Massachusetts- Romney Care to PPACA, MACRA and Beyond

Transcription

1 Massachusetts- Romney Care to PPACA, MACRA and Beyond Can we survive? Therese Mulvey, MD Massachusetts General Hospital Boston, MA

2 Learning Objectives After reading and reviewing this material, the participant should be able to: Understand the pressures facing oncology care delivery. Understand the changes caused by PPACA Understand the changes to come in care delivery post MACRA.

3 Disclosures None

4 Health Care Reform March 2010 ACA Signed into Law October 2013 ACA Health Insurance Exchanges Open Massachusetts Passes Health Reform 2008 & 2010 Massachusetts Passes Additional Health Care Reform Bills to Control Costs and Align with ACA 2014 ACA Individual Mandate Effective

5 Overview of MA Health Reform Goal: Provide near-universal health insurance coverage for all state residents Creation of health insurance marketplace Individual mandate CHIP & Medicaid expansion Insurance market reforms Increased employer responsibility

6 Overview of MA Health Reform - Commonwealth Health Insurance Connector Commonwealth Care Subsidized private health insurance for low-income residents (<300% FPL) Sliding scale, with <150% FPL fully subsidized Commonwealth Choice Non-subsidized private health insurance Must meet certain cost and coverage standards Gold, silver, and bronze benefit designs

7 What Changed with the ACA Romneycare Obamacare

8 What Changed with the ACA Health Insurance Marketplace Single marketplace for subsidized and non-subsidized plans Increased availability of subsidies; Individuals <400% FPL now eligible (previously <300% FPL) Individual Mandate Penalty increased for some individuals CHIP & Medicaid Expansion Medicaid expanded to all individuals under age 65 with incomes <133% FPL

9 What Changed with the ACA Insurance Market Reforms Expanded dependent coverage to age 26 Eliminated lifetime limits Employer Responsibility Fee for employers not providing insurance increased from $295 per employee annually to $2,000 employer annually, but only for businesses with 50 or more employees Additional Benefits No cost sharing for preventative care services

10 Effects of Health Reform on MA Increase in health care spending Per capita spending is 15% higher than national average Increase in access to health care services Increase in use of preventative care services Increase in visits to safety net providers State working to increase number of primary care providers

11 Insurance Premiums in Massachusetts are High Average Montly Insurance Premium Per Person in Individual Market $500 $450 $400 $350 $300 $250 $200 $150 $100 $50 United States Massachusetts $ Year Source: Kaiser Family Foundation

12 Uninsured Rates in Massachusetts are Lowest in Country 18.0% 16.0% 14.0% United States Massachusetts % Uninsured 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Year Source: US Census Bureau Current Population Survey & American Community Survey

13 Practical Impacts on Medical Oncology Lowest rates un uninsured in country- 2% for individuals with major medical illnesses in Marked consolidation in market. Last private oncology practice (physician owned practice) closed May One dominant health system now controls more than 50% of all oncology cases. Closure of purchased oncology practices. Physician lay offs.

14 Dear colleagues, After thoughtful deliberation of the options, leadership at Dana-Farber Cancer Institute (DFCI) and Dana-Farber Community Cancer Care (DFCCC) have made the difficult decision to close the DFCCC practices in Quincy, Dorchester, and Milton, effective October 28, A number of factors led to this decision, including the significant clinical capital investments needed at these sites, recent changes in Medicare reimbursement for physician practices, and the availability of high-quality hematology/oncology services in our other nearby sites. Letter from Dr. Edward Benz CEO DFCI August 2016

15 Surviving and Thriving in a Post-SGR World? Is it possible?

16 Pathways Preauthorization Denials Cost of drugs Bad debt PQRS Meaningful use Staffing Competition RAC Audits The Reality

17 Information Overload clinical knowledge is doubling every 18 months David Russell Schilling industrytap.com December 2014

18 Source: ASCO Annual Practice Census 2014 Practice Pressures

19 Administrative Burden It s Not Just Your Imagination March 7, 2016

20 The Result? 56% 48% 43% 38% Physician Owned Oncology Practices Source: ASCO Annual Practice Census

21 Coordinated Care? 23,658 malpractice cases ,000 cases and 1,744 deaths linked linked to communication issues

22 MACRA WHY SHOULD YOU CARE?

23 Why is it Important Now? Completely changes basis for Medicare payment Moves to performance based updates Effective date 2019 but measurements will be based on 2017 performance

24 What is MACRA? Medicare Access and CHIP Reauthorization Act of 2015 Repeals the Sustainable Growth Rate (SGR) Formula Authorizes CMS to establish the new Quality Payment Program More of the payment based on value, not volume Streamlines reporting programs into 1 new system: Merit Based Incentive Payment System (MIPS) Incentivizes involvement in Alternative Payment Models (APMs) 24

25 How Does Medicare Pay Me Now? Physician Quality Reporting System (PQRS) Meaningful Use Electronic Health Records Incentive Program (MU) Value Based Modifier (VBM) 25

26 How Will it Change? The Merit Based Incentive Payment System (MIPS) TODAY JAN 2019 Physician Quality Reporting System (PQRS) Meaningful Use (MU) Value Based Modifier (VBM) MU PQRS CPIA (2019) Adds Clinical Practice Improvement Activity (CPIA) Consolidates penalties Increases incentives Ranks peers nationally SUNSETS DEC 2018 VBM Reports publicly Not included in

27 10% 25% Advancing Care Information (MU) Quality (PQRS) 60% Clinical Practice Improvement Activity Low Performers -9% National Median Composite Score Medicare Provider Composite Score High Performers +9% Top Performers +27%

28 How Do I Choose Quality Measures? PQRS Measure Set 271 Measures total Review & select measures fitting your practice and specialty need. Choose six measures including one outcome measure; or Choose another high priority measure General Oncology Measures 19 Measures specifically targeting oncology practice Does not include hematology or radiology, but there are at least 4 in the larger set 28

29 QOPI for PQRS Two options for PQRS reporting: QOPI plus supplemental PQRS reusing eligible charts for PQRS PQRS only no QOPI charts needed Available for both individual eligible professionals (EPs) and the Group Practice Reporting Option (GPRO) 29

30 QOPI as a PQRS Registry Standard registry reporting Consists of 7 measures in the oncology measures group Manual abstraction only 20 charts per eligible professional > 50% (11) must be Medicare patients Available to all ASCO members 30

31 QOPI now. Must register as a QOPI site May elect PQRS bundle only; not required to do the entire fall QOPI round Practice Report Dashboard under design PQRS is available year round continue to enter PQRS charts even after the round has closed No charge for 2016 or 2017 QOPI PQRS for ASCO members 31

32 How is My Reimbursement Adjusted? Adjustments MIPS Composite Score Adjustment Physican Fee Schedule Payment MIPS Exceptional Performance Final Payment 32

33 Pick-your-pace for 2017 Reporting Source: CMS

34 Most practitioners will be subject to MIPS Subject to MIPS Not in APM In non-advanced APM Qualifying Physician (QP) in APM In APM, but not a QP Some people may be in APMs but not have enough payments or patients through the APM to be a QP. Note: Figure not to scale

35 MIPPS for Most Single TIN Most reporting will be PCP based if you are in a large group. If your system is in an ACO- reporting will be in the ACO under the single TIN. Resource utilization will be the issue for oncology in a large system.

36 Patient Centered Oncology Payment Model (PCOP) STATUS Update: Pursuing designation as advanced payment model that will qualify under MACRA Active dialogue with several practices and commercial payers One pilot underway

37 What next? will be a transformative time for care delivery. OCM, PCOP, other initiatives will move us from fee for service to value based payment. Care coordination and measurable outcomes will be key to success. Measures will be process, outcomes, PROMS and value (cost based) Pathways, Come Home, Medical Homes and Neighborhoods will all play a role.

38 Massachusetts Consolidation of groups. Single EHR Reporting, feedback and improvement Infrastructure changes Re assignment of roles both administrative and clinical Resource utilization measures Some will survive and some will not but access to care for patients will not be affected.

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40 BUT Pay attention Use the resources of ASCO Begin measuring Check out your QRUR Talk to your administrators Plan for your future

41 Questions?