Physician Adoption of Value Based Care

Carol Vargo, MHS, Director, Physician Practice Sustainability

Montgomery County Medical Society

May 4, 2016

Physician Adoption of Value Based Care

© 2015 American Medical Association. All rights reserved.

Agenda

• Background on AMA Strategic Focus on Physician Professional

Satisfaction and Practice Sustainability

• Research Overview of Impact of New Payment Models on Physician

Practices

• Overview of MACRA

• AMA Tools and Resources to Assist Physicians in New Payment

Adoption

2


AMA Physician Satisfaction and Practice Sustainability

Goals and Objectives

AMA’s goal is to identify, support, and grow the

evidence-based models of care delivery and

payment that promote the long-term sustainability

of and satisfaction with medical practice, and lead

to improvement in the cost and quality of American

health care.

3


Internal to Physician Practices External to Physician Practices

Practice

Transformation

(STEPSForward)

Physician

Payment

Professional Satisfaction and Practice Sustainability

Digital

Health

Public Policy/Advocacy

Physician

Organizational

Relationships

Physician

Leadership

Training

Research

4

Creating Thriving Physician Practices


Physician Payment Models

A proliferation of new payment models impacting physician practices…

– Global payment (a.k.a., capitation)

– Shared savings (e.g., ACO)

– Medical home

– Bundled payments

…How these practices are reacting remains a black box

AMA/Rand “Effects of Health Care Payment Models

on Physician Practice in the United States”

5

Payment

models

Physician

practicesPatient care

– Hospital-physician gainsharing

– Pay-for-performance

– Subscription/retainer models


Organizational level, alternative payment models have…

• encouraged practices to consider merging or become affiliated with large provider or hospital organizations

• encouraged practices to develop team approaches to care management and new modes of patient access

to care. Relationships between physicians (e.g., referral patterns) have changed.

• increased the importance of data and data analysis, highlighting data deficiencies and inaccuracies

• conflicted with each other and with government regulations, complicating practices’ abilities to respond in a

constructive manner

Features of payment model implementation

Problems in data integrity and timeliness, errors in payment model execution (including inaccurate

measure specification and patient attribution), incomprehensible incentives, and concerns about

measure validity.

Key Findings

6


Implications

• Physician practices need support and guidance to optimize the quantity and

content of physician work under alternative payment models

• Challenge: manage multiple simultaneous changes without burning out physicians

• Addressing physicians’ concerns about the operational details of alternative

payment models could improve their effectiveness

• To succeed in alternative payment models, physician practices need data and

resources for data management and analysis

• Harmonizing key components of alternative payment models, especially

performance measures, would help physician practices respond constructively

7


Next Steps

8

AMA/Rand “Effects of Health Care

Payment Models on Physician Practice

in the United States” Report

Influence

Public Payment Policy

Influence

Private Payment Policy

Offer Information, Tools,

and Resources

to Physicians/Practices

The Medicare Access and CHIP

Reauthorization Act of 2015 (MACRA)


MACRA

• P.L. 114-10 (H.R. 2) the Medicare Access and CHIP Reauthorization Act

of 2015 (MACRA)

• Developed in bipartisan, bicameral process over 2+ years

• Supported by over 750 national and state-based physician

organizations

• Passed House of Representatives March 26, 392-37

• Passed Senate April 14, 92-8

• Permanently eliminates the SGR, which has been producing Medicare

physician payment cuts annually since 2002

9


MACRA improvements over current law

Negative Updates for foreseeable future (-21.2% in 2015)

Multiple overlapping, rigid, and sometimes contradictory reporting and penalty programs

Little support for new payment and delivery models outside CMMI and ACO programs

Modest but positive updates for 5 years, and then again in 2026 and beyond

Consolidated Merit-based Incentive Payment System (MIPS) with greater alignment and flexibility, potential for significant bonuses

Technical and financial support for small practices, transitional payments for new models, funding for measure development, more timely physician access to data

10

Then Now


Physicians will have choices

FFS (MIPS)

• Statutory updates

• Former reporting programs consolidated into MIPS with greater flexibility

• Penalty risks reduced, more opportunity for bonuses

• Benchmarks set prospectively, more timely feedback on performance

APMs

• Physicians’ role in creating new models specified

• 5% update bonuses for 5 years aides transition to new 2-sided risk models

• Demonstrated savings will produce higher payments

• Participants exempt from MIPS

Primary Care Support

• PCMH models assume cost savings, so 2-sided risk not required

• Specialty practice PCMHs may be designated

• Permanent coverage of chronic care management services with no annual wellness or preventive examination

11


MACRA Encourages Physicians to Participate in APMs

Significant Incentives for Participation in APMs Under MACRA

• Lump Sum Bonus = 5% of FFS revenues from 2019 to 2024

• Higher Annual FFS Update (0.75% vs. 0.25%) starting in 2026

• Exemption from MIPS

Flexibility in Minimum Participation Requirements to Receive Incentives

• 2019: 25% of Medicare payments through APMs


or 25% Medicare & 50% of total payments in APMs


or 25% Medicare & 75% of total payments in APMs

• Option to count % of patients instead of % of payments

• Ability for those just under these thresholds to Partially Qualify


What Does MACRA Require for an APM?

• Requirements for Alternative Payment Entity

– Participate in an Alternative Payment Model

– Bear financial risk for monetary losses under APM “in excess of a nominal amount”

OR

be designated as a medical home expanded by the Innovation Center

• Requirements for an Alternative Payment Model

– Be a model defined in the Innovation Center language under ACA, be part of the

shared savings (ACO) program, or be a Medicare demonstration

– Require participants to use certified EHR technology

– Base payment on quality measures “comparable” to MIPS

13


Milestone events

2016•Proposed and final regulations issued for MIPS and APMs (April and September?)

2017

•First performance measurement year for MIPS

•APM criteria set, proposals accepted on ongoing basis

2018

•First performance measurement year for APMs

•Separate PQRS, MU, and VBM programs/ adjustments sunset Dec. 31

•Deadline for achieving EHR interoperability Dec. 31

2019

•First MIPS payment adjustments implemented, maximum penalties 4% (phases up to 9% in 2022)

•First APM performance assessed, 5% bonus payments made to “qualifying participants”

•HHS reports if EHR interoperability achieved, penalties and decertification criteria may be recommended

14


AMA plans

AMA’s goal: To proactively shape MACRA implementation so that all physicians can succeed under the practice model of their choice

Ongoing consultation with other physician organizations

Outreach to other influential stakeholders

Securing needed technical expertise

Developing decision making and planning resources and tools for physicians

15


Critical elements in AMA’s MACRA strategy

• Tools for physicians and practice managers to facilitate their

transition/adoption of new payment models

• Correct problems with existing incentive programs (MU, PQRS, VBM)

• Maximize alignment (or minimize disconnect) between public and

private sector models

• Comprehensive and well coordinated communication and education

network including physicians and practice managers

16


Tools and Resources Under Development

17

TIMELINEWHY

MACRA

WHAT IS

MACRA

MACRA

101

MIPS

DETAILS

APM

DETAILS

DECISION

POINTS

MACRA Evaluator will educate, assess practice readiness, and provide

implementation resources for MIPS and APMs

Initial Educational Content Will Address

V.1 Launch Summer 2016; Future versions after final MACRA regulation


CMS – Transforming Clinical Practices Initiative (TCPI)

AMA SAN Awardee

Work Tracks

Market

Awareness

Promote the goals of the TCPI to the

broad healthcare community through

meetings and digital communications

Online

Education

Develop and digitally host training for

TCPI clinician participants on AMA’s

STEPS Forward™ platform

Registry

Advancement

Accelerate maturation of clinical data

registries through multiple educational

strategies, tools, and resources

Collaborative

Events

Elevate the capabilities of the PTNs

and SANs through developing and

leading four learning events per year

• Practice Transformation Networks (PTN)

• 29 awardees, ~$658M (e.g. Mayo, New

York eHealth Collaborative, Univ. of

Washington, others)

• Provide technical assistance and peer-

level support to assist clinicians in

transforming practices

• Support and Alignment Networks (SAN)

• 10 awardees, ~$27M (e.g. AMA, ACP,

ACEP, ABFM, ACR, others)

• Provide CME, disseminate practice

guidelines, share best practices, provide

access to registry data, provide coaching,

and assist with emerging alternative APMs

19

Physician Adoption of Value Based Care

Documents

Transcript of Physician Adoption of Value Based Care