macra, mips, and apms - vitl · day 2: track 3 – measuring care, quality and outcomes with data...

Day 2: Track 3 – Measuring Care, Quality and Outcomes with Data

MACRA, MIPS, and APMs

Kate McIntosh MD FAAPMedical Director VITL

VITL Summit 2016


Initial Questions

• How many of you have heard of MACRA , MIPS, or APMs?

• How many of you have a working knowledge of MACRA and have developed a readiness plan?

• How many of you are hoping that it just goes away?


What is MACRA?

• MACRA is the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015.

o Ends the Sustainable Growth Rate formula for determining Medicare payments

o Changes payment to a value and quality based system

o Combines multiple existing federal programs in to a single program

o Has two arms: MIPS (Merit-based Incentive Payment System) AAPMs (Advanced Alternative Payment Models)

• CMS will issue the final rule in November


Agenda

• Give you a working understanding of MACRA, MIPS, and APMs

• Give you a road map for how to start thinking about these programs


Learning Objectives

• Understand the difference between the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)

• Understand how to make a roadmap to prepare for MIPS or an advanced APM.


Source: Neal Halfon: UCLA Center for Healthier Children, Families, and Communities


What happens with Medicare Part B payment?

2015-2018

• 0.5% annual payment increase

2019-2024

• 0% annual payment increase

• Introduction of MIPS

• Introduction of APM

2025+

• Strong push to APMs

• Goal is 75% participation in APM Models


Between now and the end of 2018

• Existing programs continueo PCMHo PQRSo Value Modifiero Meaningful Use

• BUT- you will be judged on the quality of your data and your patient management.


The Arms of MACRA

Merit Based Incentive Payment System (MIPS)

MIPS Alternative Payment Model (APM)

Advanced APM


The general consensus

• Everyone has to be prepared for MIPS, even if they plan to participate in an advanced APM. o MIPS is the minimum requiremento Not all APMs will end up being Advanced APMso All Payer Waiver doesn’t exempt everyone from MIPS o 2017 is the first evaluation year for MIPS with payment adjustments in

2019.o It is very unlikely that any change in politics at the federal level is going to

change MIPS at this time.

• Medicaid at-risk plans like AAPMs are coming and are also probably the way of the future.

• At risk commercial plans are also coming.


Merit Based Incentive Payment System (MIPS)

• This system combines three things: Physician Quality Reporting System Value modifier (or Value-based Payment Modifier) Meaningful use (EHR Incentive Program)

• These are combined into one single program based on quality, resource use, clinical practice improvement, and meaningful use of EHR technology


Scoring of MIPS

Source: Impact-Advisors.com

Each is scored and the aggregate scoring is 100 points


How Performance affects PaymentPerformance Year Payment Year Adjustment +/- Maximum

2017 2019 4% 12%

2018 2020 5% 15%

2019 2021 7% 21%

2020 2022 9% 27%

• Payment is relative to scoring and therefore participants have risk

• Budget neutral- there will be winners and losers• Since you are scored relative to your peers, to get beyond 1 or 2

standard deviations will take a lot of work. • Benchmarks are set based on prior year performance so the

pressure to improve continues


Performance Threshold

Zero Adjustment

NegativeAdjustment

Positive Adjustment

Maximum PaymentReduction Additional positive

Adjustment factor


Quality Reporting

• Minimum of six measures

• At least one cross-cutting measure for patient-facing providers

• One outcome measure if available

• If no outcome measure is available, can use a high priority measure (appropriate use, patient safety, efficiency, patient experience, care coordination measure).


Resource Use, CPIA, and Meaningful Use

• Resource Useo Total per costs capita for attributed beneficiarieso Medicare Spending per Beneficiaries

• Clinical Practice Improvement Activityo Patient Centered Medical Home or Patient Centered Specialty Practice

qualifies fully. o Emphasis on

Practice Access Population Management Care Coordination Patient Engagement.

• Advancing Care Information= Meaningful Use


APM terminology

• APM (Advanced Payment Model)o Model itself

• APM Entity o An organization that participates in an APM through a direct agreement

with CMS or other non-Medicare payer. o APM Entities may be Accountable Care Organizations, Health Systems,

Practice Associations, or other organized groups and they can participate in: Advanced APM Shared Savings Program MIPS APM Next Gen APM Other MIPS APM


What is an Advanced APM?• 50% of participants are required to use CEHRT. • The Advanced APM must bear more than a “nominal” amount

of financial risk OR be Medical Home Model that has been expanded under Section 1115A of the Social Security Act

• Can be either:o A Medicare Medical Home Payment Modelo A Combination All Payer and Medicare Modelo An Other Payer Alternative Payment Model

• Performance-based pay• Revenue and patient thresholds that increase over time • 5% bonus from 2019-2024 then higher updates. • CMS goal is to push providers into AAPM models.


MACRA readiness- first steps

• Begin to think about medical care in completely different way• Know your data• Be honest with yourselves• Create internal expertise• Partner, partner, partner


Begin to think about medical care differently

• Start thinking about Quality for a focused number of conditions

• Start with measures that you already do well

• Think beyond fee-for-service and ask how you can provide the highest quality using your care team

• Where do you have flexibility?

• Who is qualified to provide a service to a patient?

• How do you increase patient buy-in and personal engagement?


Know your data- data matters a lot

• Know who is in your “attribution”.

• Know how different metrics are being collected by your reporting agency, whether that is your EHR or an external source.

• Understand how direct documentation in the chart is affecting your numbers. How do you increase accuracy?

• Push for transparency and actionable information in internal and external reports.

• Push toward the most reliable and highest quality data both internally and externally.


Be honest with yourselves and get involved

• Create a culture of introspection and improvement• Data is not judgment, but it is important and will eventually be a

paycheck. • If you are not participating in incentive programs, you have to

start. o https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/How_to_Get_Started.html

• Know your numberso Get a Quality and Resource Use Report from Medicare:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html

o Look at other comparison sites: http://www.whynotthebest.org https://www.medicare.gov/hospitalcompare/search.html https://www.medicare.gov/physiciancompare/search.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_to_Get_Started.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html

http://www.whynotthebest.org

https://www.medicare.gov/hospitalcompare/search.html

https://www.medicare.gov/physiciancompare/search.html


Create internal expertise

• Understand how the changes that are coming will impact your practice.

• Customize your EHR as much as possible to streamline burdensome documentation guidelines.

• Try to cut clicks as much as possible.

• Be innovative if possible to give more time for clinical care.

• Look for care variations in your practices and streamline

• Perform a security risk analysis early in 2017.


Partner, Partner, Partner

• Care coordination, telemedicine, referral tracking, and patient satisfaction are a few parts of MACRA and the push to Advanced APMs

• Look through the whole care-continuum for places to improve care and utilizationo Readmission rateso Non-compliant patientso Socio-economic or housing issues that may be affecting your highest-cost

patients. UVM and Community Health Centers of Burlington partnered with

the Champlain Housing Trust and the Vermont Community Foundation to find housing for 95 patient with chronic homelessness and documented a savings of almost $1M in health care costs, along with a 42% reduction in ED visits and 68% fewer inpatient admissions.


MACRA latest update• In response to feedback, CMS has modified the original roll-out

of MACRA to a “Pick Your Pace” approach:

o Test the Quality Payment Program: submit some data in 2017 and there will not be a negative payment adjustment in 2019.

o Participate for part the calendar year 2017 and and possibly get a small positive payment adjustment in 2019.

o Participate for the whole calendar year 2017 and possibly qualify for a modest positive payment adjustment in 2019.

o Participate in an Advanced Alternative Payment Model in 2017 and possibly qualify for a 5% incentive payment in 2019.

• Final details on data requirements will be part of the final rule


VITL’s role in MACRA and the All Payer Model

• There will be an increasing need for high quality data from a wide variety of health care organizations and sources.

• The All Payer Model may require VITL to supply additional, or different, data from MACRA’s requirements.

• Multiple groups and organizations will need data for reporting on value and quality.

• Data reports will need to be provided to a variety of organizations at both the state and federal levels.


The Brave New World of Preventive Care and Value Based Payment

• If you don’t put a code on it, you won’t get credit for it.• For example, in Peds: well child codes:

o Z00.129 Well Child without abnormal findingso Z00.121 Well Child with abnormal findings

• If a person has any chronic diagnoses at all, use the “with abnormal findings” diagnosis.

• If a chronic diagnosis isn’t listed once in a calendar year, the “system” forgets it.

• Document the complexity of your patients so you get credit for the complexity of your thought processes and care.

macra, mips, and apms - vitl · day 2: track 3 – measuring care, quality and outcomes with data...

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