeholders
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf
© 2016 Health CatalystProprietary and Confidential21
Clinical Care• Measures incorporating patient preference and shared decision-
making
• Cross cutting measures (more than one specialty)
• Outcome measures
• Focused measures for specialties that have clear gaps
Safety• Measures of diagnostic accuracy
• Medication safety related to important drug classes
Initial Priorities for Measure Development
© 2016 Health CatalystProprietary and Confidential22
Care coordination• Assessing team-based care (timely exchange of data)
• Effective use of new technology such as telehealth
Patient and caregiver experience• PROMs (Patient-reported outcome measures)
• Additional topics important to patient/family/caregivers
Affordable care• Overuse measures
Continued- Initial Priorities
© 2016 Health CatalystProprietary and Confidential23
Population Health and Prevention• Developing or adapting outcome measures at
population levels to assess effectiveness of promotion and preventative services
• IOM Vital Signs topics
• Detection or prevention of chronic disease
Continued – Initial Priorities
© 2016 Health CatalystProprietary and Confidential24
• Compare resources used to treat similar care episodes and clinical condition groups across practices
• Can be risk-adjusted to reflect external factors
• CMS will calculate from claims
Resource – Weighted 10%
© 2016 Health CatalystProprietary and Confidential25
MSPB
Medicare Spend per Beneficiary Jan to Dec 2014Period Claim Type Hospital State Nation
1 to 3 days Prior to Index Hospital AdmissionHome Health Agency 11$ 13$ 13$ 1 to 3 days Prior to Index Hospital AdmissionInpatient 12$ 4$ 5$ 1 to 3 days Prior to Index Hospital AdmissionOutpatient 117$ 70$ 117$ 1 to 3 days Prior to Index Hospital AdmissionDurable Medical Equipment 12$ 9$ 9$ 1 to 3 days Prior to Index Hospital AdmissionCarrier 456$ 535$ 532$ During Index Hospital AdmissionInpatient 13,433$ 9,456$ 9,108$ During Index Hospital AdmissionDurable Medical Equipment 33$ 21$ 24$ During Index Hospital AdmissionCarrier 2,216$ 1,617$ 1,514$ 1 through 30 days After Discharge from Index Hospital AdmissionHome Health Agency 846$ 785$ 771$ 1 through 30 days After Discharge from Index Hospital AdmissionHospice 96$ 108$ 118$ 1 through 30 days After Discharge from Index Hospital AdmissionInpatient 1,810$ 2,545$ 2,665$ 1 through 30 days After Discharge from Index Hospital AdmissionOutpatient 1,103$ 656$ 710$ 1 through 30 days After Discharge from Index Hospital AdmissionSkilled Nursing Facility 2,576$ 3,571$ 3,251$ 1 through 30 days After Discharge from Index Hospital AdmissionDurable Medical Equipment 150$ 94$ 101$ 1 through 30 days After Discharge from Index Hospital AdmissionCarrier 901$ 1,184$ 1,083$ Complete Episode Total 23,775$ 20,669$ 20,025$
Source: CMS Public Information
© 2016 Health CatalystProprietary and Confidential26
Areas: (Not yet defined in detail but there will be 90+ activities and selection of one)
• Expanded practice access
• Population management
• Care coordination
• Beneficiary engagement
• Patient safety and practice assessment
• Participation in an APM
Clinical Practice Improvement Activity (CPIA) – Weighted 15%
© 2016 Health CatalystProprietary and Confidential27
• Former Meaningful Use
• Use of certified electronic health record (EHR) technology in day-to-day practice
• Emphasis on interoperability and information exchange.
• Not all-or-nothing EHR measurement and no quarterly reporting.
• Removes reporting for CPOE(Computerized Provider Order Entry) and Clinical Decision Support
Advancing Care Information – Weighted 25%
© 2016 Health CatalystProprietary and Confidential28
Tweet from Andy Slavitt:
In 2016, MU as it has existed—with MACRA—will now be effectively over and replaced with something better #JPM16
Slavitt said: ‘The focus will move away from rewarding providers for the use of technology and towards the outcome they achieve with their patients.’
Meaningful Use
© 2016 Health CatalystProprietary and Confidential29
1. Protect patient health information
2. Patient electronic access
3. Electronic prescribing
4. Coordination of care through patient engagement
5. Health information exchange
6. Public health and clinical data registry
Six Objectives of Advancing Care Information
© 2016 Health CatalystProprietary and Confidential30
For period of January 2017 to December 2017
1. Use 2014 or 2015 edition certified EHR
2. Report eight Stage 2 or six Stage 3 advancing care information measures/objectives
3. Attest that clinicians have cooperated with the surveillance of certified EHR technology under the ONC Health IT Certification Program
4. Attest to statements related to health information exchange and information blocking
Technology
© 2016 Health CatalystProprietary and Confidential31
Each of the four areas will have a scoring calculation and points
Example for Advancing Care Information
Scoring
BaseScore\ 60 pts
PerformanceScore\10 pts
BonusScore
Composite Score
Area Maximum Points ScoringQuality 80-90 Each measure 1-10 compare
to benchmark, bonusCost (Resource use) Average score of cost Same as quality
Clinical practice improvement activities
60 Each activity=10pt,double for high, compare to a target
Advancing care information 100 Base + performance and bonus potential
© 2016 Health CatalystProprietary and Confidential32
• Converts measures/activities to points
• Eligible Clinicians will know in advance what they need to do to achieve top performance, targets will be communicated
• Partial credit available
• MIPS composite performance score in 4 weighted performance categories on a 100-point scale
• Option to do as a group
More about scoring
© 2016 Health CatalystProprietary and Confidential33
The CPS will be compared to the MIPS performance threshold to determine the adjustment percentage the eligible clinician will receive
In the first five payment years $500 million in an additional performance bonus that is exempt from budget neutrality for exceptional performance.
Scoring
Quality Resource Use
Composite Performance Score
Clinical Practice
Improvement
Advancing Care
Information
© 2016 Health CatalystProprietary and Confidential34
Payment adjustment
Performance below
Negative payment adjustment
Performance above
Neutral or positive payment adjustment
Potential for bonus not to exceed 10%
Adjustment % based on relationship between their CPS and MIPS threshold- budget neutral program
APMAlternative
Payment Model
© 2016 Health CatalystProprietary and Confidential36
MACRA does not change any existing APM programs or incentives
© 2016 Health CatalystProprietary and Confidential37
• Comprehensive ESRD Care Model (Large Dialysis organization)- 12 participants
• Medicare Shared Savings Program—Track 2 and Track 3 – 24 participants
• Next Generation ACO Model -21 participants
• Comprehensive Primary Care Plus (CPC+) Currently regional with payers, available in 2017
• Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
Models that Qualify for Advanced APM
© 2016 Health CatalystProprietary and Confidential38
Criteria to meet:
• Payment based on quality (measures similar/comparable to MIPS)
• Use of certified EHR technology- at least 50% of providers
• Bear financial risk and risk must be at certain magnitude or be part of Medical home model expanded under CMMI
It WILL be difficult to qualify for Advanced APM
Advanced APM Eligible Programs
© 2016 Health CatalystProprietary and Confidential39
Not only do you need to be part of an advanced APM, but you also need to be a QP (Qualified Provider)
• Based on advanced APM entity scoring and done for payment year
• % of payment and patients under advanced APM-based on 2017
Expanded Criteria
© 2016 Health CatalystProprietary and Confidential40
CMS Calculates Threshold Score
Payment amount formula for Threshold score %
$ for Part B professional to attributed beneficiaries divided by $ for Part B professional to attribution-eligible beneficiaries
Patient Count formula for Threshold score %
# of attributed beneficiaries given Part B professional services divided by # of attributed-eligible beneficiaries given Part B professional services
** Partial QP can choose MIPS
Use most favorable score
2019 QP 25%
2019 Partial QP 20%
2019 QP 20%
2019 Partial QP 10%
© 2016 Health CatalystProprietary and Confidential41
Now QP in advanced APM
• Do not participate in MIPS
• Get 5% increase in fee schedule
Met all criteria
© 2016 Health CatalystProprietary and Confidential42
CMS estimates 30,000 to 90,000 clinicians in advanced APM.
The costs for implementation and complying with the advancing care information performance category requirements could potentially lead to higher operational expenses. However, we believe that the combination of payment adjustments and long-term overall gains in efficiency will likely offset the initial expenditures.
CMS believes that the proposed changes will have a positive impact and improve the quality and value of care provided to Medicare beneficiaries.
Calculation for internal medicine –$1,100 to a positive of $1,900.
Impact Projected by CMS
Readiness
© 2016 Health CatalystProprietary and Confidential
How optimistic are you that the April 27th proposed regulations will produce the results that CMS is expecting from MACRA?
1. Not at all – 20.28%
2. Somewhat – 38%
3. Optimistic – 12.59%
4. Very optimistic – 0%
Poll Question #2
429 Total Responses
© 2016 Health CatalystProprietary and Confidential45
Goals
• Set predictable updates for physician fee schedules
• Encourage physicians to participate in new payment models• Both cost and quality
• Adopt interoperable electronic health record
Is this encouraging consolidation?
This is not cheap or simple.
Joseph J. Fifer, FHFMA, CPA, President HFMA
HFMA Comments
© 2016 Health CatalystProprietary and Confidential46
May push independent physicians to a breaking point
Reaction
“I am going to predict that more physicians will seek employment and figure that it is the health system problem to deal with the %s and give me the infrastructure to be successful”.
Lee Sacks, M.D., Chief Medical OfficerAdvocate Health
© 2016 Health CatalystProprietary and Confidential47
Take Medicare Part B revenue and annualize – adjust for volume and fee schedule increase of .5%
• What is impact of 4% reduction under MIPS?
• What investments do I need to participate?
• What is impact of 5% under APM?
• Have we explored these options and know investments?
$25M of revenue has potential for negative impact of ($1M) – adjust for point scoring on MIPS
Financial Impact
© 2016 Health CatalystProprietary and Confidential
Outline a strategy
• Do I know which track I want?
• What is impact on my practice?
• What do I need to do?
• What happens if I do nothing?
• What are we doing to move to value-based models?
Deadline of Q3 2016 for outline.To Do #1
© 2016 Health CatalystProprietary and Confidential49
Current strategy of organization, MACRA may help decision
Applications due for ACO
Next generation Letter of intent May 20, 2016
Application May 25, 2016
MSSP Notice of intent May 31, 2016
Application July 29, 2016
Link with Value Based
© 2016 Health CatalystProprietary and Confidential
Educate and communicate• Provide clinicians with
summarized documents.
• Use webinars.
• Make time in current meeting structure for education on topic.
• Staying informed will ease stress.
To Do #2
© 2016 Health CatalystProprietary and Confidential
Connect locally and use their websites
AMA – http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-physician-payment-reform.page
AHA – http://www.aha.org/advocacy-issues/physician/index.shtml
AAFP – http://www.aafp.org/practice-management/payment/medicare-payment.html
Use professional societies
MACRA READY program
To Do #3
© 2016 Health CatalystProprietary and Confidential
Identify thought leaders and discussTo Do #4
• Who has been your thought leader?
• Can be someone in healthcare or can you explain to someone outside of healthcare to get feedback?
© 2016 Health CatalystProprietary and Confidential
Look inward, know your strengths• What do you think you do well?
• Where do you have data that shows you do well?
• Which measures show how well your practice performs?
• Do you have an performance plan in place to improve?
• Who has accountability for performance?
Source: Bobbi Brown Art
To Do #5
© 2016 Health CatalystProprietary and Confidential
Review your QRUR and Meaningful Use Submission• Talk with the individuals that
completed the work in PQRS and MU.
• What can you learn?
• What applies to MIPS?
To Do #6
© 2016 Health CatalystProprietary and Confidential55
QRUR Report
Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/QRUR-Quick-Ref-Guide.pdf
© 2016 Health CatalystProprietary and Confidential
Evaluate readiness/ExecuteYou now have a plan and can do a quick check on reality based on your practice. You know where you have penalties and where you need to change.
You need data, best practices and an adoption methodology to succeed.
Source: Health Catalyst
To Do #6
© 2016 Health CatalystProprietary and Confidential
Questions
57
Bobbi [email protected]
Bryan T. Oshiro, M.D.Chief Medical [email protected]
© 2016 Health CatalystProprietary and Confidential
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