mastering macra: a beginner’s guide to new reimbursement models
Post on 09-Jan-2017
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A Beginner’s Guide To New Reimbursement Models
ABOUT THE PRESENTER
Ken Edwards is a Senior Manager at CureMD, overseeing the implementationsof Meaningful Use, PQRS and Alternative Payment Models.Ken has led much of the company’s recent research on healthcare reforms,primary care clinic design and revenue cycle management.
AGENDA What is MACRA? And what happens to it under the Trump administration?
Quality Payment program, incentives and penalties
MIPS, APMs, Advanced APMs
What’s the right track for your practice?
Critical deadlines
Checklist of things to do to excel under this rule
What is MACRA?
MACRA is 2 years of work, signed into law in April 2015
Extends the Children’s Health Insurance Program (CHIP) for two more years
Requires Medicare to move away from SSN based Medicare ID numbers
Includes new funding for development and testing of performance measures
Enables new programs and requirements for data sharing
Establishes new federal advisory groups
Repeals the Sustainable Growth Rate (SGR) formula
Creates the Quality Payment Program (QPP)
What is MACRA?
All signs point to MACRA not changing very much, especially not in 2017
MACRA has broad support from all political parties
CMS has responded positively to concerns from physician associations and
has them on board
The healthcare industry is in agreement with the changes & has invested in
MACRA preparation
Possible rollback to sections of the Affordable Care Act (ACA)
MACRA is not tied to the ACA and should remain unaffected
What happens to it under the Trump administration?
Quality Payment Program
CMS’s vision: To improve quality, improve care efficiency, while reducing
the cost of care
CMS wants focus on the health of the population through better care
coordination among providers
Quality Payment Program [QPP] goes into effect on January 1st, 2017 for
providers who participate in Medicare Part B [some 600k providers are
affected]
The Quality Payment Program ends Meaningful Use, PQRS and Value Based
Modifier as distinct and separate programs under Medicare
Quality Payment Program
Two tracks for providers
1. Merit-Based Incentive Payment System (MIPS), which is where
90% of Medicare Part B providers will be in 2017
2. Advanced Alternative Payment Model (APMs), which is where
the MACRA legislation ultimately wants all providers to be [Medical Homes, Shared Savings, Bundled Payments]
The MIPS track is a short term training ground to learn how to successfully
adopt Advanced Payment Models
MIPS AND APM
Quality Payment ProgramMIPS AND APM
Quality Payment ProgramINCENTIVES & PENALTIES
The Quality Payment Program actually
recalibrates Medicare adjustments
Before we go further..
MACRA is the law that resulted in a new provider reimbursement model called the Quality Payment Program
The Quality Payment Program is mostly good news:
Meaningful Use + PQRS + VBM + ICD10 leads into QPP
Cost(0% of score)
Replaces Value
Based Modifier –
Applicable from
2018
Advancing
Care
Information(25% of score)
Replaces
Meaningful Use –
ensures effective
and meaningful
use of EMR
Quality(60% of score)
Replaces PQRS on
the quality of care
provided to the
patients
Improvement
Activities(15% of score)
New category –
focusing on care
coordination,
beneficiary
engagement, and
patient safety
Merit-based Incentive Payment System
90% of providers in 2017, which affects payments in 2019
Providers are scored on a scale from 0 – 100
There are 4 categories, and in 2017:
Exemptions:• Advanced APM• First year Medicare• Low volume [< 100
patients]• Low $$ [< $30k in
allowable]
Submit
Merit-based Incentive Payment System
TIMELINE
Performance YearFeedback
Available
2017 March 31, 2018 2018 January 1, 2019
Adjustment
Cost(0% of score)
Replaces Value
Based Modifier –
Applicable from
2018
Advancing
Care
Information(25% of score)
Replaces
Meaningful Use –
ensures effective
and meaningful
use of EMR
Quality(60% of score)
Replaces PQRS on
the quality of care
provided to the
patients
Improvement
Activities(15% of score)
New category –
focusing on care
coordination,
beneficiary
engagement, and
patient safety
Merit-based Incentive Payment System
90% of providers in 2017, which affects payments in 2019
Providers are scored on a scale from 0 – 100
There are 4 categories, and in 2017:
Exemptions:• Advanced APM• First year Medicare• Low volume [< 100
patients]• Low $$ [< $30k in
allowable]
Merit-based Incentive Payment System
PICK YOUR PACE
For 2017, the transition year, MIPS providers can choose to:
Submit no data [generally a bad idea, guaranteed 4% penalty]
Submit minimal data [no penalties]
Submit complete data for 90 days [chances of an incentive]
Submit complete date for the entire year [incentive]
Submission methods remain the same as before
Weightage changes yearly, Cost counts for more and more
Reduced requirements for hospital or non-patient facing clinicians,
rural practices, small practices [<15 physicians]
Merit-based Incentive Payment System
Top MIPS percentile in 2017, “high performer” bonus of 10%, derived from a
separate budget
Those scoring below a certain threshold, or those who don’t participate,
receive a negative 4% penalty, which will increases yearly
The incentives will come from the penalties collected from those who don’t
meet their MIPS performance threshold — MACRA legislation mandates that MIPS must be revenue-neutral
Your results get published on the Physician Compare website
Successfully Meaningful Use and PQRS providers should easily meet the
performance threshold for MIPS [those categories represent 85% of the
composite score for 2017]
of providers are using
certified EHR technology
Merit-based Incentive Payment System
MIPS Recap
Combines PQRS, Meaningful Use & Value Based Modifier with a new program
called Improvement Activities
Performance across 4 categories is combined to calculate a composite score,
results to be published online
Incentives for top performers come from penalties applied to lower performers
PQRS and MU are the biggest pieces in 2017, doing well in these categories is
paramount
Alternative Payment Models
A payment model that deviates from traditional fee-for-service [CMS has been running pilots]
Some variation of the MPFS or a new model all together
APMs require healthcare organizations to align themselves with the goal of taking better care of a population of patients
E.g. MSSP/ACO: Provide high-quality and low-cost care to a defined group of Medicare beneficiaries - Medicare will share the savings
Advanced Alternative Payment Models
Advanced APMs build on existing APMs and align with MIPS:
Requires participants to use certified EHR technology
Base APM payment on quality measures comparable to those in the MIPSquality performance category
The APM entity (1) bears more than nominal financial risk for monetary losses OR (2) is a Medical Home Model expanded under Center for Medicare & Medicaid Innovation authority (CMMI)
Providers in Advanced APMs avoid MIPS reporting requirements and get better incentives
Providers with at least 25% of their Medicare patients engaged in Advanced APMs receive a 5% bonus in addition to the potential bonuses available through the APM’s themselves
Advanced Alternative Payment Models
Advanced Alternative Payment Models
Medicare Shared Savings Program — Track 2
Medicare Shared Savings Program — Track 3
Next Generation ACO Model
Medicare Shared Savings Program — Track 1+
Comprehensive Primary Care Plus (CPC+)
Comprehensive ESRD Care Model (Large Dialysis Organization Arrangement)
Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
What’s the right track for your practice?
The Alternative Payment Models that are available in 2017 only apply to
about 10% of all physicians. For most physicians, APMs may not even be an
option
MIPS allows a transition from the existing PQRS, Meaningful Use, Value Based
Modifier world to something close to an Alternative Payment Model
The ‘pick you pace’ options make it easy to participate without a lot of risk
and providers get time to put new processes in place
If you believe you can excel at MIPS, in the short term, it makes better
financial sense
What’s the right track for your practice?
Checklist of things to do to excel under this rule
Educate yourself and understand what is happening; check out qpp.cms.gov for a great overview
Take a look at your QRUR Reports & understand where you stand based on
current MU and PQRS performance
Calculate financial impacts [both penalties and lost incentive revenue]
Talk to your MU/PQRS team to ensure that they’re up to speed and discuss
the resources they would need to succeed under QPP
Look at Physician Compare and see how you’re rated
$20million/year worth of assistance to small practices with MACRA has been
budgeted, reach out to participating entities
Critical Deadlines
Do your prep work
Start collecting data for the full year reporting option; you can
always fall back to a 90 day reporting period if you find that you
need to chop and change things
Start collecting data for the 90 day reporting option; if you want to be in the running for an incentive, this is the last day to get started
Closing Thoughts
The smart move would be to commit to MIPS for the entire year in 2017.
Determine your quality measures, get your systems in place and your staff
thinking in the right terms. Come 2018, you’ll have tested the waters, made
mistakes, and made corrections that will ensure future success
Doing the minimum (or do nothing at all hoping for an extension of the grace period) will result in significant disadvantages going forward. Other
practices will be better prepared by then and the stakes will be higher.
Based on a survey of more than 50% of health insurance payers in the
country (including Medicare and Medicaid)—25% of all payments to
providers are being made under Alternative Payment Models in 2016. That
number is projected to reach 50% by 2020. Commercial payers are onboard.
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