MACRA: New Medicare Reimbursement Models Sharp HealthCare · 2017-09-09 · MACRA: New Medicare...

MACRA: New Medicare Reimbursement Models

Sharp HealthCare

August 15, 2016

August 2016

Caitlin Greenbaum, MPH Director, Health Policy & Strategy

The Health Management Academy

Nathan M. Bays, Esq. General Counsel, The Health Management Academy

Executive Director, The Academy Advisors

The Academy

Our financial relationships are with the Health Management Academy as our employer. The information and opinions in this report were prepared by The Health Management Academy or one of its affiliates

(collectively "Health Management Academy"). The information herein is believed to be reliable and has been obtained from public sources believed to be reliable. Health Management Academy makes no representation as to the accuracy or completeness of such information. Health Management Academy may engage in activities, on a proprietary basis or otherwise, in a manner inconsistent with the view taken in this research presentation. In addition, others within Health Management Academy, including strategists and staff, may take a view that is inconsistent with that taken in this research presentation. Opinions, estimates and projections in this report constitute the current judgment of the author as of the date of this report. They do not necessarily reflect the opinions of Health Management Academy and are subject to change without notice. Health Management Academy has no obligation to update, modify or amend this report or to otherwise notify a recipient thereof in the event that any opinion, forecast or estimate set forth herein, changes or subsequently becomes inaccurate.

This report is provided for informational purposes only. Nathan Bays +1 703.647.1028 Health Management Academy/The Academy Advisors August 2016 Any reproduction by any person for any purpose without Health Management Academy’s written consent is prohibited. Copyright © 2016 The Health Management Academy

2 Confidential: This material is intended solely for informational purposes

Disclosure

The Academy

• Macro Issues

- Provide background around the transition to value-based models - Explore the trajectory of value-based payments

• MACRA

- Provide an overview of the structure of the reimbursement system established by MACRA

- Discuss strategic implications of MACRA to providers


Overview & Objectives: CMS Payment Reform

The Academy 4

Within Large Systems, Very Few Are Moving Rapidly

Confidential: This material is intended solely for informational purposes Source: The Health Management Academy

The Academy 5

Value-Based Payment Models Have Been Slow To Arrive


The Academy

CMS Value Initiative Goals

• 2016 Value-based Payment Goal - 30% Medicare payments in alternative

payment models - 85% of Medicare fee-for-service payments in

VBP

• 2018 Value-based Payment Goal - 50% Medicare payments in alternative

payment models - 90% Medicare fee-for-service payments in

VBP

6 Graphic Source: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Confidential: This material is intended solely for informational purposes

The Academy 7

SGR Repeal & Physician Value-Based Payments


The Academy 8 Confidential: This material is intended solely for informational purposes

SGR Repeal: How It Changes Medicare Physician Payments

• In April the methodology used to calculate physician payments for the Medicare program, also known as the “SGR” was repealed, and replaced with a new physician payment structure referred to as the “Quality Payment Program”

• 2017 Baseline Performance Year, 2019 Implementation: Physicians (or groups/virtual groups) elect to remain in fee-for-service subject to a new value-based regime (“MIPS”) or transition their practice toward risk-based models (“APMs”), and will be reimbursed differently under each track

• Bottom line: assuming no changes, fee-for-service as it currently exists will substantially move toward “pay-for-performance” and economic incentives will drive physicians toward alternative payment models over time (“APMs”)

The Academy

Physician Payment Structure: The Next 10 Years

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2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026+

Annual Updates

In 2019, physicians elect to participate in one of two adjustment mechanisms: Merit Based Incentive System (“MIPS”) or Alternative Payment Model (“APM”) Programs

Jan-Jun 0%

Jul-Dec 0.5%

0.5% 0.5% 0.5% 0.5% 0% 0% 0% 0% 0% 0% MIPS: .25%

Qualified APMs: .75%


The Academy

MIPS Eligibility Likely to Expand Over Time

• In first 2 years, eligible providers include: - Physicians (MD, DO, DDS, DMD, DPM, OD, DC) PAs, NPs, clinical nurse specialists,

certified registered nurse anesthetists, and groups that include such professionals

• After 2021, HHS can determine other eligible professionals to subject to MIPS - Physical/occupational therapists, speech-language pathologists, audiologists, nurse

midwives, clinical social workers, clinical psychologists, dieticians/nutritional professionals

3 Exclusions to MIPS participation

1. Falls below “low-volume threshold” • Less than $10,000 in Medicare claims and fewer than 100 Medicare Part B patients

2. First year of Medicare Part B participation 3. Meeting certain levels of practice in Advanced APMs


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Merit-Based Incentive Payment (“MIPS”) Track

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Measure Performance

•Two year look-back – performance measurements begin in 2017 for 2019 adjustments •4 weighted categories – Quality, Cost/Resource Use, Advancing Care Information/EHR Use, Clinical

Practice Improvement •EHR MU, PQRS, and VBM – sunset in 2018, with certain measures incorporated into new MIPS categories

Composite Score

•Based on scores in each performance category, participants receive an annual composite score between 0-100

•Score will be publicly available via Physician Compare

Threshold Comparison

•Each clinician’s score will be compared against a performance threshold to determine payment adjustments

•Performance threshold will based on the median of MIPS scores – competition among peers

Additional Adjustments

•Adjustments are budget neutral – upward adjustment can be scaled up or down, with the scaling factor not to exceed 3 times the baseline adjustment

•Additional exceptional performance adjustment offered to small number of best performers


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MIPS Reporting Options

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• Reports at individual level for each of the 4 performance categories

• Receive individual score/payment adjustment at TIN/NPI level

• A group, defined by TIN, would be assessed as group across all 4 performance categories

• Receive individual score/payment adjustment at TIN/NPI level

• All MIPS clinicians in group receive the same annual score

• CMS will ultimately allow reporting through virtual groups, though not in 1st performance year

• Option available to MIPS clinicians practicing in an APM deemed a “MIPS APM”

• All scores aggregated at APM Entity level

• All individuals in APM Entity receive the same annual score

Individual Group APM Entity


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Components of MIPS Composite Score

13 Confidential: This material is intended solely for informational purposes Source: The Health Management Academy

Quality 30%

EHR Use 25%

Clinical Improveme

nt 15%

Resource Use 30%

Quality 50%

EHR Use 25%

Clinical Improveme

nt 15%

Resource Use 10%

2017 Performance; 2019 Payment 2019 Performance; 2021 Payment

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Quality Domain

• Will look similar to PQRS in initial years – CMS will incorporate more outcome measures over time

• Clinicians choose from list of 200+ measures, either individually or from a specialty measure set - Most clinicians will report on 6 measures (including 1 cross-cutting & 1 outcome measure if

available)—performance in these measures will influence score (receive 1-10 points for each reported measure)

- CMS will calculate 2-3 population health measures based on practice size - Bonus points for EHR reporting, and additional outcome/patient experience measures

• Reporting: - Individuals can report through claims, QCDR, qualified registry, EHR, administrative claims

(no submission required) - Groups (of 25 or more) can also report through CMS Web Interface (report all measures

included interface and populate data for first 248 ranked and assigned beneficiaries)


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Cost/ Resource Use Domain

• Beginning in 2017 PY: CMS will use total per capita cost & Medicare Spending Per Beneficiary measures, and selection of episode-specific measures - Each measure reported converted to score of 1-10 points

• Beginning in 2018 PY: New care episode, patient condition, and patient relationship codes will be included in claims - Relationship codes reported on claims will attribute patients to practitioner(s), and episode

& patient condition codes will be used to compare similar patients/ episodes

• CMS will use per patient total allowed charges for all services under Parts A & B (and Part D, if determined appropriate) for the analysis of resource use

• Scores for individuals/groups based on administrative claims, no additional reporting

15


The Academy

Clinical Practice Improvement Activities (“CPIA”) Domain

• Clinicians/groups choose from list of 90+ activities - Activities focus on expanded access, population management, care coordination,

beneficiary engagement, patient safety/ practice assessments, & APM participation

• Maximum score 60 points – clinicians can choose from “high” or “medium” weighted activities, worth 20 or 10 points each

• MIPS clinicians participating in PCMHs will be guaranteed maximum CPIA score; minimum half credit for participation in APM

• Reporting: - Individuals can report through attestation, QCDR, qualified registry, EHR, administrative

claims (if feasible) - Groups (of 25 or more) can also report through CMS web interface

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The Academy

Advancing Care Information Domain

• Similar to Meaningful Use in initial years – intended to be simpler and more flexible - No longer “all or nothing”

• Scoring: - Base Score: 6 yes/no or numerator/denominator measures that clinicians must meet – (1)

protect patient health information, (2) electronic prescribing, (3) patient electronic access, (4) patient engagement, (5) health information exchange, (6) public health/clinical data registry reporting)

- Performance Score: Clinicians select from a set of measures that best fit their practice, around patient electronic access, patient engagement, health information exchange

- 131 total possible points – need 100 for maximum score

• Reporting: - Individuals can report through attestation, QCDR, qualified registry, EHR - Groups (of 25 or more) can also report through CMS web interface


The Academy

Reimbursement at Risk Increasing Over Time

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MIPS Composite Performance Score

Payment Year 0 to 1/4

Performance Threshold

1/4 Performance Threshold to Performance

Threshold

Performance Threshold

Performance Threshold to

100 100

Multiplied by Budget Neutrality Scaling Factor, if Applicable

2019 -4%

Linear Sliding Scale to 0% 0%

Linear Sliding Scale to

Maximum

4% Max 12% with scaling

2020 -5% 5% Max 15% with scaling

2021 -7% 7% Max 21% with scaling

2022+ -9% 9% Max 27% with scaling


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MIPS Reimbursement At-Risk Timeline

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2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026+

Annual Updates Jan-Jun

0% Jul-Dec

0.5%

0.5% 0.5% 0.5% 0.5% 0% 0% 0% 0% 0% 0% MIPS: .25%


PQRS, MU, VBM Max Penalties

-3.5% -6% -9% TBD PQRS, MU, VBM Measures Incorporated into MIPS MIPS Baseline Payment Adjustment

(+/-) 4% (+/-) 5% (+/-) 7% (+/-) 9% (+/-) 9% (+/-) 9% (+/-) 9% (+/-) 9% MIPS Maximum Possible Payment Adjustment 12% 15% 21% 27% 27% 27% 27% 27%

MIPS Exceptional Performance Adjustment

$500 million provided annually by HHS

Not to Exceed 10%


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• Three primary benefits accrue to clinicians who practice through Advanced Alternative Payment Models and become Qualifying APM Participants: 1. The clinician is excluded from MIPS

2. For payment years 2019-2024, the clinician will receive a lump sum payment equal to

5% of the estimated aggregate payment amounts for Medicare Part B covered professional services from the prior year

3. For payment years 2026 and beyond, the clinician will receive an annual adjustment under the PFS that is 50 basis points greater than MIPS clinicians

20 Confidential: This material is intended solely for informational purposes.

Advanced Alternative Payment Model (“APM”) Participation Benefits

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Advanced APM Qualification: Not All Value-Based Models Are Eligible

To Be Included As Models Become Active: CPC+, Bundles (Track 1)

Included: MSSP Track 2, MSSP Track 3, Next Generation ACO, ESRD Care Model, OCM (2 sided)

Not Included: MA, MSSP Track 1, Bundles (Track 2)

Necessary Criteria for Qualification

Authorized quality measures comparable to MIPS

Certified EHR utilized

Participant in an APM entity that bears “more than nominal” financial risk (or a medical home that meets expansion criteria)

Eligible APMs


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Advanced APM Qualification Thresholds

22

Qualification Thresholds

• Physicians can qualify by meeting payment thresholds or by having a proportion of patients treated in an eligible APM.


2019 2020 2021 2022 2023 2024+

% Medicare Payments Through Eligible APMs 25% 50% 75%

% Medicare Patients Through Eligible APMs 20% 35% 50%

% All-Payer Payments Through Eligible APMs 50%

Minimum 25% Medicare 75%

Minimum 25% Medicare % All-Payer Patients Through Eligible APMs

35% Minimum 20% Medicare

50% Minimum 35% Medicare

• Thresholds primarily based on aggregate spending/patients across all clinicians in APM Entity, though clinicians can qualify individually.

• CMS will make Threshold Score calculations under both payment & patient count methods for each Performance Period and will use the most advantageous of the two scores.

The Academy

MACRA Physician Payment Timeline

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026+

Annual Updates Jan-Jun

0% Jul-Dec

0.5%

0.5% 0.5% 0.5% 0.5% 0% 0% 0% 0% 0% 0% MIPS: .25%


PQRS, MU, VBM Max Penalties

-3.5% -6% -9% TBD PQRS, MU, VBM Measures Incorporated into MIPS MIPS Baseline Payment Adjustment (+/-) 4% (+/-) 5% (+/-) 7% (+/-) 9% (+/-) 9% (+/-) 9% (+/-) 9% (+/-) 9% MIPS Maximum Possible Payment Adjustment 12% 15% 21% 27% 27% 27% 27% 27% MIPS Exceptional Performance Adjustment

$500 Million Provided Annually by HHS

Not to Exceed 10%

APM Bonus Payment

APM Participants Excluded from MIPS

5% 5% 5% 5% 5% 5%


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The Advanced APM Track Provides Greater Financial Opportunity

.75% annual increase for APMs,

.25% annual increase for non-

APMs, 2026+ 5% annual lump sum for APM clinicians,

2019-2024

.5% annual update, 2016-

2019

0.94

0.96

0.98

1

1.02

1.04

1.06

1.08

1.1

1.12

1.14

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

2031

2032

2033

2034

2035

2036

2037

2038

APMMIPS

Assumes MIPS

clinicians perform at

the 50th Percentile


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Participation Categories Between MIPS & APM Tracks

25

Please insert your text

MIPS eligible clinicians participating in Advanced APM models—plus MSSP Track 1 & one-sided OCM—but below partial qualifying thresholds

Eligible clinicians not meeting APM thresholds, or low-volume or new to Medicare exclusions

MIPS Eligible Clinician

MIPS APM Participant

Advanced APM

Qualifying Clinician

Partial Qualifying

APM Clinician

Eligible clinicians not meeting Advanced APM thresholds, but coming close

Eligible clinicians meeting full participation thresholds in 6 Advanced APMs


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MIPS APMs: Qualifying Models

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Alternative Payment Model Advanced APM MIPS APM

Comprehensive ESRD Yes Yes

Comprehensive Primary Care Plus ("CPC+")

Yes (only for participants in models

with 50 or fewer clinicians beginning in year 2)

Yes

MSSP Track 1 No Yes

MSSP Track 2 Yes Yes

MSSP Track 3 Yes Yes

Next Generation ACO Yes Yes

Oncology Care Model ("OCM") one-sided risk arrangement No Yes

OCM two-sided risk arrangement Yes Yes


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Favorable MIPS Scoring for Clinicians in MIPS APMs

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MSSP Participants Next Generation ACO Participants

Other MIPS APM Participants


• Resource Use: Re-weighted to 0

• Quality: Quality measures reported solely through APM Entity

• CPS Weights: RU points will be redistributed between ACI &CPIA

• Favorable Scoring: Guaranteed half CPIA points

• ACI & CPIA Reporting: Each participating TIN submits data; scores from each TIN averaged to weighted mean MIPS APM Entity level score


• Quality: Quality measures reported solely through APM Entity

• CPS Weights: RU points will be redistributed between ACI &CPIA

• Favorable Scoring: Guaranteed half CPIA points

• ACI & CPIA Reporting: Clinicians submit individual data; scores aggregated and averaged at APM Entity level


• Quality: Reweighted to 0

• CPS Weights: Reweighted to 25% CPIA, 75% ACI

• Favorable Scoring: Guaranteed half CPIA points for most APMs; guaranteed full CPIA points for CPC+

• ACI & CPIA Reporting: Clinicians submit individual data; scores aggregated and averaged at APM Entity level *MIPS APM provisions proposed for first PY; benefits will likely be extended in subsequent years

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Considerations for Specialists

• Most specialists initially in MIPS Track, though options will increase over next several years

• CMS provided flexibility to ensure groups of specialists are not unfairly disadvantaged - Eliminating/reweighting performance categories if no/few applicable measures available

• Alternative requirements created for non-patient-facing & hospital-based clinicians:

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Non-patient-facing clinicians

MIPS clinician/group billing 25 or fewer patient-facing encounters—including telehealth—in performance period.

• Quality: 1) Can report on specialty-specific measures

(may be less than 6); 2) Not required to report cross-cutting measures; 3) Can report through QCDR using non-MIPS measures

• RU: Not scored if case minimums not met

• CPIA: Lessened requirements—only 2 activities needed for max score

• ACI: Reweighted to zero

Hospital-based clinicians

Clinician furnishing 90+% of covered professional services in sites identified by the codes used in the HIPAA standard transaction as an inpatient hospital or ER setting in the year prior to the performance year.

• ACI: Reweighted to zero


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Considerations for Other Groups of Clinicians

Small, Rural, & Geographic Health Professional Shortage Areas Practices

“Small” = < 15 clinicians “Rural” = Counties designated as Micropolitan or Non-Core Based Statistical Areas using HRSA’s 2014-2015 Area Health Resource File “HPSA” = As designated under section 332(a)(1)(A) in the Public Health Service Act

• CPIA: - Any 2 activities needed for maximum score

• Advancing Care Information: - If “significant hardship”, may be exempt from category

• Lack of internet connectivity, extreme/uncontrollable circumstances, etc.

• Overall Support: - CMS will offer these groups additional support in transitioning practice under MACRA


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Small Groups Will Likely Look For Partners

30 Confidential: This material is intended solely for informational purposes Source: CMS

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The Next Decade: Medicare Value-Based Payment Model Trajectory


Single-site Bundling/ Multi-site Bundling

Medical Homes: Basic/Medical Homes: Advanced

Shared Savings ACO

Shared Risk ACO

Capitation

Source: Centers for Medicare & Medicaid Services

MACRA: New Medicare Reimbursement Models Sharp HealthCare · 2017-09-09 · MACRA: New Medicare...

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Transcript of MACRA: New Medicare Reimbursement Models Sharp HealthCare · 2017-09-09 · MACRA: New Medicare...