MACRA, MIPS, APMs and Other Weird Acronyms (OWAs)

Mark A. Levine, MDChief Medical Officer, Denver

Montana Medical AssociationMarch 2016

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CMS support of health care Delivery System Reform will result in better care, smarter spending, and healthier people

Key characteristics Producer-centered Incentives for volume Unsustainable Fragmented Care

Systems and Policies Fee-For-Service Payment

Systems

Key characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care

Systems and Policies Value-based purchasing Accountable Care Organizations Episode-based payments Medical Homes Quality/cost transparency

Public and Private sectors

Evolving future stateHistorical state

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MACRA: What is it?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is:

• Bipartisan legislation repealing the Sustainable Growth Rate (SGR) Formula• Changes how Medicare rewards clinicians for value over volume• Created Merit-Based Incentive Payments System (MIPS) that streamlines

three previously separate payment programs:

• Provides bonus payments for participation in eligible alternative payment models (APMs)

Physician Quality Reporting Program

(PQRS)

Value-Based Payment Modifier

Medicare EHRIncentive Program

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MACRA is part of a broader push towards value & quality

In January 2015, the Department of Health and Human Services announced new goals for value-based payments and APMs in Medicare

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…and toward transforming our health care system.

3 goals for our health care system:

Incentives

BETTER careSMARTER spendingHEALTHIER people

Care Delivery

Information Sharing

Via a focus on 3 areas

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What is “MACRA”?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015.

What does Title I of MACRA do?

• Repeals the Sustainable Growth Rate (SGR) Formula• Changes the way that Medicare rewards clinicians for value over

volume • Streamlines multiple quality programs under the new Merit-Based

Incentive Payments System (MIPS) • Provides bonus payments for participation in eligible alternative

payment models (APMs)

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MACRA Goals

Through MACRA, HHS aims to:

• Offer multiple pathways with varying levels of risk and reward for providers to tie more of their payments to value.

• Over time, expand the opportunities for a broad range of providers to participate in APMs.

• Minimize additional reporting burdens for APM participants.

• Promote understanding of each physician’s or practitioner’s status with respect to MIPS and/or APMs.

• Support multi-payer initiatives and the development of APMs in Medicaid, Medicare Advantage, and other payer arrangements.

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MIPS changes how Medicare links performance to payment

MACRA streamlines those programs into MIPS:

Merit-Based Incentive Payment System (MIPS)

Physician Quality Reporting

Program (PQRS)

Value-Based Payment Modifier

Medicare EHRIncentive Program

There are currently multiple individual quality and value programs for Medicare physicians and practitioners:

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How will physicians and practitioners be scored under MIPS?

A single MIPS composite performance score will factor in performance in 4 weighted performance categories:

MIPS Composite

Performance Score

Quality Resource use

Clinical practice

improvement activities

Meaningful use of

certified EHR technology

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How much can MIPS adjust payments?

• Based on the MIPS composite performance score, physicians and practitioners will receive positive, negative, or neutral adjustments up to the percentages below.

• MIPS adjustments are budget neutral. A scaling factor may be applied to upward adjustments to make total upward and downward adjustments equal.

MAXIMUM Adjustments

Adjustment to provider’s base rate of

Medicare Part B

payment

Merit-Based Incentive Payment System (MIPS)

4% 5% 7% 9%

2019 2020 2021 2022 onward

-4%-5% -7%-9%

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Are there any exceptions to MIPS adjustments?

There are 3 groups of physicians and practitioners who will NOT be subject to MIPS:

FIRST year of Medicare participation

Participants in eligibleAlternative Payment

Models who qualify for the bonus payment

Below low volume threshold

Note: MIPS does not apply to hospitals or facilities

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Alternative Payment Models (APMs)

CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)

MSSP (Medicare Shared Savings Program)

Demonstration under the Health Care Quality Demonstration Program

Demonstration required by Federal Law

According to MACRA law, APMs

include:

APMs are new approaches to paying for medical care through Medicare that incentivize quality and value.

• MACRA does not change how any particular APM rewards value.• APM participants who are not “QPs” will receive favorable scoring under MIPS.• Only some of these APMs will be eligible APMs.

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How does MACRA provide additional rewards for participation in APMs?

APM participants

QPs

Those who participate in the most advanced APMs may be determined to be qualifying APM participants (“QPs”). As a result, QPs:1. Are not subject to MIPS2. Receive 5% lump sum bonus payments for years

2019-20243. Receive a higher fee schedule update for 2026

and onward

Most physicians and practitioners who participate in APMs will be subject to MIPS and will receive favorable scoringunder the MIPS clinical practice improvement activities performance category.

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What is an eligible APM?

Eligible APMs are the most advanced APMs that meet the following criteria according to

the MACRA law:

Base payment on quality measures comparable to those in MIPS

Require use of certified EHR technology

Either (1) bear more than nominal financial risk for monetary losses OR (2) be a medical home model expanded under CMMI authority

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How do I become a qualifying APM participant (QP)?

QPs are physicians and practitioners who have a certain % of their patients or payments through an eligible APM.

Beginning in 2021, this threshold % may be reached through a combination of Medicare

and other non-Medicare payer arrangements, such as private payers and

Medicaid.

QPs:1. Are not subject to MIPS2. Receive 5% lump sum bonus payments for years 2019-

20243. Receive a higher fee schedule update for 2026 and

onward

eligible APM QP

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Potential value-based financial rewards

MIPS adjustments

MIPS only

APM-specific rewards

+MIPS

adjustments

APMs

eligible APM-specific rewards

+5% lump sum

bonus

eligible APMs

• APMs—and eligible APMs in particular—offer greater potential risks and rewards than MIPS. • In addition to those potential rewards, MACRA provides a bonus payment to providers committed to

operating under the most advanced APMs.

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Independent PFPM Technical Advisory Committee

PFPM = Physician-Focused Payment Model

Encourage new APM options for Medicare physicians and practitioners.

Technical Advisory

Committee(11 appointed care delivery

experts)

Submission of model proposals

Review proposals, submit

recommendations to HHS Secretary

Secretary comments on CMS

website, CMS considers testing proposed model

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What should I do to prepare for MACRA?

• Look for future educational activities

• Look for a proposed rule in spring 2016 and provide comments on the proposals.

• Final rule targeted for early fall 2016.

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Preparing for MACRA

TCPIThe Transforming Clinical Practice Initiative

Clinical Practice Leaders Have Already Charted the Pathway to Practice Transformation

Traditional ApproachPatient’s chief complaints or reasons for visit determines care.

Care is determined by today’s problem and time available today.

Care varies by scheduled time and memory/skill of the doctor.

Patients are responsible for coordinating their own care.

Clinicians know they deliver high quality care because they are well trained.

It is up to the patient to tell us what happened to them.

Transformed PracticeWe systematically assess all our patients’ health needs to plan care.

Care is determined by a proactive plan to meet patient needs.

Care is standardized according to evidence-based guidelines.

A prepared team of professionalscoordinates a patient’s care.

Clinicians know they deliver high quality care because they measure it and make rapid changes to improve.

You can track tests, consults, and follow-up after the ED and hospital.

Adapted from Duffy, D. (2014). School of Community Medicine, Tulsa, OK. 22

Transforming Clinical Practice Goals

Support more than 140,000 clinicians in their practice transformation work

Improve health outcomes for millions of Medicare, Medicaid and CHIP beneficiaries and other patients

Reduce unnecessary hospitalizations for 5 million patients

Generate $1 to $4 billion in savings to the federal government and commercial payers

Sustain efficient care delivery by reducing unnecessary testing and procedures

Transition 75% of practices completing the program to participate in Alternative Payment Models

Build the evidence base on practice transformation so that effective solutions can be scaled

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Key Accountabilities of Practice Transformation Networks

• Commit to pursue and achieve the quantitative AIMS of the initiative

• Recruit clinicians/practices and build strategic partnerships: secure more commitments

• Lead practices in continuous improvement and culture change to achieve specified AIMS

• Facilitate improved clinical practice management

• Utilize quality measures and data for improvement

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Practice Transformation Networks (PTNs)• Arizona Health-e Connection • Baptist Health System, Inc. • Children's Hospital of Orange County • Colorado Department of Health Care Policy

& Financing • Community Care of North Carolina, Inc. • Community Health Center Association of

Connecticut, Inc. • Consortium for Southeastern Hypertension

Control • Health Partners Delmarva, LLC • Iowa Healthcare Collaborative • Local Initiative Health Authority of Los

Angeles County • Maine Quality Counts • Mayo Clinic • National Council for Behavioral Health

• Nat’l Rural Accountable Care Consortium • New Jersey Innovation Institute • New Jersey Medical & Health Associates dba

CarePoint Health • New York eHealth Collaborative • New York University School of Medicine • Pacific Business Group on Health • PeaceHealth Ketchikan Medical Center • Rhode Island Quality Institute • The Trustees of Indiana University • VHA/UHC Alliance Newco, Inc. • University of Massachusetts Medical School • University of Washington • Vanderbilt University Medical Center • VHQC • VHS Valley Health Systems, LLC • Washington State Department of Health

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Support & Alignment Networks (SANs)

• American College of Emergency Physicians • American College of Physicians, Inc. • American College of Radiology • American Medical Association • American Psychiatric Association • HCD International, Inc. • National Nursing Centers Consortium• Network for Regional Healthcare Improvement • Patient Centered Primary Care Foundation • The American Board of Family Medicine, Inc.

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Key Accountabilities of Support & Alignment Networks

• Commit to pursue and achieve the quantitative AIMS of the initiative.

• Align Their Multiple Programs and Drivers with Aims & Activities of TCPI Initiative:• Continuing Medical Education• Maintenance of Certification• Registries• Journals, Newsletters, Messaging to Members• Professional Standards & Requirements• Annual Meetings• Awards Programs

• Recruit Members Into Initiative and Sustain Their Active Engagement Over 4 Years

• Support Practices with Patient & Family Engagement

6 Key Benefits to Participating Clinicians

1. Optimizes health outcomes for your patients2. Promotes connectedness of care for your patients3. Learn from high performers how to effectively

engage patients and families in care planning4. More time spent caring for your patients5. Stronger alignment with new and emerging federal

policies6. Opportunity to be a part of the national leadership

in practice transformation efforts

http://www.healthcarecommunities.org/CommunityNews/TCPI.aspx28

http://www.healthcarecommunities.org/CommunityNews/TCPI.aspx 29

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National Rural ACC

National Rural Accountable Care Consortium

The Consortium works with Primary Care Providers and specialists who work in the outpatient setting, including all of those on the 2015 PQRS List of Eligible Professionals. Our primary focus are those working in rural settings, including CAHs, FQHCs, RHCs, and rural fee-for-service providers. We will also include some urban and semi-urban providers who are part of rural referral networks.

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Vizient

VHA, Inc. and University HealthSystem Consortium (UHC) merged in 2015 and the new company name is Vizient, Inc. The membership of legacy VHA is comprised mainly of community based hospitals and the membership for legacy UHC includes over 100 academic medical centers.

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WWAMI PTN

The WWAMI PTN leverages existing relationships among eight owned and operated entities of UW Medicine, nine additional member organizations comprising the UW Medicine Accountable Care Network, and twenty-four organizations of the WWAMI-region Practice and Research Network.

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Questions? Comments?

Mark A. Levine, MDChief Medical Officer, Denver

(303) 844-7070Mark.Levine@cms.hhs.gov

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Disclaimers

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

This presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

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