preparing for the implications of macra · key, available, information that can guide health...

1 © 2016 PREMIER, INC.

©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


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


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



Test

TRA

CK

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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


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


The Education Gap is Real and Time is Running Out


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


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


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

8

MACRA Decision Tree


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


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?


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

11

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


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


Merit Based Incentive Payment System (MIPS)


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


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


•  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?


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?


  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?


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?


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


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


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


Thank You. Questions?

Bryan Bowles Premier, Inc.

[email protected] 704.816.5233

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