Payers and Payments –Where We Are, Where We’re Heading

ACEP Leadership & Advocacy ConferenceLynn Massingale, MDTeamHealth Co-Founder & ChairmanMay 6, 2019

• Volume Declines• Plan design• Alternate sites• Other forces

• Payer Actions• Rate reduction• Retroactive denials threat• Telehealth promotion• “Surprise bill” campaign

• Productivity Challenges• EHR• Boarding• Staffing mix

• Clinician Compensation Trends• Client Expectations

• Satisfaction• Resource utilization

EMERGENCY MEDICINE PAIN POINTS

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DATA POINTS

• 9/10 “Surprise Bills” are about the deductible

• Some actual denials YTD

• Unilateral rate reductions

• 19 lawsuits filed in 2018 against payers

• Average patient cost-sharing balance increasing 7% per year

• ~75% of ED visits are reimbursed below cost

• Wide variability in commercial rates

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ECONOMICS 101

• Uninsureds pay 23%

• Medicaid pays 50%

• Medicare pays 97%

• Commercial pays 273%

For each $100

of actual provider

compensation per

patient

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Payer Activities

• Out-of-Network, Balance Billing & Surprise Billing

– Historically BB/SB has been a ‘state concern’ subject to state laws and regulation

– Recently, the issue has correctly found its way to the federal government

– High profile matter with multiple stakeholders

– Physician resolution focused on these primary objectives:

– Protect Patients

– Secure Fair Market Based Reimbursement Standards for OON Care

– Mitigate Effects of Shifting Risk Guaranteeing Transparency in Marketplace

– Preserve existing reimbursement equilibrium to sustain the current EM delivery system

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Payer Activities • Out-of-Network, Balance Billing & Surprise Billing (continued)– Stakeholders All Agree – a Comprehensive Federal Solution is Needed

– The Federal ‘Cassidy Solution’:– Cassidy represents the Senate Bi-Partisan Workgroup– Draft legislation released in September 2018– The Cassidy Solution would impose a national prohibition on Surprise Billing– Need fair standard for OON reimbursement – an independent benchmarking

solution– Need reasonable patient cost sharing on EM services, and requiring insurers to

collect patient cost-sharing as a means to mitigate bad debt– High Stakes with Many Stakeholders. Law Highly Likely - anticipated end 2019

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Now What?

• Know the Facts• Know the Players• Enhance Business Knowledge and Skills• Expect a Rocky Road• Get Engaged on the Hill

Choose Wisely

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GETTING TO VALUE: CMS STRATEGY FOR IMPROVING

THE QUALITY OF CARE

American College of Emergency Physicians

May 2019

Disclaimers

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

CMS Strategic Priorities for 2019

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What is Patients Over Paperwork?

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Patients Over Paperwork

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https://www.cms.gov/About-CMS/story-page/patients-over-paperwork.html

Putting Data in the Hands of Patients

• Blue Button 2.0o Developer-friendly, standards-based API o Developer preview program – open now (over 1200 developers so far)o Data security is of the utmost importance

• Promoting Interoperability Program for Hospitals and Clinicianso Program alignmento Strong emphasis on interoperability and privacy/securityo 2015 edition Certified EHR Technology

• Prevention of Information Blocking• Star Ratings• Interoperability Rule out for public comment• Public display of hospital charges

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What this means for CMS

A New Approach to Improving Outcomes

Launched in 2017, the purpose of the Meaningful Measures initiative is to:

• Improve outcomes for patients and provide meaningful information to consumers to make care choices

• Reduce data reporting burden and costs on clinicians and other health care providers

• Align across programs

• Identify gap areas for development (opioids, nursing homes, care transitions, PROM)

• Prioritize outcome measures

• Innovate measures (electronic data, Patient reported)

What is the Meaningful Measures Initiative?

Meaningful Measures Framework

Meaningful Measures: Progress to Date

• Removed 79 measures overall (nearly 20%); in MIPS we removed 26 measures immediately while adding new outcome and appropriate use measures

• CMS Measure Inventory: o 41% (180) are outcome measureso 10% (43) are patient-reported outcome o 22% (96) able to be submitted through electronic means

• Measure alignment internallyo MA, Medicaid, Exchangeso Across PAC settings

• Measure alignment with states, MA plans and commercial payerso Core Quality Measures Collaborative

Meaningful Measures: Advancing Electronic Sources

• Developing more APIs for quality measure data submission• Prototype the use of the FHIR standard for quality measurement• Interoperable electronic registries – incentivizing use• Harmonizing measures across registries• Timely and actionable feedback to providers• Working with CMMI on use of artificial intelligence to predict outcomes

Quality Payment Program

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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program:

• Comprised of four performance categories

• So what? The points from each performance category are added together to give you a MIPS Final Score

• The MIPS Final Score is compared to the MIPS performance threshold to determine if you receive a positive, negative, or neutral payment adjustment

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100 Possible Final Score

Points=

MIPS Performance Categories

Quality Cost Improvement Activities

PromotingInteroperability

+ + +

Merit-based Incentive Payment System (MIPS) Quick Overview

MIPS – The Path to Value

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The Vision for the Future

• Consumers have the information on cost, quality, and engagement to make decisions about high value providers

• Incentives exist to encourage consumers to select high value providers

• The Meaningful Measurement framework leads to measures that are meaningful, simple to report and valuable to clinicians and patients

How to be involved

ü Work with your specialty society

ü Submit comments on our annual proposed rules

ü Participate in our call for nominations for technical expert panels and clinical subcommittees

ü Contact us directly

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Reena Duseja MD, MSChief Medical Officer, Quality Measurement and Value Based Incentives Group

Center for Clinical Standards and QualityReena.Duseja@cms.hhs.gov

PAYORS AND PAYMENTSRebecca Parker, MD, FACEPChief Medical Affairs Officer

Envision Physician Services

DISCLOSURE

In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and the policy of the American College of Emergency Physicians, presenters must disclose the existence of significant financial interests in or relationships with manufacturers or commercial products that may have a direct interest in the subject matter of the presentation, and relationships with the commercial supporter of this CME activity. These presenters do not consider that it will influence their presentation.

Dr. Parker does not have a significant financial relationship to report.

BUNDLED PAYMENT FOR CARE IMPROVEMENT (BPCI)

� CMS Innovation Center� Payment tied to episode of care� Financial and performance accountability for episodes of care� Goals: higher quality, better care coordination, lower cost

Value Based Care is here and will continue

BPCI

https://innovation.cms.gov/initiatives/bundled-payments/

� 3rd quarter 2015-2nd quarter 2018� Full risk versus partial risk� Partnerships, local presence� Very successful

BPCI - Classic

� Medical Bundles� Cardiac (acute MI, PCI, arrhythmia,

pacemaker, CHF)� Pulmonary (COPD, bronchitis, asthma)� Infectious (sepsis, Simple pneumonia,

cellulitis)� Locations

BPCI - Classic

� Started 4th quarter 2018

� Goals:� Help improve care coordination

� Promote the sharing of best practices

� Foster strategic partnerships � Focus on getting patients the right care at the

right time

Looking Forward: BPCI - A

MULTI-SPECIALTY COLLABORATION

� Task force� White Paper, current state� Quality Committees 2019� Multi-Specialty Collaboratives

Curbing the Opioid Crisis

� Lessons learned white paper:� EM� Surgeons� Pain specialist� Hospitalist� Neonatology� Radiologist

Curbing the Opioid Crisis

� Lessons learned from collaboratives:� Education resources� Screening tools and assessment tools� “Bridge to Nowhere”� Care coordination issue� Not reinvent the wheel?

Curbing the Opioid Crisis

THANK YOU!