MACRA: Medicare's Shift to Value-based Delivery & Payment Models. Presented by Amy Mullins, MD, CPE, FAAFP

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1 MACRA: Medicare's Shift to Value-based Delivery & Payment Models Presented by Amy Mullins, MD, CPE, FAAFP

2 Current State Over Utilization Volume over Value Fee for Service Silos of Care 2

3 Push Toward Value & Quality Tied to quality or value by end of 2016 Tied to quality or value through APMs by end of

4 Medicare Access & CHIP Reauthorization Act (MACRA) To repeal the Medicare SGR and strengthen Medicare access by improving physician payments Photo Courtesy of Amy Mullins, MD 4

5 What is MACRA? Signed into law April 16, 2015 Passed 392 to 37 in the House and 92 to 8 in the Senate 5

6 What Does MACRA Do? Repeals the Sustainable Growth Rate (SGR) Extends CHIP funding for 2 years Streamlines quality programs (MIPS) Provides bonus payments for participation (APMs) Provides Annual Baseline Fee Schedule Updates

7

8 Merit Based Incentive Payments (MIPS)

9 MIPS Highlights Combines programs Establishes Performance Score Adjust payments accordingly 9

10 Combines Quality & Value Programs Physician Quality Reporting System Value Based Payment Modifier VBPM PQRS MU Meaningful Use MIPS 10

11 Establish Composite Performance Score Quality Resource Use Meaningful Use Clinical Performance Improvement Activities 11

12 Clinical Performance Improvement Activities Access Population Management Care Coordination Beneficiary Engagement Patient Safety Participation in an Alternative Payment Model 12

13 Weighting by Category Quality 50% 45% 30% Resource Use 10% 15% 30% EHR MU 25% 25% 25% CPIA 1 15% 15% 15% 1 - Certified patient-centered medical home will receive the full 15 points for CPIA 13

14 Certified PCMH Not defined in law Advocating for functionality over certification Risk-Stratified Care Management Access and Continuity Planned Care for Chronic Conditions and Preventive Care Patient and Caregiver Engagement Care Coordination Across the Medical Neighborhood 14

15 Performance Threshold Set annually Average or mean of previous year s MIPS scores Established by Secretary years 1 and 2 Below = negative payment adjustments Above = positive adjustments 15

16 Adjust Payments Adjustment to provider s base rate of Medicare Part B payment 15% 21%27% 12% onward Note: AAFP interpretation of initial ruling -4% -5% -7% -9% 16

17 Adjust Payments 15% 21%27% 12% Maximum Adjustments 4% 5% 7% 9% onward Adjustment to provider s base rate of Medicare Part B payment -4% -5% -7% -9% 17

18 Adjust Payments With respect to positive MIPS adjustment factors the Secretary shall increase or decrease such adjustment factors by a scaling factor in order to ensure that the budget neutrality requirement is met 15% 21%27% 12% 4% 5% 7% -4% -5% -7% 9% onward -9% 18

19 Exceptions Year 1 Medicare Eligible APMs w/bonus Below low volume threshold 19

20 Caveats Automatically adjust lowest quartile of providers to max penalty At threshold = no adjustment Exceptional Performers = potential adjustment up to 10% 20

21 -3.5% -6% -9%? PQRS, Value Modifier, Meaningful Use

22 Virtual Groups: A Pathway For Small Practices Small practice = 10 or fewer professionals Performance = combined score of all EPs in group Group = based on geography or specialty Requires written agreement and one year commitment All or nothing 22

23 MIPS Summary Replaces existing quality reporting programs in Medicare Part B Provides potentially significant bonuses for high performers Creates risk of penalty 23

24 Alternative Payment Models (APMs)

25 Alternative Payment Models (APMs) Qualifying programs include: MSSP (Medicare Shares Savings Program) CMS Innovation Center Model* Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration Demonstration required by Federal Law 25

26 Alternative Payment Models (APMs) Qualifying programs include: MSSP (Medicare Shares Savings Program) CMS Innovation Center Model* Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration Demonstration required by Federal Law 26

27 Eligible APMs 1 Not yet defined Base payment on quality Use of certified EHR technology More than nominal risk 1 OR Medical Home model under CMMI authority* (*Not CPC) 27

28 How to Become a Qualifying APM Participant Percentage of patients or payments thru eligible APM In 2019, the threshold is 25% of Medicare payments. Patient threshold is yet to be determined. 28

29 Additional Rewards for Qualifying Participants Not subject to MIPS 5% bonus Higher fee schedule update

30 Summary of APMs Qualifying APMs Unsure about CMMI expansion to allow greater participation Eligible APMs nominal financial risk Qualifying Participants Potentially more financial certainty with a 5% annual bonus (and no potential for penalty) 32

31 Am I in a Qualifying APM? Yes No 33

32 Am I in an eligible APM? No Yes Am I in a Qualifying APM? Yes No 34

33 Am I in an eligible APM? No Yes Am I in a Qualifying APM? Yes No Enough payments or patients? Yes No 35

34 Am I in an eligible APM? No Yes Am I in a Qualifying APM? Yes No Enough payments or patients? Yes No Qualifying APM Participant 5% bonus payment Higher fee schedule AMP-specific rewards Excluded from MIPS 36

35 Am I in an eligible APM? No Yes Am I in a Qualifying APM? Yes No Enough payments or patients? Yes No Subject to MIPS Favorable MIPS scoring APM-specific rewards 37

36 Am I in an eligible APM? No Yes Am I in a Qualifying APM? Yes No Subject to MIPS Favorable MIPS scoring APM-specific rewards 38

37 Am I in a Qualifying APM? Yes No 1 st year in Medicare OR below low-volume threshold? Yes No Not subject to MIPS 39

38 Am I in a Qualifying APM? Yes No 1 st year in Medicare OR below low-volume threshold? Yes No Subject to MIPS 40

39 Am I in a Qualifying APM? Yes No Am I in an eligible APM? No Yes Enough payments or patients? Yes No Qualifying APM Participant 5% bonus payment Higher fee schedule AMP-specific rewards Excluded from MIPS 1 st year in Medicare OR below low-volume threshold? Yes Not subject to MIPS No Subject to MIPS Subject to MIPS Favorable MIPS scoring APM-specific rewards 41

40 Potential Value-Based Rewards MIPS Only MIPS adjustments Qualifying APMs APM-specific rewards MIPS adjustments Qualifying APM Participant Eligible APMspecific rewards 5% lump sum bonus 42

41 -3.5% -6% -9%? PQRS, Value Modifier, Meaningful Use

42 What Can I Do Right Now? Continue with practice improvement initiatives Aafp.org/TCPI Project Overview Find My PTN Aafp.org/MACRA Frequently Asked Questions Timeline for Implementation MIPS and APM side by side comparison Getting Paid Blog Family Practice Management 44

43 What Can I Do Right Now? Continue practice improvement initiatives Aafp.org/TCPI Project Overview Find My PTN Aafp.org/MACRA FAQ Timeline MIPS and APM comparison Family Practice Management 45

44 Technical Assistance $20 million for Technical Assistance Transforming Clinical Practices Initiative (TCPI) 46

45 Payment Reform Is Here Final regulations in likely performance year for MIPS Help is available 47

46 For More Information: Aafp.org/MACRA 48

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