The Value Modifier & Medicare Access and CHIP Reauthorization Act (MACRA)New Medicare Value-Based Physician Payment is Closer Than You May Think!
February 11, 2016
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AGENDA• Demystify new Medicare payment incentives:
– Value-Based Payment Modifier (VM)– Medicare Access & CHIP Reauthorization Act (MACRA)
• Main Messages:– New Law: Physician payment under Medicare PFS (Physician Fee
Schedule) is changing significantly for PCPs and specialists– Physician engagement with PCMH and quality improvement is
essential– IBM Watson Health continues to help providers to maximize CMS
performance and payment• Next Steps
Value-based Payment Modifier (VM)
© 2014 International Business Machines Corporation Health and Social Programs 4
Introduction: the Value Modifier• One of the current annual payment adjustments, but will be
folded into MACRA• Payment adjustments to the Medicare Physician Fee Schedule
(MPFS) are made based upon:– Quality of care– Cost of care
• Assessment by measures• Quality-Tiering: the process by which quality and cost determine
the direction and the degree of the payment adjustment• The adjustment made is called the Value Modifier
2015 2015
2017
Multiple Quality Measures
Multiple Quality Domains
Value-based Payment Modifier (VM)
VM Quality Composite: Measures• Three sources for potential quality measures:
– Physician Quality Reporting System (PQRS)– Three Claims-Based Outcome Measures– Consumer Assessment of Health Providers and Systems (CAHPS)
Source #2
VM Quality Composite: PQRS Reporting• In regards to the Value Modifier, PQRS Reporting will cause an
immediate categorization for all groups “based on whether and how groups and solo practitioners participate in the PQRS in 2015.” – CMS
• Category 1: – Satisfactory PQRS Reporters
• Category 2:– Non-Satisfactory PQRS Reporters
Source #2, #3
The First VM Hurdle
Note: An automatic downward Value Modifier adjustment can occur in additionto a downward PQRS payment. This could mean multiple payment penalties annually from the VM, PQRS, and Meaningful Use.
VM Quality Composite: 3 Claims-Based Outcome Measures1. 30-Day All-Cause Hospital Readmissions2. Preventable Hospitalizations for Acute Conditions
– Bacterial Pneumonia– Urinary Tract Infection– Dehydration
3. Preventable Hospitalizations for Chronic Conditions– Short-Term Complications from Diabetes– Long-Term Complications from Diabetes– Uncontrolled Diabetes– Lower Extremity Amputation among Patients with Diabetes– Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults– Heart Failure
Source #6
VM Quality Composite: CAHPS • Consumer Assessment of Health Providers and Systems (CAHPS)• Patient Experience Surveys• Pertain to healthcare/hospital systems, insurance programs, clinicians
groups, etc. • Some groups will be required, and some groups may elect, to have
CAHPS data as a quality measure
Source #2, #7, #9 Appendix G
2015 2015
2017
Multiple Cost MeasuresTwo Cost Domains
Value-based Payment Modifier (VM)
VM Cost Composite: Review
2015 2015
2017
“Low”, “Average”, or “High”“Low”, “Average”, or “High”
Quality-Tiering: • 2017 Value Modifier for groups with 2-9 EPs as well as solo practitioners
The process by which both the Quality Composite and the Cost Composite are utilized to determine a group’s or individual’s Value Modifier.
Cost/Quality Low Quality Average Quality
High Quality
Low Cost +0.0% +1.0x* +2.0x*
Average Cost +0.0% +0.0% +1.0x*
High Cost +0.0% +0.0% +0.0%
Source #3
Source #3
Quality-Tiering: • 2017 Value Modifier for groups with ≥10 EPs
The process by which both the Quality Composite and the Cost Composite are utilized to determine a group’s Value Modifier.
Cost/Quality Low Quality Average Quality
High Quality
Low Cost +0.0% +2.0x* +4.0x*
Average Cost -2.0% +0.0% +2.0x*
High Cost -4.0% -2.0% +0.0%
Source #3
Source #3
• 2018 Value Modifier for groups of non-physician EPs, applied to PAs, NPs, CNSs, & CRNAs
Quality-Tiering:This table applies only to groups or solo practitioners that are non-physician EPs only.
Cost/Quality Low Quality Average Quality
High Quality
Low Cost +0.0% +1.0x* +2.0x*
Average Cost +0.0% +0.0% +1.0x*
High Cost +0.0% +0.0% +0.0%
Source #21
Source #21
• 2018 Value Modifier for groups of 2-9 EPs, applied to physicians, PAs, NPs, CNSs, & CRNAs
Quality-Tiering:This table applies only to groups that have at least one physician, and also to solo physician providers
Cost/Quality Low Quality Average Quality
High Quality
Low Cost +0.0% +1.0x* +2.0x*
Average Cost -1.0% +0.0% +1.0x*
High Cost -2.0% -1.0% +0.0%
Source #21
Source #21
Quality-Tiering: • 2018 Value Modifier for groups of 10+ EPs, applied to physicians, PAs, NPs, CNSs, & CRNAs
This table applies only to groups that have at least one physician
Cost/Quality Low Quality Average Quality
High Quality
Low Cost +0.0% +2.0x* +4.0x*
Average Cost -2.0% +0.0% +2.0x*
High Cost -4.0% -2.0% +0.0%
Source #21
Source #21
Value Modifier: Take Aways• Will continue to affect Medicare PFS payments in 2016, 2017, 2018• 2019: PQRS, Value Modifier and Meaningful Use will be incorporated
into MACRA
• IBM Watson Health:– Insight measures support some PQRS measures– Enables real-time assessment of quality performance
– Actionable data– Allows for tracking of patients with chronic conditions
– Better care, improved results– Implications for cost measures (preventable admissions)
Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)
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Introduction: MACRAMedicare Access & CHIP Reauthorization Act of 2015 (MACRA)• The future of payment adjustment systems, affecting 2019 payments• MACRA will retire, or “sunset”, SGR & current incentive programs,
and replace them with the following two new systems:• Merit-Based Incentive Payment System (MIPS)
• Eligible Professionals paid under MPFS• Alternative Payment Models (APMs)
• Must meet APM criteria• Will incorporate and modify existing measures• Will create new quality measures
Source #15
MACRA: Replacing the SGR
Source #15
Merit-Based Incentive Payment System (MIPS)
• New, quality-driven incentive system for physicians reimbursed under Medicare PFS, who are not in an APM
• Will incorporate existing programs within a new entity (MIPS):– Physician Quality Reporting System (PQRS)– Value-based Payment Modifier (VM)– Meaningful Use of certified EHR technology (MU)
• Projected to affect the 2019 payment period using 2017 data• Will utilize four performance categories:
– 1. Quality– 2. Resource Use– 3. Clinical Practice Improvement Activities– 4. Meaningful Use of certified EHR technology
Source #15
Alternative Payment Models (APMs)• Establishes incentive payments for Medicare PFS providers (“Eligible
Providers”) participating in different health care payment models, such as:– Accountable Care Organizations– Patient Centered Medical Homes– Bundled Payment Models
• “Lump-sum” incentive projected for 2019 - 2024– May change to higher annual payments beginning in 2026
Source #16
• Categories:– Category 1: Fee-for-Service, no link to quality– Category 2: Fee-for-Service, link to quality– Category 3: APMs built upon Fee-for-Service Architecture– Category 4: Population-Based Payment
Alternative Payment Models (APMs) Draft
Source #20
Measure Development Plan (MDP)• December 18, 2015: “CMS Quality Measure Development Plan
DRAFT” was made available• Draft plan for the development of quality measures
– Public comment: 1/1/2016 – 3/1/2016– Finalized: 5/1/2016, with annual updates
• Purpose:– Framework for future measure development– Prioritizes measure development for specialty providers– Builds upon existing quality measures– Requires public reporting on the Physician Compare website
• Measures will pertain to both MIPS and APMs
Source #16
DRAFT Measure Development Plan (MDP)
• Priority focus for MIPS measures:– Outcome measures– Specialty-specific measures
• High-priority domains1. Person and Caregiver-Centered Experience and Outcomes
– Focus on Patient Reported Outcome Measures (PROM)2. Communication and Care Coordination
– Including treatment with other providers3. Appropriate Use and Resource Use (implicit cost measures)
Source #16
Measure Development Timeline
Source #15
DRAFT Measure Development Plan (MDP)
• Public comments regarding Draft Measure Development Plan can be submitted Jan 1, 2016 – March 1, 2016:– On-line Submission Tool:
– https://www.surveymonkey.com/r/26NYQRB– MDP Dedicated Email Box:
– [email protected]– U.S. Postal Mail:
Attn: Eric Gilbertson, CMS MACRA TeamHealth Services Advisory Group, Inc.3133 East Camelback Road, Suite 240Phoenix, AZ 85016-4545
Source #16
MACRA Review
Source #15
So What?• Significant changes in current quality-incentivized programs coming• Upcoming period of rapid, new measure development that will:
– Follow trajectory of patients and populations with chronic conditions across care continuums
– Emphasize outcomes (patient-reported, global & population-based)– Utilize patient experience, care coordination, appropriate use– Promote multiple levels of accountability– Apply to multiple types of healthcare providers– Use EHR generated data as well as clinical data registries– Account for variety of payment models, align with private sector
reporting, multi-payer applicability– Stratify results by demographics for disparity screening– Utilize CMS Physician Compare
Source #15
Implications for Providers
• New Law: Physician payment under Medicare PFS is changing– VM 2017 payments, which were based on 2015 measure data (over!) – VM 2018 payments, with 2016 measures– MACRA payments starting in 2019
– Measures/details TBD – Only drafts currently available
• IBM Watson Health positioned to support the new payment incentives– Measures (quality and resource use)– Clinical practice improvement activities (PCMH)
Next Steps
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Next Steps• Ongoing updates
– Blog postings– Webinars
• 2016 TIMELINE– March 1, 2016: Comment Period ends for MDP Draft– May 1, 2016: MDP finalized and available– November 1, 2016: Final Rule on MIPS measures available
Questions
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THANK YOU!
The recording and handouts will be sent to you via email within 2 business days
Sources
• 1. Centers for Medicare & Medicaid Services. Medicare. Medicare FFS Physician Feedback Program/Value-Based Payment Modifier. Value-Based Payment Modifier. Page last Modified: 12/17/2015 11:58 AM. < https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html >
• 2. Centers for Medicare & Medicaid Services. Medicare. Medicare FFS Physician Feedback Program/Value-Based Payment Modifier. Value-Based Payment Modifier. CY 2017 Payment Adjustment - Physician Solo Practitioners and Physicians in Groups of 2 or more Eligible Professionals. Page last Modified: 12/17/2015 11:58 AM. < https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html >
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