what you need to know about, acc governance, macra...

What you need to know about, ACC Governance, MACRA,

Accreditation, Prior Authorization and MOC

14th Ponte Vedra Beach CV Symposium 2017

Robert Shor MD, FACCPast Chair Board of Governors

Chair of the Membership Committee

• Governance Changes in the College Acquainting members with the new paradigm and authority matrix

• MACRA/QPP What does it mean for me? What do I need to do?

• Accreditation New Initiatives of the College and what it could mean to you

• Prior Authorization What do the surveys say? Efforts by the College to relieve the burden

• MOC Where we were, where we are, and where we hope to be

FACC/MACC

Associate Fellow

Int'l Associate

FIT

Resident/CVT Student

CV Team/AACC

CV Admin

ACC in 2000 (26,000 Members) ACC in 2016 (52,000+ Members)

Source (Right): Data compiled from 2015 Year End Official Member Count

ACC Governance changes:

1‐Moving from a larger to a smaller "more nimble and strategic" BOT.∙ The BOT will be responsible for setting strategic goals, but is to leave the implementation to the Board Committees.∙ 13 members by 2018 (currently 31)2‐Moving from representational to competency based BOT∙ The members are to be selected based on competencies to be defined.

ACC Governance Summary of Key Elements:

3‐Centralized authority and decentralized decision making.∙ Members who previously may have wanted to be on the BOT may prefer to be on a Committee where the decisions (under some supervision and feedback to the BOT) will be made.4‐Board positions are for 3 years, with possible 2nd term.5‐At least 6 face‐to face BOT meetings/year.6‐New Board Committee Structure

Centralized Authority Decentralized Decision Making

and

ACC Governance Summary of Key Elements:

3‐Centralized authority and decentralized decision making.∙ Members who previously may have wanted to be on the BOT may prefer to be on a Committee where the decisions (under some supervision and feedback to the BOT) will be made.4‐Board positions are for 3 years, with possible 2nd term.5‐At least 6 face‐to face BOT meetings/year.6‐New Board Committee Structure

Governance at Kohler, WIAugust 2015

The Board of Trustees approved 11 principles to guide governance transformation

BOT asked the Governance Task Force to bring an implementation plan back to the Board at its

December meeting for Board review.

ACC GovernanceSet of ACC/ACCF Governance Principles• I. Governance Function• 1. The Board is strategically oriented to support the Mission.• 2. Governance focus is on strategy and policy, and not on tactical, implementation or management issues.• 3. Governance shall operate on the principle of: centralize authority and decentralize decision making.• 4. The board must insure it is aware of the needs and challenges of all of the members of the College as it relates to the Mission, and has multiple mechanisms and avenues for membership voice to be heard at the board level.

ACC GovernanceII. Governance Structure• 5. Governance structure supports optimum governance function and efficiency, and so board size and other structural components shall be consistent with best practice evidence and thinking.• 6. The Board is the ultimate authority of the College. It appoints an Executive Committee which reports to and is controlled by the Board and has a new explicit charter of its role and authority• 7. The Board determines and maintains appropriate committees with clearly defined roles, functions, authority and accountability, and appoints the members of these committees.

ACC GovernanceII. Governance Structure• 8. A majority of the members of the Board shall be members of the College.• 9. The Board shall seek diversity in its membership including but not limited to: expertise; experience; gender; race; geographic location; and age.• 10. There shall be a competency‐based selection model for composition of the Board, and the committees of the board. • 11. Board members shall not concurrently serve as chairs or members of non‐standing committees of the College.

Implementing the Principles

• A reduction in Board size from 31 to 13 members between now and 2018

• The creation of six Board standing committees• Reduction in BOT officers to President, President-

Elect, Secretary and Treasurer• Leadership appointments made by a newly formed

Nominating Committee

Board Terms

Position # of Spots

Term Renewable or Non-Renewable

Trustee 7 3 years Renewable

President-Elect and President 2 2 years Non-renewable (become Trustee Emeritus upon completion of Presidential term)

BOG Chair Elect and BOG Chair

2 2 years Non-renewable(one year as Secretary)

Treasurer 1 3 years Non-renewable

Membership Chair 1 2 years Non-renewable13 total

2013: 5-Year Strategic Plan Launched

2014: Governance

Transformation Discussions

Began

2015: Governance

Transformation Plan and Principles Approved

2016-2018: Governance

Transformation Plan

Implementation Begins

2018 – 2023: Launch New

Strategic Plan and Reassess Governance

Along the Way

Implementing the ACC’s Governance Transformation

Two-Year Phased-in Approach Tied to Launch of Next Strategic

Plan

Time to Build the BenchTime to Listen

Time to Get it Right

Organizational Chart and Authority Matrix

• Board of Trustees• Board Standing Committees• Major Operating Committees• Committees and Councils

New Governance Structure Org Chart

• Board of Trustees• Board Standing Committees• Major Operating Committees• Committees and Councils

Board Membership CommitteeComposition

Chair (Nominated position, recent past BOG Chair would be highly qualified)

– BOG Chair + Chair-Elect – AIG Chair + Chair-Elect – SSC Chair + Chair-Elect – CVT Chair + Chair-Elect – FIT Chair + Chair-Elect – Early Career Chair + Chair-Elect – Credentialing Chair

2016 – 2018 Goals and Strategic Initiatives

• Growing the Professional Home: More Mission, More Members– Recruitment and Retention of Member Segments, across

career span

• Enhancing Member Engagement and Collaboration– Accessible and current member data– Promote Section, Chapter and Committee collaborations to

address the professional and clinical needs

2016 – 2018 Goals and Strategic Initiatives

• Enhanced Member Voice and Value– Relevant and timely member communications to engaged and

vulnerable ACC members

• Bench Building and Professional Education– Life long professional Education for all ACC

members/member segments – Mentoring Platform – Leadership Development for ACC members who seek to get

involved

Why should we bother with MACRA, and AAPM’s (approved alternate payment models)?

• MACRA-The train has left the station!

• MACRA is NOT the ACA!

MACRA Impact on Health Care Delivery Will be Profound

MACRA Readiness

What Did MACRA Do? • Repealed the flawed

Sustainable Growth Rate (SGR)

• Established framework for moving Medicare from a VOLUME to a VALUE-BASED system

Background: Creation of the SGR

• The sustainable growth rate (SGR) was created by theBalanced Budget Act of 1997 as a means to controlMedicare spending by tying Medicare clinician payments toincreases in the gross domestic product (GDP).

• When health spending outpaced GDP, negative paymentupdates were threatened as a result.

• Due to the inability to find sufficient offsets, the SGR wasunable to be repealed for nearly two decades.

Congress passed 17 patches to avoid cuts (implementing cuts twice)

Elimination of the SGR

• Early 2014: Congressional leaders from the House andSenate, in close collaboration with the physician community,drafted legislation which would repeal the SGR and rewardphysicians for the value of the services they provided.

• Spring 2015: Speaker of the House John Boehner andMinority Leader Pelosi struck a deal on the offsets and theMedicare and CHIP Reauthorization Act of 2015 (MACRA) wasborn.

Virtually the entire House of Representatives united to pass MACRA, followed by the Senate.

President Obama signed the now-law on April 16, 2015.

• Broadly Written Directions to by implemented CMS and other agencies

What About the Details of the Law?

• CMS released first proposed regulations in April 2016 – The ACC submitted comments

• Repeal not likely‐this is NOT the ACA

Changing the Payment Landscape

Pre-MACRA

•21% payment cut in 2015, continued uncertainty

•Separate quality reporting programs

•Incentives for alternative payment model participation mainly from model design

Post-MACRA

•Eliminates SGR; implements stable payment increases

•Streamlined quality reporting program

•Incentives for alternative payment model participation built into payment system

Annual Payment Updates

Mid 2015-2019• 0.5% annual

payment update• Introduction of

Merit-Based Incentive Payment System starting Jan 2019

2020-2025• 0% annual

payment update

2026 and After• 0.75%: Alternative

Payment Model participants

• 0.25%: All other professionals

Averted a 21% payment cut in 2015 and future uncertainty

Proposed Rule

• 962-page rule released by CMS on April 27, 2016, subsequent final rule.

• Proposed policies implementing the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) participation

• Includes CMS responses to RFI comments and proposed policies and measures for the 2017 performance period (2019 payment)

It is a New DawnLearn: Make sure you or someone in your practice/system understands what is coming AND what you are already doing.

Educate: Your practice leadership &/or system Leadership. All must be rowing in the same direction.

Prepare: Understand your gaps, what you are going to measure and the information you are going to collect in the future

Proceed: Likely MIPS-decide what you are going to do in each category.

Stay informed: of changes by CMS. Your ACC continues to work on your behalf.

It is a New DawnLearn: Make sure you or someone in your practice/system understands what is coming AND what you are already doing.

Who are the people responsible? Don’t all need to be “chiefs”, it’s alright to be an “Indian” Educate: Your practice leadership &/or system Leadership. All must be rowing in the same direction.

What is being done in your system. Currently we are doing MIPS as an independent practice(PSA). Potential integration changes our reality and so we need to know what the System is doing.Prepare: Understand your gaps, what you are going to measure and the information you are going to collect in the future.

It is a New DawnProceed: Likely MIPS-decide what you are going to do in each category.

Begin to measure and identify where you fall short to correct by 2017. We are also exploring an APM as part of a CMMI grant proposal.

Stay informed: of changes by CMS. Your ACC continues to work on your behalf.

Bundles and other changes may yet again through a “Monkey wrench” in our plans. Bundles have been delayed. We were not included in the MSAs for the Bundles or the Rehab initiative. Were you included in the area doing Bundles?

Proposed Participation PathwaysMerit-Based Incentive

Payment System

Likely default pathway for most clinicians starting in 2019

MIPS adjustments(+/-4% in 2019)

MIPS APMParticipation

Participation in a MIPS APM or participation in an advanced

APM below the required threshold

APM-specific adjustments+

MIPS adjustments(+/-4% in 2019)

Advanced APM Participation

Based on a threshold of revenue/patients treated under the model (≥25% of

Medicare in 2019)

APM-specific adjustments+

5% lump sum bonus(2019-2024)

I. Merit-Based Incentive Payment SystemM

IPS

Quality (PQRS)

Advancing Care Information (EHR

Incentive)

Resource Use (Value Modifier)

Clinical Practice Improvement

• Individual programs continue through 2018

• MIPS begins in 2019 for physicians and most mid-level clinicians– 2017 performance year

• Eligible professionals scored against benchmark based on prior year’s performance

• Low-volume providers and some APM participants may be exempt from MIPS requirements

II. Advanced Alternative Payment Model

• Comprehensive ESRD Care Model• Comprehensive Primary Care Plus• Medicare Shared Savings Program –

Track 2• Medicare Shared Savings Program –

Track 3• Next Generation ACO Model• Oncology Care Model Two-Sided

Risk Arrangement (2018)• More to be identified…

2019 Payment Year

25% of Medicare Payments

Or20% of Medicare

Patients

Exempt from MIPS

5% lump sum bonus base on prior

year’s Part B payments

(2019-2024)

Entity is an Advanced APM…Clinician meets threshold

under the APM…

Clinician is a Qualifying Participant

Summary: MACRA Payment Adjustments

Potential for higher MIPS

bonuses based on budget-

neutrality factor and exceptional

performance

MIPS penalties are capped at 9% starting in 2022. Under the current programs, clinicians would have seen maximum penalties of 11% or more.

Most will be subject to MIPS in 2019

• 29,176 cardiology clinicians• 5,488 exempt from MIPS

– First year, low-volume, Advanced APM

• MIPS APM participants may have different scoring thresholds

https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/Value‐Based‐Programs/MACRA‐MIPS‐and‐APMs/Quality‐Payment‐Program‐MACRA‐NPRM‐Slides.pdf

Fundamentals:Overall Reimbursement Timetable

CY 2019 and beyond CMS will distribute negative and positive MIPS Part B payment adjustments on a budget neutral basis.

CY 2019 – CY 2024 $500 million available annually for “additional” Part B positive payment adjustments for "exceptional" MIPS “final scores“ (no budget neutrality requirement for these “additional” adjustments)

CY 2019 – CY 2024 Lump sum payment = 5 percent of prior year’s Part B approved claims, available annually for a "Qualifying APM professional" ("QP"). No MIPS payment adjustment.

CY 2026 and beyond QPs receive 0.75 percent physician fee schedule increase.

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Fundamentals (cont d): “MIPS Eligible Clinician”

• CMS computes a MIPS “final score” for every "MIPS eligible clinician" – MIPS eligible clinicians (for 2017):

• There are exceptions.

Physicians Physician assistants

Nurse practitioners

Clinical nurse

specialists CRNAs

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Clinicians PercentEligible Clinicians 1,400,000 100% Excluded via MACRA Definition (200,000) 14% Low Medicare Volume Providers (380,000) 27%Eligible for MACRA 820,000

Qualifying Participant in an AAPM (120,000) 15%Total MIPS Clinicians 700,000 85%

Fundamentals (cont’d):“MIPS final score”

• A MIPS “final score” is comprised of a MEC’s performance on up to 4 MIPS performance categories:

• But not all 4 performance categories will be scored for 2017.

Quality Cost Advancing

Care Information

Improvement Activities

MIPS Eligible Clinician

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MIPS Performance Category Weights for CPSs for the 2017

Performance Period

Individual MIPS Eligible Clinicians

("MECs") in Physician Groups Not Participating in a MIPS APM*

MECs in Physician Groups Participating in a Medicare Shared

Savings ACO

MECs in Physician Groups Participating in a Next Generation

Model ACO

MECs in Physician Groups Participating in "Other" MIPS

APMs

Quality 60% 50% 50% 0%

Cost 0% 0% 0% 0%

Advancing Care Information 25% 30% 30% 75%

Improvement Activity 15% 20% 20% 25%

*MIPS APMs: (1) Medicare Shared Savings Program; (2) Next Generation ACO Model; (3) Oncology Care Model; (4) Comprehensive Primary Care Plus Program; and (5) Comprehensive ESRD Program. 54

Quality50%

Advancing Care Information

25%

Quality• Most PQRS measures• QCDR measures• “High-priority measures”

– Outcome, appropriate use, patient safety, efficiency, patient experience, care coordination

MIPS Composite, 2019

Resource Use• Value-Based Modifier Cost measures• Condition and procedure-specific

episode groups

Clinical Practice Improvement• Expanded Practice Access• Population Management• Care Coordination• Beneficiary Engagement• Patient Safety • Practice Assessment (ex. MOC)• Patient-Centered Medical Home or specialty APM

Advancing Care Information• Protecting Patient Health Information• E-prescribing• Patient electronic access• Coordination of care through patient

engagement• Health Information Exchange• Public Health and Clinical Data

Registry Reporting

CV Specific Measureso Prescribe ACE inhibitor or ARB therapy and beta-blocker therapy for

patients with left ventricular systolic dysfunction (LVSD) o Prescribe antiplatelet and beta-blocker therapy for patients with

coronary artery disease (CAD) o Discuss and provide a care plan o Provide BMI screening and follow up o Document current medications o Use aspirin or other antiplatelet agent to treat ischemic vascular

disease o Control high blood pressure o Screen for high blood pressure and provide follow up o Avoid inappropriate cardiac stress imaging in patients with low

preoperative risk o Avoid inappropriate cardiac stress imaging in asymptomatic, low-risk

patients o Avoid inappropriate, routine cardiac stress imaging after PCI o Prescribe anticoagulation therapy to treat atrial fibrillation and atrial

flutter o Screen for hypertension and follow up o Transmit specialist reports o Screen for tobacco use and provide cessation intervention o Prescribe statin therapy to prevent and treat cardiovascular disease

Quality (60%)Assess the value of care to ensure patients

get the right care at the right time(60 points)

Quality



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Quality: 60%• 6 measures, including 1 cross-cutting and 1 outcome or high-priority

measure, or a specialty-specific measure set– Plus claims-based population measures

• Acute and chronic condition composites, all-cause readmission• Most PQRS measures will carry over into 2017• Recognition of “non-MIPS” QCDR measures

– Exempt from MUC and peer-reviewed journal processes• Measures scored 0-10 points based on benchmark, then averaged

Base measuresoConduct security risk analysis oePrescribe oProvide patient electronic access oSend a summary of care oReceive/accept a summary of care

Advancing Care Info(25%)

Support the secure exchange and the use of certified electronic health record technology

(5 required measures)

Quality



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Improvement Activities(15%)

Support Care Coordination patient engagement, patient safety, population management,

and health equity(40 points, high & medium weights)

Quality



Attest to 4 measureso Provide 24/7 access to clinicians/groups who

have real-time access to patient’s medical record o Participate in systematic anticoagulation program o Implement anticoagulant management

improvements o Use Qualified Clinical Data Registry (QCDR) for

feedback reports that incorporate population health

o Participate in Transforming Clinical Practice Initiative (TCPI)

o Collect and follow up on patient experience and satisfaction data

o Engage new Medicaid patients and follow-up 59

$Cost (0% year 1)

Helps create efficiencies in Medicare spending

Quality



Reprieve in Year 1o No reporting requirement in 2017

(measures are calculated based on Medicare claims data but will not be used to determine your payment adjustment in the first payment year 2019 of the program)

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Cost data found on your QRUR; use this year to get prepared!

Challenges Ahead, Engagement Necessary

• Early years of implementation will post challenges to those accustomed to the current system– Those already familiar with the current Medicare programs

(PQRS, EHR Incentive, Value Modifier) will be best prepared

• ACC working with HHS and CMS to minimize these challenges to support evidence-based, cost-effective, high quality care.

What can you do now to prepare? Ensure that you are currently successful in the existing

programs – PQRS, Meaningful Use, Value Modifier Find out if you are participating in an alternative payment

model Work with your administrator to find and understand your cost

and quality data Understand cost and episodes of care Make care coordination an organizational priority Focus on proper documentation Watch acc.org/macra for updates

Recognizing NCDR Participation

• NCDR registries as a way to meet reporting requirements under three MIPS components:– Quality– Advancing care information– Clinical practice improvement

activities

• ACC staff is working towards creating specific NCDR Registry-based solutions to the performance Improvement participation requirement.

There Will Be Opportunities for ACC to Provide Input Into How the Law Will

Function

MACRA

More information is available on the ACC’s online MACRA hub at

www.ACC.org/MACRA

Updates are provided via the hub and through the ACC’s Advocate

newsletter.

&

Cathie Biga, RN, President & CEO, Cardiovascular Management of [email protected]

Joel Sauer, Vice President, MedAxiom [email protected]

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ADVANCING CARE COORDINATION THROUGH EPISODE PAYMENT MODELS (EPMS) AND CARDIAC REHABILITATION INCENTIVE MODEL

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EPMs (Episode Payment Models)• Cape Coral-Ft Meyers• Crestview-Ft Walton Beach-

Destin• Lakeland-Winter Haven• Palm Bay-Melbourne-Titusville*• Pensacola-Ferry Pass-Brent*• Port St Lucie*• Sebring

*Rehab

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Episode Payment Models (i.e. Cardiac Bundles)

Final Rule published December 20, 2016

Impacts 98 MSAs nationally

Effective Oct 1, 2017 (tentatively), and runs for 5 performance years

90 Day bundles for AMI and CABG

https://innovation.cms.gov/initiatives/epm

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Episode begins with inpatient admission to a participating hospital

providing care for:AMI• MS-DRGs 280-282• MS-DRGS 246-251 with AMI as a

principal or secondary diagnosis

CABG• MS-DRGs 231-236

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Inclusions & exclusionsIn

• Physicians' services• Inpatient hospitalization(including

readmissions)• Inpatient Psychiatric Facility (IPF)• Long-term care hospital (LTCH)• Inpatient rehabilitation facility (IRF)• Skilled nursing facility (SNF)• Home health agency (HHA)• Hospital outpatient services• Independent outpatient therapy• Clinical laboratory• Durable medical equipment (DME)• Part B drugs• Hospice

Out• Services unrelated to the hospital• Hospital readmissions that group to the following

categories of MS-DRGs- Oncology- Trauma medical admissions- Surgery for a chronic or acute condition

unrelated to the EPMs• New technology add-on payments, both for

hospital inpatient and outpatient• Hemophilia clotting factors

AMI Quality Metrics

• Required Hospital 30 day, all cause

mortality, risk standardized mortality rate

Excess days in Acute Care after AMI hospitalization – examples are days in ED observation and readmissions

• Voluntary Hybrid 30-day AMI Mortality

Measure % WeightMaximum

Points

MORT-30-AMI 50% 10

AMI Excess Days 20% 4

Hybrid AMI Mortality

10% 2

HCAHPS Survey 20% 4

TOTAL 100% 20

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AMI hybrid metrics – voluntary

30 day, all cause, risk standardized mortality rate

6 – EHR Linked Elements

• CMS certification number

• Medicare health insurance claim

• Number (HIC)

• Date of Birth

• Sex

• Admission date

• Discharge Date

5 Core Clinical Elements

• Age – at admission

• Heart rate – 2 hours

• Systolic blood pressure – 2 hours

• Troponin – 24 hours

• Creatinine – 24 hours

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• EPM Participant • Cannot limit or restrict access

of care• Must notify the patient they are

in an EPM• May provide some incentives to

patient during the episode• Must maintain appropriate

records

• Financial relationships are only those permitted by law

• EPM Participants can share Reconciliation Payments and Repayment Amounts

• Must be substantially based on quality metrics and the provision of EMP activities, but not on volume of referrals

Beneficiary Protection Financial Relationships with EPM Collaborators

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“Incident To” Rule

• Patients can receive post-discharge visits by licensed clinical staff if they do not qualify for home health visits

• AMI – 13 visits• CABG – 9 visits • New G code

(G9863) to report these visits

• Waive 3 day rule for episodes that occur on/after Oct 4, 2018 to a qualified SNF

• Qualified SNF – 3 or more stars on Nursing Home Compare website

• Waived geographic and originating site requirements for any allowable telehealth services

• CMS did not change the services that are eligible under telehealth

• 9 new G codes to describe services

• Waive the definition of physician to include non-physician practitioners to perform supervisory physician functions

SNF 3 Day Rule TelehealthCardiac

Rehabilitation Services

Waivers to Medicare program requirements

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• Clinical literature shows a clear benefit of CR services for AMI and CABG patients; • CMS claim data shows these services are under-utilized

CR Incentive Payment Model will be tested in EPMs and in FFS• 45 of the 98 MSAs that are in EPMs• 45 MSAs not in EPMs, but were in the EPM eligible pool

Two levels of payment• Regular FFS payment• Incentive PaymentIncentive Payment• $25 for each of the first 11 CR services provided• $175 for each service after

• Incentive Payments provided annually (not on a per-service basis)• Cannot share CR incentive payments with any collaborators

May provide transportation services to patients during the episode

Cardiac Rehabilitation (CR) Incentive Payment Model

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So with all this, what are organizations doing to prepare?!?

Eliminate “bad” variability

24

ACC’s Health System Strategy and Accreditation

Critical need:

To provide hospitals, health systems and other facilities with an integrated, holistic approach to quality improvement across the cardiovascular care spectrum. Bending the quality cost curves in the new world of Population Health Management.

Building On Our Collective Strengths:

Accreditation Services

Registry Services

Quality Initiatives

Education

Given the Changing Environment + Focus on Volume Value…

A Solid Health System Strategy is Essential to ACC’s Mission

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