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.