Navigating the Valley between Volume and Value

Cathie Biga

Illinois ACC

cbiga@cardiacmgmt.com

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MACRA Readiness

FACC

The Tipping Point at Altitude

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Triple Aim in 2016

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The march to value……..

The train has left the station, and it ain’t coming back

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Triple Aim

Manage Population Health

Enhance the Experience of

Care

Reduce Per Capita Cost

Ideal Care System

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HHS mandate followed by MACRA

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The Basics of MACRA

• MACRA = Medicare Access & CHIP Reauthorization Act

• Eliminate SGR

• Effective 1/1/19 • BUT data collection begins 1/1/17

• Payment updates • 2016 was negated

• MACRA • APM

• MIPS

January 1, 2019

Rapid Pace of Change Continues

• MIPS changes

• APM changes

• Episodes of Care

• Attribution

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Advancing Care Information: 25%

• 131 points (100 = 25% credit) • Removed all or nothing

approach • Customized set of measures • Base score + performance

Clinical Practice Improvement (15%) • 60 points • Weighted activities

• 10-20 points • 90 activities • APM’s = ½ credit

Quality/PQRS: 50%

• 80-90 points • 6 measures (1 cross

cutting) • OR • specialty measure set • Population measures

Resource Use: 10% • 10 points per

measure • Claims based • Total cost per capita • MSPB • Episode-based

measures

MIPS Composite Score

Quality 50%

Resource Use: 10%

EHR Meaningful

Clinical Practice Improvement: 15%

Quality Use: 50%

Allocation change announced: 4/8/16

What are we seeing in this proposal

• Reduce reporting burdens

• Adds flexibility

• Accountability

• Negative performance can NOT be > 4%

• Positive performance should be 4% with some bonuses

• If in a qualifying APM BUT don’t qualify for incentive – they can elect MIPS

• 1/1/17 – data collection begins

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Summary

• Quality – 50% of total

• Replaces PQRS and quality component of VM

• Changes will allow for variances between specialties

• Groups 2-9: 2 claims based population measures

• Groups > 10: 3

• 80 or 90 possible points

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Core Measure set

• Announced in April 2016 • Measure sets:

• Cardiology • Gastroenterology • HIV and Hepatitis C • Medical Oncology • Obstetrics and Gynecology • Orthopedics • ACO

• Measure Development Plan released yesterday

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Summary

• Advancing Care Information aka MU • Replaces the Medicare EHR program

• New emphasis on interoperability and information exchange

• Eliminates the current all or nothing program

• Clinical Practice Improvement • New in MIPS

• 90 options – including participating in APM’s and pt. centered homes

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Are your clinics ready?

Cost

• Each cost measure worth up to 10 points

• If 20 pt. sample not met – revert to average

• MSPB

• Total cost per beneficiary

• 40 episodes

BOTTOM LINE:

No Outcome…….No Income

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Transparency

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Physician Value Agenda

• Meaningful Use • PQRS • Value modifier

• QRUR report • Exhibits

• Supplemental QRUR • Drill Down exhibits

• Physician Compare

• Know the interaction amongst and between

these

Total at risk payments thru 2017

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QRUR……

Supplemental QRUR

MACRAeconomics

• Current PQRS report cards

• 43% of cardiology was Unsuccessful in ‘14

• Current MU report cards

• VM (5,477 providers were penalized – ’14 data)

• QRUR

• Supplemental QRUR

• Is physician comp tied to quality?

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Are you MACRA ready?

• Organizational focus

• Currently successful in

• PQRS

• MU

• VM

• You have found your data

• You know your numbers

• Reducing variability is a priority

• Understanding cost per case and episodes of care

• Care coordination is an organizational priority

• Documentation is a focus – clinic & hosp.

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What we don’t have time for

Risk Adjusted scores

• Your documentation matters

• It only counts if it is BILLED • What is your average number

Dx/claim

• It MUST have specificity • What are your top 10

diagnosis

Attribution

• Two step process • Total cost in QRUR

• Cost per the 4 index conditions

• MSPB • 3 days pre and 30 days post

• Condition Episodes

• Procedural Episodes

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Stay tuned

Part 2:

Alternate payment models & other updates

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ACO update

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• 477 ACO’s as of 1/31/16 (433 MSSP) • 8.9% of the population is in an ACO • Top states: Il, CA, FL, MA, TX, PA, NY

• ACO’s in 49 states

• MSSP welcomed 100 new ACOs, adding 15,000 more participating physicians, on January 1, 2016

• With the new group of ACOs, CMS will have 434 ACOs participating in the Shared Savings Program next year, serving more than 7.7 million beneficiaries

Alternative Payment Models

ACO’s

Pioneer model

• Medicare: 3 models MSSP model Next Generation model (proposed) • Medicaid

• Commercial

Where are we in 2016

447 ACO’s including MSSP, Pioneer, NG, ESRD 64 are in a Qualifying APM (22 in MSSP 2/3)

Distribution of ACO’s

BPCI NextGen

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Advanced Alternative Payment Models

• Data year 2017 • Data year 2019 (2021) – private payer/Medicaid • Everyone will report MIPS yr. 1 • Qualifying APM’s:

• Comprehensive ESRD Care Model • Comprehensive Primary Care Plus (CPC+) • Medicare Shared Savings Program—Track 2 & 3 • Next Generation ACO Model • Oncology Care Model Two-Sided Risk Arrangement

(available in 2018)

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Pulling it all together: Value Based Future

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DEGREE OF INTEGRATION

LEV

EL O

F FI

NA

NC

IAL

RIS

K

MIPS

Qualified APM

Performance-Based Contracts

Fee for Service

Global Payments

Shared Savings

Bundled/Episode Payments

*Potentially Qualified APM

APM

Shared Risk

* Must have more than nominal risk & threshold dependent – 2021 includes Non-Medicare population

Decision points

• Working/reporting individually vs as a group

• Attribution

• Documentation

• Risk scores

• CMI

• Episodes of care

• RFI completed

• Proposed ruling coming

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Basic episode

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Ortho to cardiac….

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CAD Episode

• Goals: • Patient level: improve quality of life for CAD pts.

• Reduction in AMI

• System level: Increase rate of value services, reduce complications and inappropriate procedures

• Overarching Design = Nested episode • CAD – payment for 12 months of preventive care

• CAD procedures “nested” – sub-bundle payment • Within the course of the condition episode

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Game changer?

• Did not want to repeat procedure episode

• Procedure within episode – incentivizes the use of low-resource tools (meds/life style) with the goal of avoiding the procedure

• Nested episode drives collaboration

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What it might look like

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The makeup of a “nested” episode

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Variability of care…

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Our Service Lines

• Continue to align CV care across the continuum

• Partnering in Value Programs

• Active in Episode calculations

• Same day discharges

• Radial approach

• 2 mid-night rule

• New Observation rules are here

• Moving from a wRVU comp model

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CMS Hospital Quality Incentives and Penalties

CMS at risk dollars for Quality are 6.5% of Total Medicare Reimbursement in the current Fiscal Year, and will escalate to 11% over the next 5 years.

2011 2012 2013 2014 2015 2016 2017 2018 2019

Note: The above is the CMS Fiscal Year Payout Period.

The Performance Period is generally the Calendar Year Two Years

Prior.

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Originally mandated by section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. this authorized CMS to pay hospitals that successfully report quality measures a higher annual update to their payment rates.

In addition to giving hospitals financial incentive to report the quality of services, the program provides CMS with data to help consumers make more informed decisions about their health.

This information is available on the Hospital compare website

Inpatient Quality Reporting (IQR) Program

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Public Reporting and Our Hospitals

• 2005: TJC and CMS

• Hospital Compare • Payment & value for specific diagnosis

• Readmissions and mortality

• Timely and effective care

• Value Based Purchasing

• 5 – Star Ratings • Totally revised

• Soon to be released

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Remember the Programs

• Hospital acquired conditions

• Hospital Readmission Reduction

• CABG joins the ranks of CHF and MI

• Hospital Inpatient Reporting (IQR)

• Cost of CHF

• Cost of MI

• MU

• Value Based Purchasing

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CMS Value Based Purchasing

Clinical Process of

Care 20%

Outcomes 30%

Patient Experience

of Care 30%

Efficiency 20%

Payment Period FY 2015

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CMS is rapidly changing the weighting of each Value Based Purchasing Domain as well as the content within each domain making systematic and proactive performance improvement more difficult.

FY 2014 FY 2015 FY 2016

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2017

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2018….change marches on

• New domains all equally weighted:

• Clinical Care

• Pt. and caregiver experience

• Safety

• Efficiency and Cost reduction

• And in the future

• Adding COPD mortality

• A 30 and 36 month outcome on Hip and Knee

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Questions??

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