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Strategies to Support MACRA Standards

October 13, 2016

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OBJECTIVES

• Discuss MACRA and the differences between the Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS)

• Identify the potential financial impacts of bonuses and penalties on healthcare providers

• Describe the ways that Holy Family Memorial is using information technology (IT) to prepare for the impact of MACRA

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Monica Nichter is the Director of Revenue Integrity and Payor Contracting for Holy Family Memorial Manitowoc, WI. With over 25 years’ healthcare leadership experience in a variety of settings, she has overseen numerous successful system implementations and process enhancements for financial recovery. Monica was also an operations leader for Medicare Advantage plans and Commercial Lines of Business for a regional health plan. She has BSN and MSN degrees from the University of Wisconsin - Oshkosh.

Monica Nichter, RN, MSN Director, Revenue Integrity and Payor Contracting, Holy Family Memorial

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Jim Deren is Director of Information Technology (IT) Healthcare Planning for CareTech Solutions, where he has performed over 40 detailed IT assessments and several IT strategic plans for hospitals in the U.S. He has over 35 years’ IT experience, including over 26 years in the healthcare industry. Mr. Deren is a certified project manager (PMP) with CPHIMS certification and a B.S. degree in education/computer science from Eastern Michigan University. He has also presented at numerous conferences.

James Deren Director of Information Technology Healthcare Planning, CareTech Solutions

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HIGHLIGHTS

• Proposed rule developed on April 27, 2016 • Final rule expected November 2016 • Current plan requires measurement of 2017 data and affects

2019 payments • On September 8 CMS announced that they will provide flexibility in

2017 to allow providers to avoid negative payment adjustments • Repeals the sustainable growth rate payment model • Providers can select one of two options: Merit Based Incentive System MIPS Advanced Alternative Payment Models (APMs)

• CMS budget neutral • Priority, BCBS and others are adopting similar programs • Overlaps several meaningful use stage 3 requirements

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TWO PATHS FOR PROVIDERS

Merit Based Incentive Payment System (MIPS) • 100 point scale known as the Composite Performance Score • 2017 data reported in 2019 • 4 Categories

• Quality • Resource Use • Clinical Practice Improvement Activities • Advancing Care Information

• Majority of providers will be subject to MIPS

Advanced Alternative Payment Models (APMs) • Can receive bonus payments • Fewer providers will meet qualifications • Must use certified EHR technology • Payments based upon quality measures • Bear more than nominal financial risk or is a medical home

model under CMMI authority

MIPS

APMs

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First Year of Medicare Part B Participation

Below low patient volume threshold

Certain participants in advanced alternative

payment models

Medicare billing charges less than or equal to $10,000 and

provides care for 100 or fewer Medicare patients in one year

NOTE: MIPS does not apply to hospitals or facilities

PROVIDERS NOT ELIGIBLE FOR MIPS

Eligible Providers Include: Physicians, PAs, NPs, dentists, Nurse Anesthetists year 1. (Therapist, audiologist, midwifes, social workers, psychologists, dieticians year 3)

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Not in APM In APM In Advanced APM

MIPS adjustments

APM-specific rewards

5% lump sum bonus

APM-specific rewards

+ MIPS adjustments

+ If you are a

Qualifying APM Participant (QP)

Potential Financial Rewards

ALTERNATIVE PAYMENT MODEL INCENTIVES

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FINANCIAL SUMMARY AND TIMELINE

2017 Activity/2019 payment adjustments • MIPS: +/- 4% Medicare FFS, • +12% for “exceptional performance” • APMS: + 5% Medicare FFS

NOTE This is the maximum adjustment. It may be scaled up or down to achieve neutral cost

American Medical Association 2016

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NEW - MACRA OPTIONS FOR 2017

Test the Quality Payment Program

• Submit some data to the quality payment program

• Ensure that provider systems are working

Participate for a Part of the Calendar Year

• Submit quality payment data for a reduced number of days

• Reduced number of days to be determined

• CMS will provide a list of quality measures

Participate for the Full Calendar Year

• May qualify for a modest payment adjustment

Participate in Advanced Alternative

Payment Model

• Would quality for a 5% incentive

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)

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MIPS COMPONENTS

Quality Reporting

(PQRS)

Resource Use or Cost

(Value-based Modifier)

Advancing Care

Information (MU)

Clinical practice

improvement activities

MIPS

MIPS aims: • Streamline 3 independent programs • Add 4th component to promote

improvement and innovation • Provide more flexibility and choice of

measures • Retain a fee-for-service payment

option

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MIPS COMPONENT WEIGHTS AND SCORING IN 2019

Quality: (50%) (Report on 6 measures)

80 points groups <10 90 points for larger groups

Advancing Care Information:(25%) (Meaningful Use Criteria)

50 points base score 80 points performance score

Clinical Practice Improvement Activities: (15%) (Select from list of approved activities)

60 points (3-6 activities; 2 activities for small and rural practices)

Resource Use: (10%) (Submission of cost data)

10 points per measure Score is average of attributable measures

25%

15%

10%

50%

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MIPS PAYMENT ADJUSTMENTS

At Threshold No payment adjustment

Below Threshold Negative payment

adjustment

Above Threshold Positive payment

adjustment

Exceptional Performer

Bonus payment adjustment

Up to 3 x maximum adjustment (12% for year 1) “Exceptional performer” yet to be defined

The aggregated MIPS composite performance score would be compared against a MIPS performance threshold (Mean score of all clinicians during prior period) CMS updates threshold on an annual basis

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COMPOSITE SCORE CALCULATION

MIPS Category Options Possible Selections

Required Selections Value Points Maximum

Score Composite

Score

Quality

Basic Quality Measures 200 6 10 60 Population Measures > 9 providers 3 10 30 90

Population Measures < 10 providers 2 10 20 80

Total Quality 50

Resource Use Submit Cost Data 41 Total Resource Use 10

Advancing Care Information

Basic Reqs. 6 6 50 50 Performance Metrics 8 8 10 80 80 Bonus (optional registry) 3 0 1 1 1 Total Advancing Care Information 131 100 25

Clinical Practice Improvement

Patient Centered Medical Home 90 0 60 60

Other providers option a * 90 3 20 60 60 Other providers option b * 90 6 10 60 60 Total Clinical Practice Improvement 15

Composite Score 100

* may pick combination of 10 or 20 point measures to achieve 60 points

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MACRA FINANCIAL SCENARIO

MACRA SCENARIO MIPS adjustment

Sustainable Growth Rate

(0.5%)

Neutral (0%)

Low Performer

(-4-9%)

High Performer

(+4-9%)

Highest Performer

(+12%)

Advanced APM (5%)

Year 1 +/-4% $2,400,000 $2,400,000 $2,304,000 $2,496,000 $2,688,000 $2,520,000

Year 2 +/-5% $2,412,000 $2,400,000 $2,280,000 $2,520,000 $2,688,000 $2,520,000

Year 3 +/-7% $2,424,060 $2,400,000 $2,232,000 $2,568,000 $2,688,000 $2,520,000

Year 4 +/-9% $2,436,180 $2,400,000 $2,184,000 $2,616,000 $2,688,000 $2,520,000

Year 5 +/-9% $2,448,361 $2,400,000 $2,184,000 $2,616,000 $2,688,000 $2,520,000

Total 5 Years $12,120,602 $12,000,000 $11,184,000 $12,816,000 $13,440,000 $12,600,000

Difference from SGR 0 ($120,602) ($936,602) $695,398 $1,319,398 $479,398

Patients per day 15 Days per year 200 Average cost of office visit $200 % Medicare patients 20% Physicians in practice 20

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ESTIMATED FINANCIAL IMPACT ON PHYSICIAN GROUPS

CMS - HIMSS 2016

Practice Size Eligible Clinicians

Aggregate Impact

Negative Payment

Adjustments ($m)

Aggregate Impact Positive

Adjustments ($m)

Impact on this group ($m)

Impact per clinician average

Aggregate Positive

Adjustments (exceptional performance

payments) ($m) solo 100,788 ($300) $65 ($235) ($2,332) $105 2-9 eligible clinicians 123,695 ($279) $182 ($97) ($784) $295

10 - 24 eligible clinicans 81,207 ($101) $103 $2 $25 $164

25 - 99 eligible clinicians 147,976 ($95) $147 $52 $351 $230

100 or more eligible clinicians 305,676 ($57) $336 $279 $912 $539

Overall 761,342 ($833) $833 $0 $1,333

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MIPS COMPONENT SCORING OVER TIME

CATEGORY 2019 2020 2021 2022 onward

Quality 50% 45% 30% 30%

Resource use 10% 15% 30% 30%

Advancing Care Information 25% 25% 25% 25%

Clinical Practice Improvement

Activities 15% 15% 15% 15%

Penalty risk -4% -5% -7% -9%

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QUALITY REPORTING BASICS

Measures • 6 measures required out of 200 available,

reported by physicians • Include one cross-cutting measure, one

outcome • 3 population health measures (groups of

10 or more only)

Scoring • Each measure worth up to 10 points • 90 total points for groups >10 • 80 total points for smaller groups • Distribution of points for each measure

based on performance benchmarks (80% for claims reporting, 90% for registry reporting)

Bonus points • Up to 4 bonus points may be added for

reporting on outcome and high priority measures

• 1 bonus point possible for each measure captured and reported through CEHRT

• Total bonus points capped at 5% of those used to calculate the quality score

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RESOURCE USE BASICS

Measures • Continues use of VBM cost measures

(Medicare spending per beneficiary and total per capita cost) developed for hospital-level measurement

• 41 episode-specific measures potentially added

Scoring • 10 points, calculated average of all

attributable cost measures (worth 10 points each)

• 20 patient sample required for measure attribution

• Scoring is the same as currently • If patient volume insufficient for all

measures, score is zero and other MIPS categories will be reweighted

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ADVANCING CARE INFORMATION BASICS

Base measures and scoring • 50 points for achieving 6 objectives

(pass/fail) • Immunization registry reporting required;

Reporting to more than one public health registry earns bonus point

• CPOE and clinical decision support no longer required

• Provide numerator/denominator or yes/no attestation for each

• Failure to attest to “protecting patient health information” results in zero total ACI score

Performance measures and scoring • 80 points available; total combined score

exceeding 100 gets full credit • Clinicians select from measures across 3

objective areas: patient electronic access, patient engagement, HI exchange

• ACI performance category will be reweighted to zero and other MIPS categories increased if objectives don’t apply (e.g., for hospital-based clinicians)

• Clinical quality measures from Meaningful Use no longer required

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ADVANCING CARE INFORMATION SCORING

BASE SCORE Makes up to 50

points

PERFORMANCE SCORE

Makes up to 80 points

BONUS POINT Earn up to 1 point COMPOSITE SCORE

Provide numerator / denominator of the 6

requirements

How well did you perform in 8 selected

measures

Report to a registry beyond immunizations

Earn 100 or more points and receive the

full 25 points in ACI category

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ADVANCING CARE INFORMATION (MEANINGFUL USE) OBJECTIVES

Protect Patient Health Information

Electronic Prescribing

Patient Electronic Access

Public Health Reporting

Health Information Exchange

Coordination of Care Through Patient

Engagement

• Security risk analysis

• Implement and use e-prescribe

• Patient access • Patient specific

information

• View, download, transmit PHI

• Secure messaging • Patient generated

health data

• Patient care record exchange

• Request/accept patient record

• Clinical information reconciliation

• Immunization registry (Optional) • Syndromic surveillance • Electronic case reporting • Public health registry

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CLINICAL PRACTICE IMPROVEMENT ACTIVITIES BASICS

To get 100% score (15% of total): Patient centered medical home (PCMH) need to come up with 60 points. (others 30) – could mean 2 to 6 activities selected

CPIA categories

8 activity categories 90+ activities Do not need activities in each category

Scoring

60 points = 100% CPIA score 7 of 8 categories have both high (20 points) and medium (10 points) weighted activities

Exceptions Certified PCMH (60 points); other APM (30 points) Participation in upcoming CMS study on CPIA and Measurement (60 points) Non-patient facing specialties, small rural practices, physician shortage areas need fewer points (one activity for partial credit, 2 activities for full credit)

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CPIA CATEGORIES AND EXAMPLES

Expanded Practice Access • 24/7 access to clinicians/care

teams • Use of telehealth • Patient experience data used to

improve practice

Population Management • Participation in systematic

anticoagulation program • Participation in CMMI models such

as Million Hearts Campaign • QCDR participation that includes

use of data for QI

Care Coordination • Participate in Transforming

Clinical Practice Initiative • Closing the referral loop • Develop and update individual

care plans

Beneficiary Engagement • Collect / follow up on patient

experience & satisfaction data • Use QCDR for shared clinical

decision making • Provide access to enhanced

patient portal

Patient Safety & Practice Assessment • Consult PDMP for Schedule-II

opioid prescriptions of >3 days • Participate in MOC part IV • Complete AMA STEPS Forward

program

Achieving Health Equity • Timely care for Medicaid

patients (including duals) • Participate in State Innovation

Model activities • Use QCDR to screen for social

determinants of health

Emergency Response & Preparedness • Participate in Disaster Medical

Assistance teams • Participate in domestic or

international humanitarian volunteer work

Integrated Behavioral & Mental Health • Colocation of mental health

services in clinical care settings • Depression screening and follow-

up planning • Prevention & treatment for

unhealthy alcohol or tobacco use

RED are 20 points – the others are 10 (list is not all-inclusive)

ALTERNATIVE PAYMENT MODELS (APMS)

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CMS CRITERIA FOR ADVANCED PAYMENT MODELS

2 categories – APMs and Advanced APMs

MIPS APMs Measured based upon the group (similar to ACO) Must meet MIPS measures

Advanced APMs

Must belong to a specified advanced APM Must use certified EHR technology

At least 50% of clinicians in first year, 75% thereafter

Payment based on quality measures comparable to MIPS

Bear “more than nominal risk” for monetary losses Clinicians would need to reduce their rates,

withhold payments, or pay CMS when actual expenditures exceed expected expenditures.

May be a medical home model expanded under CMMI authority Expanded Medical Home models exempt from

risk Other Medical Home models have different

standards

APMs

EHR use

Quality Reporting

Financial Risk

Advanced APMs

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CURRENTLY PROPOSED ADVANCED APMS

Comprehensive ESRD Care Model

(large dialysis organization)

Comprehensive Primary Care Plus

Medicare Shared Savings Track 2

Medicare Shared Savings Track 3

Next Generation ACO Model

Oncology Care Model, 2-Sided Risk

Arrangement

Next Generation ACO Pioneer ACO 21 ACOs spread among 13

states 9 ACOs spread among 7

states

To be expanded

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MEDICAL HOME MODELS

Medical Home Models: Have a unique financial risk criterion for

becoming an advanced APM Enable participants (who are not excluded

from MIPS) to receive the maximum score in the MIPS CPIA category

• Medical Home Model APM Features:

Participants include primary care practices or multispecialty practices that include primary care physicians and practitioners and offer primary care services

Empanelment of each patient to a primary care clinic

Have at least four of the following: Planned coordination of chronic and

preventative care Patient access and continuity of care Coordination of care across the medical

neighborhood Patient and caregiver engagement Shared decision making Payment arrangements in addition to or

substituting fee-for-service payments

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HFM’S MACRA JOURNEY

Monica Nichter, RN, MSN Director, Revenue Integrity and Payor Contracting

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HOLY FAMILY MEMORIAL THOUGHT LEADERSHIP

Since 2010 HFM has been featured at: • AHA’s Healthcare Forum, Partnership for Patients and Society

for Healthcare Strategy & Market Development

• HHN Most Wired Hospital 2013-2016. Top 1% of US hospitals

• One of the 100 Great Community Hospitals for 2016 by Becker’s Hospital Review

• ACHE Congress 2010-2016

• American Society for Quality International Forum

• University of Michigan Health Management and Policy Program & Griffith Leadership Center

• Published in HealthLeaders, Hospitals and Health Networks, Becker’s, Remington Report, and Insight

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American Hospital Association “Hospitals & Care Systems of the Future” Fall 2011

PAYMENT MODEL

COLLABORATION

CULTURE

INFRASTRUCTURE

FIRST CURVE FFS

SECOND CURVE

POPULATION

HEALTH & VALUE-BASED HEALTHCARE

HOW WILL YOUR HOSPITAL SUCCESSFULLY NAVIGATE THE SHIFT?

MOVEMENT: FIRST CURVE TO SECOND CURVE

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RIGHT CARE MODEL

• The most effective evidence based approach possible

• The most cost effective, safest, highest quality and greatest value

• Achieve the greatest long term benefit to the patient and society while minimizing physical and financial risk

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TOP-QUADRANT PERFORMANCE IN QUALITY AND EFFICIENCY

HFM identified among the most

efficient hospitals in Northeast Wisconsin

*Data is Severity and Risk Adjusted

All Commercial Payers, Wisconsin (Source: BSG Analytics, 2014 data)

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HFM’S TECHNOLOGY JOURNEY

In 2003 our CMO was appointed CIO to leverage technology to improve care and safety processes.

Maximized MEDITECH Platform. Recognized that MEDITECH could not get HFM to the next level. Decision was made to move forward with Cerner. Go-live planned for April 1, 2017.

Most Wired and HIMSS EMR recognition reflect deep IT and Operations integration.

IT Strategic Plan is aligned with hospital Strategic Right Care and Innovation Plans.

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MACRA READINESS TEAM • Brett Norell, CFO – Champion • Steve Driggers, Senior Medical Advisor • Vicki Wetenkamp, Administrative Director Clinical and Service

Excellence • Kate Casey, Clinical Quality Assistant • Zarine Anklesaria, Administrative Director, Primary Care and

Continuity of Care • Jill Rauber, Director, Health Information Management • Theron Pappas, Director, Information Services • Monica Nichter, Director, Revenue Integrity and Payor Contracting • Dean Pollnow, CMO – Ad hoc

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WHERE ARE WE AT TODAY? QUALITY

• Our Quality Team works closely with the Operations and the Leadership Teams to make decisions based on fact.

• The Quality Team tracks and trends data, slices and dices it to find areas that can be improved and work closely with Leaders and Staff to facilitate those improvements.

• The Quality Team acts as consultants; as they learn requirements, regulations, etc., they make certain that the Network is informed and that we meet deadlines and data reporting requirements. Educate, educate, educate.

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WHERE ARE WE AT TODAY? DATA

• HFM is well prepared for MIPS. Breast cancer screenings Colorectal cancer screenings Diabetes management Hemoglobin A1c Tobacco use – screening and cessation intervention Pneumonia vaccination for older adults Community wide falls prevention program Working with IT to verify other measurers and the

accuracy of those measurers

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WHERE ARE WE AT TODAY? PCP

• Improvements have been made in primary care delivery Single phone line for primary care appointments Same day access HFM Right Now (e-visits) for common conditions Standard protocols Patient Portal

• Cerner platform will allow HFM to meet the requirements for Medical Home Certification

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WHERE ARE WE AT TODAY? IT •Technology investments must facilitate Second Curve care

delivery.

•Technology investments must improve patient quality

and/or safety.

•Information technology must support & accelerate

innovation and improvement

•Engaged IT – both internal/CareTech and Cerner

•CareTech and Cerner are in a consultative role regarding

MACRA readiness

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He who has the data, wins.

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INFORMATION TECHNOLOGY TO SUPPORT MACRA

Culture • IT

investments to support MACRA

• End user adoption plan

• Community engagement

• Oversight and accountability

• Quality mindset

Staffing • Educate staff

on MACRA • Engage

vendor(s) • Secure

adequate IT resources

• End user support plan

Workflow • Re-engineer

workflow for MACRA

• Implementation plan for new features

• Utilize data for decisions

Applications • Data reporting

and dashboards • New Technology • Security

measures • Certified EMR • IT Tools for

patients

Infrastructure • Data/System

reliability • Accessibility • Integration • Point of Care

devices • Disaster Recovery

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RECOMMENDED PROJECT PLAN

MACRA PROJECT PLAN 2016 2017

qtr 3 qtr 4 qtr 1 qtr 2 qtr 3 qtr 4 Assign project manager Understand the MACRA rule Determine financial implications Define scope and requirements Select MIPs or APM options Analyze current metrics to select best measures Develop project team and governance Educate all staff Engage vendor to ensure certified and capable EMR Develop detailed project plan Upgrade IT systems Implement clinical practice improvement activities Implement Advancing Care Information activities Measure resource use - Medicare claims Track core quality measures Monitor and manage MACRA project plan

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IT IMPLICATIONS AND ACTION NEEDED

General

• Determine which measures to report • Determine EHR capabilities and upgrades

needed • Upgrade to certified EHR • Workflow changes to fulfill requirements • Build tracking of composite score

Clinical Practice

Improvement Activities (options)

• Provide telehealth capabilities • 24 x 7 access to support patient access to

caregivers • IT functions to improve patient experience • Automated care plans • Decision support and alerts • Share patient data across registries

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IT IMPLICATIONS AND ACTION NEEDED

Advancing Care Information

• Registry reporting • Security assessment • Share via Health Information Exchange • ePrescribe • Patient portal and engagement tools • Patient entered data • Secure messaging

Resource Use • Submit Medicare claims • Measure quality of claims

Quality • Numerator and denominator for quality

measures • Track core quality measures (CQMs)

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RECOMMENDATION: MEASURE YOUR PROGRESS

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RESOURCES

HIMSS http://www.himss.org/news/cms-releases-macra-proposed-rule CMS https://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

AAFP http://www.aafp.org/practice-management/payment/medicare-

payment/faq.html AHA http://www.aha.org/advocacy-issues/physician/index.shtml

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Kaiser Permanente

UCLA Medical Center

Holy Family Memorial

Cleveland Clinic

Which health system has achieved?

HHN Most Wired (4x) HIMSS Analytics Stage 6.5 99% Inpatient CPOE Adoption 92% Outpatient CPOE Adoption 40% Growth in clinic visits over 10 years Top 5 Patient Safety Award (Grade “A” 2015) Becker’s Hospital Review 100 Great

Community Hospitals (2016)

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Any Questions?

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