the value modifier & medicare access and chip ......medicare access & chip reauthorization...

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


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


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.


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.


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


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


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)


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


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


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 >

• 3. Centers for Medicare & Medicaid Services. Overview of the 2017 Value-Based Payment Modifier. PowerpointPresentation. <https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/VMP/2017-Value-Modifier-PowerPoint.PPTX >

• 4. Centers for Medicare & Medicaid Services. 2015 Physician Quality Reporting System (PQRS): Understanding 2017 Medicare Quality Program Payment Adjustments. October 2015. PDF. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Understanding2017MedicarePayAdjs.pdf

• 5. Centers for Medicare & Medicare Services. 2014 Physician Quality Reporting System (PQRS) List of Eligible Professionals. March 2, 2015. PDF. < https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/pqrs_list-of-eligibleprofessionals_022813.pdf >

Sources

• 6. Centers for Medicare & Medicaid Services. 2014 Measures Information About the Acute and Chronic Ambulatory Care-Sensitive Condition Composite Measures, Calculated for the Value-Based Payment Modifier Program.September 2015. PDF. < https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2014-ACSC-MIF.pdf >

• 7. Centers for Medicare & Medicaid Services. Action for Physician Groups with 2 or More Eligible Professionals and Physician Solo Practitioners to Take In Order To Earn an Incentive Based on Performance and Avoid the Automatic CY2017 Downward Payment Adjustment under the Value-Based Payment Modifier. < https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/What-To-Do-In-2015-For-The-2017-VM.pdf >

• 8. Centers for Medicare & Medicaid Services. Physician Quality Reporting System. Payment Adjustment Information. Payment Adjustment Information. Website. Page last modified: 11/24/2015 3:45PM. Downloaded 12/29/2015 10:26 AM. <https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html>

• 9. Centers for Medicare & Medicaid Services. 2015 Physician Quality Reporting System (PQRS): Implementation Guide. 1/15/2015, most recent revision date of 10/02/2015. PDF. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf

• 10. Centers for Medicare & Medicaid Services. Computation of the 2016 Value Modifier. September 2015. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-VM-Fact-Sheet.pdf

Sources

• 11. Centers for Medicare & Medicaid Services. 2014 Measure Information about the Per Capita Costs for All Attributed Beneficiaries Measure, Calculated for the Value-Based Payment Modifier Program. April 2015. <https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2014-MIF-TPCC.pdf>

• 12. Centers for Medicare & Medicaid Services. 2014 Measure Information about the Four per Capita Cost for Beneficiaries with Specific Conditions Measures, Calculated for the Value-based Payment Modifier Program. April 2015. Website PDF. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2014-MIF-CSTPCC.PDF

• 13. Centers for Medicare & Medicaid Services. 2014 Measure Information about the Medicare Spending Per Beneficiary, Calculated for the Value-Based Payment Modifier Program. April 2015. Website PDF. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2014-MIF-MSPB-TIN-2015-May.pdf

• 14. Centers for Medicare & Medicaid Services. Computation of the 2016 Value Modifier. September 2015. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-VM-Fact-Sheet.pdf

• 15. Centers for Medicare & Medicaid Services. CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) (DRAFT). PDF. December 18, 2015. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Draft-CMS-Quality-Measure-Development-Plan-MDP.pdf

Sources

• 16. Centers for Medicare & Medicaid Services. Medicare. Value-Based Programs. MACRA MIPS & APMs. MACRA: MIPS & APMs. Website. No publish date available. Date accessed: 12/20/2015. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

• 17. Centers for Medicare & Medicaid Services. Estimated Sustainable Growth Rate and Conversion Factor, for Medicare Payments to Physicians in 2015. Baltimore, MD: Centers for Medicare & Medicaid Services; 2014. https://www.cms.gov/medicare/medicare-fee-for-service-payment/sustainablegratesconfact/downloads/sgr2015p.pdf

• 18. Centers for Medicare & Medicaid Services. Quality Measures. Quality Measures. Website. Page last Modified 04/17/2015. Downloaded 12/20/2015. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html?redirect=/QUALITYMEASURES/

• 19. Centers for Medicare & Medicaid Services (CMS) Daily Digest Bulletin. New Guidance for EPs Reporting the Diabetes: Hemoglobin A1c (CMS122v3) Measure for Program Year 2015. Email. Sent 01/01/2016 11:37 AM from Centers for Medicare & Medicaid Services. Received 01/04/2016 08:12 AM.

• 20. Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group. Alternative Payment Model (APM) Framework: Draft White Paper. For Public release. Version Date: 10/22/2015.

• 21. Centers for Medicare & Medicaid Services & The Medicare Learning Network. “The Medicare Quality Reporting Programs: What Eligible Professionals Need to Know in 2016.” Presented Webinar 2/10/2016. PDF.

the value modifier & medicare access and chip ......medicare access & chip reauthorization...

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