making sense of macra - maryland...
TRANSCRIPT
Making Sense of MACRA: Implications for Your Move to Value
Nico Lewine
Director, Transformation
Evolent Health
August 19, 2016
Agenda
• Introduction
• MACRA Overview
• Strategic Implications
• Q&A
1
About Evolent
• Nico Lewine is a Director in
Evolent’s Transformation and
Strategy Consulting group, where
helps health system partners
develop successful value-based
care strategies.
• Nico is a leader in Evolent’s policy practice, where he
helps Evolent and its clients understand new policy
developments and identify risks and opportunities.
• Nico has served many of Evolent’s partners in
developing system-level strategies, with particular
focus on Medicare programs such as Next Generation
ACO, MSSP, CPC+, and more.
• Prior to joining Evolent in early 2014, Nico was an
Engagement Manager at a boutique healthcare
consultancy in Boston.
• He received his BA in Molecular & Cellular Biology
from Harvard University.
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Evolent Health partners with leading health systems to
drive value-based care transformation. By providing
clinical, analytical and financial capabilities, Evolent helps
physicians and health systems achieve superior quality and
cost results.
Founded in 2011 by UPMC Health Plan and The Advisory
Board Company, we are a high-growth firm headquartered
in Arlington, Virginia. We provide an integrated platform,
which includes the technology, clinical programs, and
knowledge and infrastructure to help health systems make
the transition to value-based care. When combined
together, our approach breaks down barriers, aligns
incentives and powers a new model of care delivery
resulting in meaningful alignment between providers,
payers, physicians and patients.
Speaker Bio
Evolent Health National Network of Partners
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A National Network of Leading Provider-Led Risk Bearing Organizations
Live Markets Developing Markets
Example Partner Systems From
Around the Country
Agenda
• Introduction
• MACRA Overview
• Strategic Implications
• Q&A
4
Note: All information in this presentation is based on the Proposed Rule
issued in late April. It could be subject to change in the Final Rule,
expected to be released in September or October.
Medicare is moving to value-based care through both
voluntary models and mandatory payment changes
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Traditional
FFS
Medical
Home (CPC+)
Bundled
Payment
No-risk
ACO (MSSP T1)
Medicare
Advantage Shared-risk
ACO (Next Gen,
MSSP T3)
Increasing Financial Risk
Incre
asin
g S
up
po
rt fo
r
Mo
dific
ations in C
linic
al P
ractice
50% of Original Medicare
payments under
Alternative Payment
Models by
2018
CMS Payment
Goals Evolution of CMS Payment Models
Summary of the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA)
MIPS (Merit-Based Incentive Payment System)
APM Bonus (Alternative Payment Model)
Providers that participate in
Advanced APMs could be eligible
for a 5% bonus
Providers that do not meet APM thresholds will be publicly
scored on a combination of quality, cost, and infrastructure
• Each provider’s score will translate into a payment
adjustment ranging from ±4% in 2020 to ±9% in 2025*
• The scoring is competitive; providers are measured
against each other
• MIPS replaces other CMS payment adjustments under
Value-Based Modifier, Meaningful Use, and PQRS
1 2
• From 2019 – 2025, base physician payment rates will be frozen
• Payments will be only be adjusted through one of two methodologies:
Alternative Payment Model (APM) bonus
Merit-Based Incentive Payment System (MIPS)
1
2
* Additional upside available for top performers
6
The time is now
2017: Performance Year
Claims from 1/1/17 to 12/31/17 will determine the MIPS/APM
payment adjustment for 2019
2017: Performance
Year
2018: Reporting Year
2019: Payment Year
2019 Payment Year
2017: Performance Year
2018: Performance
Year
2019: Reporting Year
2020: Payment Year
2020 Payment Year
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MIPS payment adjustments will be based on
metrics spanning four categories At the outset, participants will have choice in their Quality and
Practice Improvement measures
50%
25%
15%
10%
45%
25%
15%
15%
30%
25% 15%
30%
PY 2017 PY 2018 PY 2019
Advancing Care Information
Quality
Clinical Practice Improvement
Resource Use
Weightings will be different for any physicians qualifying for the “APM Scoring Standard”
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Providers’ Fate Under MACRA
Exempted from MIPS;
Receive 5% Bonus
Can choose to
participate in or opt
out of MIPS
Subject to MIPS
payment adjustments,
but reporting, measures,
and weighting could be
adjusted
Subject to MIPS
Did you participate in an
Advanced APM (AAPM)?
Did the AAPM
collectively meet the “QP
Threshold”?
Did the AAPM
collectively meet the
“Partial QP Threshold”?
Did you participate in any
APM?
Yes
A
B
C
Yes No
Yes No Yes No
No
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APMs and Advanced APMs
Did you participate in an
Advanced APM (AAPM)? Did you participate in any APM?
A Yes
No
Advanced APMs Non-Advanced APMs
• Next Generation ACO
• MSSP Tracks 2-3
• CPC+, if <50 clinicians
• Oncology Care Model – 2-sided risk
arrangement
• Comprehensive ESRD Care Model –
“LDO arrangement”
All others, including:
• MSSP Track 1
• CPC+, if >50 clinicians
To count as “participating” in an AAPM, a provider (TIN or NPI) needs to be on the AAPM’s
roster as of December 31 of the relevant Performance Period.
A
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QP Threshold B
Did you participate in an
Advanced APM (AAPM)?
Did the AAPM
collectively meet the “QP
Threshold”?
A B Yes
Yes
No
Exempted from MIPS;
Receive 5% Bonus
• If an AAPM meets the “QP Threshold”, it will be exempted from MIPS and will receive
the 5% bonus
• The QP Threshold is measured at the AAPM level; either all of the participants in an
AAPM will be QPs, or none of them will
QP Threshold:
Payment Year 2019 2020 2021 2022 2023 2024
Performance Period 2017 2018 2019 2020 2021 2022
QP Threshold:
Payment
Amount
Medicare payments to ACO physicians for ACO-attributed benes
Total Medicare payments to ACO physicians
25+% 25+% 50+% 50+% 75+% 75+%
QP Threshold:
Patient Count
# of benes attributed to ACO who were seen by ACO physicians
Total # of Medicare benes who were seen by ACO physicians
20+% 20+% 35+% 35+% 50+% 50+%
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Partial QP Threshold C
Did you participate in an
Advanced APM (AAPM)?
Did the AAPM
collectively meet the “QP
Threshold”?
A B Yes
Yes
No
Did the AAPM
collectively meet the
“Partial QP Threshold”?
• If an AAPM does not meet the “QP Threshold”, but is above the “Partial QP Threshold”,
it can choose to be exempted from MIPS
Partial QP Threshold:
Payment Year 2019 2020 2021 2022 2023 2024
Performance Period 2017 2018 2019 2020 2021 2022
Partial QP Range:
Payment Amount
Medicare payments to ACO physicians for ACO-attributed benes
Total Medicare payments to ACO physicians
20-25% 20-25% 40-50% 40-50% 50-75% 50-75%
Partial QP Range:
Patient Count
# of benes attributed to ACO who were seen by ACO physicians
Total # of Medicare benes who were seen by ACO physicians
10-20% 10-20% 25-35% 25-35% 35-50% 35-50%
C
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Agenda
• Introduction
• MACRA Overview
• Strategic Implications
• Q&A
13
Strategic Implications
1. MACRA will drive alignment of physicians to health systems
offering value-based capabilities and AAPM contracts
2. If a system wants to achieve the 5% AAPM bonus, it must be
judicious with its balance of PCPs and specialists
3. For health systems, achieving shared savings in an Advanced
APM offers greater ROI on value-based capabilities than any
MIPS/APM bonuses
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1
2
3
MIPS bonuses will be volatile and unpredictable
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1
Perc
ent
of
Score
s
MIPS Score 0 100
MIPS Threshold (mean or median)
Providers
Receiving
Penalties
Providers
Receiving
Bonuses
ILLUSTRATIVE
Illustrative Distribution of MIPS Scores
• MIPS is competitive;
bonuses are relative to other
providers’ performance
• Regulators expect scores to
cluster together
• If scores cluster on certain
metrics, other metrics could
have out-sized impact
• Metrics may not fully capture
actual quality of care
• Risk adjustment
• Attribution
• Sample size
• Metric choice
2019 Payment
Adjustment 0% +4% -4%
MACRA will drive alignment of physicians to systems
offering value-based capabilities and AAPM contracts
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1
Population
Health
Infrastructure
Access to robust technology and population
health initiatives to improve performance under
MIPS and/or APM contracts
Network
Benefits
Tighter care coordination within high
performing ACO network to drive performance
on clinical and efficiency outcomes under MIPS
and/or APM contracts
Advanced
APM
Participation
Opportunity to participate in value-based
contracts with downside risk to qualify for APM
bonuses and avoid participation in MIPS
Drivers of
Physician
Alignment
Balancing PCPs and Specialists
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2
Because the QP Threshold is measured at the APM level, ACOs with
too many specialists may miss out on the AAPM bonus.
PCP-Dominated
ACO
Specialist-
Dominated ACO
ACO with more
specialists
PCPs
Specialists
Illustrative % AAPM:
50-70%
PCPs
Specialists
Illustrative % AAPM:
20-50%
PCPs
Specialists
Illustrative % AAPM:
5-20% ?
What Capabilities do you Need to Succeed?
18
3
ALIGNED
DELIVERY
NETWORK
INTEGRATED
TECHNOLOGY
PLATFORM
POP HEALTH
CAPABILITIES
QUALITY AND RISK
CODING
PHYSICIAN-LED
TRANSFORMATION
Integrated technology that can not only stratify risk, but identify
“impactable” spending and quality gaps and drive specific
action steps
PCP network that provides care to at least 5K (MSSP) /
10K (Next Generation) beneficiaries in your market
Structured care management capabilities, not a collection of
independent initiatives
Infrastructure and workflows to track / report quality and ensure
benchmark is appropriately risk adjusted (in full risk model)
Support physicians in creating lasting, long-term relationships
with Medicare beneficiaries
Maximizing ROI
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3
Driving performance through MIPS or an Advanced APM requires
similar investments, but financial return is much greater under APMs
0%
20%
40%
60%
80%
100%Physician
IPHospital
OPHospital
SNF
Other
Medicare Part A/B Spending
MIPS/APM Bonuses –
up to 5-10% of
physician spending
Maximum Financial
Opportunity as % of
Medicare Dollar
Advanced APM Shared
Savings –
up to 5-7% peak savings 5-7%
1-2%
Viable Advanced APMs
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3
In newer ACO models, CMS has addressed
many of the issues that plagued earlier versions
Provider Value Drivers MSSP
Track 1 and 2
MSSP
Track 3
Next Generation
ACO
MA
Plan
Lives on Platform
Infrastructure Cost
Risk Exposure
Shared Savings
Defined Population and
Benchmark Target
Cash Flow and Prepayment
Benefit Design
Less Favorable More Favorable
Agenda
• Introduction
• MACRA Overview
• Strategic Implications
• Q&A
21
800 N Glebe Rd, Suite 500
Arlington, VA 22203
evolenthealth.com
800 N Glebe Rd, Suite 500
Arlington, VA 22203
evolenthealth.com
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Nico Lewine – Director, Transformation