macra: an overview and implications for your organization · mips: 2017 transitional performance...
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MACRA: An Overview and Implications for Your
Organization
Patrick J. Hurd, Esq.
March 30, 2017
VASHRM
MACRA: How Did We Get Here?
MACRA: How Did We Get Here?
Medicare Access and CHIP
Reauthorization Act of 2015
• Eliminates the Flawed SGR Payment System
• Consolidates 3 Existing Quality-Based Dr.
Payment Programs into MIPs
– Value Modifier (“VM”)
– Physician Quality Reporting System (“PQRS”)
– Meaningful Use (”MU”)
• Provides Incentives for APMs
MACRA Basics
MIPS
APMs
MACRA Basics
Merit Based Incentive Payment System
(“MIPS”)
• A modified fee-for-service model
• Retains some performance-based payments
• Adds performance improvement & innovation
component
• Greater flexibility and wider selection of quality
measures
Quality Reporting
(was PQRS)
Advancing Care Information (was MU)
Cost (was Value-based
Modifier)
Improvement Activities
MIPS
From AMA 01/2017
Presentation
MACRA Basics (“MIPS”)
MIPS
Participants in MIPS
• Medicare Part B clinicians billing more than
$30,000 a year and providing care for more than
100 Medicare patients a year. (MDs/DOs, PAs,
NPs, CNSs & CRNAs)
Clinicians exempt from MIPS
• First year of Part B participation
• Medicare allowed charges < $30K or < 100 patients
• Advanced APM participants
MIPS: 2017 transitional performance reporting options* *Table from AMA 01/11/2017 AMA MACRA Presentation
• Report some data at any point in CY 2017 to demonstrate capability
• 1 quality measure, or 1 improvement activity, or 4/ 5 required ACI measures
• No minimum reporting period
• No negative adjustment in 2019
MIPS Testing
• Submit partial MIPS data for at least 90 consecutive days
• 1+ quality measure, or 1+ improvement activities, or 4/ 5 required ACI measures
• No negative adjustment in 2019
• Potential for some positive adjustment ( < 4%) in 2019
Partial MIPS reporting
• Meet all reporting requirements for at least 90 consecutive days
• No negative adjustment in 2019
• Maximum opportunity for positive 2019 adjustment ( < 4%)
• Exceptional performers eligible for additional positive adjustment (up to 10%)
Full MIPS reporting
• No MIPS reporting requirements (APMs have their own reporting requirements)
• Eligible for 5% advanced APM participation incentive in 2019
Advanced APM
participation
8
MIPS Performance Categories
Category CY 2019 CY 2020 CY 2021 and
beyond
Quality 60% 50% 30%
Resource use (Cost) NA 10% 30%
Clinical practice
improvement activities 15% 15% 15%
Advancing Care
Information (i.e.,
Meaningful Use)
25% 25%
25%
When Does MIPS Begin?
MIPS
Advanced APMs
• “Advanced” APMs
– greatest risks but offer potential for greatest rewards
• Qualified Medical Homes
– different risk structure but otherwise treated as
Advanced APMs
• MIPS APMs
– participants receive favorable MIPS scoring
• Physician-focused APMs--TBD
Advanced APM Incentives
MACRA provides incentives for qualifying
professionals
• Lump-sum bonus payment of 5% of Part B
payments for professional services
• Exemption from MIPS reporting requirements and
payment adjustments
• Higher base rates beginning in 2026
Incentives in 2019 based on 2017 APM
participation
Advanced APM Criterion 1: Use of
Certified EHR Technology
Requires that at least 50% of the clinicians
in each APM Entity use certified EHR
technology to document and communicate
clinical care information with patients and
other health care professionals.
Advanced APM Criterion 2: MIPS-
Comparable Quality Measures
Bases payments on quality comparable to
those used in MIPS quality performance
category.
• Ties payment to quality measures that are
evidence-based, reliable, and valid.
• At least one of these measures must be an
outcome measure if an appropriate outcome
measure is available on the MIPS measure list.
Advanced APM Criterion 3: Bear More
than Nominal Amount of Financial Risk
If actual expenditures exceed expected
expenditures, Advanced APM may:
• Withhold payment for services to the APM
Entity and/or the APM Entity’s eligible clinicians
• Reduce payment rates to the APM Entity and/or
the APM Entity’s eligible clinicians
• Require direct payments by the APM Entity to
CMS.
Advanced APM Total Amount of
Risk
The total amount of risk must be equal to at
least either:
• 8% of the average estimated total Medicare
Parts A and B revenues of participating APM
Entities; OR
• 3% of the expected expenditures for which an
APM Entity is responsible under the APM.
Advanced APMs
For 2017, Models are:
• Comprehensive End Stage Renal Disease Care
Model
• Shared Savings Program Track 2 & Track 3
• Next Generation ACO Model
• Oncology Care Model
• Comprehensive Primary Care Plus (CPC+)
MACRA & The Role of Healthcare
Risk Managers
Fundamental Basis of MACRA: Financial
Risk Sharing
Adverse Outcomes = Increased Risk
Core Healthcare Risk Manager Expertise:
Management of Risk
Guiding Principles of Enterprise Risk
Management: Translate to MACRA
MACRA: Financial Risk Sharing
“Old Days:” Volume of Services
• Less Financial Risk
• More Uncertainty Due to SGR
“Today:” Outcomes Measures
• Financial Incentives for Improved Quality
• Some Penalties for Lack of Improvement
“Tomorrow:” Improve Quality while Controlling
Costs
• Greater Rewards for Greater Risk
• Significant Penalties for Failing to Participate
MACRA: Adverse Outcomes =
Increased Financial Risk
MACRA and ERM
ASHRM ERM Principles
• Advance safe and trusted healthcare
• Manage uncertainty
• Maximize value protection and creation
• Encourage multidisciplinary accountability
• Optimize organizational readiness
• Promote positive organizational culture which will
impact readiness and success
• Utilize data/metrics to prioritize risks
• Align risk appetite and strategy
Other Impacts of MACRA
Hospital and Health System Employed
Physicians vs. Private Medical Staff
Significance of Incident Reports, RCA’s,
FMEA’s
Risk Management Data & Quality Reporting
System Effectiveness
Evolution of Physician Compensation
Structure
QUESTIONS?