A MACRA Overview. A web discussion with guests Ivy Baer, Gayle Lee, and Tanvi Mehta of AAMC

Transcription

1 A MACRA Overview A web discussion with guests Ivy Baer, Gayle Lee, and Tanvi Mehta of AAMC An Affinity Group Brought to you by HFMA and Vizient Sponsored by Kaufman Hall June 6, 2016

2 Meeting Notes Plan to attend the next in-person meeting - June 27, 2016 at ANI in Las Vegas Sneak Peek at the agenda: Structuring AMC Partnerships with Community Health Systems Quantifying the Societal Benefit AMCs Provide Strategies for Dealing with Narrow Network Products Update on Funds Flow Models 2

3 About Our Speakers Ivy Baer is Senior Director and Regulatory Counsel at AAMC. In this role she heads AAMC's Regulatory and Policy Group that is responsible for monitoring, educating, and advocating on a wide variety of regulations issued by the CMS, OIG, and other HHS agencies. She holds a law degree from Emory University and Masters of Public Health degree from the Harvard School of Public Health's Department of Health Policy and Management. Gayle Lee is the Director of Physician Payment Policy and Quality for AAMC. She is responsible for educating and advocating on federal regulations and policies that impact teaching hospitals and physicians. Ms. Lee received her law degree at the Washington College of Law at the American University DC. Tanvi Mehta is Physician Payment and Quality Specialist at AAMC. She is engaged in the rulemaking process and educating AMC faculty practices on physician payment and quality programs. Ms. Mehta earned a Masters in Health Services and Administration, Health Management and Policy from the University of Michigan. 3

4 Merit-Based Incentive Payment System and Alternative Payment Models (MACRA): Proposed Rule Ivy Baer, J.D., M.P.H. Gayle Lee, J.D. Tanvi Mehta

5 Tolerance of Uncertainty

6 HHS s Ambitious Goals Moving to alternative payment models: By end of 2016: tie 30 % of fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements By end of 2018: 50 % percent of payments to these models Moving traditional fee for service payment to: 2016: tie 85% of payment to quality or value (HVBP, HRRP, e.g.) 2018: move to 90%

7 April 2015: MACRA Is Enacted; MIPS/APMs Rule The Current System: Volume Based Provide a service, get paid. The Future State: Value Based Provide a service and your payment will vary depending on such factors as: Meeting quality measures Participating in alternative payment models Being in a primary care medical home that meets the standards set out by the Center for Medicare and Medicaid Innovation (CMMI) The more services you provide, the more revenue you get Starting in 2019 (based on performance in 2017) payments will be linked to quality and value under a Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (APMs). Payment can be increased or decreased based on performance.

8 Fee Schedule Remains Bedrock of Payment... Fee Schedule

9 ... What changes is how much you get paid and why

10 MACRA Legislation Repeals the Sustainable Growth Rate (SGR) Formula and sets up 2 payment programs: MIPS and APMs Streamlines multiple quality programs (Meaningful Use, PQRS, Value-based Modifier) under MIPS APM: Bonus payments for participation in advanced APM models.

11 Timeline: How Much Payment Is At Risk? Potential Reductions Medicare EHR Incentive -1.0% or -2.0% -3.0% Up to % c -4.0% d PQRS -1.5% -2.0% -2.0% -2.0% Value-modifier -1.0% -2.0% -4.0% -4.0% (Max reduction) c MIPS % -5.0% -7.0% -9.0% Total Possible Reduction -4.5% -6% -9% -10% -4% -5% -7% -9% c Penalty increases to 2% if Eligible Clinician is subject to 2014 erx penalty and Medicare EHR Incentive. d AFTER 2017, the penalty increases by 1 percent per year (to a max of 5%) if min 75% of Eligible Clinicians are not participating; otherwise max is 3%

12 MACRA Timeline Fee Schedule Updates and later for QAPMS.25 for MIPS/ partial QAPMS QAPMS 5% Incentive Payment MIPS 1st MIPS performance year +4% +5% +7% +9% *QAPMS: qualifying alternative payment models based on Medicare payment/patient threshold requirements and excluded from MIPS *MIPS: Merit-based Incentive Payment System, a consolidated pay-for-performance program, $500M annual pool is allocated for exceptional performers for CY

13 Why You Need to Get Ready Now 2019: First payment year under MIPS or Advanced APMs 2017: The performance year that determines the 2019 payment

14 MACRA Crossroads Quality Payment Programs MIPS +/- 4% in /-9% in 2022 CMS estimates 687, ,000 clinicians APMs +5% for CMS estimates 30,658-90,000 Eligible Clinicians would become QPs

15 MIPS Background

16 Overview of MIPS A New Consolidated Payfor-Performance Program Meaningful Use Program Value Modifier Program PQRS Merit-Based Incentive Payment System (MIPS)

17 Eligible Clinicians: Starting in 2019 Who Does MIPS apply to? Physician ( 1861(r)) Physician assistant (PA) Nurse practitioner (NP) Clinical nurse specialist CRNA Starting 2021, this category can be expanded: Proposed rule mentions OTs, PTs, clinical social workers

18 Exceptions to MIPS Participation for Certain Clinicians Low Patient Volume Billing charges less than or equal to $10,000 and provider care for 100 or fewer Medicare patients in one year. Participants in Advanced APMs Must meet threshold of Medicare payments or patients through APM to be qualifying APM participant or partially qualifying APM participant. 1 st year clinician enrolled in Medicare program Not treated as MIPS eligible clinician until subsequent year

19 Eligible Clinician Identifiers in MIPS: Two Options Individuals Defined by Unique TIN/NPI Similar reporting mechanisms as current programs Groups Defined by TIN Similar reporting mechanisms as current programs Also option for MIPS/APM program

20 How to Identify as a Group Under MIPS MIPS General Single TIN of 2+ clinicians that have reassigned billing rights to the TIN All MIPS eligible clinicians in group must use same TIN MIPS APM Unique APM identifier for each eligible clinician who is part of APM entity Could include more than 1 TIN as long as the MIPS eligible clinicians identified as participants by unique APM participant identifiers Some eligible clinicians in a TIN can be APM participants and others in same TIN not be participants Must be APM participant on 12/31 of performance period

21 MIPS Performance Categories

22 Composite Performance Score: Four Categories Composite Performance Score (CPS) Quality Resource Use Clinical Practice Improvement Activities (CPIA) Advancing Care Information (ACI) (Previously known as MU)

23 Clinical Practice Improvement Activities (15%) (Choose from a list of 94 activities) The Secretary is required to specify clinical practice improvement activities. Subcategories of activities are also specified in the statute, which are: Expanded Practice Access Same day appointments for urgent needs After hours clinician advice Population Management Monitoring health conditions & providing timely intervention Participation in a QCDR Care Coordination Timely communication of test results Timely exchange of clinical information with patients AND providers Use of remote monitoring and Telehealth Beneficiary Engagement Establishing care for complex patients Patient self management & training Employing shared decision making Patient Safety & Practice Assessment Use of clinical or surgical checklists Practice assessments related to maintain certification Participation in an APM As defined in prior slide At a minimum receive ½ CPIA score for APM participation CPIA fall in two categories: high-weighted (20 points) and medium-weighted (10 points) Refer to Table 23, 81 Fed. Reg. p to get a list of the 11 high-weighted activities. Appendix H lists all activities. As a Medical Home participant, you can receive full credit in CPIA and an ACO receives half credit. Total possible points is 60.

24 CMS Proposes Three Additional CPIA Categories Achieving Health Equity Achieve high quality for underserved populations Integrated Behavioral and Mental Health Shared/integrated behavioral health and primary care records to address substance use disorders or other behavioral health conditions Emergency Preparedness and Response Participation in Medical Reserve Corps Active duty MIPS eligible clinician or group activities

25 Advancing Care Information (25%) (Replaces Meaningful Use Program) Key Changes from Current EHR Program Can report as Individuals and Groups Scoring based on two categories: Base and Performance Scores Failure to meet requirement to protect patient health information in EHR = 0 score for performance category More flexibility in choosing measures to report for Performance Score Removed Reporting Requirement for Clinical Provider Order Entry and Clinical Decision Support Objectives Optional reporting for: NPs, PAs, CNS, CRNAs in 2017

26 ACI: Overview of Base Score *An Eligible Clinician must complete submission on the immunization registry reporting measure of this objective and the measure, if applicable. Patient Electronic Access (N/D) Coordination of Care through Patient Engagement (N/D) Electronic Prescribing (N/D) Health Information Exchange (N/D) Protect Patient Health Information (No/Yes) Base Score (50 points) Public Health and Clinical Data Registry Reporting (No/Yes)* All or nothing approach means must: provide the numerator/denominator or yes/no for each objective and measure But failure to meet requirement to protect patient health information in EHR will result in 0 base score and 0 score in performance category

27 ACI: Overview of Performance Score Performance Score (up to 80 points) Patient Electronic Access Patient Access Patient Specific Education Coordination of Care through Patient Engagement VDT Secure Messaging Patient-Generated Health Data Health Information Exchange Patient Care Record Exchange Request/Accept Patient Care Record Clinical Information Reconciliation Clinicians can: Select measures that best fit their practices from the 8 associated measures from the 3 objectives For each measure, reported under the Performance Score, a clinician can receive up to 10 percent of their performance score based on their performance rate for the given measure.

28 Quality and Resource Use Categories Quality Performance (50%) Resource Use (10%) Similar Measures to PQRS Requires Reporting 6 Measures (instead of 9*) and adds population measures GPRO users report 17 measures Similar to Value Modifier Program Measures (MSPB and total per capita cost) Adds 40+ episode specific measures (for specialty groups) *One of 6 measures must be cross-cutting measure, one outcomes measure (or high priority measure)

29 MIPS APMs

30 Eligible Clinicians Participating in APMs MIPS/APM Defined by APM Identifier Participate in an APM that isn t an Advanced APM or doesn t meet Advanced APM full or partial threshold Reporting mechanism varies based on APM model Each Eligible Clinician who is a participant of an APM Entity would be identified by unique APM participant identifier combination of 4 identifiers APM Identifier-established by CMS (this is the model) APM Entity Identifierestablished by CMS this is entity (e.g. ACO) Tax Identification Numbers-9 numeric characters Eligible Clinicians NPI-10 numeric characters

31 MIPS APMs and Scoring Eligible Clinicians considered part of APM Entity Must be on APM participation list on December 31 of MIPS performance year If not on list, must report under standard MIPS methods (group or individual) Criteria for MIPS APM APM Entities participate in APM under agreement with CMS APM Entities include eligible clinicians on participation list APM bases payment incentives on performance on cost/utilization and quality measures Examples (note: some APMs are MIPS APMs and Advanced APMs) Shared savings program (all tracks) Next Generation ACO CPC Plus Oncology Care

32 MIPS Performance Category Weights and Payment Adjustments

33 MIPS Performance Categories/Weights Performance Category MIPS General* Year 1 (2019) Year 2 (2020) Year 3 (2021) MIPS APM Quality 50% 45% 30% Varies depending Resource Use 10% 15% 30% on APM CPIA 15% 15% 15% ACI 25% 25% 25% *For MIPS General weights will be adjusted for certain factors, such as non-patient facing clinicians

34 MIPS APM Scoring for Eligible Clinicians in Next Generation MIPS Performance Category Data Submission Requirement Performance Score Weight Quality Submit quality measures to CMS web Interface for participating eligible clinicians MIPS quality performance category requirements and benchmarks will be used to develop ACO MIPS quality score. 50% Resource Use CPIA MIPS eligible clinicians not assessed All MIPS eligible clinicians in the APM entity group submit individual level data. Not applicable 0% All ACO eligible clinicians will receive one half of the possible points at a minimum. If eligible clinician is in a PCMH, will receive the highest possible score. All MIPS eligible clinician scores will be aggregated and averaged to one ACO score. 20% Advancing Care Information All MIPS eligible clinician's in APM Entity group submit individual level data. All of MIPS eligible clinician scores will be aggregated and averaged to yield one ACO score. An ACO eligible clinician that does not report this performance category would contribute a score of zero. 30%

35 MIPS Payment Adjustment Based on the MIPS composite performance score, providers receive positive, negative, or neutral payment adjustments Year Payment Adjustments % % % 2022 and beyond +9% Exceptional performers may be eligible for additional payments

36 MIPS Payment Adjustment Maximum Negative Adjustment Sliding Scale Negative Adjustment Sliding Scale Positive Adjustment 0 adjustment Composite Score 0 25% of performance threshold Performance Threshold (mean or median- TBD by CMS) 25% and above get exceptional performance bonus 100

37 MIPS Performance Threshold Will use Part B charges, PQRS data submissions, QRUR and sqrur feedback data, and Medicare and Medicaid MU data Approximately half of eligible clinicians will be above threshold and half below Budget neutrality required

38 MIPS Timeline td2018kjjm 2017 Performance Period (Jan. Dec.) July: 1st feedback report 2018 Reporting and Data Collection (analysis of score) July: 2 nd feedback report 2019 MIPS payment adjustments

39 Additional Payments for Exceptional Performers Eligible Clinicians with scores above performance threshold, can have adjustment increased or decreased by a scaling factor of up to 3, BUT must maintain budget neutrality EX: for 2019 could be 3 x 4% = 12% additional incentive payment: up to $500m pool each year for exceptional performance Maximum adjustment cannot be more than 10% of Eligible Clinicians Medicare payments Exceptional performance: 25 th percentile of CPS for MIPS eligible clinicians at or above the performance threshold 2015 AAMC. May not be reproduced without permission.

40 MIPS Public Reporting Information about the performance of MIPS Eligible Clinicians must be made available on Physician Compare: Composite score for each Eligible Clinician and performance in each category Names of Eligible Clinicians in APMs May include performance regarding each measure or activity in resource use

41 Advanced APMs

42 Advanced APMs and Bonus Payments Clinicians who participate in the most advanced APMs may be determined to be qualifying APM participants ( QPs ). The QPs: Are not subject to MIPS Receive 5% lump sum bonus payments for years Receive a higher fee schedule update for 2026 and onward APM Participants Qualified APM participants

43 Not All APMS Qualify as Advanced APMs Term Alternative Payment Model (APM) Advanced APM Criteria Model under CMMI (except innovation awards) MSSP ACO CMS demonstration projects Demonstration required under law Entity that meets the following requirements: Use of CEHRT: at least 50% of Eligible Clinicians must use CEHRT in first year, and later increases to 75%) AND Payment is based on quality measures comparable to MIPS: measures must be evidence-based, reliable, and valid and at least one measure must be an outcome measure (if appropriate) And Is a medical home expanded under section 1115A(c) or comparable medical home under Medicaid program OR Entity bears risk in excess of a nominal amount

44 Medicare Threshold Requirements for Qualifying and Partial Qualifying APMs To be classified as qualifying APM participant or partial qualifying APM participant, have to meet or exceed certain thresholds related to APM entities Thresholds determined by payments for services in APM but MA revenue does not count in Threshold can be set using patients or services Years Min Thresholds for APM Participant (Payment) Min Thresholds for APM Participant (Patient) Qualifying Partial Qualifying Qualifying Partial Qualifying % 20% 20% 10% % 40% 35% 25% 2023 and beyond 75% 50% 50% 35% The thresholds are based on Medicare FFS revenue and patients ONLY. FFS & All- Payer combination begins in 2021 and have separate requirements.

45 All-Payer Combination Option: Threshold Requirements for Qualifying and Partial Qualifying APMs Starting 2021 To be classified as qualifying APM participant or partial qualifying APM participant, have to meet or exceed certain thresholds related to APM entities Threshold can be set using patients or services Min Thresholds for APM Participant (Payment) Years Medicare Qualifying Total Medicare Partial Qualifying Total % 50% 20% 40% % 50% 20% 40% 2023 and beyond 25% 75% 20% 50%

46 Advanced APM Determination Initial set of Advanced APM determination related no later than January 1, 2017 Won t know if you meet threshold until 2018 For new APMs announced after 1/1/2017, will be determination in conjunction with another proposed rule for Request for Applications List of Advanced APMs updated at least annually

47 Calculation of Threshold Within an Advanced APM, all participating Eligible Clinicians are assessed together Calculation of threshold is based on Medicare Part B professional services and beneficiaries attributed to the Advanced APM in 2017 If collectively, the Eligible Clinicians meet the payment or patient threshold, all Eligible Clinicians in the Advanced APM would receive 5% bonus 5% bonus payment amount would be based on Medicare Part B payments in 2018

48 Examples of Advanced APMs (from CMS) APM Medicare Shared Savings Program- Track 1 Medicare Shared Savings Program- Track 2 Medicare Shared Savings Program- Track 3 Oncology Care Model two-sided risk Oncology Care Model one-sided risk Advanced APM No Yes Yes Yes No BPCI Comprehensive Primary Care Initiative No Yes Next Generation ACO Comprehensive Care for Joint Replacement Yes No

49 Physician-Focused Payment Models (PFPM) Purpose: to identify physician models that could be APMs or Advanced APMs General Concern about specialists ability to participate in APMs No definition yet; should CMS use factors considered by CMMI to select models? Want to promote robust and well-developed proposals Technical Advisory Committee that will review, comment on, and provide recommendations on which PFPMs CMS should test Will release criteria by November 1

50 Summary

51 Physician Options for 2019 (Performance Year 2017) Qualifying APM Participant Significant participation in APM (25% Medicare payments/patients) Eligible for 5% bonuses ( ) paid in a lump sum Higher update starting 2026 (.75%) Avoid MIPS Partial Qualifying APM Slightly lower threshold for participation No APM incentive payments Lower annual updates Can avoid MIPS or choose to participate in MIPS; if participate in MIPS are considered to be a MIPS Eligible Clinician and may be subject to payment adjustment Starting 2026:.25% update MIPS: General or APM Eligible Clinicians for first 2 years: physician, PA, NP, CNS, and CRNA 3 rd year onwards: additional Eligible Clinicians may qualify as per the Secretary discretion If exceptional performance, eligible for bonus from $500M pool ( ) Starting 2026:.25% update Potential payment adjustment

52 MACRA Transition Timeline Jul-Dec and beyond Annual Updates +0.5% +0.0% PQRS Penalty Medicare EHR Penalties VM Max Penalty* 1% or 2% Up to 1% 2% 2% 3% 3% or 4% Up to 2% Up to 4% TBD Merit-Based Incentive Payment System (MIPS)* (Only max reduction listed; incentives available, see notes) Exclusions from MIPS 2 Options: Qualifying APM: +0.75% Other: +0.25% Penalties transition to MIPS; $500M pool for additional incentives for exceptional performance 4% at risk 5% at risk 7% at risk 9% at risk +0.25% update + (9%) at risk Qualifying APM Participant (QP) Bonus: 5% lump sum payment (based on services in preceding year); No MIPS risk No Bonus; No MIPS risk +0.75% update; No MIPS risk Other MIPS Exclusions (Low volume; Partial Qualifying APM w/ no MIPS reporting) No Bonus, No MIPS risk +0.25% update; No MIPS risk * VM and MIPS have possible upward or downward adjustments. Due to budget neutrality, incentives scale based on available funds. Maximum reduction for MIPS listed in statute. 52

53 Regulatory Timeline CMS Released Proposed Rule on April 27, 2016 Comments Due June 27, 2016 Final Rule Expected Fall 2016 Performance Year Begins 2017 (determines payment in 2019)

54 AP M MIPS: General or APM OR Advanced APM? MIPS/APM Reporting with different weighting for composite performance score No Advanced APM? Yes OR MIPS General or MIPS/ APM? Do you meet the threshold requirement? (patient/payment) Yes No No MIPS reporting, qualify for 5% bonus! MIPS/APM reporting MIPS: do you meet APM Requirements? No Do you meet the threshold requirements for a partial qualifying APM? No MIPS General Reporting Yes MIPS/APM reporting Yes MIPS/APM reporting Optional 2015 AAMC. May not be reproduced without permission.

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56 Questions? 56

57 Thank you for joining us! Plan to Attend: AMC CFO Council Meeting at ANI Monday, June 27, 2016 Las Vegas, Nevada For more information contact Marjorie Clare at Visit the AMC CFO Council web page at: 57