Prac cal Approach to Payment Changes

2016‐2017 and Beyond

Carol Henwood, DO, FACOFP dist.

Bruce Williams, DO, FACOFP

9/7/2016

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Understanding MACRAThe New Merit Based Payment System

Carol L. Henwood, D.O., FACOFP dist

Bruce R. Williams, D.O., FACOFP

OMED, Anaheim, California

September 19, 2016

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NAFLD

HTN

BPH

IBS

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PCPCCMRA

CPCI

MACRA

APMS

MIPS

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Double –Triple Aim

• External Triple Aim• Improved the health of population

• Improved patient care and satisfaction with that care

• Improved per capita cost

• Internal Triple Aim• Improved practice efficiency

• Improved satisfaction of physicians and staff

• Improved practice financial security

• April 16, 2015 - SGR repealed

• Replaced by MACRA

Medicare Access and CHIP Reauthorization Act

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MACRA

• Moves Medicare from a fee-for-service system to a system paying for quality of care

• Repealing the SGR provides predictability in physician payments

• Provides positive payment incentives via annual updates for 5 years

• Aligns with the osteopathic principal of providing patient-centered care

PAYMENT UPDATES

• July 2015 -2019 • 0.5% update annually

• 2019 – 2024• Merit- Based Incentive Payment System (MIPS)

incentives or 5% Alternate Payment Model (APM) bonus

• 2026 and beyond• 0.75% update in APM

• 0.25% update in FFS

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WHEN AND WHAT

• 2017 • Reporting lookback period

• Measures to be finalized

• 2019 • Select participation in MIPS or APMS

Merit-based Incentive Payment System(MIPS)• Preserves fee-for-service

• Streamlines EHR Meaningful Use, PQRS, into one reporting program

• Reduces administrative burdens

• Adds bonuses

• Bonuses and penalties are determined on a sliding scale comparing composite performance score to the average of all physicians

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MIPS

Who will participate : individual and groups

“eligible clinicians”

physicians – DO, MD, DMD/DDS

extenders – PA’s, NP’s, CRNA’s, clinical nurse

specialists

May be expanded to include PT,OT,ST, social workers,

clinical psychologists, dieticians

MIPS

Who will NOT participate :

First year of Medicare Part B participation

Low patient volume – billing <$10,000

< 100 medicare patients

Participating in ADVANCED alternative payment

models

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MIPS PERFORMANCE CATEGORIES

Scoring in four categories

1. Quality 50%

2. Resource Use 10%

3. Clinical Practice Improvement 15%

4. ADVANCED CARE INFORMATION 25%

QUALITY• Replaces PQRS

• 6 MEASURES (Includes 1 Cross-Cutting Measure and a high quality or outcomes measure)

• INDIVIDUAL MEASURES OR SPECIALTY MEASURE SET

• POPULATION MEASURES AUTOMATICALLY CALCULATED BY CMS

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RESOURCE USE

• COMPARE RESOURCES USED TO TREAT SIMILAR CARE EPISODES AND CLINICAL CONDITION GROUPS

• CMS CALCULATES BASED ON CLAIMS – NO PHYSICAN REPORTING

• RISK ADJUSTED

• REPLACES THE VALUE MODIFIER PROGRAM

Medicare Risk Assessment (MRA)• A value based modifier

• Evaluates the overall health of the Medicare individual

• Provides a numerical value to the patient’s overall health

• The higher the number, the “sicker” the patient and thus the more resources that need to be utilized (1.0 is a threshold or breakeven point-<1.0 less resources are necessary, >1.0 more resources are necessary). So if the patient has an MRA of 0.80 and excessive resources are being used, this is overutilization and will be a negative impact

• Factors: Diagnoses, Hospital admissions(and readmissions), medications (brand name vs generic), ER visits, Procedures

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Medicare Risk Assessment (MRA)• In diagnosing the patient, coding and the documentation to

support it is of extreme importance (i.e. E11.65 type2 diabetes with hyperglycemia vs E11.21- type2 diabetes with diabetic nephropathy). The E11.21 will provide a heavier weight to the MRA than the E11.21

• ICD-10 will help practices with this – need to understand ICD10

• The code will NOT be enough, there WILL need to be documentation of the patients condition to support it ( so if the provider claims diabetes with renal complications, there will need to be documentation of low eGFR or microalbuminAND that it is addressed)

CPIA – CLINICAL PRACTICE IMPROVEMENT ACTIVITY• Full credit for PCMH recognition

• ½ credit for participation in APM

• ? OCC

• EXAMPLE : CARE COORDINATION, ENHANCED PRACTICE ACCESS, SHARED DECISION MAKING

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ADVANCED CARE INFORMATION

• HEALTH IT INTEROPERABILITY AND INFORMATION EXCHANGE

• PROMOTE CARE COORDINATION FOR BETTER OUTCOMES

• 6 CATEGORIES – HIPPA, eRx, PATIENT PORTAL,CHRONIC CARE MANAGEMENT, REGISTRY REPORTING, HEALTH INFO EXCHANGE

• REPLACES MEANINGFUL USE (MU)

COMPOSITE PERFORMANCE SCORE CALCULATION

• QUALITY 80-90 POINTS

• RESOURCE AVERGE SCORE OF COST MEASURE

• CPIA 60 POINTS

• ADVANCING CARE INFO 100 POINTS

• REPORTING VIA QUALIFIED CLINICAL DATA REGISTRY (WWW.CMS.GOV>PQRS>DOWNLOADS)

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Performance Threshold for MIPS payment

• Average performance of all physicians in program

Above threshold = positive update

At threshold = no update

Below threshold = negative update

• Budget Neutral Program

Smaller penalties Larger bonuses

Current MIPS Current MIPS

-11% -4% 2019 0% +4%

-11% -5% 2020 0% +5%

-11% -7% 2021 0% +7%

-11% -9% 2022 0% +9%

Penalties and Bonuses for MIPS

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Alternative Payment Models (APMs)

• Exempts physicians from MIPS

• Earn shared savings, PLUS:• 5% annual bonus in 2019 – 2024

received as a lump sum

• .75% in 2026 and beyond

• GOAL TO MOVE 50% MEDICARE PAYMENTS BY 2018

ADVANCED ALTERNATIVE PAYMENTMODELS

MODELS INCLUDE

• Accountable Care Organization TAKING RISK (Next Generation ACO’s)

• Bundled payments

• Comprehensive Primary Care Plus (CPC+), Medicare Shared Savings Programs- Track 2 and 3 (MSSP), Comprehensive ESRD Model, and Oncology Care Model Two-Sided Risk Arrangement

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Required % of revenue under risk-based models

2019 – 2020 25% in medicare

2021 - 2022 50% in medicare OR

25% in medicare and 50% all payer

2023 and beyond 75% in medicare OR

25% in medicare and 75% all payer

What To Do – How To Do It Today

Major functions of PCMH vs Recognition as PCMH

• ACCESS

• QUALITY METRICS

• CARE COORDINATION

• CG-CHAPS

• POPULATION HEALTH

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Access to Care

• See who needs to be seen

• Identify who has NOT been seen

• Manage chronic condition population

• Consider alternative access (web visits)

• Aligning with urgent care centers and retail clinics to produce greater continuity of care

• Implementation of improved interface of technology while considering over implementation(HIPPA).

Quality Markers

• Tools to help manage the metrics

• More than just an EMR (BUT!!!!! You need an EMR!)

• Care at the individual patient level AND at the population level!

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Suites & Measures

ANALYTICS 29

Suite Name Reference Guidelines* Measures in Suite

ADHD (Child & Adolescent) ICSI 2012 Guideline 6

Asthma (All Ages) NAEPP 2012 Guideline 14

Breast Cancer Screening USPSTF 2014 Guidelines 1

Cervical Cancer Screening USPSTF 2014 Guidelines 2

Chronic Heart Failure ACCF/AHA 2013 Guideline 24

Chronic Kidney Disease KDIGO 2012 Guidelines 25

Colorectal Cancer Screening USPTF 2014 1

COPD GOLD 2013 Guideline 7

Diabetes ADA 2014 22

Diabetes (Child & Adolescent) ADA 2014 & AAP 2013 Guidelines 24

Hypertension JNC-8 2014 & AHA 2014 10

Hypertension (Child & Adolescent) NHLBI 2011 15

Immunizations (Child & Adolescent) ACIP 2014 11

Ischemic Vascular Disease AHA 2014 Guideline 15

Obesity (Child & Adolescent) ICSC - 2013/MQIC-2012 17

Preventative Services (Child & Adolescent)

AAP Bright Futures Guideline

NHLBI 2011 Guideline 11

Tobacco Usage and Exposure (All Ages) SPH Standard 5

Vitals (All Ages) SPH Standard 11

ANALYTICSExceed quality care by utilizing

our embedded decision support built on evidence based care protocols published by major

professional societies200+ measures

Diabetes: Quality Reporting

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Diabetes: LDL ReportingCare Opportunities: LDL Patients

Quality Improvement Reporting:All Diabetes Measures

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PATIENT CARE SUMMARYPrepare for patient visits with the patient-centric

view of care opportunities.

Coordinate care team member activities using patient centric clinical

notes

Care Coordination• Utilization of the entire staff within the practice

• Utilize personnel to the extent of their license

• Utilize standing orders to provide authority to obtain tests prior to the physician seeing the patient (preorder labs based on risk factors and evidence based parameters ) to provide more efficient care and better utilization of staff and patient time (i.e. get more done before the physician walks in the room).

• Much of this can be done on-line or on the phone pre-visit.

• A dedicated individual of adequate training to review the data base to identify the at-risk population and contact them for care.

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TRANSITION CARE MANAGEMENT

• IDENTIFY WHO HAS ACCESSED HEALTH CARE SYSTEM - ER/OBS/ADMISSION

• TCM CALLS PER CMS GUIDELINES

• PREVENT 30 DAY READMISSIONS

Geisinger Readmission Risk Assessment

YES NO

Age 65 or greater 1 0

Admitted from SNF or requires home care 1 0

Currently has CHF,COPD,AKI,CKD or on dialysis 2 0

Takes more than 5 prescription medications 1 0

Takes digoxin,insulin,anticoagulants,narcotics,ASA/Plavix 1 0

History wound infection or poor healing wound 1 0

History of pulmonary embolism or DVT 1 0

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Readmission Risk Assesment

yes no

Use of device or person for ambulation 1 0

Alone or unable to attain help after D/C 2 0

Previous hospital admission past 12 mo 5 0

On disability 2 0

Risk score greater than/equal to 8 = high risk

CG-CHAPS• Patient experience tool (in the technology age-we are or will

be judged! Yes, very subjective but real! We need to consider how we are viewed by our patients).

• “extra credit” from NCQA (more points for PCMH) for using it.

• Others are available and may be in use (Press-Ganey and M3) and these can be used to document patient experience as well but they will not get the same weight as CG-CHAPS for PCMH recognition.

• All practices, PCMH or not, need to consider patient satisfaction in the coming payment models and address opportunities. If the practice seeking NCQA recognition, this is mandatory.

• This is the “look in the mirror”!

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POPULATION HEALTH

• Central to MACRA, ACA, HITECH

• Looks at the population health vs that of the individual (not minimizing either)

• Focuses on Pre-condition metrics (how can we impact the population BEFORE disease develops?)

• Preventive care is paramount (Colonoscopies, Mammograms, Screening lab, annual wellness visits, immunizations, risk history)

COMORBIDITYAssess risk of your patient population.

Identify patients with the highest chronic disease burden and

highest risk for complications.

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Care Opportunity

CARE OPPORTUNITYUnderstand care

opportunity status by disease state and

measure. View upcoming, overdue and missing

opportunities by group, clinician and patient.

Goal Progress

GOAL PROGRESSDemonstrate

performance against practice goals. Compare achievement between

disease states and measures.

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Goal Progress - Trend

GOAL PROGRESS: TRENDTrend

performance improvement

over time.

SUMMARY

New payment modules moving to value based care

Emphasis on quality

Deliver on the double-triple aim

NOW IS THE TIME FOR PRACTICE TRANSFORMATION