pathologists and value-based care: risks and rewards€¦ · pathologists and value-based care:...
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Pathologists and Value-Based Care:Risks and Rewards
Donald Karcher, MD
Chair, Department of Pathology
George Washington University Medical Center
Pathologists and Value-Based Care:Risks and Rewards
We’ll discuss . . .
• Where value-based care came from
• The current models of value-based care
• MACRA: The next step toward value-based care
• Impact of value-based care on pathology practice
• How pathologists can prepare for value-based care
The dream . . .
. . . the challenge
. . . the challenge
. . . the challenge
. . . the challenge
. . . the challenge
. . . the challenge
. . . the challenge
. . . the challenge
. . . the challenge
So what’s wrong with the traditional health care system?
• No built-in system for coordination of care
• No real incentive to give high-quality care
• Little connection between care of individual patients and the health of the population
• No effective way to control costs volume rewarded over value
17.5% in 2014
Modern health care reform: The “triple aim”
• Better quality care for individuals
• Improved health for the population
• Lower cost
Value =Quality/Outcome
Cost
The goal: Value-based health care
value rewarded over volume
Value-based health care: Where did it come from?
• Institute of Medicine – Crossing the Quality Chasm: A New Health System for the Twenty-First Century, 2001 “Health care that is safe, effective, patient-centered, timely, efficient, and equitable”
• Donald Berwick – Institute for Healthcare Improvement, Harvard School of Public Health
• Elliott Fisher – Institute for Health Policy and Clinical Practice, Dartmouth Medical School
• Private payers – Have been driving the movement to value-based care from the beginning.
Value-based health care: Where did it come from?
Federal Legislative History
2000 – Benefits Improvement and Protection Act
- Beginning of “pay-for-performance” (P4P)
2005 – Medicare Physician Group Practice Demo.
2009 – HITECH Act “Meaningful Use” of HIT
2010 – Affordable Care Act
- CMS Medicare Shared Savings Program ACOs
- CMS CMMI Pioneer ACOs
- Expanded other value-based and P4P models
Value-based health care . . . so far
• Accountable care organizations
• Patient-centered medical homes
• Bundled payment arrangements
• Pay-for-performance (P4P)
• Meaningful use of HIT
• __________________??MACRA
2015 – HHS announced targets for value based payments
• By end of 2016
- 85% of provider payments value-based
- 30% of payments “alternative” models (done by 3/16)
• By end of 2018
- 90% of provider payments value-based
- 50% of payments “alternative” models
2015 – HHS announced targets for value based payments
• By end of 2016
- 85% of provider payments value-based
- 30% of payments “alternative” models*
• By end of 2018
- 90% of provider payments value-based
- 50% of payments “alternative” models*
*MACRA advanced alternative payment models (APMs)??
Accountable care organizations: What are they?
• Health care organizations that accept accountability for the . . .
- Quality of care
- Health of the population served
- Per capita cost of care for a designated
population
• Formed by combination of providers and/or hospitals
group practice, network of individual provider practices, joint
venture/partnership of hospital(s) and providers, hospital-
employed providers, etc.
>50% are physician group-operated
Accountable care organizations: What are they not?
HMOs by another name?
HMO ACO
1. Better quality care for individuals* ?? +
2. Improved health for the population* ? +
3. Lower cost* + +
*HIT/informatics can now facilitate all three
Accountable care organizationsTotal Number of ACOs – 2011-2016
Source: Accountable Care Learning Collaborative
Source: Accountable Care Learning Collaborative
857 as of 10/2016
Accountable care organizations:Different models as of 1/2015
CMS Medicare Shared Savings Program (MSSP) ACOs………………………… 427
CMS CMMI Pioneer ACOs….... 23
Medicaid ACOs……………….... 16 states
Private sector ACOs…………… 278
Total 744
Source: Accountable Care Learning Collaborative
Accountable care organizations:Different models as of 1/2016
CMS Medicare Shared Savings Program (MSSP) ACOs………………………… 434
CMS CMMI Pioneer ACOs….... 12
CMS CMMI Next-Gen ACOs…. 21
CMS ESRD ACOs……………... 13
Medicaid ACOs……………….... 17 states
Private sector ACOs…………… 341
Total 838
Source: Accountable Care Learning Collaborative
Accountable care organizationsNumber of ACOs by State − 1/2016
Source: Accountable Care Learning Collaborative
Accountable care organizationsNumber of ACOs by Hospital Region − 1/2016
Source: Accountable Care Learning Collaborative
Accountable care organizationsTotal Covered Lives in ACOs – 1/2016
Source: Accountable Care Learning Collaborative
Accountable care organizations% Covered Lives in ACOs by Hospital Region − 1/2016
Source: Accountable Care Learning Collaborative
Accountable care organizationsTotal Covered Lives in ACOs – By 2020
Source: Accountable Care Learning Collaborative
Accountable care organizationsCovered Lives in ACOs by Payer – 1/2016
Source: Accountable Care Learning Collaborative
Pathologists and ACOs
Number of pathologists currently participating in one or
more ACOs . . .
• 2011 CAP Practice Characteristics Survey 5%
• 2014 CAP Practice Characteristics Survey 17%
• 2016 CAP Practice Leader Survey 30%
Accountable care organizationsTotal Covered Lives vs. Pathologists in ACOs
Sources: ACO Data – Accountable Care Learning Collaborative; Pathologist Data – CAP
% Path
olo
gists in A
CO
s8
0 7
0 6
0 5
0 4
0 3
0 2
0 1
0 0
Accountable care organizations:Common elements
• Coordination of care key to success
−Chronic disease management, transitions of
care (i.e. handoffs), population health
management, etc.
• Use of EHR and informatics to improve care,
manage utilization, and monitor performance
• Payment: − Based on meeting quality measures
− Shared FFS savings capitation,
bundled payments, etc.
Accountable care organizations:Different models
CMS Medicare Shared Savings Program ACO
• Basic, entry-level ACO
• First cohort of 27 in April, 2012; now 434
Accountable care organizations:Different models
CMS Medicare Shared Savings Program ACO
• Accountable for the . . .
- Quality of care – 34 quality measures
- Cost of providing care (compared to past/benchmark)
• Costs and savings still based on fee-for-service
• ACO can share in FFS savings and/or be at risk for
added costs (Tracks 1, 2, and 3)
Accountable care organizations:Different models
CMS Medicare Shared Savings Program ACO
34 quality measures
• Patient experience – 8 (e.g. timely appts.)
• Care coordination – 10 (e.g. all readmissions,
unplanned admissions for CHF, etc.)
• Preventive health – 9 (e.g. flu vaccination)
• At-risk pop. care – 7 (e.g. hgb A1c control, LDL control,
etc.)
Accountable care organizations:Different models
CMS Medicare Shared Savings Program ACO
Risk Tracks
• Track 1 – Shared savings (“upside” risk) only
• Track 2 – Shared savings + losses (“upside” and
“downside” risk) higher shared savings
• Track 3 – Shared savings + losses even higher
shared savings + higher risk for losses
Accountable care organizations:Different models
CMS Medicare Shared Savings Program ACO
Risk Tracks 2016
• Track 1 – Shared savings (“upside” risk) only 95%
• Track 2 – Shared savings + losses (“upside” and
“downside” risk) higher shared savings 1%
• Track 3 – Shared savings + losses even higher
shared savings + higher risk for losses 4%
ACO performance – early results (2014)
CMS Medicare Shared Savings Program
(MSSP) ACOs
• After first full year 28% beat benchmarks
1-2% overall savings
CMS CMMI Pioneer ACOs
• 9 dropped out after first year
• After first two years 11/23 (48%) beat benchmarks
1% overall savings
Private sector ACOs 2-12% overall savings
ACO performance – as of 2015
CMS Medicare Shared Savings Program
(MSSP) ACOs
• Beat benchmarks
Total 31%
Started in 2012 42%
Started in 2013 37%
Started in 2014 22%
CMS CMMI Pioneer ACOs
• 6/12 (50%) beat benchmarks
Accountable care organizations:Different models
Next Generation ACO Model
• Even more advanced model than Pioneer ACO
• Ultimately moves away from recent expense
benchmark greater incentives to move to
capitated payments
• First cohort in January, 2016 = 21
Patient-centered medical home
• Care delivery model based on “partnership” between
individual patients and their provider
• Usually primary care; may be specialty care
• Team-based care coordinated across the continuum of
care
• Focused on quality and patient safety
• Currently, >8,000 accredited PCMHs (accredited by
TJC, NCQA, etc.)
PCMHs and ACOs(James Crawford, 2014)
PCMHPractices
Hospital(s)Emergency Dept.SNF, Rehab.
Laboratory, Imaging, Pharmacy, “Urgent Care” Clinic
Patient-centered medical home
CMMI Advanced Primary Care Practice Demonstration
• 2011-2014 pilot project extra payment for care coordination activities and payment of shared FFS savings
• 434 participating sites
CMMI Comprehensive Primary Care Plus
• Started April, 2016
• Financial incentives and greater flexibility for improving primary care
• Up to 5,000 practices, 20,000 providers, 25 million patients
Bundled payment arrangements
• Single “fixed dollar” global payment to hospital, provider
organization, and/or individual providers for single
“episode of care”
• Similar to Medicare DRGs for hospitals, but . . .
providers may now be included in bundle
• Distribution of payment is determined internally
• CMMI developing several models for inpatient and/or
outpatient care
Bundled payment arrangements
CMMI Medicare Bundled Payments for Care
Improvements (BPCI)
• Demonstration project, started in 2013
• 4 models
1. Retrospective acute-care hospital stay
2. Retrospective acute-care hospital + post-acute care
3. Retrospective post-acute care
4. Prospective acute-care hospital + post-acute care
• 48 clinical condition episodes
Bundled payment arrangements
CMMI Medicare Bundled Payments for Care
Improvements (BPCI)
• Demonstration project, started in 2013
• 4 models
1. Retrospective acute-care hospital stay
2. Retrospective acute-care hospital + post-acute care*
3. Retrospective post-acute care*
4. Prospective acute-care hospital + post-acute care*
• 48 clinical condition episodes
*includes providers
Bundled payment arrangements
CMMI Comprehensive Joint Replacement Model*• Began April 1, 2016
CMMI Oncology Care Model*• Began July, 2016 (5 year demo)
• For cancer chemotherapy “episode of care”; begins with first chemotherapy; includes all services for 6 months
• FFS + bundled payment + performance-based bonus (via Medicare and private payers) for improving coordination and quality of care and/or decreasing cost
*providers included
Pay-for-performance (P4P)
• Started in 2000 with Benefits Improvement and
Protection Act
• Reinforced with
2009 HITECH Act
2010 Affordable Care Act
• Applies to hospitals and providers
• Started as voluntary bonus payments for good
performance Now rewards + penalties
Pay-for-performance (P4P)
• Physician Quality Reporting System (PQRS)
• Value-Based Modifier (VBM) for providers
• Value-Based Purchasing (VBP) for hospitals
• Meaningful Use of HIT
Physician quality reporting system (PQRS)
• Provider payment based on reporting of quality
measures
• Reporting by various means
Individual providers – Claims, registry, EHR, etc.
Group members – Registry, EHR, Web, etc.
• Quality measures must be approved by CMS;
process measures outcome measures
Physician quality reporting system (PQRS)
Pathology quality measures approved by CMS
Prior to 2015
• Breast cancer resection report elements
• Colorectal cancer resection report elements
• Barrett’s esophagus report elements
• Radical prostatectomy report elements
• HER2 by IHC in breast ca using ASCO/CAP guidelines
New in 2015
• Lung cancer biopsy/cytology report elements
• Lung cancer resection report elements
• Melanoma resection report elements
Physician quality reporting system (PQRS)
Pathology quality measures approved by CMS
Prior to 2015
• Breast cancer resection report elements
• Colorectal cancer resection report elements
• Barrett’s esophagus report elements
• Radical prostatectomy report elements
• HER2 by IHC in breast ca using ASCO/CAP guidelines
New in 2015 MACRA final rule on October 14
• Lung cancer biopsy/cytology report elements outcome
• Lung cancer resection report elements outcome
• Melanoma resection report elements outcome
Value-based modifier (VBM)
• Cost and quality (i.e. PQRS) data reported to CMS and used to calculate payment for services
• Implementation: Reporting and impact schedule
As of 2015 All providers Impact in 2017
* impact if PQRS data not reported
Meaningful (MU) use of HIT
• HITECH Act of 2009
• Encourages hospitals and providers to “meaningfully”
use certified EHR; for providers ambulatory care only
• Payment penalties: 1% 5% over five years
• Essentially no current measures appropriate for
pathologists
• “Hardship” exemption for pathologists granted by CMS
Consequences of PQRS, VBM, MU
By 2019 . . .
Failure to report PQRS (-2%, -4% -6%)
Failure to attest to MU (-5%)
-2%
-4%
-6% -11%-5%
Medicare Sustainable Growth Rate (SGR)
• Balanced Budget Act of 1997
• Increase in Medicare payments to physicians could not
exceed growth in GDP
• Never implemented Congress passed temporary “fix”
every year for 17 years
• If had been implemented in 2015 27.5% decrease in
physician payments
Medicare Sustainable Growth Rate (SGR)
First attempt to permanently fix SGR – Failed,
instead . . .
PAMA – Protecting Access to Medicare Act of 2014
Medicare Sustainable Growth Rate (SGR)
Second attempt to permanently fix SGR
MACRA – Medicare Access and CHIP
Reauthorization Act of 2015
MACRA
Quality Payment Program
Merit-Based Incentive Payment System (MIPS)
Alternative Payment Models (APMs)
MACRA
Merit-Based Incentive Payment System (MIPS)
• Replaces PQRS, VBM, and MU; has 4 components
1. Quality
2. Resource use
3. Clinical practice improvement
4. Advancing care information (formerly MU)
MACRA
Merit-Based Incentive Payment System (MIPS)
• Replaces PQRS, VBM, and MU; has 4 components
1. Quality – 60% in year 1
2. Resource use – 0% in year 1
3. Clinical practice improvement – 15% in year 1
4. Advancing care information (formerly MU) – 25% in year 1
• Each provider receives a composite performance score based on
the above distribution; scoring in 2017 for 2019 payment
• Program must be budget-neutral Winners and losers
• Gain/loss range: 2019 ± 4%; 2020 ± 5%, 2021 ± 7%; 2022 ± 9%
MACRA
Merit-Based Incentive Payment System (MIPS)
Impact on pathology payments (per CAP analysis) . . .
MACRA
Alternative Payment Models (APMs)
• Participation in eligible Advanced APM a) exempts provider from
MIPS and b) leads to payment rewards
2019-2024: Automatic +5% payment adjustment
2026 and on: +0.75% annual adjustment (others get +0.25%)
• Payment and patient thresholds for eligible Advanced APM
Medicare Only Option% Payments
in an Advanced APM
All Payer Option% Payments
in an Advanced APM
2019-2020 25% NA
2021–2022 50% 25% Medicare/25% all other payers
2023 and on 75% 25% Medicare/50% all other payers
MACRA
Alternative Payment Models (APMs)
• Participation in eligible Advanced APM a) exempts provider from
MIPS and b) leads to payment rewards
2019-2024: Automatic +5% payment adjustment
2026 and on: +0.75% annual adjustment (others get +0.25%)
• Payment and patient thresholds for eligible Advanced APM
Medicare Only Option% Patients
in an Advanced APM
All Payer Option% Patients
in an Advanced APM
2019-2020 20% NA
2021–2022 35% 20% Medicare/15% all other payers
2023 and on 50% 20% Medicare/30% all other payers
MACRA
Alternative Payment Models (APMs)
• Participation in eligible Advanced APM a) exempts provider from
MIPS and b) leads to payment rewards
• Examples . . .
CMS ACOs (MSSP Tracks 2 and 3, Next-Gen, etc.)
Bundled payments (e.g. Oncology Care Model with 2-sided risk)
PCMHs (e.g. Comprehensive Primary Care Plus Model)
Physician-focused payment models (PFPMs)
• Eligible Advanced APM – Certain requirements, including “more than
nominal” downside financial risk
MACRA
Alternative Payment Models (APMs)
• Participation in eligible Advanced APM a) exempts provider from
MIPS and b) leads to payment rewards
• Examples . . .
CMS ACOs (MSSP Tracks 2 and 3, Next-Gen*, etc.) Track 1+
Bundled payments (e.g. Oncology Care Model with 2-sided risk**)
PCMHs (e.g. Comprehensive Primary Care Plus Model*)
Physician-focused payment models (PFPMs) ?? for pathologists
* Extended to 2018 cohort
** Accelerated to 2017
MACRA – “Final Rule with Comment” Oct. 14
Highlights . . .
• Very flexible reporting requirements in 2017
• All 8 pathology PQRS quality metrics approved for MIPS,
3 newest metrics declared “outcome-based”
• Non-patient-facing = <100 patient-facing encounters per
year; if <25% of group patient-facing, entire group NPF
Non-patient-facing providers require reporting on
fewer quality and practice improvement metrics
MACRA – “Final Rule with Comment” Oct. 14
Highlights . . .
• Very flexible reporting requirements in 2017
• All 8 pathology PQRS quality metrics approved for MIPS,
3 newest metrics declared “outcome-based”
• Non-patient-facing = <100 patient-facing encounters per
year; if <25% of group patient-facing, entire group NPF
• Pathologists at independent labs qualify
• Lower downside financial risk to qualify as advanced
APM
• MSSP Track 1+ ACO proposed
MACRA – MIPS Metrics Reporting
• Reporting options in 2017 2019 payment
adjustment . . .
1. Report nothing 4% negative payment adjustment
2. Report anything on one metric neutral payment
adjustment
3. Report required metrics for 90 days neutral or
small positive payment adjustment
4. Report required metrics for full year moderate
positive payment adjustment
• Qualified Clinical Data Registry (QCDR)
Health Care Payment Learning and Action NetworkAPM Framework
Category 1 – FFS, no link to quality/value
Category 2 – FFS, with link to quality/value (P4P, MIPS, etc.)
Category 3 – APMs built on FFS architecture (MSSP ACOs,
Next-Gen ACOs [early], etc.)
Category 4 – Population-based payment (e.g. capitation,
bundled payments, etc.)
. . . the challenge
Value-based health care:Challenges for pathologists
• Meet MACRA/MIPS metrics
• Establish value-added roles in support of ACOs, PCMHs, bundled payment arrangements, and other APMs
Gain recognition* for these roles
Get paid fairly* for these roles
*as judged by colleagues/organization
Value-based health care: Meeting the challenges
Value-added roles for pathologists . . . some
examples:
• Lab utilization management – CP and AP
• Consultation – Pre-order and post-result
• Assist in chronic disease/population health
management
• Ensure actionable lab/pathology result format in EHR
• Use HIT/informatics for practice analytics, care
improvement
Value-based health care: Meeting the challenges
Value-added roles for pathologists . . . some
examples:
• Lab utilization management – CP and AP
CP – Develop lab test order sets, testing algorithms, test
“formularies”; emphasis on molecular and other high-cost
tests the right test at the right time
AP – Manage ancillary testing in surgical pathology,
hematopathology
Value-based health care: Meeting the challenges
Value-added roles for pathologists . . . some
examples:
• Lab utilization management – CP and AP
• Consultation – Pre-order and post-result
- With clinicians
- With patients
Value-based health care: Meeting the challenges
Value-added roles for pathologists . . . some
examples:
• Lab utilization management – CP and AP
• Consultation – Pre-order and post-result
• Assist in chronic disease/population health
management
- Use HIT for scheduled testing alerts, testing
compliance/test result tracking, intervention alerts
- Develop and apply clinical decision support tools
Value-based health care: Meeting the challenges
Value-added roles for pathologists . . . some
examples:
• Lab utilization management – CP and AP
• Consultation – Pre-order and post-result
• Assist in chronic disease/population health
management
• Ensure actionable lab/pathology result format in EHR
Provides clinical decision support to clinicians
Value-based health care: Meeting the challenges
Value-added roles for pathologists . . . some
examples:
• Lab utilization management – CP and AP
• Consultation – Pre-order and post-result
• Assist in chronic disease/population health
management
• Ensure actionable lab/pathology result format in EHR
• Use HIT/informatics for practice analytics, care
improvement, peer-review, etc.
“ACOs and value-based health care will bring on a renaissance for clinical pathology.”
“ACOs and value-based health care will bring on a renaissance for clinical pathology.”
− Donald Karcher, MDMay, 2012
What can anatomic pathologists do to survive/thrive with value-based care?
• Continue to do what they do
. . . but also (a few examples):
• Develop and follow evidence-based and cost-
effective diagnostic pathways (IHC, genomics, etc.)
• “Own” the AP report in the EHR make it clear,
user-friendly, clinician- and patient-centered,
actionable, and (if possible) integrated with
imaging and other studies
• Provide direct patient consultation (with the
concurrence of the patient’s clinician)
• Use AP’s unique perspective to assist in
organizational peer review and patient safety
• etc.
Payment of providers in VBC
APMs: ACOs and bundled payments
• Employee $ incentives
• Member FFS a/o share in savings/losses*
FFS a/o share in bundled payment*
• Vendor/subcontractor low FFS
*Determined by internal negotiation, based on perceived contributions as judged by colleagues/organization
“As soon as possible, Medicare should extend
competitive bidding to medical devices,
laboratory tests, radiographic diagnostic
services, and all other commodities.”
− The Center for American Progress, et al
NEJM, August 1, 2012
Health care reform and value-based care: Looking over the horizon
• Population health management, coordinated and
team-based care delivery will be the norm, with HIT
and clinical informatics as key tools
• Pure FFS will be mostly replaced by a value-based
payment system some combination of value-
based FFS, capitation, and bundled payment
(APMs); eventually, FFS reserved for
“commodities” only?
• All payment will be impacted by quality metrics,
increasingly outcome-based
• Payment of providers increasingly determined by
internal sharing arrangements
Value-based care and the CAP
• Advocacy for P4P, MU, and now MACRA
• CAP ACO Network – 2011-2016, ~70 members
• Member, Accountable Care Learning Collaborative
• CAP value-based care strategic initiative started in 2015
• “From Volume to Value” at www.cap.org (coming . . . still
under construction) Practice Management Resource
Center: Glossary of VBC terms, practice modeling tools,
instructional videos, etc.
Value = Quality/Outcome
Cost