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MACRA – MIPS vs. APMs for Ortho Fracture Surgeons

Alexandra Page, M.D.Chair, AAOS Health Care Systems Committee

Let the fun begin!

DISCLOSURES

My disclosures are listed on the AAOS Website.

I have no conflicts relevant to this presentation

Payment Reform 2017 - MACRAnyms:

1. MACRA: Medicare Access and CHIP Reauthorization Act of 2015

2. QPP: Quality Payment Program◦ MIPS: Merit-based Incentive Payment

System ACI: Advancing Care Information

◦ APMs: Alternative Payment Models◦ A-APMs: Advanced APMs

3. CJR: Comprehensive Care for Joint Replacement

4. EPM: Episode Payment Model◦ SHFFT: Surgical Hip/Femur Fracture Treatment

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MIPS vs. APM

90%+ will need to report via MIPS (Merit-based Incentive Payment System)

Currently (2017) APM options limited, particularly for specialists

Reimbursement (and ease of reporting) strongly favor APMs, hence need to stay aware of the opportunity

Should be more options available by 2018 (CJR, SHFFT, new “advanced” BPCI)

“Pick your Pace” in MIPS

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https://qpp.cms.gov/measures/quality

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https://qpp.cms.gov/

AAOS Performance Measures Committee

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(Clinical Practice) Improvement Activity – 15%

40 Points: ◦ 2 high-weighted (20 pts) Activities

◦ 4 medium-weighted (10 pts) Activities

◦ Or any 40 point combo

◦ (decrease from proposed 60 points)

Only 20 points required for:◦ Small, rural, HPSA

◦ Non-patient facing specialties

Preferential scoring if Activity done via CEHRT

2017 – Required to only report on 1 93 different choices

Improvement Activities: Examples

ACTIVITY NAMEACTIVITY WEIGHTING

Use of patient safety tools

Consultation of Physician Drug Monitoring Program (PDMP)

Medium

High

Use of QCDR data for ongoing practice assessment and improvements Medium

Leveraging a QCDR for use of standard questionnaires Medium

Implementation of use of specialist reports back to referring clinician or group to close referral loop Medium

Implementation of fall screening and assessment programs Medium

Engage patients and families to guide improvement in the system of care. Medium

Engagement of new Medicaid patients and follow-up High

Collection and use of patient experience and satisfaction data on access Medium

Care transition documentation practice improvements Medium

Annual registration in the Prescription Drug Monitoring Program Medium

Care coordination agreements that promote improvements in patient tracking across settings Medium

https://qpp.cms.gov/measures/iaNeed 40 points. Medium activity (the vast majority) are 10 points; high weighting is 20 points.

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https://qpp.cms.gov/measures/aci

“We intend for the information on cost to be actionable by clinicians . . . improving the delivery of high-value care and . . .smarter spending “

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CostQRUR: Quality and Resource Use ReportsNo reporting required; will be calculated from claims data

www.CMS.gov

Cost: Key Points

Cost containment motivates CMS Timely access to cost data remains a

challenge for clinicians Score based on episode- specific claims Attribution may remain an issue Look to bundle models for optimizing

costs, e.g. implant costs, length of stay, post-acute care/rehab

Reporting Options

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Adjustments:

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Small Practice Implications

Exempt from reporting in 2017 if treating:Fewer than 100 Medicare beneficiaries

-OR-Less than $30,000 in billing

Estimated that this represents 32.5% of physicians but accounts for only 5% of Medicare spending

Cost of non-compliance? Recognize 2017 as a pacifying transition

year Anticipate ongoing regulatory adjustments Cost will accelerate to 30% by 2019 Threshold of #/$ for reporting may change What is the cost of compliance vs.

Medicare reimbursement in YOUR practice?

Value-Based Reimbursement:

Alternative Payment Models (APMs)

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APMs:

But, tough to meet the thresholds of participation:◦ 2019 and 2020, must have 25% of Part B

payments for covered professional services furnished by APM that meets criteria of eligible alternative payment entity. ◦ 2021/2022 50% of Part B payments ◦ 2023 onward 75% of Part B payments

APMs & Ortho

Bundles: CJR, SHFFT Accountable Care Organizations◦ Seeing some activity◦ May work with primary care hitting the marks

Future Models◦ Physician-Focused Payment Model Technical

Advisory Committee (PTAC)◦ ACS/Brandeis Groupers

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Why an ACO could work:

CJR & SHFFT

Comprehensive Care for Joint Replacement (CJR) Hospital Initiator (owner) of bundle; includes all

services associated with inpatient & post-acute care Mandatory in 67 markets (1/3rd of all markets in USA)

Retrospective Payment Design, requires Quality Thresholds

Financial Options/Gainsharing with physicians and “collaborators” this offers the potential pathway for surgeons to take risk & meet APM/A-APM requirement

Includes hemis/THR for fx but with a higher target price

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SHFFT: Surgical Hip/Femur Fracture

Mirrors CJR: locations, quality measures DRGs 480-482. Does not include hemi/THR

done for fx (under CJR) Potential as an APM in 2018, earn the

incentive payment beginning in performance year 2019

Potential as an A-APM as early as performance year 2018 if collaborate with participant hospitals in Advanced APM path.

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Surgeon readiness for APMs/ Risk-sharing Collaborative Environment Proper systems/processes◦ Registries◦ Managing the entire care continuum (post-

acute care) ◦ Careful co-management by hospital and

surgeon Contracts & Relationships with SNF &

Home Health Cost Monitoring DATA: cost, complications

Alexandra(Alexe)Page,M.D.

alexe.page@gmail.com(619)8408973

MusculoskeletalHealthCareSolutions