This session presented in partnership with Konica Minolta. · MACRA: How the New Merit-Based...
Transcript of This session presented in partnership with Konica Minolta. · MACRA: How the New Merit-Based...
This session presented in partnership with Konica Minolta.
Imagination at work GE Healthcare Camden Group
MACRA: How the New Merit-Based Incentive Payment System Will Impact Physician Practices HIMSS/AHIMA Conference Coralville, Iowa
May 2, 2016
GE Healthcare Camden Group | May 2, 2016 | 3
Key forces driving change in healthcare
HIT costs and complexity
ACA and Health
Reform
Collaborate vs.
Compete
Volume-to-Value Payment Models Innovation and Technology
Consumerism
Competition
Pressure to reduce total cost of
care
GE Healthcare Camden Group | May 2, 2016 | 4
Destination: Better Health. Better Care. Lower Cost.
Patient Safety and
Throughput
Hospitalist and Hospital-
Based
Physicians
Reduce Re-Admissions
Bundled Payment
Patient-Centered Medical Home
Transactions/Network
Development
ACO
Physician Relationships/Leadership
Development
Hospital Case
Management Improvement
Clinical Co-Management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
Moving from volume-to-value
GE Healthcare Camden Group | May 2, 2016 | 5
Value-based payment models
GE Healthcare Camden Group | May 2, 2016 | 6
Trends driving change
Customer/Patient Expectations
Payment Change
Market Opportunity
IT/ Biotech
Health Care Team
Health
Care
System
Change
GE Healthcare Camden Group | May 2, 2016 | 7
Balancing the pace of change
Risks with Moving too Slow Risks with Moving too Fast
• Lost market share through tiered/narrow networks
• Reduced utilization driven by other organizations
• Inability to capture dollars for
reduced utilization • Limited leverage for aligning
other providers • Allows others to dictate your
future
• Reduced reimbursement
rates • Lower utilization driven by
own organization • Limited gains in market
share for being low- cost/high-quality relative to market
• Unnecessary infrastructure investment
GE Healthcare Camden Group | May 2, 2016 | 8
CMS transitions to value-based reimbursement
2011
Historical Performance Goals
2014 2016 2018
Payments linked to alternative payment models
Fee-for-service (“FFS”) linked to quality
All Medicare FFS
30%
85%
50%
90%
~20%
>80%
0%
~70%
Source: The Center for Medicare & Medicaid Innovation (“CMMI”), Bundled Payment Summit, June 2015
Imagination at work GE Healthcare Camden Group
Value-Based Programs
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“Value-based programs reward healthcare providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how healthcare is delivered and paid for.”1
Value-based programs
1Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html
Better care for individuals
Better care for populations
Lower cost
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MACRA*
Ends the sustainable growth rate (“SGR”) formula
Makes a new framework for rewarding providers for giving better care
Combines existing quality reporting programs
*Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”)
GE Healthcare Camden Group | May 2, 2016 | 12
Value-based programs
Reporting begins in 2017
GE Healthcare Camden Group | May 2, 2016 | 13
Categories: New healthcare payment models
1 2 3 4
FFS: no link to quality and value
FFS: link to quality and
value
Alternative payment
models built on FFS
architecture
Population-based
payment
GE Healthcare Camden Group | May 2, 2016 | 14
Payments linked to quality
Target percentage of Medicare FFS payments linked to quality and alternative payment models in 2016 and 2018
2016 2018
Payments linked to alternative payment models (Categories 3-4)
FFS linked to quality (Categories 2-4)
All Medicare FFS (Categories 1-4)
30%
85%
50%
90%
Source: The Center for Medicare & Medicaid Innovation (“CMMI”), Bundled Payment Summit, June 2015, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html
GE Healthcare Camden Group | May 2, 2016 | 15
MACRA
2015 2021
MIPS and APMs will go into effect over a timeline from 2015 through 2021 and beyond
MACRA
Merit-Based Incentive Payment
System (“MIPS”)
Alternative Payment Model
(“APM”)
• FFS system
• Innovative payment model
GE Healthcare Camden Group | May 2, 2016 | 16
MIPS programs
MIPS
Value-based payment modifier (“VBPM”)
Physician quality
reporting system
(“PQRS”),
Meaningful use (“MU”)
*Merit-based incentive payment system (“MIPS”)
Clinical Practice
Improvement Activities (“CPIA”)
GE Healthcare Camden Group | May 2, 2016 | 17
MIPs Eligible Professionals
Eligible Professionals (“EPs”) in 2017 and 2018 performance years
• Physicians
• Physicians assistants
• Nurse practitioners
• Clinical nurse specialists
• Nurse anesthetists
More EPs added in 2019 • Physical or occupational therapists
• Speech-language pathologists
• Audiologists
• Nurse midwives
• Clinical social workers
• Clinical psychologists
• Dietitians or nutrition professionals
GE Healthcare Camden Group | May 2, 2016 | 18
Who is exempt in MIPs?
Exempt Physicians and Providers
1st year of Medicare Participation
MSSP ACO* providers and other participants in eligible alternative
payment models (“APM”) who qualify for the bonus
payment
Providers not meeting the “low volume threshold”
*Medicare Shared Savings Program (“MSSP”) Accountable Care Organization (“ACO”)
GE Healthcare Camden Group | May 2, 2016 | 19
MIPS scoring
15%
25%
30%
30%
MIPS Composite Score 0 to 100
Clinical practice improvement activities
Meaningful use of certified electronic health record (“EHR”) technology
Resource use
Quality
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MIPS: clinical practice improvement activities
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety Practice
Assessment
Alternative Payment Models
• Same day appointments for urgent needs
• After hours clinician advise
• Monitoring health conditions and providing timely intervention
• Participation in a qualified clinical data registry
• Timely communication of test results
• Timely exchange of clinical information with patients AND providers
• Use of remote monitoring
• Use of telehealth
• Establishing care plans for complex patients
• Beneficiary self-management assessment and training
• Employing shared decision-making
• Use of clinical checklists
• Use of surgical checklists
• Assessments related to maintaining of certification
• Participation in an APM will also count for CPIA
Source: www.cms.gov
GE Healthcare Camden Group | May 2, 2016 | 21
Eligible APMs
*Expanded under the Center for Medicare & Medicaid Innovation (“CMMI”), including Comprehensive Primary Care (“CPC”) initiative participants
Alternative Payment Model
(“APM”) APMs innovative payment model
MSSP ACO
Medicare healthcare quality demonstration program
Medicare acute care episode demonstration program
Or another demonstration program
GE Healthcare Camden Group | May 2, 2016 | 22
Encourages expansion of APM options*, especially specialists
Bonus payments
Not subject to MIPS
*Sample models: Medicare ACOs, Patient-Centered Medical Home(“PCMH”), Physician Focused Payment Models (“PFPMs”)
APMs
GE Healthcare Camden Group | May 2, 2016 | 23
MACRA timeline and payment impact
*Qualifying APM conversion factor, **Non-qualifying APM conversion factor
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Timeline.PDF
MIPS Payment Adjustment (+/-)
Excluded from MIPS
Measurement/Report Period is typically 2
years earlier
GE Healthcare Camden Group | May 2, 2016 | 24
MACRA implications
Receiving APM payments?
Payments are from eligible APMs?
In first year of Medicare or below low-volume threshold?
Receiving enough payment through eligible APMs?
Quality for APM track (if desired)
Exempt from MIPS
Subject from MIPS
Subject to MIPS, but … Get scoring advantage
May be exempt via “partial APM” pathway
YES NO
YES
YES
YES NO
NO
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Proposed timeline for MIPS rulemaking process
2015 2016 2017
Jan: MIPS first performance year begins
Nov: Final 2017 MIPS rule
July: Proposed 2017 MIPS rule
Nov: RFI public comments
submitted to CMS
Oct: CMS released RFI seeking comments
April: MIPS legislation passed
GE Healthcare Camden Group | May 2, 2016 | 26
The CMS bundled payments imperative
• Hip and knee replacements are the most common inpatient procedures among Medicare
beneficiaries, with more than 400,000 in 2014
• More than $7,000,000,000 in hospitalizations alone
• Wide variation in procedural costs across
geographies
• CMS goal: link 30 percent of all Medicare FFS
payments to alternative payment models by 2016,
and 50 percent by 2018
Source: CMS
GE Healthcare Camden Group | May 2, 2016 | 27
• Lower extremity joint replacements (“LEJR”) (MS-DRGs 469 and 470)
• Commences April 1, 2016
• Mandatory 5-year program
• No downside risk in Year 1
Inpatient stay* *Facility and professional fees
Readmissions
Skilled Nursing Facility (“SNF”)
Inpatient Rehabilitation Facility (“IRF”)
Home Health Agency (“HHA”)
Long-Term Care Hospital (“LTCH”)
• 67 metropolitan statistical areas (“MSA”) affected
• Based on Bundled Payments for Care Improvement (“BPCI”) Model 2
• 90-day retrospective episode of care
• Annual reconciliation
• Payments tied to quality measures: complications and patient satisfaction
CJR overview
Source: Centers for Medicare & Medicaid Services (“CMS”)
90 days post-discharge*
Comprehensive Care for Joint Replacement (“CJR”)
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Estimate of episode savings
Final rule announced
Nov 16 2015
Jan 2018
Program begins Year 1 No downside risk
Apr 2016
Year 3 Downside risk cap: 10%
Year 5 Downside risk cap: 20%
Jan 2020
Q1 / Q2 2016
Anticipated data sets from CMS
Year 4 Downside risk cap: 20%
Dec 2020
Program ends
Likely number of participant hospitals
Percent of national LEJR episodes in the program
CJR 5-year timeline
$343M 23% 794
Jan 2017
Year 2 Downside risk cap: 5%
Jan 2019
Source: CMS
GE Healthcare Camden Group | May 2, 2016 | 29
Composite quality score
CJR payments link to quality
• HCAHPS survey
• NQF #0166
Complication rates
[required]
• Hospital-level risk-standardized
complication rate (“RSCR”)
following elective primary total
hip arthroplasty (“THA”) and/or
total knee arthroplasty (“TKA”)
• National quality forum (“NQF”)
#1550
Patient satisfaction
[required]
50% 10% 40%
• THA/TKA PRO and limited risk
variable data: 4 unique patient
identifiers and 11 risk variable
data elements
Patient reported outcomes
(“PRO”) [voluntary]
Performance points Improvement points
Based on the performance percentile scale for
complications and HCAHPS and successful
submission of PRO
Points added if the hospital’s score on an individual
measure increases from the previous performance
year by at least 3 deciles
Source: CMS
Imagination at work GE Healthcare Camden Group
Implications for Physician Practices
GE Healthcare Camden Group | May 2, 2016 | 31
Population Health Management
Wellness/ Preventive
Care
Primary Care/ PCMH
Specialty Care
Community - Based
Services Pharmacies
Behavioral Health
Urgent Care
Emergency Services
Hospital Care
Post-Acute Care/
Home Care
End-of-Life Care
Seamless Patient Experience Across the Continuum
Patient-Focused
Technology and Tools
Patient-Directed
Access to Care
Effective Care
Teams and Care
Delivery
GE Healthcare Camden Group | May 2, 2015 | 32
Value-based critical success factors
Strong Care Management Capabilities
Enabling Information Technology
Effective Care Teams
Larger Patient Population
Efficient Clinical Operations
Contracting Models Support Population Health
Physician Compensation Model that Aligns Incentives
GE Healthcare Camden Group | May 2, 2016 | 33
Challenges for physicians
• Understanding the shift from volume-to-value
• Potential reduced reimbursement for services
• Tracking of quality and cost management
• Reimbursement based on performance
• Competing in the new world of value-based reimbursement
• Positioning for success under value-based (quality and
cost management ) reimbursement
GE Healthcare Camden Group | May 2, 2016 | 34
Key MACRA considerations for medical groups
• Review the Quality and Resource Use Report (“QRUR”)
• Know if EPs received a penalty letter or any payment adjustments and calculate estimated incentives and penalties
• Know the deadlines related to PQRS/VBM, MU, and APMs
• Understand the MIPS scoring and how they may be impacted
• Be familiar with public reporting and the reputational impact of the EP/group
• Employ adequate resources and education opportunities to be successful
Medical groups must:
GE Healthcare Camden Group | May 2, 2016 | 35
CMS Quality and Resource Use Report 2014 Annual Quality and Resource Use Report
• Made available September 9, 2015
• Enterprise Identity Management System (“EIDM”) account is required to access the report
• Access report on the CMS Enterprise Portal (https://portal.cms.gov)
• More information on www.cms.gov
GE Healthcare Camden Group | May 2, 2016 | 36
Sample QRUR
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Publicly reported MIPs score
CMS Physician Compare website
Each MIPS-eligible professional's MIPS score and individual
category scores will be available on the Physician Compare
website, including the ranges of all such scores for eligible
professionals across the country.
GE Healthcare Camden Group | May 2, 2016 | 38
Monitoring and performance improvement
Create Value
1 2 3 4
Define objectives
Select KPIs and
Measures
Activate plan Measure and evaluate consistently
GE Healthcare Camden Group | May 2, 2016 | 39
Key performance indicators and measures
KPIs
Revenue Cycle
Operations
Cost/ Profitability
Production Quality and
Cost
Patient Access
Patient Experience
Charge lag Staffing ratios Cycle time and wait time EMR optimization
Days in AR , collection rates, AR aging, denial rate
POS collections, collected vs. collectable, cost to collect
Self-service payments
Operating margin Expense as percent of
revenue Cost per wRVU Net income/provider
Visits wRVUs Occupancy rate Panel size
Portal usage, on-line registration
First agent resolution Patient satisfaction Patient retention
Next appointment 3rd available
appointment Continuity of care
Clinical quality measures PCMH, HCC, RAF Cost of care, PMPM ICD-10 coding
GE Healthcare Camden Group | May 2, 2015 | 40
Challenges to overcome
Focusing on the right
initiatives Ensuring correct
coding Tracking quality and
cost data
GE Healthcare Camden Group | May 2, 2015 | 41
Real Value: operationalizing the data
Performance Reports (KPIs) Operational Impact
Average cost-of-care by member Identify specific care management programs by disease state
Average cost (PMPM) per chronic disease category
Monitor financial impact of clinical chronic disease programs
Domestic vs. non-domestic utilization Pinpoint utilization by disease category focusing on minimizing out-of-network leakage rate through care management
Projected month total spend during contract year
Evaluate success of programs and care management allowing for modifications as necessary
Member cost and utilization Identify high cost member outliers and establish proper level of care navigation
Top facilities, providers, and diagnosis by cost and encounter volume
Identify out-of-network providers for future contracting and/or steerage
GE Healthcare Camden Group | May 2, 2015 | 42
10 steps to become the practice of the future
1
2
3
4
5
6
7
8
9
10
Create a profile of your
current and potential
patients.
Assess your market.
Examine your practice from
your patients’ perspective.
Create process excellence to
drive patient, provider, and
staff satisfaction.
Develop patient-directed,
convenient access points to
your practice.
Change your care delivery model
to facilitate population health
management.
Assess your current business
model based on what is
necessary to succeed in fee-for-
value world.
Optimize your use of data to
enhance care, ensure
accountability, and achieve your
goals.
Implement strategies to
foster patient “stickiness”
to your practice.
Optimize the use of technology.
Imagination at work GE Healthcare Camden Group
Questions?