Emerging Challenges in Primary Care: 2016 A Practical Discussion of Value and Quality Based Payments What Do I Do Now? Modified from AHLA Physicians and Hospitals Law Institute 2016 Faculty Ellie Bane Corporate Counsel Catholic Health Initiatives Houston, TX 2 Disclosures Ellie Bane has no relationships to disclose. 3 1
Learning Objectives Gain a better comprehension of recent changes to reimbursement Understand how reimbursement changes may impact your medical practice Incorporate tools into your practice to better meet changing reimbursement models 4 What is Happening & Why? US health care is moving from traditional FFS FFS is increasing cost of healthcare generally Encourages more services, tests, etc. CMS/Federal Government has been moving toward value based compensation models for some time Insurers have also been moving to value based models The next few years will bring a paradigm shift in compensation for healthcare services 5 Abbreviation Key MAPCP- Multi-Payer Advanced Primary Care Practice CPC-Comprehensive Primary Care Initiative BPCI- Bundled Payments for Care Improvement OCM-Oncology Care Model CJR- Comprehensive Care for Joint Replacement MLR Ratio-Medical Loss Ratio PCMH- Primary Care Medical Home APM- Alternative Payment Model(s) - Merit Based Incentive Payment System MACRA- Medicare Access & CHIPS Reauthorization Act of 2015 6 2
Quality & Value-The Beginning Ø Incentivizing Quality in Medicare is not new In 1998, CMS began using STAR measures for Medicare Advantage Managed Care Organizations (MA MCOs) The STAR rating system is the holy grail of MA MCOs 5 STAR rating system based on measures like- Staying healthy: screenings, tests, and vaccines. Managing chronic (long-term) conditions Member experience with the health plan: member satisfaction with the plan. Member complaints and changes in the health plan s performance. Health plan customer service The STAR rating determines enrollment, bonuses, payment, basically determines what MA MCOs succeed The STAR ratings system helped build the foundation for future quality efforts. 7 Quality & Value- The beginning-qio/pros In the early 2000s, CMS ramped up its focus on quality with Quality Improvement Organizations (QIO). The QIOs were first Provider Review Orgs from the 1980s. SSA 1156(a) requires Medicare and Medicaid providers to ensure that healthcare items and services offered or furnished to beneficiaries: 1. will be provided economically and only when, and to the extent, medically necessary; 2. will be of a quality which meets professionally recognized standards of health care; and 3. will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing quality improvement organization in the exercise of its duties and responsibilities 8 Medicare already extensively manages performance In 1999, the Inspector General issued a Special Bulletin providing HHS guidance on gainsharing arrangements; issued several advisory opinions supporting gainsharing 2003 legislation required hospitals to report quality measures (Reporting Hospital Quality Data for Annual Payment Update or RHQDAPU program) 2005 legislation increased the penalty for hospitals not reporting to 2% 9 3
Medicare already extensively manages performance 2006 legislation offered physicians incentive payments to report quality data (Physicians Quality Reporting Initiative) Transformed into a penalty in 2010 2009 legislation created monetary incentives for Meaningful Use of EHR technology 10 ACA accelerated change Value-based purchasing (VBP) under IPPS launched 2012 Plans to implement VBP programs for SNFs, HHAs, ASCs required by 2011 Pilots for IPFs, LTCHs, IRFs, hospice, Cancer Hospitals due by 2016 Hospital Readmissions Reduction Program (2012) Hospital-Acquired Conditions penalty (2015) Quality reporting for post-acute care providers (Long Term Care, Hospice) 11 Value-Based Payment Goals for Medicare FFS ² January 2015-HHS announces plans to shift payments from volume to value Ø Two stages: First deadline end of 2016, Second deadline end of 2018 Different targets and rules for APMs and VBP APM- Alternative Payment Models VBP-Value Based Payment ² More than 30% of Medicare Part A & B payments are already tied to APMs as of January 2016 12 4
FFS vs Value Based Care Fee For Service Provider-Centered Incentives for Volume FFS Payment Systems and models Value Based Patient-Centered Incentives for Outcomes Coordinated Care Value Based Purchasing ACOs Medical Homes Quality/cost transparency 13 Insurers and Value United, Aetna, and Anthem: Want to match the transition to value-based payment models described by HHS, 30% FFS to value based in alternative payment models (like ACOs) in 2016 and 50% by 2018 14 Insurers and Value United- has more than $45B spent and associated with value-based contracts. 770 ACO contracts with 425 ACOs; 220 Patient centered Medical Homes PCMHs in FFS result in 3-5% savings Value-based contracts 1-6% savings 15 5
Medicare Access & CHIP Reauthorization Act Applies to physicians, PAs, nurse practitioners, clinical nurse specialists, and CRNAs. Final rule released on October 14. Final implementation January 1, 2017 Replaces SGR methodology for updates to Physician Fee Schedule and replaces it with a quality based payment program. Uses either Advanced Payment Models or Merit-based Incentive Payment System for eligible clinicians and groups Information can be found on CMS website (Quality Payment Program or MACRA/ page) 16 Merit-based Incentive Payment System Eligible professionals will be measured in 4 performance areas Meaningful use Quality Resource use Clinical practice improvement Each performance area will be weighted 17 CMS - > than 50% of clinicians will be excluded from due to several factors (some may be excluded due to low volume ($30,000 or 100 Medicare patients) 4 integrated performance categories linked by mission of supporting care improvement): ü Quality ü Cost ü Improvement activities ü Advancing care information 18 6
Reporting Options individual eligible clinician or as part of a group. Data may be submitted via relevant third party intermediaries, such as qualified clinical data registries (QCDRs), health IT vendors, qualified registries, and CMS-approved survey vendors Within each performance category, CMS is finalizing specific requirements for full participation in. Will submit data on quality measures, improvement activities, and use of certified EHR technology on a minimum of any continuous 90 days up to the full calendar year in 2017 in order to be eligible for a positive payment adjustment. 19 Quality measures - selected annually through a call for quality measures process final list of quality measures published in the Federal Register by November 1 of each year. For eligible clinicians choosing full participation in and the potential for a higher payment adjustment, for a minimum of a continuous 90-day performance period: Clinician or Group will report at least six measures including at least one outcome measure if available. If fewer than six measures apply - must only report on each applicable measure 20 Alternatively - eligible clinician or group can report one specialty-specific measure set, or the measure set defined at the subspecialty level, if applicable for one continuous 90 day period If measure set contains: ü Fewer than six measures - report all available measures within the set. ü Six or more measures - choose six or more measures to report within the set. 21 7
CMS is finalizing: Process for providing performance feedback to clinicians (Annual?) Targeted review process so clinicians can request that CMS review the calculation of payment adjustment factor. Requirements for 3 rd party data submission to Process for public reporting of information through the Physician Compare website 22 CMS estimates the following: Approximately 600,000 eligible clinicians will be required to participate in in its transition year. payment adjustments will be approximately equally distributed between negative payment adjustments ($199 million) and positive payment adjustments ($199 million) to clinicians. Positive payment adjustments will also include an additional $500 million for exceptional performance payments to clinicians whose performance meets or exceeds a final score of 70 23 Alternative Payment Models Congress has specified what will constitute a qualifying APM Model tested by Centers for Medicare and Medicaid Innovation (CMMI) (other than a Health Care Innovation Award) Demonstration required by Federal law Statutory definition of an APM Demonstration under the Health Care Quality Demonstration Program Accountable Care Organization (ACO) under the Medicare Shared Savings Program (MSSP) 24 8
APM: Criteria Statute requires that an eligible APM entity that participates in an APM must meet the following requirements: EHR Requires the use of certified EHR technology Measures Provides for payment for covered professional services based on quality measures comparable to those used under Risk Bears financial risk for monetary losses under such a model that are in excess of a nominal amount OR Is a medical home expanded under section 1115A (c), under which a model tested by the CMMI can be expanded and even applied nationwide 25 APM: Types of Participation Category Qualifying APM participant Partial qualifying APM participant** Description (Eligible professionals who ) meet or exceed the following thresholds: 2019-2020: 25% of Medicare payments (during the most recent period for which data are available) 2021-2022: 50% of Medicare payments or 50% of total payments* (and at least 25% of Medicare payments) 2023 and beyond: 75% of Medicare payments or 75% of total payments (and at least 25% of Medicare payments) meet somewhat lower payment thresholds: 2019-2020: 20% of Medicare payments 2021-2022: 40% of Medicare payments or 40% of total payments (and at least 20% of Medicare payments) 2023 and beyond: 50% of Medicare payments or 50% of total payments (and at least 20% of Medicare payments) * Total payments exclude payments made by the Defense/Veterans Affairs and Medicaid payments in states without medical homes or Medicaid APMs. **Partial qualifying APM participants are not subject to but also do not qualify for the bonus payments provided to qualifying APM participants. 26 What does all this mean to you? Choose to report to for: a full 90 day period or, ideally, the full year, and maximize the eligible clinician s chances to qualify for a positive adjustment. Exceptional performers in, as shown by the practice information that they submit, are eligible for an additional positive adjustment for each year of the first 6 years of the program. 27 9
What does all this mean to you? Choose to report to for a period of time less than the full year performance period 2017 but for a full 90 day period at a minimum and report: > 1quality measure > 1 improvement activity, or > than the required measures in the advancing care information performance category In order to avoid a negative payment adjustment and to possibly receive a positive payment adjustment. 28 What does all this mean to you? Clinicians can choose to report: 1 measure in the quality performance category 1 activity in the improvement activities performance category, or the required measures of the advancing care information performance category And avoid a negative payment adjustment. If eligible clinicians choose to not report even one measure or activity, they will receive the full negative 4 percent adjustment. Ø From CMS Executive Summary of Final Rule October 14, 2016 29 What does all this mean to you? Ø eligible clinicians can participate in Advanced APMs if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will qualify for a 5 percent bonus incentive payment in 2019. Ø From CMS Executive Summary of Final Rule October 14, 2016 30 10
What does all this mean to you? Small Practices: CMS added several measures to try to address MACRA s impact on small practices Many small practices will be excluded from new requirements due to the low-volume threshold, which has been set at less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients Solo and small practices may join virtual groups and combine their reporting. 31 What does all this mean to you? Small Practices: $100 million in technical assistance will be available to eligible clinicians in small practices, rural areas, and practices located in geographic health professional shortage areas (HPSAs), including IHS, tribal, and urban Indian clinics, through contracts with quality improvement organizations, regional health collaboratives, and others to offer guidance and assistance to eligible clinicians in practices of 15 or fewer eligible clinicians. Priority will be given to practices located in rural areas. 32 Challenges & Strategies for Healthcare Providers Redefining the delivery of care Moving from fee based to value based How can we forecast financial need/impact in value based models? Know the Value Based Modifier categories, they are also very similar to other value based/quality payment models CMS uses Look at efficiency and collaboration Physician alignment Employed and independent providers Fraud & Abuse considerations 33 11
Challenges & Strategies for Hospitals and Physicians Value/Quality metrics. What things are most commonly measured by CMS? Basically NCQA and AHRQ measures, relating to the Big Four Disease types-copd, Heart Failure, Coronary Artery Disease (CAD), and Diabetes Medication Therapy Management Cardiac Disease monitoring- like the use of Statins Diabetes testing Mammography Bone Density/Osteoporosis monitoring Admissions/readmissions 34 Challenges & Strategies for Hospitals and Physicians Because of the ACA, Medicaid, and Medicare Advantage, premiums are being fixed like never before. The new reality is - if a payer is not within $30 of what s being offered as premium, then they can not survive in the world of exchanges and the new insurance marketplace. 35 Challenges & Strategies for Hospitals and Physicians So, where is the money and what is it being used for? MA, Dual Alignment- based on the most quality and efficient care being offered in narrow networks ACA changed the MLR ratios If there is $ left over, how do you share in that? Who decides who gets/shares the $? 36 12
Common Physician Quality Measures In February, the Core Quality measures Collaborative (includes CMS, AHIP, Medicare and Medicaid MCOs, etc.) Alignment between CMS and payers and providers Core measures 7 categories ACOs, PCMHs, Primary Care Cardiology Gastroenterology HIV & Hep C Medical Oncology Obstetrics & Gynecology Orthopedics 37 Challenges & Strategies - Commercial Payers To be successful, what does P-P-P alignment look like?- It must have the following 5 keys 1. Data 2. Physician Leadership 3. Alignment 4. Operational Execution/Robustness 5. Creativity 38 Quality Measures-What Could Happen? What standards will CMS establish and what will they measure? VBM, STAR ratings- all good predictors. Will the standards change during a year? Will they change from year to year? How often? 39 13