MACRA and Beyond - Global Health Care, LLC legislation signed into law on April 16, 2015. MACRA...
Transcript of MACRA and Beyond - Global Health Care, LLC legislation signed into law on April 16, 2015. MACRA...
MACRA and Beyond: APM Payment Innovation: Surgical Episodes
National MACRA
MIPS/APM SummitHyatt Regency on Capitol Hill
December 2, 2016
Medicare Payment Prior to MACRA
The Sustainable Growth Rate (SGR)• Established in 1997 to control the cost of Medicare
payments to physicians
Fee-for-service (FFS) payment system, where clinicians are paid based onvolume of services, not value.
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Target Medicare
expenditures
Overall physicia n costs
>I F Physician
payments cut across the board
The Medicare Access and CHIP Reauthorization Act of 2015: bipartisan legislation signed into law on April 16, 2015.
MACRA reconfigures the physician payment landscape:1.
Repeals the Sustainable Growth Rate (SGR) formula
2.
Changes the way that Medicare rewards physicians for value over volume
3.
Streamlines multiple quality programs under the new Merit‐based Incentive Payment System (MIPS)
4.
Incentivizes the development of Alternative Payment Models (APMs)
5.
Preserves global surgical payments
What is “MACRA”?
Our World After MACRAMedicare Access and CHIP Reauthorization Act of 2015
Revisions to Payment Policies under the Physician Fee Schedule
and Other Revisions to Part B, CY 2017
APMsMIPS
G CodesGXXX1‐5
Our World After MACRAMedicare Access and CHIP Reauthorization Act of 2015
Revisions to Payment Policies under the Physician Fee Schedule
and Other Revisions to Part B, CY 2017
APMsMIPS
G CodesGXXX1‐5
“MandatoryCABG
Bundle”
Score will factor in performance across four categories:
MIPS Score
Quality: PQRSResource use: VBMCPIA: new, Registry
Year 1 Performance Category Weights for MIPS
QUALTY 50%
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ADVANCING CARE
INFORMATION (Meaningful Use)
25%
CLINICAL PRACTICE
IMPROVEMENT ACTIVITIES
15%
Resources Use10%
201
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2018 July 2019 2020
1st Feedback Report (July)
Analysis and Scoring
Performance Period
(Jan-Dec)
Reporting and Data Collection
2nd Feedbac k Report (July)
Targeted Review
Based on 2017 MIPS
Performance
MIPSAdjustments
in Effect
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Proposed Rule: MIPS Timeline
Alternative Payment Models
• Purpose: Increase quality while reducing cost and resource use.
MACRA Incentives Nudging Physicians into APMs:
APMs and MACRA
• Only a subset of APMs—those deemed “advanced APMs”—
will be Qualified APM Participants (QPs) eligible for
the 5% bonus under MACRA.
• All others fall under MIPS.
Advanced Alternative Payment Model(s)
• Advanced APMs meet the following criteria set forth in MACRA:
Base payment on quality measures similar to
those in MIPS
Use of certified EHR
Bear “more than nominal” risk
Most clinicians will be subject to MIPS.
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Not in APM In non-Advanced APM
QP in Advanced APM
Note: Figure not to scale.
Subject to MIPS
Some people may be in Advanced APMs but
not have enough payments or patients through the Advanced
APM to be a QP.
In Advanced APM, but not a QP
Who Designs and Reviews an APM?
• Physician‐focused Payment Model Technical Advisory Committee (PTAC)
• Health Care Payment Learning and Action Network (HCP‐LAN)
• STS in process of becoming “Committed Partner”
• Physicians developing APMs:– Brandeis & American College of Surgeons – STS White Paper
Who Designs and Reviews an APM?
• Physician‐focused Payment Model Technical Advisory Committee (PTAC)
• Health Care Payment Learning and Action Network (HCP‐LAN)
• STS in process of becoming “Committed Partner”
• Physicians developing APMs:– Brandeis & American College of Surgeons – STS White Paper
G Codes……GeeWhiz
RAND recommended a set of time‐based post‐ operative visit codes that could be used for
reporting care provided during the post‐ operative period
Applied to a REPRSENTATIVE Sample of Surgical Pts.‐Time/Intensity Values
G Codes……GeeWhiz
What does this mean?•In MACRA, we were able to block dissolving of 90
day Globals•CMS didn’t like that
•They have gone outside of legislative directives to est G codes, starting Jan 1 2017
•STS developed strategies with ACS, AMA,AAOS, AANS, SVS to challenge this Rule and its
implementation (Doc Caucus, Individual lobbying efforts with Congress)
•Final Rule, Federal Register Nov.15,2016‐DROPPED
CMS Proposed Rule for “Mandatory Bundle for CABG”
• Under Social Security Act (Section 1115A) authorizes the
Innovation Center‐CMS to test innovative payment models
• Fee for Service: separate payments to providers for services
• Amount of payments dependent on Volume; providers may
not have incentives to invest in quality‐improvement and/or
care‐coordination services—as result, care may be
fragmented or unnecessary
• The Goal of Proposed EPMs: improve quality of care
provided to beneficiaries in episodes while reducing
spending through Financial Accountability
Episode Payment Models=EPMs
CMS Proposed Rule for “Mandatory Bundle for CABG”
Proposed EPMs: • Acute Myocardial Infarction (AMI)• Coronary Artery Bypass Graft (CABG)• Surgical hip/femur fracture treatment (SHFFT) excluding
lower extremity Joint Replacement• PURPOSE: TEST whether the proposed models would
benefit Medicare beneficiaries by improving the
coordination and transition of care, encourage more
provider investment in infrastructure and redesigned care
processes for higher‐quality and more efficient service
delivery• Propose to test EPMs for 5 years: July 1,2017‐December 31,
2021
Directive to Hospitals for Care Redesign
• Increasing post‐hospitalization follow‐up and medical mgt. for
patients
• Coordinating across the inpatient and post‐acute care spectrum• Conducting appropriate discharge planning• Improving adherence to treatment or drug regimens• Reducing readmissions and complications during post‐discharge
period
• Managing chronic diseases and conditions related to the EPM
episodes
• Choosing the most appropriate post‐acute care setting• Coordinating between providers and suppliers such as hospitals,
physicians, and post acute‐acute care providers
Proposed Models allow CMS to gain Additional Experience with Episode‐ Payment Approaches
• Variance in historic care and utilization patterns• Patient population and Care patterns• Variance in roles within the local markets• Variance in volumes of services• Variance in levels of access to financial community• Variance in levels of population and health‐care
provider density• Variations in use of different categories of post‐acute
care providers
Summary of Payment
• EPM participants’
quality performance also would be assessed at reconciliation; each
participant would receive composite quality score and quality category.
• EPM participants that achieve quality category as “acceptable”
or higher are eligible for payment.
• Proposed measures for CABG model: All‐ Cause,30 Day, Risk‐Standardized Mortality Rate
following CABG (NQF #2558)
Strategic Building Blocks • Collaborative structure• Clinical/financial database *• Data integrity• Performance measures• Cost estimation (tied to clinical)• Dashboards (tied to decisions)• Control of care processes *• Incentive and savings models *
• * Landmine
VCSQI’s Purpose
Facilitate collaboration between hospitals and physicians to improve
clinical quality across an entire state in programs of all sizes through data sharing, outcomes analysis, and
process improvements
A Focus on Quality
A focus on quality contains costs in cardiac surgical care by
lowering complications, improving efficiency, and reducing resource use
Additive Costs: Primary and Secondary Complications (CABG- only)
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$26,056 $26,056 $26,056 $26,056 $26,056 $26,056 $26,056
$2,700 $4,000 $9,800$25,700 $22,900
$11,000$23,500
$9,300$16,100
$24,200
$14,900 $26,200$38,100
$39,300
Co‐morbidityPrimaryCABG Baseline
Focused Initiatives to Potentially Lower Complications and
Reduce Costs
• Atrial Fibrillation• Glucose Management
• Transfusion• Early Extubation
Difference in cost of care of study population undergoing CABG between transfused and non-
transfused groups for the two year interval:
$44,000,000
2002-2004: VCSQI Submits Unsolicited
Demonstration to CMSApproved by HHS Secretary Tommy
Thompson-Dec. 2004
Presented at STS Annual meeting by Sec. Thompson-Jan.2005
Key elements of CMS Demonstration for Cardiac
Surgery• Alignment of Cardiac Surgeons, Cardiologists, Subspecialists, Hospitals providing CABG, Valve
Replacement/repairs w/without Cath.• Global pricing methodology developed within each
participating provider group• Rates for DRGs agreed upon with CMS-providers
with risk methodology established• Episode of care for surgical procedures extended to
90 days• Incentives created within Demonstration for improved
quality associated with decreased costs
• OIG Cautions VCSQI – CMS Demo May Violate Stark / CMP Laws due to
Incentive Structure – 2006
• This Demonstration served as a model for the recently approved ACE
Demonstration from CMS in Cardiac Surgery and Orthopedics (Joint
Replacement)-Texas, Oklahoma, New Mexico, Colorado
• All recognized Key elements included
Demonstration Methodology
• Despite financial alignment, there remains distrust of each provider of others, PHYSICIAN BUY-IN
• Billing and cost accountability remains unique to each patient, no uniform system in place for providers and/or insurers
• Often there are unacceptable time delays in reimbursement to providers
• Significant infrastructure required by all participants to account for each bill-not covered by insurers borne solely by providers
• Post acute care costs are relevant-no consensus as to coverage of care and by whom –SURGEONS ARE HELD ACCOUNTABLE TO 90 days!!!!!