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©2016 Premier Inc. Proprietary and confidential
Preparing for the Implications of MACRA
Bryan Bowles, MBA Vice President, Population Health Premier, Inc.
WVHFMA Fall Education Seminar
September 2016
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Increasing Payment Risk
Expanded Measurement
New Payment Models
Changing Care
Model
Cross- Continuum
Performance
Provider Integration
Value as the New Economy
MARKET IMPACT
MARKET PRESSURES
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TRA
CK
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Physicians & Other
Providers
Outpatient
Hospitals Hospitals
Long-Term Care
Hospitals
Inpatient Rehab
Nursing Homes
Home Health
MACRA 2013 Pay for Reporting
2012 Pay for Performance
2014 Pay for Reporting
2016 Pay for Reporting
Test
2018 Pay for Performance
2016 Pay for Performance
Test
TRA
CK
2
ALTERNATIVE PAYMENT MODELS
ACCOUNTABLE CARE ORGANIZATIONS
ACUTE AND POST-ACUTE CARE EPISODE BUNDLING
POST-ACUTE CARE EPISODE BUNDLING
ACUTE CARE BUNDLING
MEDICAL HOME
TRADITIONAL PAYMENT MODELS
MEASURE ALIGNMENT
Value Based Payment Across Silos
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The MACRA legislation was passed by Congress and signed by the President in 2015 and CMS is in the process of codifying the regulations
Final regulations are expected November 2016 and the first
performance period beings January 1, 2017
Health systems are required to make decisions with less than perfect information
Premier has identified the key, available, information that
can guide health systems in the decision making process
MACRA passed with overwhelming bipartisan support. Provides new tools in implementing the payment reforms. Applies to expanded group of clinicians and creates clear timetable and benchmarks.
MACRA Background
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The Education Gap is Real and Time is Running Out
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Now is the time to evaluate a practical path forward and build a roadmap of the capabilities necessary to operate successfully in value based payment.
MACRA begins January 2017
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CMS is now offering a “Pick your Pace” plan for the first year of the Quality Payment Program to allow clinicians to choose their participation level while avoiding a negative adjustment
• Test Participating: Submit some data to avoid a negative payment adjustment
• Submit Partial Year Data: Receive a small positive payment adjustment
• Submit Full Calendar Year Data: Receive a modest positive payment adjustment
Evolving options for 1st year
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Am I in an APM?
NO
Is this my first year in Medicare or am I below the low volume threshold
Exempt from MPS Subject to MPS
NO YES
Am I in an ADVANCED APM?
NO
Do I meet the payment & patient volume thresholds?
Favorable MPS scoring & APM
specific rewards
YES
YES
YES
NO
Excluded from MPS 0% lump sum bonus payment (2013-2024) Higher fee schedule
updates (2024) APM Rewards
Favorable MPS scoring & APM
specific rewards
MACRA decision tree
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MACRA Decision Tree
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Greater growth & competition around APMs, which could provide opportunity or additional friction.
3
Pressure growing on FFS practitioners, with push toward track 2 & alternative payment models (APMs)
2
Increased physician employment or collaboration. 4
Physicians and other eligible providers will take notice! 1
Emphasis on registry reporting, data
transparency, and public disclosure.
7
Planning should begin now for 2019. 6
Details will require important policy decisions. 8
Hospitals have extensive measure submission, VBP and APM experience that will be of
value to practitioners. 5
Implications for Providers under MACRA
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The financial impact of the chosen path can impact up to 9% of reimbursements. Organizations must consider the operating infrastructure required.
Impact of MIPS on Employed Providers
Impact of MIPS Track + Cost of Upside ACO
Impact of integrating providers and care
TOTAL MIPS TRACK TOTAL NON-QUALIFIED APM TRACK
TOTAL QUALIFIED APM TRACK
Advanced Alternative
Payment Models
MIPS + Non-Qualified
APM Track
MIPS Track
What is the Right Model Now, and in the Future?
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Health systems which build qualified APMs may have some
employed clinicians remain in MIPS
Independent physicians, especially those in smaller practices,
face the greatest risk under MIPS and the greatest incentive to join an AAPM
MACRA & MIPS= incentive to move toward population
health; a carrot, not a stick
Value Modifier and PQRS performance scores for employers of large numbers of physicians appear
close to the mean
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MACRA Readiness – Early Observations
The APM bonus may not equal the total cost of
developing a two-sided risk ACO
The risk poised by MIPS is typically less than the risk inherent
in a two-sided ACO
more organizations to start an upside risk ACO (that do not qualify for an APM bonus)
than two sided risk models
On its face the CPC+ model appears compelling to some, however
more details are needed and the commercial payers’ interest level is unclear
MACRA appears to motivate
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Assessment of measure collection and reporting strategy
across the organization’s employed and independent
clinicians
MEASURE REPORTING
Provide a high level assessment of productivity and opportunity for
savings in the enterprises physician network
PRODUCTIVITY
Assess financial impact and best method to optimize revenue under MACRA
(MIPS, MIPS+APM, A-APM)
FINANCIAL IMPACT
Assess the optimal measure strategy and TIN structure under
current and future APM strategies
TIN AND MEASURE STRATEGY
MACRA Roadmap Inputs
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Merit Based Incentive Payment System (MIPS)
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Design your MIPS plan for 2017
50%
10%
15%
25% 45%
15%
15%
25%
2019 (+/- 4%)
30%
30% 15%
25%
Quality
Resource use
Advancing care information
Clinical practice improvement activities
2020 (+/- 5%)
2021 (+/- 7%)
Things to Know: • FFY2017 performance scenarios under MIPS and the variables that contribute to the
composite score.
• MIPS eligibility, reporting criteria, scoring and payment adjustments.
• Opportunities for eligible clinicians attributed to your TIN, characteristics of your patient population, and associated risk beneficiary scores.
• Specific measures utilized to derive your Quality composite score and identify opportunities to improve performance.
• Specific measures utilized to derive your Resource Use composite score and identify opportunities to improve performance.
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MIPS Readiness: Know the Score
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Practice Size
Eligible Clinicians
Physician Fee
Schedule Allowed Charges
(mil)
Percent Eligible
Clinicians with Negative Adjustment
Percent Eligible
Clinicians with Positive Adjustment
Aggregate Impact
Negative Adjustment
(mil)
Aggregate Impact
Positive Adjustment
(mil)
Solo 102,788 $12,458 87.0% 12.9% -$300 $1052-9 123,695 $18,697 69.9% 29.8% -$279 $295
10-24 81,207 $9,934 59.4% 40.3% -$101 $16425-99 147,976 $12,868 44.9% 54.5% -$95 $230100+ 305,676 $18.648 18.3% 81.3% -$57 $539
Overall 761,342 $72,606 45.5% 54.1% -$833 $1,333
MIPS Proposed Rule Estimated Impact on Total Allowed Charges by Practice Size
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• Unclear if new and low-volume exclusions apply for the Advanced APMs
Starting 2019
• Eligible Clinicians For Advanced APMs: • Physician, • Physician Assistants, • Nurse Practitioners, • Certified-Nurse Specialists, • Certified Registered Nurse Anesthetists • Physical or occupational therapist, • Speech-language pathologists, • Audiologists, • Nurse midwives, • Clinical social workers, • Clinical psychologists, • Dieticians, and • Nutritional professionals.
Eligible Clinician's in an Advanced APM Entity?
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Proposed Approved Advanced APM
Comprehensive ESRD Care (CEC) (LDO arrangement)
Comprehensive Primary Care Plus (CPC +)
Medicare Shared Savings Program tracks 2 & 3
Next Generation ACO Model and Oncology Care Model (OCM) two-sided risk arrangement
*conspicuously absent, CJR and BPCI
Advanced APMs – What’s In?
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For 2019-2020: • 25% of Medicare payments (Medicare Option) • NOTE: For each timeframe there is a lower patient count option
For 2021-2022: • 50% of Medicare payments (Medicare Option) or • 50% of total payments, and at least 25% of Medicare payments (All-
Payer Combination Option)
For 2023 and beyond: • 75% of Medicare payments (Medicare Option) or • 75% of total payments, and at least 25% of Medicare payments (All-
Payer Combination Option)
Medicare Advantage plans do not qualify as Medicare; they will be considered in the All-Payer Combination Option Total payments exclude payments made by the Secretaries of Defense/Veterans Affairs and Medicaid payments in states without medical home programs or Medicaid APMs.
Can you meet the threshold score?
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1. Simpler quality programs • Single scoring system • -4% in 2019 under MIPS vs. -9%+ under old system • Added CPIA and significantly altered ACI • Still have 5 ways to report measures
2. Stable payments • Don’t have threat of 30% cut any longer • Payments rates essentially frozen • Still have 2% sequestration cut • Hard to model new system to second guess +/- or APM bonus
3. Spur participation on APMs • Allow revenue test at Model level • Lower standard for risk in medical home • Very few proposed Advanced APMs • Maybe 13% eligible clinicians will get 5% bonus • Timing is tricky; don’t know if APM until after MIPS reporting
MACRA Goals Achieved?
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What are the biggest challenges for moving in to population health and value-based care?
• Financing the infrastructure for population health management
• Evolving the strategy for physician alignment
• Synchronization of measures across quality measures programs
• Preparation for bundled payments across multiple DRGs
• Integrated analytics (ambulatory +acute) for supporting alternative payment models
Challenges to overcome
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ANALYZE
Understand likely financial impact of new regulations?
Educated clinicians on the program?
Clear on MACRA rules and options?
Scorecards available for performance management?
IMPLEMENT
IMPROVE
DESIGN
Adopt & share industry best-practices?
Project and optimize for payment incentives?
Re-assess and develop long-term care delivery strategies?
Defined approach to care model redesign?
Clear approach to provider alignment?
Strategy to meet quality reporting requirements? Activated
systems to manage costs-to-performance?
Defined teams to deploy programs across the continuum?
Roadmap for Sustainable Success under MACRA
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Links to Important Resources
• Proposed rule • CMS press release • HHS blog on proposed rule • CMS blog • CMS fact sheets and other information on MACRA • Premier detailed summary • Premier's Flash Update
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Thank You. Questions?
Bryan Bowles Premier, Inc.
[email protected] 704.816.5233