MACRA’s Quality Payment Program: 2018 Update on Medicare’s...
Transcript of MACRA’s Quality Payment Program: 2018 Update on Medicare’s...
April21,2018
MACRA’sQualityPaymentProgram:2018UpdateonMedicare’sNewProgramfor
PayingPhysiciansandOtherHealthcareProfessionals
JohnMcInnes,MD,JD,Arnold&Porter
OEIS2018FiJhAnnualNaKonalScienKficMeeKng
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Agenda
• ReviewofMACRAFundamentals
• OverviewofSelectMACRA2018FinalRuleProvisions
• Ques@ons&Discussion
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MACRAFUNDAMENTALS
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MACRAFundamentals
• TheMedicareAccessandCHIPReauthoriza@onActof2015(MACRA)establishedanewMedicarepaymentsystemforphysiciansandotherhealthcareprovidersbeginningin2019.
• MostsignificantchangeinMedicare’spaymentsystemforphysiciansin25years.
• Repealedtheannual~25%paymentcliffsfromtheSustainableGrowthRate(SGR)formulaandreplaceditwithanew2-tracksystemthatmakesadjustmentstowhatwouldotherwisebepaidunderMedicare’sPhysicianFeeSchedule.
• Maintainsfocusonmovingfrom“volumetovalue,”heighteningproviderincen@vestomaketreatmentdecisionsconsideringqualityandresourceuse.
• CurrentAdministra9on–“Pu<ngPa9entsFirst”and“Pa9entsOverPaperwork.”
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QualityPaymentProgram(QPP)
• PaymentsystemestablishedbyMACRAiscalledtheQualityPaymentProgram(QPP)
• Consistentwiththestatute,theQPPhas2pathways:– Merit-BasedIncen@vePaymentSystem(MIPS)
– AdvancedAlterna@vePaymentModels(APMs)
• BothpathwaysadjustMedicarefee-for-servicepaymentsforPartBservicestoincen@vize:– QualityCareandBeaerHealthOutcomes
– Efficiency(i.e.,costsavings)
– Useofelectronichealthrecords(EHR)
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QualityPaymentProgram(QPP)–2018FinalRulePrinciples:
1) Supportscareimprovementbyfocusingonbeaeroutcomesforpa@ents,andpreservingtheindependentclinicalprac@ce;
2) Promotestheadop@onofAdvancedPaymentModels(APMs)thatalignincen@vesforhigh-quality,low-costcareacrosshealthcarestakeholders;and
3) Advancesexis@ngdeliverysystemreformefforts,includingensuringasmoothtransi@ontoahealthcaresystemthatpromoteshigh-value,efficientcarethroughunifica@onofCMSlegacyprograms.
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TheQPP’sTwoPathways:
Merit-BasedIncenKvePaymentSystem(MIPS)
AdvancedAlternaKvePaymentModels(APMs)
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MIPS APMs
PaymentadjustmentsstartJanuary1,2019,baseduponperformancein2017
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AppliestoMedicarefee-for-servicepayments(forphysicianservices),notMedicareAdvantage
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Intendedtorewardhigher-quality,lower-cost,higher-valuecare ! !
ReplacesthePhysicianQualityRepor@ngSystem(PQRS) ! !
ReplacestheValueModifier ! !
ReplacesMeaningfulUse ! !
MIPSandAdvancedAPMshavesomethingsincommon:
OR
MACRAStatute:QPPStartedin2017(PerformanceYear)for2019(Payment
Year),TwoNewPathways
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MIPSPathway AdvancedAPMPathway
Merit-Based
IncenKvePaymentSystem(MIPS)
PhysicianQuality
ReporKngSystem(PQRS)*
ValueBasedModifier(VBM)*
MeaningfulUseofEHR*
AdvancedAlternaKvePaymentModel(APM)
*3LegacyProgramsEndaKer2018PaymentYear(basedon2016Repor9ng)
2018MACRAFINALRULE
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MIPSPATHWAY
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Whopar@cipatesinMIPS?
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Threegroupsdonotpar@cipateinMIPS:1. DoctorsintheirfirstyearofMedicarepar@cipa@on;2. Lowvolumeprac@ces:
a. ≤$90KinPartBallowedcharges,orb. ≤200PartBbeneficiaries
3. AdvancedAPMpar@cipants
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MIPSHasFourComponentswithDifferentWeights:
MIPSCategories “AdvancingCare
informaKon”(akameaningfuluse
ofEHR)
Quality Resourceuse(cost)
ClinicalpracKce
improvementacKviKes
MIPSCompositePerformanceScore(CPS)
(0-100)
$
TheCPScomparedtothe“PerformanceThreshold”willdeterminethepaymentadjustment.
Merit-BasedIncen@vePaymentSystem(MIPS)(2018Performance
Year,2020PaymentYear)
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MIPS(2019PerformanceYear,2021PaymentYear–andBeyond)*
14*Requiredbystatute
MIPSPaymentAdjustments
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1.QualityPerformanceCategory
" EligibleclinicianswillreportselecKonof6individualmeasuresormeasuresfrom“specialtymeasuresets”(availableforcertainspecialKes).
" Mustincludeanoutcomemeasure,andifnotavailablethena“highpriority”measure(appropriateuse,paKentsafety,efficiency,paKentexperience,andcarecoordinaKonmeasures).
" 300+individualmeasurestochoosefrom;mostmeasuresfromPQRS.
" Scoreforthiscategorywillbebasedonperformancecomparedtoabenchmark.Infutureyears,scorewillalsoaccountforimprovement.
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QualityMeasureExamples
• IndividualMeasures(CMSwillconKnueannualcallfornewmeasures):– Diabetes:HemoglobinA1c(HbA1c)PoorControl(>9%)– Diabetes:MedicalAhenKonforNephropathy– Diabetes:FootExam– ChronicObstrucKvePulmonaryDisease(COPD):InhaledBronchodilatorTherapy– ChronicObstrucKvePulmonaryDisease(COPD):SpirometryEvaluaKon– PneumoniaVaccinaKonStatusforOlderAdults– PrevenKveCareandScreening:Cholesterol–FasKngLowDensityLipoprotein(LDL-C)TestPerformedANDRisk-StraKfiedFasKng
LDL-C
• SpecialtyMeasureSets(madeupofasubsetofindividualmeasures):– Allergy/Immunology/Rheumatology– Cardiology– GeneralPracKce/FamilyMedicine– InternalMedicine
• Cross-CulngMeasures– CarePlan– DocumentaKonofCurrentMedicaKonsintheMedicalRecord– Controlling:HighBloodPressure– PrevenKveCareandScreening:TobaccoUse:ScreeningandCessaKonIntervenKon
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2.ResourceUsePerformanceCategory
" CostsbasedonMedicarebeneficiarieswhoareahributedtotheclinician.
" Includes“totalcostpercapitaforallahributedbeneficiaries”and“Medicarespendingperbeneficiary”(MSPB)measuresfromValueModifierprogram.
" Episode-basedmeasuressKllindevelopment.
" NoreporKngrequirement--CMScalculatesbasedonMedicarePartAandBclaims(includingPartBdrugclaims).PartDclaimsmaybeincludedinfutureyears.
$
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3.ClinicalPrac@ceImprovementAc@vi@es(CPIA)PerformanceCategory
• NewcategorydesignedtoincenKvizeacKviKesthatimproveclinicalpracKceorcaredeliveryandthatarelikelytoresultinimprovedhealthoutcomes.
• 90+proposedacKviKesover9categoriesweightedeither“high”or“medium”.
• Examples:populaKonmanagementfordiabeKcs(high);evidence-baseddecisionaids(medium)
• ToachievehighestpotenKalscore,mostcliniciansmustsubmit2high-weightedCPIAsor4medium-weightedCPIAs,oracombinaKon.
• FullcreditforpaKent-centeredmedicalhomeparKcipaKon;minimumofhalfcreditforAPMparKcipaKon.
$
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4.AdvancingCareInforma@onPerformanceCategory
" MeaningfulUserebrandedas“AdvancingCareInformaKon”
" ACIPerformanceCategoryscore=basescore+performancescore+bonuspoint
– BasescoreachievedforreporKngallthemeasuresforsixobjecKves─ e.g.thePa@entElectronicAccessobjec@vehastwomeasures:Pa@entAccessand
Pa@ent-SpecificEduca@on─ Performancescoreachievedbasedonperformancerate(numerator/denominator)on8
measuresacrossspecific3objecKves(withinthe6)─ BonuspointforreporKngoneormoreaddiKonalmeasuresinthePublicHealthand
ClinicalDataRegistryReporKngobjecKve(ImmunizaKonRegistryReporKngrequired)
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Calcula@ngtheCompositePerformanceScore
ScoresfromeachperformancecategorywillbeweightedandusedtocalculateCPSonascalefrom0to100.
$
50% 10% 15% 25%
ADVANCEDAPMPATHWAY
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WhatisanAlterna@vePaymentModel(APM)?
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APMsarenewapproachestopayingformedicalcarethroughMedicarethataredesignedtoincenKvizequalityandvalue.
AsdefinedbyMACRA,
APMsinclude:
# CMSInnovaKonCentermodel(underSocialSecurityAct§1115A,otherthanahealthcareInnova@onAward)
# MSSP(MedicareSharedSavingsProgram)
# DemonstraKonundertheHealthCareQualityDemonstra@onProgram(SocialSecurityAct§1866C)
# DemonstraKonrequiredbyfederallaw
WhatisanAdvancedAPM?
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# TheAPMrequirespar@cipantstousecerKfiedEHRtechnology.
# TheAPMbasespaymentonqualitymeasures“comparableto”thoseintheMIPSqualityperformancecategory.
# TheAPMeither:(1)requiresAPMEn@@estobearmorethannominalfinancialriskformonetarylosses;OR(2)isaMedicalHomeModelexpandedunderCMMIauthority.
AsdefinedbyMACRA,AdvancedAPMsmustmeet
thefollowingcriteria:
WhataretheCurrentAdvancedAPMs?
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Basedontheproposedcriteria,thefollowingAPMswillbeAdvancedAPMs:
# MedicareAccountableCareOrganizaKon(ACO)Track1+Model
# SharedSavingProgramACO(Tracks2and3)
# NextGeneraKonACOModel
# VermontMedicareACOIniKaKve
# ComprehensiveESRDCare(CEC)Model(LDOarrangement)
# ComprehensiveESRDCare(CEC)(non-LDOtwo-sidedriskarrangement)
# ComprehensivePrimaryCarePlus(CPC+)Model
# OncologyCareModel(OCM)
# ComprehensiveCareforJointReplacement(CJR)PaymentModel(Track1–CEHRT)
# BundledPaymentsforCareImprovementAdvancedModel(BPCIAdvanced)
Mustbea“QualifyingPar@cipant”inanAdvancedAPMtobeassignedtotheAdvancedAPMPathway
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QualifyingParKcipants(QPs)Toqualify,cliniciansmustreceiveenoughoftheirpaymentsorseeenoughoftheirpa@entsthroughanAdvancedAPM.Thepar@cipa@onrequirementsarespecifiedinlawandincreaseover@me.
SignificantIncen@vestobeaQPinAdvancedAPMs
• MACRAdoesnotchangehowanypar@[email protected],itcreatesextraincen@vesforAPMpar@cipa@on.
• For2019-2024,all�qualifyingAPMpar@cipants�willbeexcludedfromMIPSandwillreceivealump-sumbonusof5%oftotalMedicarePartBpaymentsreceivedintheprioryear.Bonuspaymentsstopawer2024.
• Beginningin2026,qualifyingAPMpar@cipantswillreceivebaseMedicarePartBpaymentsusingaconversionfactorthatreceivesahigherannualupdatethantheMIPSupdate(0.75%comparedto0.25%).
• CMSes@matesthatatmost10%ofeligibleclinicianswillbeassignedtotheAPMpathwayin2019.Longer-termoutlookunclear.DependspartlyonhowstringentthefinalCMScriteriatobean�Advanced�APM.
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Par@alQPs:Almost,ButNotQuiteThere
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Ifclinicianmeetsaslightlyreducedthreshold(%ofpa@entsorpaymentsinanAdvancedAPM),heorsheisconsidereda�ParKalQualifyingAPMParKcipant�(ParKalQP)andcan:" OptoutofMIPSandreceivenopaymentadjustmentupordown;or" Par@cipateinMIPSandbesubjectto�MIPSAMP�Alterna@veScoring(andreceiveaminimumCPIAcategoryperformancescoreof50%).
QPPPaymentSummary
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QUESTIONS&DISCUSSION
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