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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What is MACRA?

• Signed into law

April 16, 2015

• Passed 392 to 37

in the House and

92 to 8 in the

Senate



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



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%



Payment Models

• Consolidates quality programs

Merit-Based Incentive Payment System (MIPS)

• Potential for bonus payment for participation

Alternative Payment Model (APM)



Merit-Based Incentive

Payment System

(MIPS)



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



Consolidates Quality & Value

Programs

11

• Physician Quality

Reporting System

• Value Based

Payment Modifier

• Meaningful Use

MIPS

MU

VBPM PQRS



Establish Composite Performance

Score

12

Quality Resource

Use Clinical

Practice

Improvement

Activities

Meaningful

Use



Clinical Practice Improvement

Activities (CPIA)

• Access

• Population Management

• Care Coordination

• Beneficiary Engagement

• Patient Safety

• Participation in an

Alternative Payment Model



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



“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



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



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”



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



Exemptions

19

• Year 1 Medicare

• Eligible APMs with Bonus

• Below low volume threshold

• Federally Qualified Health Clinics and Rural Health

Clinics



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



MACRA Timeline

2016 2017 2018 2019 2020 2021 2022-

2024 2025 2026


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

+0.75%**

*Non-Qualifying APM Conversion Factor



PQRS, Value-based Modifier, &

Meaningful Use

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

Activities

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

+0%

+/-9%



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



10 or fewer

Combined score

Geography or Specialty

Written agreement

One year commitment

“All or nothing”

23

Virtual

Groups



Alternative Payment Models

(APMs)



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



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



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




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



Additional Rewards for

Qualifying Participants

29

• Not subject to MIPS

• 5% bonus 2019-2024

• Higher fee schedule update 2026



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)



31

Yes No

Am I in a Qualifying APM?



32

Yes No

Am I in an eligible APM?

Yes No




33

Yes No


Enough payments or patients?

Yes No

Yes No




34

Yes No



Yes No

Yes No



5% bonus payment 2019-2024

Higher fee schedule 2026+

APM-specific rewards

Excluded from MIPS



35

Yes No



Yes No

Yes No


Subject to MIPS

Favorable MIPS scoring




36

Yes No


Subject to MIPS



Yes No




37

Yes No

1st year in Medicare OR

below low-volume threshold?

Not subject

to MIPS

Yes No




38

Yes No



Subject to

MIPS

Yes No




39

Yes No


Yes No



Yes No


5% bonus payment 2019-2024

Higher fee schedule 2026+


Excluded from MIPS

Yes No



Not subject

to MIPS Subject to

MIPS

Subject to MIPS





MACRA Timeline

2016 2017 2018 2019 2020 2021 2022-

2024 2025 2026


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

+0.75%**

*Non-qualifying APM Conversion Factor



PQRS, Value-based Modifier, &

Meaningful Use

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

Activities

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


5% Incentive payment

Excluded from MIPS

+0%

+/-9%



Technical Assistance

41

• $20 million for

Technical

Assistance 2016-

2020



Payment Reform Is Here

• Final regulations in 2016

• 2017 likely performance year for MIPS

– Advocating for 2018

• Help is available



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 - [email protected]



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 [email protected] with any questions.



mailto:[email protected]

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



AAFP.ORG/MACRA

• FAQs

• Timeline

• MIPS/APM

Comparison table

• Related articles

• Related links

46



fmcc 2016 macra plenary by amy mullins

Health & Medicine