4/8/17. The Changing Nature of Physician Payment and Health Care Reform in The AMA A Unifying Voice for Physicians

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1 The Changing Nature of Physician Payment and Health Care Reform in 2017 U of Mo Family Medicine Update April 7, 2017 David Barbe, MD MHA President-elect American Medical Association VP Regional Operations Mercy Springfield The AMA A Unifying Voice for Physicians 186 state, specialty and sub-specialty societies together represent >650,000 physicians All professional career stages All practice settings No other organization is better positioned to unify and advocate for physicians, the profession, and our patients 1

2 AMA Our People Membership >230,000 students, residents and physicians, th straight year of growth House of Delegates > 1000 state and specialty society delegates / alternate delegates Board of Trustees 21 members 3 Presidents (elect, Pres, immed past) Speaker and Vice-Speaker House of Delegates Student, Resident, Young Physician 12 At large members One public member James Madara, MD CEO 900+ co-workers Chicago Washington DC AMA Shaping the Future Key Areas Public Health - The Burden of Chronic Disease Medical Education Graduate Medical Education Physician Morale / Dissatisfaction / Burnout Regulatory relief Physician Payment Physician Workforce Medical Liability Reform Scope of Practice / Care Model Changes / Teams Opioid Epidemic Heath Insurance Mergers Health Insurance Affordability Narrow networks Prescription Drug Pricing / availability Maintenance of Certification Telemedicine The AMA strategic plan 6 2

3 Physician Payment Under MACRA / QPP Sustainable Growth Rate (SGR) repealed by Medicare Access and CHIP Reauthorization Act (MACRA) 2015 Quality Payment Program 3

4 Medicare Physician Payment 1997 Sustainable Growth Rate (SGR) Fight to repeal SGR 2015 SGR repeal, MACRA The shift toward measuring and paying for quality, adoption of healthcare IT, and even cost-effectiveness is not brand new 10 years of Incentives and Penalties for Value 4

5 MACRA established two Medicare paths for physicians MACRA was designed to offer physicians a choice between two payment pathways: A modified fee-for-service model (Merit based Incentive Payment System or MIPS) New payment models that reduce costs of care and/or support high-value services not typically covered under the Medicare fee schedule (APMs) In the beginning, most are expected to participate in MIPS CMS named the physician payment system created by MACRA the Quality Payment Program (QPP) APMs MIPS Some observations about MIPS Positives: Overall reduction in measures, many thresholds eliminated Overlapping quality measurement across separate programs eliminated More flexibility in measure choice Pass/ fail approach effectively eliminated Financial risk from penalties significantly reduced Issues to address: Administrative burden for practices is still too high A more holistic approach is still needed to integrate the 4 components into a single program MU measures largely retained in ACI; need greater flexibility and focus on goal vs. process Methodological issues of cost and quality measures remain Ease reporting requirements 15 5

6 MACRA / QPP Regulatory Wins Exclusion threshold raised Pace of Participation significantly eased Three options in 2017 to avoid penalties in 2019 Report one quality measure for one patient Report one clinical improvement activity Report 4 Advancing Care Information (MU) for at least 90 days Report more than above possible incentive No participation = 4% penalty in 2019 MIPS components Quality Reporting (was PQRS) Advancing Care Information (was MU) MIPS Resource Use or Cost (was Value-based Modifier) Clinical Practice Improvement Activities MIPS aims: Align 3 current independent programs Add 4 th component to promote improvement and innovation Provide more flexibility and choice of measures Retain a fee-for-service payment option Clinicians exempt from MIPS: First year of Part B participation Medicare claims < $30K AND patients < 100 Advanced APM participants 17 Improvement Activities categories Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety & Practice Assessment Achieving Health Equity Emergency Response and Preparedness Integrated Behavioral & Mental Health 6

7 Relative weights of MIPS components onward Quality (PQRS) 60% 45% 30% 30% Resource use (VBM) Advancing Care Info (MU*) 0% 15% 30% 30% 25% 25% 25% 25% CPIA 15% 15% 15% 15% Penalty risk -4% -5% -7% -9% *MU weight may be reduced to 15% if 75% of EPs are successful 19 MIPS Reporting Requirements Quality Reporting including core measures Six measures including one outcome measure Advancing Care Information Numerator/denominator for 4 measures = 50% Improvement Activities Submit 4 medium or 2 high-weighted activities HPSA 2 med / 1 high Accredited Medical Home for MIPS = full points MIPS component scoring For 2017: Quality = 60% ACI = 25% IA = 15% Cost = 0% Component Scoring Quality: 60 points groups <15 70 points for larger groups Advancing Care Information: 50 points base score 90 points performance score Improvement Activities: 40 points (2-4 activities; 1-2 activities for practices < 15 clinicians, rural practices) Cost (2018?): 10 points per measure Score is average of attributable measures 7

8 Accommodations for Small Practices Excluded from penalties if < $30,000 Medicare billing or < 100 patients Pick Your Pace Fewer required Improvement Activities 1 high or 2 medium-weighted activities Technical support available our area TMF Option for virtual groups in future years Estimate 80% of clinicians in small groups will receive no penalty or positive payment Accommodations for Small and Rural Practices MIPS Testing Partial MIPS reporting Full MIPS reporting Advanced APM participation Pick Your Pace: 2017 transitional performance reporting options Report some data at any point in CY 2017 to demonstrate capability 1 quality measure, or 1 improvement activity, or 4/ 5 required ACI measures No minimum reporting period No negative adjustment in 2019 Submit partial MIPS data for at least 90 consecutive days 1+ quality measure, or 1+ improvement activities, or 4/ 5 required ACI measures No negative adjustment in 2019 Potential for some positive adjustment ( < 4%) in 2019 Meet all reporting requirements for at least 90 consecutive days No negative adjustment in 2019 Maximum opportunity for positive 2019 adjustment ( < 4%) Exceptional performers eligible for additional positive adjustment (up to 10%) No MIPS reporting requirements (APMs have their own reporting requirements) Eligible for 5% advanced APM participation incentive in 2019 The only physicians who will experience negative payment adjustments (-4%) in 2019 are those who report no data in

9 From CMS QPP website Quality measures Fam Med Specific Quality Measures 9

10 Advancing Care Information Measures 10

11 Improvement Activities Measures 2019 payment adjustments (based on 2017 performance) Quality score weighted (60%) Cost score weighted (0%) Up to $500 million available to provide 10% extra bonus for those who meet or exceed a 70 point threshold ACI score weighted (25%) Improvement Activity score weighted (15%) Final Performance Score Final score above threshold (up to 70 points) = up to 0 to +4% Final score at 2017 threshold of 3 points (one data element reported) = 0% No data reported = - 4% Adjustment amounts depend on: choice of 90-day or full-year reporting whether some or all data elements are reported performance under each reported measure compared to other physicians whether bonus points are earned budget neutrality calculations Current Advanced APMs Comprehensive ESRD Care Model (13 ESCOs) Comprehensive Primary Care Plus (CPC+) (14 states/regions) Medicare Shared Savings Track 2 (6 ACOs, 1% of total) Medicare Shared Savings Track 3 (16 ACOs, 4% of total) Next Generation ACO Model (currently 18) Oncology Care Model Track 2 (A portion of 196 practices will qualify) 11

12 New Advanced APMs for 2018 (subject to rulemaking) ACO Track 1+ Advancing care coordination through episode payment models Track 1 (CEHRT) Voluntary bundled payment models Vermont Medicare ACO Initiative (all payer ACO model) Comprehensive Care for Joint Replacement Payment Model (CEHRT Track) Adv APM for Medical Homes Advanced Alternative Payment Model more than Nominal financial risk at risk for losses of at least 8% of Part A and B revenue or at least 3% of the benchmark Medical Home Model AAPM 2.5% in 2017 up to 5% in 2020 and beyond Primary care model care coordination, access and continuity, risk stratification, patient engagement / shared decision-making, APM Timeline on payment adjustments on Fee Schedule Updates 0.5% annual baseline updates No annual baseline updates 0.25 % or 0.75 % MIPS Max Adjustment (additional bonuses possible) 4 % 5 % 7 % 9 % 9 % 9 % 9 % QPs in Adv. APMs 5% bonus 12

13 ama-assn.org/medicare-payment Repeal and Replace / Repair Health System Reform 2017 Pathways to Change Health Care 1. Reconciliation fiscal impact only, not policy Simple majority in Senate 2. Administrative regulation by HHS / CMS 3. Regular order requires 60 votes in Senate 13

14 AMA Top 9 Reform Goals Ensure coverage Adequately fund safety net programs Affordability and access Stabilize the insurance market Maintain key insurance market reforms Continue payment and delivery reforms Greater transparency Reduce regulatory burdens Medical liability reform 14

15 What would YOU include in reform? What was in AHCA Medicaid funding per beneficiary allocation with cap per capita cap (vs block grant) Eliminate individual and employer mandate Encourage uptake: Maintain continuous coverage, < 63 days lapse 30% penalty for one year Defund Prevention and Public Health Fund Create Patient and State Stability fund - $100 B over 9 years What was in AHCA Tax credits beginning in 2020 age related only (vs age + income + market cost) < 30 $2, $2, $3, $3,500 =/> 60 $4,000 credits continue to higher income levels decrease over $75,000 for individual ($150k/joint) Phase out about $100k / $200k Can be used for purchase of individual policy 15

16 Congressional Budget Office score Follow the Money 10 years $1.2 T reduction in spending $0.9 T reduction in revenue $337 B reduction in deficit spending over 10 yrs Amendments decreased this to $150 B $880 B reduction in Medicaid Funding (rollback expansion, per capita caps) Approx $300 B net reduction in subsidies CBO Score - Premiums Impact on Insurance Premiums Premiums rise x 2 years (15-20%), then begin to decline lower compared to current law projections (-10% by 2026) Some decrease related to elimination of specific actuarial value requirements Expectation of increased enrollment of younger, healthier in out years Use of Patient and State Stability Fund Older individuals will pay more / younger less 5 x premium spread vs current 3x 16

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18 CBO Score - Coverage million more uninsured million more uninsured million more uninsured million fewer Medicaid million fewer in individual market Dropping to 2 million less in 2026 compared to current law By million uninsured vs 28 million under current law Discussion The Changing Nature of Physician Payment and Health Care Reform in 2017 David Barbe, MD MHA President-elect American Medical Association VP Regional Operations Mercy Springfield 18