9/20/2017 1 Presented by Thomas M. Donohoe| 303.801.3534 | [email protected]MACRA: Here to Stay and What You Need to Know Montana Hospital Association Fall Convention and Trade Show September 21, 2017 2 This is not practice as usual. This is not what we've done for the past 10 to 20 years in group practice. This is a whole new world. - Aric Sharp, VP Accountable Care, UnityPoint Health, Iowa, August, 2016 Six months into MACRA rollout, docs still unprepared - Modern Healthcare Article, June 28, 2017 (in response to KPMG report) Overview • Introductory concepts • MACRA and the final rule • The Merit‐Based Incentive Payment System (“MIPS”) • MIPS performance categories and scoring • Alternative payment models • QPP and rural providers • Strategies for success 3
Six months into MACRA rollout, docs still unprepared
- Modern Healthcare Article, June 28, 2017 (in response to KPMG report)
Overview• Introductory concepts
• MACRA and the final rule
• The Merit‐Based Incentive Payment System (“MIPS”)
• MIPS performance categories and scoring
• Alternative payment models
• QPP and rural providers
• Strategies for success
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Introductory Concepts
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Health Care Reform – A Road to Value?• Innovative delivery models
• Population health
• Bundled payments
• Medicaid expansion
• Accountability and shared risk
• Market consolidation
• Gainsharing
• Provider‐sponsored health plans
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Triple Aim
Access
Cost Quality
The Broader HHS Quality Strategy• Goal #1: Medicare Payments Tied to Quality Through Alternative Payment Models
• 2016 – Goal of 30%
• 2018 – Goal of 50%
• Goal #2: Medicare FFS Payments Tied to Quality or Value
• 2016 – 85%
• 2018 – 90%
• Private sector initiatives
• Development of the "Quality Payment Program"
• CMS commentary from the proposed rule:
• This rule is needed to propose policies to improve physician payments by changing the way Medicare incorporates quality measurement into payments and by developing new policies to address and incentivize participation in alternative payment models.
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The Ask Is A Paradigm Shift
Providers will be forced to improve/maintain quality for business purposes, not just for patient
care
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MACRA and the Final Rule
MACRA: Oh Boy, Here We Go!• MACRA makes 3 significant changes to how Medicare pays for professional
services:
• Ends the Sustainable Growth Rate (“SGR”) formula for determining Medicare payments for health care providers’ services
• Establishes a new framework for rewarding health care providers for giving better care not more just more care
• MIPS
• Alternative Payment Models (“APMs”)
• Combines existing quality reporting programs into one system
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What Is the Quality Payment Program?
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MIPS
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MIPS: A Streamlined Approach
12Source: CMS Website
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MIPS: Key Concepts• Major discussion items
– MIPS ECs
– Performance Categories/Quality Measures
– MIPS Scoring and Payment Adjustments
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Who Participates in MIPS? • Medicare Part B clinicians billing more than $90,000 a year and providing care to
more than 200 Medicare beneficiaries a year
• MIPS ECs*
– Physicians
– Physician assistants
– Nurse practitioners
– Clinical nurse specialists
– Certified registered nurse anesthetists
*After Years 1‐2, eligibility may expand to other categories of eligible clinicians
*Clinicians can participate as groups across all four MIPS performance categories
– For all performance categories and most submission mechanisms: MIPS performance period = any continuous 90‐day period within CY 2017
• Need not score all performance categories during the same 90 day period.
– Exception: For data reported through the CMS Web Interface, the CAHPS for MIPS survey, and administrative claims‐based cost and quality measures, the performance period under MIPS is CY 2017
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Individual or Group Scoring• Two scoring methodologies for ECs in physician groups not
participating in a MIPS APM:
– Physician group elects to have its ECs scored individually
• I got mine, you get yours
– Physician group elects to have its ECs scored as a group
• All for one, one for all (collective assessment and a single score calculated and applied to each EC in the group)
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Individual or Group Scoring (cont’d)• ECs in physician groups participating in a MIPS APM (e.g., the
Medicare Shared Savings Program):
– Separate MIPS scoring methodologies for:
• Medicare Shared Savings Program
• Next Generation ACO Program
• All “other” MIPS APMs (e.g, the Oncology Care Model)
• Pros and cons to these scoring methodologies:
– MIPS scoring relevant in deciding to join or withdraw from a MSSP ACO, Next Gen ACO, or other MIPS APMs?
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Third Scoring Option: MIPS APM• “APM Scoring Standard” applies to ECs participating in a
“MIPS APM” (e.g., a MSSP ACO, Next Gen ACO, OCM, and others) on “snapshot” dates of March 31, June 30, and August 31 of a performance year
• Simply stated, the APM Scoring Standard provides for the collective assessment of all ECs participating in an “APM Entity” (e.g., a MSSP ACO, a Next Gen ACO, an OCM practice, etc.) to produce a single MIPS final score that will be attributed to each of the participating ECs for the performance year
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Upside/Downside Risk Under MIPS
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Source: CMS Website
2017 Transition Year
29Source: CMS Website
MIPS Payment Adjustments: 2017• Performance year 2017; payment adjustment year 2019
• Standard adjustments
– Final score less than 3 points = negative payment adjustment (up to ‐4%) from 2019 MPFS
– Score of 3 points = no adjustment (report 1 quality measure, 1 improvement activity or the ACI “base score” measures)
– Final score greater than 3 points and less than or equal to 100 points = positive payment adjustment for 2019
• Budget neutrality = positive payment adjustments must equal negative adjustments (much less than anticipated in proposed rule)
• Additional adjustments: for ECs with final score of at least 70 points or more, $500M available (no budget neutrality); paid on sliding scale30
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Determining the MIPS Payment Adjustment
31 Source: CMS Website
“You can run, but you can’t hide”ECs’ 2017 MIPS final score (scored individually, as a group, or under the APM Scoring Standard) and associated 2019 payment adjustment, will follow them to their new practice
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Alternative Payment Models
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Alternative Payment Models
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Source: CMS Website
Advanced APMs
35Source: CMS Website
Advanced APMs: 2017 Performance Year
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Source: CMS Website
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APM Participation Requirements
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Source: CMS Website
APM Incentive Payments• Payment is a lump sum payment equal to 5 percent of a
Qualifying APM Participant's (“QP’s”) prior year's payments for Part B services UNDER ALL OF QP’S TINS during the prior year
• QPs are not subject to MIPS payment adjustments
– "Partial QPs" are not eligible for an APM incentive payment but may elect not to be subject to a MIPS payment adjustment
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Summing It Up
39Source: CMS Website
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The QPP and Rural Providers
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Rural Provider Considerations• Low volume threshold – $90,000 in Medicare Part B billings and 200
Medicare beneficiaries per year
– Raised from proposed rule
• RHCs and FQHCs not included
• ECs include mid‐level providers and not just physicians (which are more prominent in rural areas)
• Understand the financial implications: does the infrastructure cost outweigh the potential penalties?
– Need to think through future performance years
• Technical assistance through CMS: $100M over 5 years41
Strategies for Success
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Strategies for Success• Strategies will vary based on:
– Size
– Resources
– Sophistication
– Realities
• Strategies may include:
– Avoiding negative payment adjustments (doing the bare minimum)
– Seeking positive payment adjustments/performing under MIPS
– Participating in Advanced APMS
• Avoid MIPS reporting
• 5% and greater bonuses
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MIPS• MIPS strategies for success:
– Organize TINs/groups appropriately to maximize/minimize impact
– Align EC compensation and incentives with MIPS metrics/performance
– Streamline data collection and data reporting tools
– Engage ECs and educate them regarding MIPS; solicit involvement in developing tools for success
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Advanced APMs• Advanced APM Strategies
– Identify Advanced APMs the ECs can participate in; understand deadlines and participation criteria
– Perform analysis of MIPS impact versus Advanced APM success
• APM and Advanced APM Options:
– Track 1 ACO
• Provides infrastructure for reporting
• MIPS APM reporting requirements
– CPC+
• Advanced APM
• No MIPS reporting requirements; eligible for 5% bonus45
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Takeaways• MACRA is here…and likely is not going away
• First year compliance is not difficult; there should be no excuses for negative payment adjustment
• Full compliance expected for CY 2018 (pending any changes to a final rule); providers should be prepared
• Providers should understand the impact of compliance versus non‐compliance
• Providers should consider thoughtful strategies for being successful in MIPS or an AAPM and understand what that looks like for both
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