fmcc 2016 macra plenary by amy mullins

MACRA: Medicare's Shift to

Value-based Delivery & Payment

Models

Presented by Amy Mullins, MD, CPE

Current State

Over Utilization

Volume over Value

Silos of Care

2 Materials herein reflect public law 114-10

dated April 16, 2015 2

Fee for Service

Push Toward Value & Quality

3

• Medicare payments tied to quality or value by end of 2018

• Of those through alternative payment models (APMs) by end of 2016

• Private payer business through value-based arrangements by 2020 75%

Materials herein reflect public law 114-10

dated April 16, 2015

Medicare Access & CHIP

Reauthorization Act (MACRA)

4

“To repeal the Medicare SGR and

strengthen Medicare access by improving

physician payments…”

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Materials herein reflect public law 114-10

dated April 16, 2015

What is MACRA?

• Signed into law

April 16, 2015

• Passed 392 to 37

in the House and

92 to 8 in the

Senate

5 Materials herein reflect public law 114-10

dated April 16, 2015

What Does MACRA Do?

• Repeals the Sustainable Growth Rate (SGR)

• Extends Children’s Health Insurance Program (CHIP) funding for 2 years

• Creates 2 payment tracks

• Provides Annual Baseline Fee Schedule Updates 2016-2018

6 Materials herein reflect public law 114-10

dated April 16, 2015

MACRA Timeline

2016 2017 2018 2019 2020 2021 2022-

2024 2025 2026

Medicare Part B Baseline Payment Updates

-.27% +0.5% +0.5% +0.5% 0% 0% 0% +0.25%*

+0.75%**

*Non-qualifying APM Conversion Factor

**Qualifying APM Conversion Factor

+0%

7 Materials herein reflect public law 114-10

dated April 16, 2015

Payment Models

• Consolidates quality programs

Merit-Based Incentive Payment System (MIPS)

• Potential for bonus payment for participation

Alternative Payment Model (APM)

8 Materials herein reflect public law 114-10

dated April 16, 2015

Merit-Based Incentive

Payment System

(MIPS)

Materials herein reflect public law 114-10

dated April 16, 2015

MIPS Highlights

Consolidates existing quality and value programs

• To ease administrative burden

Establishes a Performance Score

• Adds a category for Clinical Practice Improvement Activities

Opportunity for payment adjustments

• Both positive and negative

10 Materials herein reflect public law 114-10

dated April 16, 2015

Consolidates Quality & Value

Programs

11

• Physician Quality

Reporting System

• Value Based

Payment Modifier

• Meaningful Use

MIPS

MU

VBPM PQRS

Materials herein reflect public law 114-10

dated April 16, 2015

Establish Composite Performance

Score

12

Quality Resource

Use Clinical

Practice

Improvement

Activities

Meaningful

Use

Materials herein reflect public law 114-10

dated April 16, 2015

Clinical Practice Improvement

Activities (CPIA)

• Access

• Population Management

• Care Coordination

• Beneficiary Engagement

• Patient Safety

• Participation in an

Alternative Payment Model

13 Materials herein reflect public law 114-10

dated April 16, 2015

Weighting by Category

2019 2020 2021

Quality 50% 45% 30%

Resource Use 10% 15% 30%

EHR MU 25% 25% 25%

CPIA1 15% 15% 15%

1 - “Certified” patient-centered medical home will receive the full 15 points for

CPIA

14 Materials herein reflect public law 114-10

dated April 16, 2015

“Certified” Patient-Centered

Medical Home (PCMH)

15

• Not defined in law

• Joint Principles of PCMH

• Functions of Comprehensive Primary Care (CPC) – Risk-Stratified Care Management

– Access and Continuity

– Planned Care for Chronic Conditions and Preventive Care

– Patient and Caregiver Engagement

– Care Coordination Across the Medical Neighborhood

Materials herein reflect public law 114-10

dated April 16, 2015

Annual Performance Threshold

• Established by Secretary years 1 and 2

• Mean or median of previous year’s MIPS

scores

• Below = negative payment adjustments

• Above = positive payment adjustments

16 Materials herein reflect public law 114-10

dated April 16, 2015

Adjust Payments

-4%

-5%

-7%

-9%

4%

5%

7% 9%

2019 2020 2021 2022 onward

“With respect to positive

MIPS adjustment

factors…the Secretary

shall increase or decrease

such adjustment factors by

a scaling factor in order to

ensure that the budget

neutrality requirement …is

met”

17 Materials herein reflect public law 114-10

dated April 16, 2015

Adjust Payments

18

-4%

-5%

-7%

-9%

12%

15%

21%

27%

4% 5%

7% 9%

2019 2020 2021 2022 onward

Adjustment to provider’s

base rate of Medicare Part

B payment

Maximum Adjustments

Materials herein reflect public law 114-10

dated April 16, 2015

Exemptions

19

• Year 1 Medicare

• Eligible APMs with Bonus

• Below low volume threshold

• Federally Qualified Health Clinics and Rural Health

Clinics

Materials herein reflect public law 114-10

dated April 16, 2015

Adjustment Summary

20

Performance Score Payment Adjustment

Lowest quartile = Maximum negative

adjustment

At threshold = No adjustment

“Exceptional

Performers” =

Eligible for up to 10%

positive adjustment

“Exceptional Performers” has yet to be defined

Materials herein reflect public law 114-10

dated April 16, 2015

MACRA Timeline

2016 2017 2018 2019 2020 2021 2022-

2024 2025 2026

Medicare Part B Baseline Payment Updates

-.27% +0.5% +0.5% +0.5% 0% 0% 0% +0.25%*

+0.75%**

*Non-Qualifying APM Conversion Factor

**Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)

PQRS, Value-based Modifier, &

Meaningful Use

Quality, Resource Use, Meaningful Use, & Clinical Practice Improvement

Activities

-6% -9% -9%? +/-4% +/-5% +/-7%

+0%

+/-9%

21 Materials herein reflect public law 114-10

dated April 16, 2015

MIPS Summary

Composite Performance Score

• Consolidates existing quality reporting programs in Medicare Part B with Clinical Practice Improvement Activities

Positive payment adjustments

• Includes the potential for significant adjustments for “Exceptional Performers”

Risk of payment penalty

• Risk of negative payment adjustment if performance below threshold

22 Materials herein reflect public law 114-10

dated April 16, 2015

10 or fewer

Combined score

Geography or Specialty

Written agreement

One year commitment

“All or nothing”

23

Virtual

Groups

Materials herein reflect public law 114-10

dated April 16, 2015

Alternative Payment Models

(APMs)

Materials herein reflect public law 114-10

dated April 16, 2015

Definitions

Qualifying APM

• Based on existing payment models

Eligible APM

• Based on criteria of the payment model

Qualifying APM Participant

• Based on individual physician payment or patient volume

25 Materials herein reflect public law 114-10

dated April 16, 2015

Qualifying APMs

26

• MSSP (Medicare Shares Savings Program)

• CMS Innovation Center Model*

• Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration

• “Demonstration required by Federal Law”

Qualifying APMs

Materials herein reflect public law 114-10

dated April 16, 2015

Eligible APMs

27

• Quality measures

comparable to MIPS

• Use of certified EHR

technology

• More than nominal

risk1 OR Medical

Home model under

CMMI authority 1 – Not yet defined

Qualifying APMs

Eligible APMs

Materials herein reflect public law 114-10

dated April 16, 2015

Qualifying APM Participant

28

• Percentage of patients or payments thru eligible APM

• In 2019, the threshold is 25% of Medicare payments. Patient threshold is yet to be determined.

Qualifying APMs

Eligible APMs

Qualifying APM

Participant

Materials herein reflect public law 114-10

dated April 16, 2015

Additional Rewards for

Qualifying Participants

29

• Not subject to MIPS

• 5% bonus 2019-2024

• Higher fee schedule update 2026

Materials herein reflect public law 114-10

dated April 16, 2015

Summary of APMs

Qualifying APMs

• AAFP advocates for CMMI expansion to allow greater participation

Eligible APMs

• “nominal financial risk”

Qualifying Participants

• Potentially more financial certainty with a 5% annual bonus (and no potential for penalty)

30 Materials herein reflect public law 114-10

dated April 16, 2015

31

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10

dated April 16, 2015

32

Yes No

Am I in an eligible APM?

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10

dated April 16, 2015

33

Yes No

Am I in an eligible APM?

Enough payments or patients?

Yes No

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10

dated April 16, 2015

34

Yes No

Am I in an eligible APM?

Enough payments or patients?

Yes No

Yes No

Am I in a Qualifying APM?

Qualifying APM Participant

5% bonus payment 2019-2024

Higher fee schedule 2026+

APM-specific rewards

Excluded from MIPS

Materials herein reflect public law 114-10

dated April 16, 2015

35

Yes No

Am I in an eligible APM?

Enough payments or patients?

Yes No

Yes No

Am I in a Qualifying APM?

Subject to MIPS

Favorable MIPS scoring

APM-specific rewards

Materials herein reflect public law 114-10

dated April 16, 2015

36

Yes No

Am I in an eligible APM?

Subject to MIPS

Favorable MIPS scoring

APM-specific rewards

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10

dated April 16, 2015

37

Yes No

1st year in Medicare OR

below low-volume threshold?

Not subject

to MIPS

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10

dated April 16, 2015

38

Yes No

1st year in Medicare OR

below low-volume threshold?

Subject to

MIPS

Yes No

Am I in a Qualifying APM?

Materials herein reflect public law 114-10

dated April 16, 2015

39

Yes No

Am I in a Qualifying APM?

Yes No

Am I in an eligible APM?

Enough payments or patients?

Yes No

Qualifying APM Participant

5% bonus payment 2019-2024

Higher fee schedule 2026+

APM-specific rewards

Excluded from MIPS

Yes No

1st year in Medicare OR

below low-volume threshold?

Not subject

to MIPS Subject to

MIPS

Subject to MIPS

Favorable MIPS scoring

APM-specific rewards

Materials herein reflect public law 114-10

dated April 16, 2015

MACRA Timeline

2016 2017 2018 2019 2020 2021 2022-

2024 2025 2026

Medicare Part B Baseline Payment Updates

-.27% +0.5% +0.5% +0.5% 0% 0% 0% +0.25%*

+0.75%**

*Non-qualifying APM Conversion Factor

**Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)

PQRS, Value-based Modifier, &

Meaningful Use

Quality, Resource Use, Meaningful Use, & Clinical Practice Improvement

Activities

-6% -9% -9%? +/-4% +/-5% +/-7%

Qualifying APM Participant

5% Incentive payment

Excluded from MIPS

+0%

+/-9%

40 Materials herein reflect public law 114-10

dated April 16, 2015

Technical Assistance

41

• $20 million for

Technical

Assistance 2016-

2020

Materials herein reflect public law 114-10

dated April 16, 2015

Payment Reform Is Here

• Final regulations in 2016

• 2017 likely performance year for MIPS

– Advocating for 2018

• Help is available

42 Materials herein reflect public law 114-10

dated April 16, 2015

What Can I Do Right Now?

1. Evaluate your practice

– Are you submitting PQRS?

– Have you reviewed your QRUR?

– Attested for Meaningful Use?

– Ask the Expert - aco@aafp.org

43 Materials herein reflect public law 114-10

dated April 16, 2015

What Can I Do Right Now?

2. Find a PTN – Go to aafp.org/tcpi

– Click “Find a PTN” to find a practice transformation network in your area

– Email tcpi@aafp.org with any questions.

44 Materials herein reflect public law 114-10

dated April 16, 2015

Family Practice Management

Articles

45

FPM Journal Article -

http://www.aafp.org/fpm/2015/1100/p19.pdf

FPM Journal Article -

http://www.aafp.org/fpm

Materials herein reflect public law 114-10

dated April 16, 2015

AAFP.ORG/MACRA

• FAQs

• Timeline

• MIPS/APM

Comparison table

• Related articles

• Related links

46

Materials herein reflect public law 114-10

dated April 16, 2015