Making Sense of MACRA
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The healthcare transformation from fee for service to fee for outcomes just got an adrenaline shot in the arm April 27th when the Department of Health and Human Services surprised many in the market by announcing a Quality Payment Program, a proposed set of new rules to take effect in 2019 based on key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
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Making Sense of MACRA
- 1. Making Sense of MACRA May 10, 2016
- 2. Š 2016 Health Catalyst Proprietary and Confidential How ready are you to participate in MACRA? 1. Not at all â 12.36% 2. Somewhat â 22.53% 3. Unsure â 55.77% 4. Ready â 8.24% 5. Very ready â 1.10% Poll Question #1 364 Total Responses
- 3. Š 2016 Health Catalyst Proprietary and Confidential Who reads 962 pages of regulations? Remember all these slides reflect PROPOSED regulations Question 3
- 4. Š 2016 Health Catalyst Proprietary and Confidential Purpose of HR Bill 02 4 Physician Fix Passed in April 2015 ⢠Offer multiple pathways for risk/reward ⢠Minimize additional reporting burdens ⢠Streamline multiple programs ⢠Reward clinicians for value over volume
- 5. Š 2016 Health Catalyst Proprietary and Confidential ⢠MACRA â Medicare Access and CHIP Reauthorization Act of 2015 ⢠SGR â Sustainable Growth Rate (replaced by MACRA) ⢠MIPS â Merit-based Incentive Payment System ⢠APM â Alternative Payment Models (Advanced) ⢠EP â Eligible professional becomes EC Eligible clinician Acronyms 5
- 6. Š 2016 Health Catalyst Proprietary and Confidential Goals of CMS ⢠Overall goal â 90% of Medicare payments shifted to quality or value by 2018 ⢠In 2014, 22% of Medicare payments (approximately $138B) for physicians ⢠Invite private sector to match/exceed goal 6
- 7. Š 2016 Health Catalyst Proprietary and Confidential Better care Smarter spending Healthier people Goals of CMS 7 Incentives Care delivery Information sharing
- 8. Š 2016 Health Catalyst Proprietary and Confidential âMost profound change to physician compensation in more than 25 years. There is going to be a lot of anger and frustration.â Steven Stack, M.D., President of AMA âMake policies simple, flexible to allow providers to make choices to meet their needs and outcomes-oriented.â Patrick Conway, M.D., Chief Medical Officer, CMS âFeedback mechanisms are too removed from the performance year.â Anders Gilberg, Senior Vice President of Government Affairs, MGMA âQuite frankly, the rank-and-file physicians arenât paying attention.â Chet Speed, JD, LLM, Vice President of Public Policy, AMGA Reactions 8
- 9. Š 2016 Health Catalyst Proprietary and Confidential Performance Year 9
- 10. Š 2016 Health Catalyst Proprietary and Confidential ⢠$100M of technical assistance for small practices (under 15 professionals) ⢠$75M for physician groups to improve quality measure development Additional Aspects 10
- 11. Š 2016 Health Catalyst Proprietary and Confidential Two Tracks of MACRA`` 11 2020 .5% annual update thru 2019 Combine MU, PQRS, VBM 2018 MIPS APM QP 2019 Performance year Base year +/- 5%+/-4% +/- 7% +/- 9% 2017 Performance year 20232021 2022 2024 20202018 20192017 20232021 2022 2024
- 12. Š 2016 Health Catalyst Proprietary and Confidential MIPS participants who participate in APMs would receive credit toward scores in the Clinical Practice Improvement Activities category. Certain Advanced APMs participants, who fall short of the payment or patient participation requirements for the incentive payment can choose whether they would like to receive the MIPS payment adjustment. The proposed rule aligns standards between the two parts of the Quality Payment Program in order to make it easy for clinicians to move between programs. Cross Over Between the Tracks 12
- 13. Š 2016 Health Catalyst Proprietary and Confidential Public commentary until June 27, 2016 Final regulations published in November 2016 Comments may be submitted electronically to CMS: Source: http://www.cms.gov/Regulations-and- Guidance/Regulations-and- Policies/eRulemaking/index.html?redirect=/eRulemaking Proposed Rulemaking 13
- 14. Š 2016 Health Catalyst Proprietary and Confidential Reporting period will be annual - only see your results once a year ⢠First feedback report â July 2017 ⢠Second feedback report â July 2018 All data will be made available on Physician Compare Reporting 14
- 16. Š 2016 Health Catalyst Proprietary and Confidential Eligibility Year 1, 2 Medicare Part B clinicians: ⢠Physicians ⢠Physician assistants ⢠Nurse practitioners ⢠Clinical nurse specialist ⢠Certified registered nurse anesthetists Hospitals are not part of program Year three expansion: ⢠Physical or occupational therapists ⢠Speech-language pathologists, Audiologists ⢠Nurse midwives ⢠Clinical social workers, Clinical psychologists ⢠Dietitians / Nutritional professionals 16
- 17. Š 2016 Health Catalyst Proprietary and Confidential ⢠First year of Medicare participation ⢠Low volume threshold ⢠Participants in advanced APM Exceptions for MIPS 17
- 18. Š 2016 Health Catalyst Proprietary and Confidential Composite Performance Score (CPS) Measurement 18 Area Weight in 2019 (Changes by year) Quality 50% Cost (Resource use) 10% Clinical practice improvement activities (CPIA) 15% Advancing care information (Meaningful use of certified EHR technology) 25%
- 19. Š 2016 Health Catalyst Proprietary and Confidential ⢠Six measures with no domain required â select from over 300 measures (last 200 pages of regulation) ⢠One cross-cutting and one outcome measure required Cross cutting measure example Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed. Outcome measure example- CMS defines Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Quality â Weighted 50% 19
- 20. Š 2016 Health Catalyst Proprietary and Confidential Stakeholders 20 Source: https://www.cms.gov/Medicare/Quality -Initiatives-Patient-Assessment- Instruments/Value-Based- Programs/MACRA-MIPS-and- APMs/Final-MDP.pdf
- 21. Š 2016 Health Catalyst Proprietary and Confidential Clinical Care ⢠Measures incorporating patient preference and shared decision-making ⢠Cross cutting measures (more than one specialty) ⢠Outcome measures ⢠Focused measures for specialties that have clear gaps Safety ⢠Measures of diagnostic accuracy ⢠Medication safety related to important drug classes Initial Priorities for Measure Development 21
- 22. Š 2016 Health Catalyst Proprietary and Confidential Care coordination ⢠Assessing team-based care (timely exchange of data) ⢠Effective use of new technology such as telehealth Patient and caregiver experience ⢠PROMs (Patient-reported outcome measures) ⢠Additional topics important to patient/family/caregivers Affordable care ⢠Overuse measures Continued- Initial Priorities 22
- 23. Š 2016 Health Catalyst Proprietary and Confidential Population Health and Prevention ⢠Developing or adapting outcome measures at population levels to assess effectiveness of promotion and preventative services ⢠IOM Vital Signs topics ⢠Detection or prevention of chronic disease Continued â Initial Priorities 23
- 24. Š 2016 Health Catalyst Proprietary and Confidential ⢠Compare resources used to treat similar care episodes and clinical condition groups across practices ⢠Can be risk-adjusted to reflect external factors ⢠CMS will calculate from claims Resource â Weighted 10% 24
- 25. Š 2016 Health Catalyst Proprietary and Confidential MSPB Medicare Spend per Beneficiary Jan to Dec 2014 25 Period Claim Type Hospital State Nation 1 to 3 days Prior to Index Hospital AdmissionHome Health Agency 11$ 13$ 13$ 1 to 3 days Prior to Index Hospital AdmissionInpatient 12$ 4$ 5$ 1 to 3 days Prior to Index Hospital AdmissionOutpatient 117$ 70$ 117$ 1 to 3 days Prior to Index Hospital AdmissionDurable Medical Equipment 12$ 9$ 9$ 1 to 3 days Prior to Index Hospital AdmissionCarrier 456$ 535$ 532$ During Index Hospital AdmissionInpatient 13,433$ 9,456$ 9,108$ During Index Hospital AdmissionDurable Medical Equipment 33$ 21$ 24$ During Index Hospital AdmissionCarrier 2,216$ 1,617$ 1,514$ 1 through 30 days After Discharge from Index Hospital AdmissionHome Health Agency 846$ 785$ 771$ 1 through 30 days After Discharge from Index Hospital AdmissionHospice 96$ 108$ 118$ 1 through 30 days After Discharge from Index Hospital AdmissionInpatient 1,810$ 2,545$ 2,665$ 1 through 30 days After Discharge from Index Hospital AdmissionOutpatient 1,103$ 656$ 710$ 1 through 30 days After Discharge from Index Hospital AdmissionSkilled Nursing Facility 2,576$ 3,571$ 3,251$ 1 through 30 days After Discharge from Index Hospital AdmissionDurable Medical Equipment 150$ 94$ 101$ 1 through 30 days After Discharge from Index Hospital AdmissionCarrier 901$ 1,184$ 1,083$ Complete Episode Total 23,775$ 20,669$ 20,025$ Source: CMS Public Information
- 26. Š 2016 Health Catalyst Proprietary and Confidential Areas: (Not yet defined in detail but there will be 90+ activities and selection of one) ⢠Expanded practice access ⢠Population management ⢠Care coordination ⢠Beneficiary engagement ⢠Patient safety and practice assessment ⢠Participation in an APM Clinical Practice Improvement Activity (CPIA) â Weighted 15% 26
- 27. Š 2016 Health Catalyst Proprietary and Confidential ⢠Former Meaningful Use ⢠Use of certified electronic health record (EHR) technology in day-to-day practice ⢠Emphasis on interoperability and information exchange. ⢠Not all-or-nothing EHR measurement and no quarterly reporting. ⢠Removes reporting for CPOE(Computerized Provider Order Entry) and Clinical Decision Support Advancing Care Information â Weighted 25% 27
- 28. Š 2016 Health Catalyst Proprietary and Confidential Tweet from Andy Slavitt: In 2016, MU as it has existedâwith MACRAâ will now be effectively over and replaced with something better #JPM16 Slavitt said: âThe focus will move away from rewarding providers for the use of technology and towards the outcome they achieve with their patients.â Meaningful Use 28
- 29. Š 2016 Health Catalyst Proprietary and Confidential 1. Protect patient health information 2. Patient electronic access 3. Electronic prescribing 4. Coordination of care through patient engagement 5. Health information exchange 6. Public health and clinical data registry Six Objectives of Advancing Care Information 29
- 30. Š 2016 Health Catalyst Proprietary and Confidential For period of January 2017 to December 2017 1. Use 2014 or 2015 edition certified EHR 2. Report eight Stage 2 or six Stage 3 advancing care information measures/objectives 3. Attest that clinicians have cooperated with the surveillance of certified EHR technology under the ONC Health IT Certification Program 4. Attest to statements related to health information exchange and information blocking Technology 30
- 31. Š 2016 Health Catalyst Proprietary and Confidential Each of the four areas will have a scoring calculation and points Example for Advancing Care Information Scoring 31 Base Score 60 pts Performance Score10 pts Bonus Score Composite Score Area Maximum Points Scoring Quality 80-90 Each measure 1-10 compare to benchmark, bonus Cost (Resource use) Average score of cost Same as quality Clinical practice improvement activities 60 Each activity=10pt,double for high, compare to a target Advancing care information 100 Base + performance and bonus potential
- 32. Š 2016 Health Catalyst Proprietary and Confidential ⢠Converts measures/activities to points ⢠Eligible Clinicians will know in advance what they need to do to achieve top performance, targets will be communicated ⢠Partial credit available ⢠MIPS composite performance score in 4 weighted performance categories on a 100-point scale ⢠Option to do as a group More about scoring 32
- 33. Š 2016 Health Catalyst Proprietary and Confidential The CPS will be compared to the MIPS performance threshold to determine the adjustment percentage the eligible clinician will receive In the first five payment years $500 million in an additional performance bonus that is exempt from budget neutrality for exceptional performance. Scoring 33 Quality Resource Use Composite Performance Score Clinical Practice Improvement Advancing Care Information
- 34. Š 2016 Health Catalyst Proprietary and Confidential Payment adjustment Performance below Negative payment adjustment Performance above Neutral or positive payment adjustment Potential for bonus not to exceed 10% Adjustment % based on relationship between their CPS and MIPS threshold- budget neutral program 34
- 36. Š 2016 Health Catalyst Proprietary and Confidential MACRA does not change any existing APM programs or incentives 36
- 37. Š 2016 Health Catalyst Proprietary and Confidential ⢠Comprehensive ESRD Care Model (Large Dialysis organization)- 12 participants ⢠Medicare Shared Savings ProgramâTrack 2 and Track 3 â 24 participants ⢠Next Generation ACO Model -21 participants ⢠Comprehensive Primary Care Plus (CPC+) Currently regional with payers, available in 2017 ⢠Oncology Care Model Two-Sided Risk Arrangement (available in 2018) Models that Qualify for Advanced APM 37
- 38. Š 2016 Health Catalyst Proprietary and Confidential Criteria to meet: ⢠Payment based on quality (measures similar/comparable to MIPS) ⢠Use of certified EHR technology- at least 50% of providers ⢠Bear financial risk and risk must be at certain magnitude or be part of Medical home model expanded under CMMI It WILL be difficult to qualify for Advanced APM Advanced APM Eligible Programs 38
- 39. Š 2016 Health Catalyst Proprietary and Confidential Not only do you need to be part of an advanced APM, but you also need to be a QP (Qualified Provider) ⢠Based on advanced APM entity scoring and done for payment year ⢠% of payment and patients under advanced APM- based on 2017 Expanded Criteria 39
- 40. Š 2016 Health Catalyst Proprietary and Confidential CMS Calculates Threshold Score Payment amount formula for Threshold score % $ for Part B professional to attributed beneficiaries divided by $ for Part B professional to attribution-eligible beneficiaries Patient Count formula for Threshold score % # of attributed beneficiaries given Part B professional services divided by # of attributed-eligible beneficiaries given Part B professional services ** Partial QP can choose MIPS Use most favorable score 40 2019 QP 25% 2019 Partial QP 20% 2019 QP 20% 2019 Partial QP 10%
- 41. Š 2016 Health Catalyst Proprietary and Confidential Now QP in advanced APM ⢠Do not participate in MIPS ⢠Get 5% increase in fee schedule Met all criteria 41
- 42. Š 2016 Health Catalyst Proprietary and Confidential CMS estimates 30,000 to 90,000 clinicians in advanced APM. The costs for implementation and complying with the advancing care information performance category requirements could potentially lead to higher operational expenses. However, we believe that the combination of payment adjustments and long-term overall gains in efficiency will likely offset the initial expenditures. CMS believes that the proposed changes will have a positive impact and improve the quality and value of care provided to Medicare beneficiaries. Calculation for internal medicine â$1,100 to a positive of $1,900. Impact Projected by CMS 42
- 43. Readiness
- 44. Š 2016 Health Catalyst Proprietary and Confidential How optimistic are you that the April 27th proposed regulations will produce the results that CMS is expecting from MACRA? 1. Not at all â 20.28% 2. Somewhat â 38% 3. Optimistic â 12.59% 4. Very optimistic â 0% Poll Question #2 429 Total Responses
- 45. Š 2016 Health Catalyst Proprietary and Confidential Goals ⢠Set predictable updates for physician fee schedules ⢠Encourage physicians to participate in new payment models ⢠Both cost and quality ⢠Adopt interoperable electronic health record Is this encouraging consolidation? This is not cheap or simple. Joseph J. Fifer, FHFMA, CPA, President HFMA HFMA Comments 45
- 46. Š 2016 Health Catalyst Proprietary and Confidential May push independent physicians to a breaking point Reaction 46 âI am going to predict that more physicians will seek employment and figure that it is the health system problem to deal with the %s and give me the infrastructure to be successfulâ. Lee Sacks, M.D., Chief Medical Officer Advocate Health
- 47. Š 2016 Health Catalyst Proprietary and Confidential Take Medicare Part B revenue and annualize â adjust for volume and fee schedule increase of .5% ⢠What is impact of 4% reduction under MIPS? ⢠What investments do I need to participate? ⢠What is impact of 5% under APM? ⢠Have we explored these options and know investments? $25M of revenue has potential for negative impact of ($1M) â adjust for point scoring on MIPS Financial Impact 47
- 48. Š 2016 Health Catalyst Proprietary and Confidential Outline a strategy ⢠Do I know which track I want? ⢠What is impact on my practice? ⢠What do I need to do? ⢠What happens if I do nothing? ⢠What are we doing to move to value- based models? Deadline of Q3 2016 for outline. To Do #1
- 49. Š 2016 Health Catalyst Proprietary and Confidential Current strategy of organization, MACRA may help decision Applications due for ACO Next generation Letter of intent May 20, 2016 Application May 25, 2016 MSSP Notice of intent May 31, 2016 Application July 29, 2016 Link with Value Based 49
- 50. Š 2016 Health Catalyst Proprietary and Confidential Educate and communicate ⢠Provide clinicians with summarized documents. ⢠Use webinars. ⢠Make time in current meeting structure for education on topic. ⢠Staying informed will ease stress. To Do #2
- 51. Š 2016 Health Catalyst Proprietary and Confidential Connect locally and use their websites AMA â http://www.ama-assn.org/ama/pub/advocacy/topics/medicare- physician-payment-reform.page AHA â http://www.aha.org/advocacy-issues/physician/index.shtml AAFP â http://www.aafp.org/practice-management/payment/medicare- payment.html Use professional societies MACRA READY program To Do #3
- 52. Š 2016 Health Catalyst Proprietary and Confidential Identify thought leaders and discuss To Do #4 ⢠Who has been your thought leader? ⢠Can be someone in healthcare or can you explain to someone outside of healthcare to get feedback?
- 53. Š 2016 Health Catalyst Proprietary and Confidential Look inward, know your strengths ⢠What do you think you do well? ⢠Where do you have data that shows you do well? ⢠Which measures show how well your practice performs? ⢠Do you have an performance plan in place to improve? ⢠Who has accountability for performance? Source: Bobbi Brown Art To Do #5
- 54. Š 2016 Health Catalyst Proprietary and Confidential Review your QRUR and Meaningful Use Submission ⢠Talk with the individuals that completed the work in PQRS and MU. ⢠What can you learn? ⢠What applies to MIPS? To Do #6
- 55. Š 2016 Health Catalyst Proprietary and Confidential QRUR Report 55 Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeedbackProgram/Downloads/QRUR-Quick-Ref-Guide.pdf
- 56. Š 2016 Health Catalyst Proprietary and Confidential Evaluate readiness/Execute You now have a plan and can do a quick check on reality based on your practice. You know where you have penalties and where you need to change. You need data, best practices and an adoption methodology to succeed. Source: Health Catalyst To Do #6
- 57. Š 2016 Health Catalyst Proprietary and Confidential Questions 57 Bobbi Brown Bobbi.brown@healthcatalyst.com Bryan T. Oshiro, M.D. Chief Medical Officer bryanoshiro@healthcatalyst.com
- 58. Š 2016 Health Catalyst Proprietary and Confidential Healthcare Analytics Summit 16 Hereâs a sneak preview ⌠Industry-leading Speakers Don Berwick, M.D. Former Administrator, Centers for Medicare and Medicaid Services Founding CEO, Institute for Healthcare Improvement Summit highlights 3-day Agenda Weâve increased the time of this yearâs summit to allow for more sessions, topics, and networking. CME Accreditation for Clinicians This activity has been approved for AMA PRA Category 1 Creditsâ˘. More Case Study Sessions Health system case studies addressing even more clinical, technical, operational, and financial examples. Hands-On Experiences Examples, vignettes, and audience-based activities demonstrate principles in fun and memorable ways. Analytics-Driven Engagement Real-time polling, networking, Q&A, and gamification experiences Networking Experience networking options that use analytics creatively to help you find and connect with others. Pre-Summit Classes and Training An early half-day of pre-session classes and training options specifically for Health Catalyst clients. 3X the sessions 8 keynotes, 25 breakouts, 30-40 analytics walkabout mini-sessions Buy 1 (save $300) $495/Pass (through May 27) Buy 3 (save $1,050) $445/Pass (through May 27) Buy 5+ (save $2,000) $395/Pass (through May 27) Liz Wiseman President, theWiseman Group Bestselling Author, Speaker & Executive Advisor Anne Milgram Former NJ Attorney General Senior Fellow at NYU School of Law, Vice President of Criminal Justice, Laura and John Arnold Foundation Eric Siegel, Ph.D. President, Prediction Impact, Inc. Best Selling Author and Founder of Predictive Analytics World Taylor David VP, Analysis & Strategy, KLAS KLASâs lead statistician, Associate Professor of Statistics of Utah David Eccles School of Business Early Registration Pricing, Optimized For Teams