A look into the future - Community Care Physician Networkcommunitycarephysiciannetwork.com/wp-content/uploads/Getting-Paid... · A look into the future ... –US Dept of Health and

Getting Paid with MACRAA look into the future…

R.W. “Chip” Watkins, MD, MPH, FAAFP

CCPN Provider Series – Part 1

16 August 2016

The “Getting Paid” Series

• Part 1: A “Deep Dive” Into MIPS

–Quality Measures

–Resource Use

–Clinical Improvement Activities

–Advancing Care Information

• Part 2: More Than You Ever Really Want to Know About APMs

–Review MIPS

–Overview APMs

–Healthcare Marketplace

–How Your Quality Information is being used

• ? Part 3: How to Read Your Practice’s QRUR

Your Speaker

R.W. “Chip” Watkins, MD, MPH, FAAFPSenior Medical Director, CCWNC

Senior Physician Consultant, CCNC

Associate Medical Director, High Country Community Health, Boone, NC

PCMH CAHPS Technical Expert Panel –Agency for Healthcare Research and Quality (AHRQ) – US Dept of Health and Human Services

NCQA Foundational Concepts of the Medical Home Faculty

NCQA Physician Review Oversight Committee

Objectives

• Learn what is happening in terms of payment reform with Medicare (CMS)

• Protect yourself and your practices from significant penalties

• Learn ways to improve your practice’s bottom line through VBP (Value-Based Payments)

• Understand what options are available to help you through the transition to VBP

• In this first presentation, we will head into the world of MIPS

• This Live series activity, Getting Paid With MACRA - Part 1 & II, from 08/16/2016 - 08/31/2016, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

• Approved for 1.0 AAFP Prescribed credits per program

• AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician’s Recognition Award

• If you want CME credit, please cut and paste the following URL into your browser and fill out the form

• http://tinyurl.com/attest816

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Special Thanks…

• David Nash, MD – Dean, Jefferson College of Population Health

• Susan Dentzer - President and CEO, The Network for Excellence in Health Innovation (NEHI)

• Amy Mullins, MD – Medical Director, Quality Improvement, AAFP

• CMS – MACRA Resources & Quality Payment Programs

– http://go.cms.gov/QualityPaymentProgram

I Think We Feel Like This A Lot of the Time…

Goals of Payment and Delivery System Innovation: Improving Value And Affordability

New ModelOld Model

Reward unit cost

Inadequate focus on care efficiency and patient centeredness

Payment for unproven services; limited alignment with quality

Reward health outcomes and population health

Lower cost while improving patient experience

Improve quality, safety and evidence

HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.

This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments

Why the Move Toward Reform?

“So let me be

clear: If we

do not control

these

(healthcare)

costs, we will not

be able to control

the deficit.”

“MONEY WON’T MAKE YOU HAPPY…BUT

EVERYBODY WANTS TO FIND OUT FOR THEMSELVES”

Zig Ziglar

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What’s A Practice To Do?

•Falling Reimbursements/Penalties

•Extra Paperwork

•Expensive EHR Systems

•Billing/ICD-10

•Quality Initiatives/Requirements

•PCMH Recognition

•Contracting

• Increased Complexity/Regulations

Leaving Many to Think about

Retirement

Payment Reform IS HERE!

Payment Reform is Happening!

• On April 16, 2015 the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law1

• MACRA permanently repealed the SGR avoiding a 21.2% Medicare physician payment cut

• 300 pages

• 298 “The Secretary Shall(s)…”

• Bipartisan effort:

– 392 to 37 in the House

– 92 to 8 in the Senate

1 Medicare Access and CHIP Reauthorization Act, HR2, 114th Congress.

MACRA’s Purpose

• Opening Line:

“To repeal the Medicare SGR and strengthen Medicare access by improving physician payments…”

• Great Start:– Then things get

complicated….

Big Picture

• Aligns three physician quality and performance programs into one single program

• Provides funds for technical assistance for small/solo practices to facilitate transformation

• Extends funding for Children’s Health Insurance Program (CHIP) for two years

• Establishes two tracks for payment (2019):

• Merit Based Incentive Payment System (MIPS)

• Alternative Payment Models (APMs)

2015-2017 CRUCIAL for QI and Reporting

(PQRS, MU, and VBPM)

To 2019 and Beyond!!

To 2019 and Beyond!

• Beginning in 2019 payments will occur through two different tracks

–Merit Based Incentive Payments (MIPS)

–Alternative Payment Models (APMs)

• From 2016-2020, CMS is to spend $20 million annually on technical assistance to help practices (with </=15 professionals) improve their MIPS performance or transition to APMs

–Priority will be given to those in underserved/health professional shortage areas

Who Is Eligible?? Who is Exempt??

Eligibility – must meet volume or $ thresholds

• 2017 Performance Year:

–MDs, NPs, PAs, CNSs, CRNAs

• 2019 Performance Year:

–PTs, OTs, SLPs, AuDs, CNMs, LCSWs, LPCs, RDNs, LNs

Exempt - < $10K in Medicare Part B or < 100 Patients

–First Year Medicare Provider

–Qualifying or Partial Qualifying APM participant

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Question 1

Question 1

• Going forward, it is important to continue to do our reporting to CMS under the current system of PQRS, MU, and VBPM because:

a. We like reporting quality metrics to CMS in our spare time because it is fun

b. Learning all the acronyms helps us build new neural pathways

c. If we don’t (didn’t) report in 2015 and 2016, we may be subject to a 9% penalty in 2017 and 2018, and if we don’t report in 2017, Medicare Part B payments are at risk once MACRA starts in 2019!

In the next installment, most of our time will be spent learning about APMs, but

today is a MIPS kind of day…

CMS estimates that only 4% of practices would qualify for APM status and even then, many of them would need to

report MIPS data.

MIPS

• Beginning in 2019, MIPS consolidates Meaningful Use

(MU), Physician Quality Reporting System (PQRS), and

Value Based Modifier (VBPM) into one program

MIPS Scoring

Physicians will be assessed, and receive payment adjustments, based on a composite score (1-100) based on:

Glossary

*Healthcare Acronyms 101:• CMS, Center for Medicare & Medicaid Services• MU, Meaningful Use• MACRA, Medicare Access & CHIP Reauthorization Act of 2015• MIPs, Merit-Based Incentive Payment System• HHS, Health & Human Services• ONC, Office of the National Coordinator for Health Information

Technology• PQRS, Physician Quality Reporting System• VBM, Value-Based Payment Modifier• APM, Alternative Payment Models• eCQMs, Electronic Clinical Quality Measures• EHR, Electronic Health Record• NPRM, Notice of Proposed Rulemaking• QRUR, Quality and Resource Use Report

Quality

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/downloads/General_Practice_Family_Specialty_Measure_Set.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/downloads/2016_PQRS-Crosscutting.pdf

Movement Toward Core Measures

• Core Quality Measures Collaborative (CMS, AHIP, the American Academy of

Family Physicians and the National Partnership for Women and Families)

• Seven sets of quality measures to be used across public and private payers

announced in Feb. 2016

• Core measures in

Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMHs), and

Primary Care

Cardiology

Gastroenterology

HIV and Hepatitis C

Medical Oncology

Obstetrics and Gynecology; Orthopedics

Question 2

Question 2

• What percentage of your MIPS score in 2020 will rely on your quality marks?

A. 25%

B. 30%

C. 45%

D. 50%

Clinical Performance Improvement

• The law says that a professional who is in a practice that is a “certified” PCMH (as yet undefined) that is, patient centered medical home will be given the highest score for the CPI portion of the MIPS score (15 points)

• Sources at NCQA are confident this will mean NCQA recognized medical homes will at least one of the definitions or part of the definition

Clinical Performance Improvement

What Happened To MU?

• Meaningful Use of certified EHR technology is renamed to “advancing care information” and the criteria are streamlined - removing the CPOE and Clinical Decision Support requirements.

• In 2017, clinicians may still use 2014 edition certified technology and report on eight Stage 2 measures.

• In 2018, clinicians will need to use 2015 edition certified technology and report on six Stage 3 measures, described momentarily…

Why is EHR Use Dropping?

• A new report by SK&A Market Insights reveals that physician office EHR use has decreased by nearly 4% over the last year, clocking in at just 59% between 2015 and 2016.

• While dips in EHR use were consistent across practices of various sizes, smaller physician practices saw the largest year-over-year decline.

• Why? EHRs have been difficult to use, outrageously expensive and decades behind other data sectors like those used in the banking industry.

• Legislatively directed usage will never carry the day since the physician never had his/her needs fundamentally considered in the drafting of the legislation that directly impacts their world

• The diversity of systems without a universal record format and interoperability are extreme barriers

http://medicaleconomics.modernmedicine.com/medical-economics/news/why-ehr-use-dropping?page=0,2

Question 3

Question 3

Q: Okay, this is a government issue or a “your tax dollars at work” issue that is concerning me:

If MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015, and it only extends CHIP funding for another two years, what are they going to call MACRA in 2017?

MAA!!!!!!!

Disclaimer

• The Presenter is not responsible for increasing your anxiety, triggering a major depression or alcoholic bender, fugue state or any other damage to your nervous system, other physiological system, or bodily function.

• We strongly suggest if you are watching this webinar on the second floor or higher of a building, that you watch it with a friend who can be responsible for you, or if you watch it alone, that you at a minimum, nail your windows shut from the OUTSIDE and remove all firearms or other lethal implements and sharp objects from the area close to your computer screen.

• Actually, I’m hoping it won’t be THAT BAD!

The 6 Objectives for Base Score

The six criteria which are required as of calendar year 2018 are:

1. Protect Patient Health Information - Security Risk Analysis (yes/no)

2. Electronic Prescribing (num/denom)

3. Patient Electronic Access - Patient Access, Patient-specific education

(num/denom)

4. Coordination of Care through Patient Engagement -

View/Download/Transmit, Secure Messaging, Patient Generated Health

Data (num/denom)

5. Health Information Exchange - Patient Care Record Exchange,

Request/Accept Patient Care Record, Clinical Information Reconciliation

(num/denom)

6. Public Health and Clinical Data Registry Reporting - Immunization

Registry Reporting (yes/no)

Examples: Coordination of Care Through Patient Engagement:

1. Secure Messaging Measure: For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).

Examples: Coordination of Care Through Patient Engagement:

2. View, Download, or Transmit: During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either:

(1) view, download or transmit to a third party their health information; or

(2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician’s certified EHR technology, or

(3) a combination of (1) and (2).

So What Do Ya Gotta Do, and When?

For the period January 1, 2017 to December 31, 2017 (not 90 days), clinicians must:

a. Use a 2014 or 2015 Edition Certified EHRb. Report on either eight stage 2 or six stage 3 advancing care information objectives and measures:c. Attest to their cooperation in good faith with the surveillance and ONC direct review of their EHRd. Attest to their support for health information exchange and the prevention of information blocking.e. Continue to see patients…

Question 4

Question 4

• Question: What if I am doing really good care (the term “benchmark” care will be the new standard) but my EMR doesn’t do a great job of capturing the information that is being sent to CMS?

• Answer: I DON’T KNOW!! I’m thinking it is not good.

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Question 5

Question 5

In 2017, for the ACI (Advancing Care Information) Portion of MIPS you can:

A. Use a 2014 Edition Certified EHR and report on 6 stage 2 ACI Objectives

B. Use a 2015 Edition Certified EHR and report on 4 stage 3 ACI Objectives

C. Use a 2014 or 2015 Edition Certified EHRand report on either 8 stage 2 or 6 stage 3 advancing care information objectives and measures

D. Start using paper charts and paper scheduling systems again before the EMP (electromagnetic pulse) from the sun blasts us back to a post-apocalyptic Stone Age

Performance Thresholds for MIPS

• The “performance threshold” will be set yearly, based on the average of all recorded MIPS scores from the previous year. The score 1-100 will be compared to this threshold.

• The first two years: The Secretary of HHS will establish the performance threshold

• Those who score below the threshold will see negative adjustments, those who score above it will see positive adjustments.

• The “Game” is Budget Neutral - there will be “winners” and “losers”

Playing the Game

• If you score in the lowest quartile of providers, you will automatically be adjusted down to the maximum penalty

• If you score at threshold, you receive no adjustment

• Higher scores receive proportionally larger incentive payments, up to three times the maximum positive adjustment for the year (12% in 2019)

• Scores in the highest quartile are eligible for an additional positive payment adjustment up to 10%

• The program is budget neutral, so the total negative adjustments will equal the total positive adjustments

MIPS Summary

• MIPS replaces existing quality reporting programs in Medicare Part B

• MIPS bonuses are potentially significant for high performers

• There is a risk for penalty

More Bad News for Smaller Practices?

…page 676 of the proposed rule outlining the details of the Merit-based Incentive Payment System (MIPS), CMS estimates that 87% of the nation’s solo practices (nearly 103,000 physicians) will face a penalty in 2019, the first year of the program, to the tune of $300 million. The news is equally as pessimistic for practices of two to nine physicians (an estimated 124,000 physicians) who could see penalties to the tune of $279 million.

“There are winners and losers [in MACRA] and smaller practices are more likely to be the losers,” Lund told Medical Economics. “It appears the proposed rule would create a penalty system where the big guys [larger practices] will be funded by the little guys.”

Medical Economics, May 4, 2016 Interview with Ingrid Lund, PhD, practice manager for research and insights at The Advisory Board Company

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Compared to practices with 10–19 physicians, practices with 1–2 physicians had 33 percent fewer preventable admissions, and practices with 3–9 physicians had 27 percent fewer. Physician-owned practices had fewer preventable admissions than hospital-owned practices. In an era when health care reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures—such as independent practice associations—that may make it possible for small practices to share resources that are useful for improving the quality of care.

Health Aff September 2014 vol. 33no. 9 1680-1688. Published online before Print August 2014, doi:10.1377/hlthaff.2014.0434

How I Was Wrong About ObamaCare – 7/31/16

• Bob Kocher - Only physician on the National Economic Council which penned ObamaCare

• What I know now, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care.

• Small, independent practices know their patients better than any large health system ever can.

• These small businesses can learn faster without holding weeks of committee discussions and without permission from finance, legal and IT departments to make a change.

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http://www.wsj.com/article_email/i-was-wrong-about-obamacare-1469997311-lMyQjAxMTE2NTAyMjIwNDIxWj

How I Was Wrong About ObamaCare

• Recognizing the strength in the small practices, the federal government needs to write rules that make it easier for them to thrive under ObamaCare and don’t tip the scales toward consolidation.

• They should introduce payment models that limit losses for small providers to the Medicare dollars they receive rather than total spending, and which rely on multiyear benchmarks instead of single-year swings.

• They should compare small practices to other small ones—instead of to large health systems with large balance sheets—when determining if a practice deserves bonus payments for savings.

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Advice for Independents

• Independent practices should assume that their participation will be through the MIPS path and not its alternative, the advanced payment models (APMs)

• Even CMS estimates that only 4% of these practices would qualify for APM status and even then, they would need to report MIPS data.

• Key to success is: Your practice’s ability to

collect and measure and then report DATA

• Build templates that can help you collect data

• Check your EMR reports

So…What’s Next?

What Should I Do Next?

• Start focusing on quality reporting, especially the six measures identified under the quality category that will comprise 50% of a physician’s MIPS score

• Define what measures your practice will be required to report out on and see which ones best match your practice

• Concentrate on the measures you are already doing and/or are good at to get best score

• Read and Understand your QRUR

What Should I Do Next?

• Add a portal (25% = Advancing Care Information)

• Think about PCMH Recognition (Clinical Practice Improvement)

• Learn about the Value of possibly joining CCPN (Community Care Physician Network)

• Join the PTN (Practice Transformation Network)

• Learn about your CCNC Network Resources (and please note your network may or may not have these services)

– Quality Improvement

– PCMH Help

– Chronic Care Management Codes, etc.

– Pharmacy Care Services

Conclusions

• Payment reform has happened/is happening

• Learn to embrace MACRA if you are in it for the long haul

• Or, figure out a different path (lots of models)

• Final rule is out the end of October 2016

• CMS will probably delay the rollout or the program or at least extend the reporting periods

• Don’t forget about the current rules that are still in place as we work our way to 2019!

Conclusions (cont.)

• MACRA law – April 16, 2015 – 300 pages

• MACRA Proposed Rule – April 27, 2016 – 962 pages

• There are many very smart and well-meaning good folks at CMS

• And, it is hard to imagine that if ANYONE actually does understand these overwhelmingly complex rules, CMS will be able to deliver what they are setting out to do on the timeline they have suggested.

Conclusions

• This Live series activity, Getting Paid With MACRA - Part 1 & II, from 08/16/2016 - 08/31/2016, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

• Approved for 1.0 AAFP Prescribed credits per program

• AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician’s Recognition Award

• If you want CME credit, please cut and paste the following URL into your browser and fill out the form

• http://tinyurl.com/attest816

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Getting Paid with MACRAA look into the future…

R.W. “Chip” Watkins, MD, MPH, FAAFP

CCPN Provider Series – Part 1

16 August 2016