fmcc 2016 macra plenary by sandy marks

Sandy Marks

Family Medicine Congressional Conference

April 18, 2016

New Payment Models Under MACRA

© 2016 American Medical Association. All rights reserved.

MACRA, MIPS, APMs, VBP, MU, ACO …

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2019 (first year) penalty risks compared

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Prior Law 2019

adjustments

PQRS -2%

MU -5%

VBM -4% or more*

Total penalty risk -11% or more*

Bonus potential (VBM

only)

Unknown (budget

neutral)*

MIPS factors 2019 scoring

Quality measurement 50% of score

MU 25% of score

Resource use 10% of score

Clinical improvement

activities

15% of score

Total penalty risk Max of -4%

Bonus potential Max of 4%, plus

potential 10% for high

performers *VBM was in effect for 3 years before MACRA passed, and

penalty risk was increased in each of these years; there

were no ceilings or floors on penalties and bonuses, only a

budget neutrality requirement.


Proactively Shaping MACRA Regulatory Policies

• AMA and 100+ state and specialty society sign-on comment letter based on principles developed by AMA MACRA Task Force (includes AAFP):

– Reduce administrative burdens

– Substantially improve current quality & reporting programs

– Physicians in all specialties, localities and practice settings should have choices about the kind of model in which they want to participate

• AMA MACRA Workgroups on MIPS & APMs (inc. AAFP) crafted detailed 45-page AMA RFI response

The Merit-based

Incentive Payment

System (MIPS)

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What Congress Intended for MIPS

• MACRA requires CMS to adjust the current reporting programs to meet the

purposes of MIPS, which has a separate identity from existing programs

• Rep. Pitts: We are replacing the SGR, once and for all, with a system that

allows greater freedom for physicians to practice medicine

• Rep. Pallone: It allows providers to give more focus to their patients

• Rep. Brady: The sole practitioner in rural Pennsylvania, as well as a doctor

in a major institution in downtown Houston, can both practice to their

highest capability and continue to practice until they decide to retire, not

until Medicare or some flawed formula encourages them to retire early


Key RFI Comments on MIPS

• Current Medicare P4P programs must be reset so that MIPS will

be meaningful and relevant for physician practices

• Growing requirements + insufficient measures =

physician frustration

• CMS needs to learn from mistakes:

– Physicians treating sickest patients most likely to incur penalties

– Attribution methods hold many physicians accountable for costs over

which they have no control, while others have no patients attributed

• Specialty societies should be able to define meaningful measures

Goal: more limited requirements + more options to meet them

Alternative payment

models (APMs)

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24 CMMI Models Authorized by ACA (i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, medical homes that address women’s unique health care needs, and models that transition primary

care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment.

(ii) Contracting directly with groups of providers of services and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payment or salary-based payment.

(iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one of the following:

(I) An inability to perform 2 or more activities of daily living.

(II) Cognitive impairment, including dementia.

(iv) Promote care coordination between providers of services and suppliers that transition health care providers away from fee-for-service based reimbursement and toward salary-based payment.

(v) Supporting care coordination for chronically ill applicable individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health

technology.

(vi) Varying payment to physicians who order advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) according to the physician’s adherence to appropriateness criteria for the ordering of such services, as determined in consultation

with physician specialty groups and other relevant stakeholders.

(vii) Utilizing medication therapy management services, such as those described in section 935 of the Public Health Service Act.

(viii) Establishing community-based health teams to support small-practice medical homes by assisting the primary care practitioner in chronic care management, including patient self-management, activities.

(ix) Assisting applicable individuals in making informed health care choices by paying providers of services and suppliers for using patient decision-support tools, including tools that meet the standards developed and identified under section 936(c)(2)(A)

of the Public Health Service Act, that improve applicable individual and caregiver understanding of medical treatment options.

(x) Allowing States to test and evaluate fully integrating care for dual eligible individuals in the State, including the management and oversight of all funds under the applicable titles with respect to such individuals.

(xi) Allowing States to test and evaluate systems of all-payer payment reform for the medical care of residents of the State, including dual eligible individuals.

(xii) Aligning nationally recognized, evidence based guidelines of cancer care with payment incentives under title XVIII in the areas of treatment planning and follow-up care planning for applicable individuals described in clause (i) or (iii) of subsection

(a)(4)(A) with cancer, including the identification of gaps in applicable quality measures.

(xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or skilled nursing care during an inpatient stay and the 30 days immediately following discharge.

(xiv) Funding home health providers who offer chronic care management services to applicable individuals in cooperation with interdisciplinary teams.

(xv) Promoting improved quality and reduced cost by developing a collaborative of high-quality, low-cost health care institutions that is responsible for—

(I) developing, documenting, and disseminating best practices and proven care methods;

(II) implementing such best practices and proven care methods within such institutions to demonstrate further improvements in quality and efficiency; and

(III) providing assistance to other health care institutions on how best to employ such best practices and proven care methods to improve health care quality and lower costs.

(xvi) Facilitate inpatient care, including intensive care, of hospitalized applicable individuals at their local hospital through the use of electronic monitoring by specialists, including intensivists and critical care specialists, based at integrated health

systems.

(xvii) Promoting greater efficiencies and timely access to outpatient services (such as outpatient physical therapy services) through models that do not require a physician or other health professional to refer the service or be involved in establishing the

plan of care for the service, when such service is furnished by a health professional who has the authority to furnish the service under existing State law.

(xviii) Establishing comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities, that, through their structure, operations, and joint-activity deliver a full

spectrum of integrated and comprehensive health care services to applicable individuals while also incorporating innovative methods for the clinical training of future health care professionals.

(xix) Utilizing, in particular in entities located in medically underserved areas and facilities of the Indian Health Service (whether operated by such Service or by an Indian tribe or tribal organization (as those terms are defined in section 4 of the Indian

Health Care Improvement Act)), telehealth services—

(I) in treating behavioral health issues (such as post-traumatic stress disorder) and stroke; and

(II) to improve the capacity of non-medical providers and non-specialized medical providers to provide health services for patients with chronic complex conditions.

(xx) Utilizing a diverse network of providers of services and suppliers to improve care coordination for applicable individuals described in subsection (a)(4)(A)(i) with 2 or more chronic conditions and a history of prior-year hospitalization through

interventions developed under the Medicare Coordinated Care Demonstration Project under section 4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b–1 note).

(xxi) Focusing primarily on physicians’ services (as defined in section 1848(j)(3)) furnished by physicians who are not primary care practitioners

(xxii) Focusing on practices of 15 or fewer professionals.

(xxiii) Focusing on risk-based models for small physician practices which may involve two-sided risk and prospective patient assignment, and which examine risk-adjusted decreases in mortality rates, hospital readmissions rates, and other relevant and

appropriate clinical measures.

(xxiv) Focusing primarily on title XIX, working in conjunction with the Center for Medicaid and CHIP Services;

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Key AMA Comments on APMs

• Today, despite all the CMS demonstrations and models that were

authorized, most physicians still do not have access to Medicare

payment models that provide the resources they need to improve

care for Medicare patients

• MACRA rules must establish a clear pathway for physician-focused

payment models to be implemented by CMS as ―qualified‖ APMs.

• In considering expansion of Comprehensive Primary Care Initiative,

CMS should: reduce administrative burdens, offer physicians

flexibility to redesign the delivery of primary care services, and link

accountability to costs that primary care physicians can influence.


More Ways to Create APMs than Current CMS Approaches

Physician-Focused APM Models

1. Payment for a High-Value Service

2. Condition-Based Payment for a

Physician’s Services

3. Multi-Physician Bundled Payment

4. Physician-Facility Procedure Bundle

5. Warrantied Payment for Physician

Services

6. Episode Payment for a Procedure

7. Condition-Based Payment


AMA Work on Physician-Focused Payment Models

• Helping specialties develop a range of payment models that will

provide more flexibility and enable more physicians to participate,

including small and independent practices

• Convening meetings with physicians from many specialties to

discuss APMs focused on management of conditions that often

involve teams of primary care and other specialties, including:

– Stroke

– Osteoarthritis

– Cancer

– Emergency medicine

– Opioid use disorder

– Kidney disease

– Asthma

– Headache

– Epilepsy

– Long-term care

Key MACRA

Advocacy Issues

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Setting Initial Performance Periods

• First MACRA payment adjustments will occur in 2019

• Forthcoming regulations will set ―performance period‖ that

will provide basis for these 2019 adjustments

• MACRA requires that performance period be ―as close as

possible‖ to the time that payment adjustments are made

• Advocating for regulations to give physicians adequate

time to learn what the new requirements will be, make

needed changes in their practices so that they can succeed

• Also need to ensure that physicians have access to APMs

and a meaningful opportunity to earn APM bonus payments

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Defining ―More than Nominal Financial Risk‖ for APMs

• ―Nominal‖ means ―a very small amount‖ or risk ―in name only‖

• Regulations should define nominal risk as far less than the existing CMS definition of ―substantial‖ risk, should not require physicians to be at risk for the ―total cost of care‖ of a patient population, and should not impose greater financial risk for APM participants than physicians face in MIPS

• Financial risk should count:

– start-up costs to organize APM

– ongoing costs such as care coordinators

– costs of high-value services that are not payable under FFS

– costs of lower FFS revenue due to avoiding complications, improving appropriateness

– keeping patients healthy

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Physician-Focused APMs Must Be ―Qualified‖ APMs

What CMS Is Saying:

• Only the ―most highly advanced‖ APMs will be qualified APMs

• CMS need only review and comment on APMs recommended by Physician-Focused Payment Models Advisory Committee (PTAC)

What MACRA Says:

• MACRA has few APM criteria – quality measures, electronic health records, nominal risk, Medicare ACO or CMMI models – never uses term ―advanced‖

• Independent PTAC is important pathway to get qualified APMs that are proposed by stakeholders implemented by CMS

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AMA Plans

Goal: To proactively shape MACRA implementation so that all physicians can succeed under the practice model of their choice

Work collaboratively with physician specialty organizations and state medical societies (MACRA task force, MIPS and APM workgroups) to promote common recommendations and physician engagement

Conduct outreach to other influential stakeholders and find common ground

Secure needed external expertise

Develop decision-making and planning tools, educational programs for physicians

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MACRA Resources

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http://www.ama-assn.org/go/medicarepayment



http://www.ama-assn.org/go/apm




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fmcc 2016 macra plenary by sandy marks

Health & Medicine