MACRAFrom10,000Feet

PaulRudolf,MD,JDPartner,Arnold&PorterKaye

Scholer,LLP

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•  MACRAaffectsonlyfee-for-servicepaymentsonthePhysicianFeeSchedule(PFS)–notMedicareAdvantage,PACE,orSNFpaymentsystems

–  Replacesthe(un)SustainableGrowthRateformulaMedicareusedtopayphysiciansonthePFS

•  DuringthetransiNontotheQualityPaymentProgram(QPP),Congressseta(small)stableupdate:

+0.5%eachyearin2016-2018

•  MACRA’snewpaymentpoliciesbeginJan.1,2019

•  ButthosepaymentsarebasedonperformanceinCY2017

•  YoursuccessinthefirstyearofQPPdependsonsuccessfullyparNcipaNngduring2017!

MedicareAccessandCHIPReauthoriza6onActof2015(MACRA)

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•  TwotrackstotheQPP:

–  Merit-BasedIncenNvePaymentSystem(MIPS)

–  AlternaNvePaymentModels(APMs)

QPPHasTwoTracks:BothHaveUpside&DownsideFinancialRisk

MIPS APMs

UPSIDE Paymentadjustmentsof+4%to+9%forthosewhoseperformancemeetsorexceedstheperformancethresholdAddiNonalbonusforhighestperformers

Medicarepaysabonusof5%oftotalPartBbillingsfortheyearbaseduponparNcipaNoninAPMsMustbea“qualifyingparNcipant”inan“AdvancedAPM”

DOWNSIDE Paymentadjustmentsof-4%to-9%forthosewhoseperformanceisbelowtheperformancethresholdMaximumpenaltyforfailuretoreport

AdvancedAPMsmustacceptdownsidefinancialriskorbeaPaNent-CenteredMedicalHome

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AdvancedAPMsfor2017

•  ComprehensiveESRDCare(two-sidedrisk)•  ComprehensivePrimaryCarePlus•  NextGeneraNonACOModel•  SharedSavingsProgram(Tracks2and3)•  OncologyCareModel(two-sidedrisk)•  ComprehensiveCareforJointReplacementPaymentModel(Track1–CEHRT)

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UnderstandingYourChoicesEligiblecliniciansmustchooseapath.Here’show:1.   DetermineifyouareinanAdvancedAPM.CMShas

announcedtheAdvancedAPMsfor2017;ifyouarenotenrolledinonealready,youcannotjoinunNl2018.CMSes'matesthatlessthan1%ofinterven'onalradiologistsandvascularsurgeonsand~1.5%ofcardiologistswillbeQualifyingPar'cipantsinAdvancedAPMsin2017.

2.   DetermineifyouareexcludedfromMIPS.TwogroupsofcliniciansareexcludedfromMIPS:– NewInPracNce–firstyearbillingMedicare– LowVolumeThreshold–Lessthan$30,000OR100MedicarepaNentsseeninayear(from9/1/2015to8/30/2016)CMSes'matesthat67%ofinterven'onalradiologists,77%ofvascularsurgeons,and73%ofcardiologistswillbeinMIPS;remainderareexcluded(primarilybecauselowvolume). 5

MIPS:4PerformanceCategories

ReportQualityMeasures(LikePQRS)

CMSCalculatesUsingClaims(LikeValueModifier)

NewCategoryforClinicalPracNceImprovement

ReplacesEHRIncenNveProgram&MeaningfulUse

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MIPSPerformanceCategoriesCombineIntoCompositeScore

IndividualorGroupPerformancein4Domains

(weightfor2019)

Individual’s or Group’s CPS Compared With

Performance Threshold

Payment Adjustment Amount

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60%

15%0%

25%

SeveralRepor6ngMethodsAvailable

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Individuals Groups

•  Claims•  Registries•  EHRVendors

•  NoClaims•  Registries•  EHRVendors•  CMSWebsite(Groupsof25+)•  CAHPSSurveyVendors

•  Claims •  Claims

•  AnestaNon•  Registries•  EHRVendors

•  AnestaNon•  Registries•  EHRVendors•  CMSWebsite(Groupsof25+)

•  AnestaNon•  Registries•  EHRVendors•  Claims

•  AnestaNon•  Registries•  EHRVendors•  CMSWebsite(Groupsof25+)

AvoidaMIPSPaymentPenalty

•  For2017,CMSestablishedarevisedscoringmethodologytominimizepenalNesthatbystatutewouldbe-4%forMIPS-eligibleclinicianswhodonotparNcipate:

•  AnyMIPS-eligibleclinicianwhoreports:

1qualitymeasure,1improvementacNvity,orrequiredEHRmeasures

Iseligibletoreceiveaneutralor(small)posiNvepaymentadjustment.

•  PaymentpenalNeswillonlybeassignedifyoudonothing!•  ReporNngfulldataformaximumperiodapracNceisable(at

least90daysuptofullyear)increaseslikelihoodofaposiNveadjustment

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SpecialMIPSRulesforCertainProviders

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SoloandSmallGroupPrac6ces

(<15)

Non-Pa6ent-Facing

Clinicians

Hospital-BasedClinicians NewinPrac6ce Low-Volume

Threshold

NoscoringonAll-Cause

Readmissions

Doublepointsfor

ImprovementAcNviNes

Doublepointsfor

ImprovementAcNviNes

AdvancingCareInformaNonscore=zero

IneligibleforMIPS

IneligibleforMIPS

•  CMSmadechangestorulesintendedtoincreasetransparency,e.g.,

–  APMparNcipaNon“snapshots”3Nmesperyear,

–  ProvideaniniNaldeterminaNontoletcliniciansknowinadvanceoftheperformanceperiodiftheymeetMIPScriteriaforspecialexclusions;furtherdeterminaNonsbasedonmorerecentdatawouldidenNfyaddiNonalexcepNonsduringtheperformanceperiod

•  CMShasnotyetnoNfiedcliniciansofexclusionsanNcipatedinDecember2016

TransparencyofScoringCalcula6ons

QualityMeasureRepor6ngAllergy/Immunology PlasNcSurgery

Anesthesiology PrevenNveMedicine

Cardiology Neurology

Gastroenterology Mental/BehavioralHealth

Dermatology Radiology(diagnosNc)

EmergencyMedicine Radiology(intervenNonal)

GeneralPracNce/FamilyMedicine

Radiology(radiaNononcology)

InternalMedicine Surgery(vascularsurgery)

Obstetrics/Gynecology Surgery(generalsurgery)

Ophthalmology ThoracicSurgery

OrthopedicSurgery Urology

Otolaryngology Oncology(general)

Pathology Oncology(radiaNononcology)

Pediatrics Hospitalists

PhysicalMedicine Rheumatology

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For50%ofpaNentsseenintheyear(acrossALLpayers):•  Report6quality

measuresviaEHRorregistryorweb(1mustbeoutcomemeasure)

OR•  Reportspecialty-specific

measureset

ReporNngallofthemeasuresinaspecialtymeasuresetwillsaNsfyrequirements,ifthespecialtyhasfewerthan6measures(trueformanysub-specialistsincludingintervenNonalradiologists(4measures).

DevelopmentofCostMeasures•  CostmeasuresdonotaffectMIPSscoreinYear1(0%)butwill

inyear2(10%)andbeyond(30%)•  CMSdefinescostmeasureasMedicarepaymentsforthe

itemsandservicesfurnishedtoabeneficiaryduringanepisodeofcare

•  EpisodegroupsmustaccountforatargetofanesNmatedonehalfofexpendituresunderPartsAandB–  CMSaskedforcommentonbestwaytoincorporatePartDspending

inthefuture

•  CMSmustalsocreatepaNentrelaNonshipcodestoallowphysicianstoclassifythemselvesinrelaNontothepaNent–  LikelytobeimplementedthroughHCPCSmodifiers

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CMSS6llSor6ngThroughNumerousIssuesRelatedtoEpisodeGroups

AppropriateEpisodes

Adequacyofdata

Validityvs.reliability

AssigningresponsibilitybasedonpaNent

relaNonship

Riskadjustment

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EpisodeGroups

AcuteInpaNentCondiNon

•  FocusondiseaseexacerbaNons,injuries,orillnessesexpectedtoresolvewithindefinedNmeperiod(usually90days

•  TriggeredbyICD-10diagnosiscodeorMS-DRG

•  Dratgroupsincludeperipheralvasculardisorders

Procedural

•  Relatedtoperformanceofmedicalorsurgicalprocedures(diagnosNcortreatment)

•  TriggeredbyCPT,HCPCSorICD-10procedurecodesorMS-DRG

•  DratgroupsincludecoronaryarterydiseaseandlowerextremityDVTrequiringanNcoagulaNon

ChronicCondiNon

•  Relatedtolonger-termmanagementofpaNentswithchronicdisease(noendtotheprovisionofcare);enddatedeterminedadministraNvely(typically12months)

•  TriggeredbyE&McodecombinedwithICD-10diagnosiscode

•  Dratgroupsincludecoronarythrombectomy,PCI,andlowerextremityperipheralvasculardiseasetreatment

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DratepisodegroupsandissuesandcostmeasuredevelopmenttopicsopenforpubliccommentthroughApril24,2017.

Pa6entRela6onshipCodesIni6alDrabCategories

•  ConNnuingcarerelaNonship–  Responsibleforprovidingor

coordinaNngongoingcareor–  ProvidesconNnuingspecialized

chroniccare

•  AcutecarerelaNonship–  Providesorcoordinatesoverall

healthcareduringanacuteepisodeor

–  Consultantduringanacuteepisode

•  AcuteorconNnuingcarerelaNonship–  Furnishescareonlyasorderedby

anotherclinician

RevisedDrabCategories•  ConNnuous/broad

–  Comprehensivecarewithnoplannedendpoint

•  ConNnuous/focused–  ExperNseneededforongoing

managementofchronicdisease

•  Episodic/broad–  Comprehensivecareduringa

definedperiodorcircumstance

•  Episodic/focused–  SpecialistfocusedonparNcular

typesofNme-limitedtreatment

•  Onlyasorderedbyanotherclinician

16FinalcategoriesexpectedtobereleasedinApril2017

PhysicianFocusedPaymentModel(PFPM)TechnicalAdvisoryCommicee(PTAC)

•  MakesrecommendaNonstoHHSSecretaryaboutproposedpaymentmodelsthatcouldqualifyasadvancedAPMsunderMACRA–  Comprisedofphysiciansandhealthpolicyexperts

•  StakeholderscansubmitproposalsonarollingbasisthatarecomparedtocriteriaspecifiedbyCMS–  ModelsneedtoprovidesincenNvesandflexibilitytodeliverhigh-qualitycare

andimprovequalityatnoaddiNonalcost,maintainqualitywhiledecreasingcost,orimprovequalityanddecreasecost

–  LookingformodelsthatincludeenNNeswhoseopportuniNestoparNcipateinAPMshavebeenlimited

•  PTACReviewTeamsarenotrecommendinganyoffirstfourproposals–  ProposalfromAmericanCollegeofSurgeonsforPFPMforbroadarrayof

surgicalproceduresdidnotadequatelydescribehowcaredeliverywouldchangetoimprovequalityand/orreducecosts 17

•  2017isatransiNonyear;requirementswillincreaseinfutureandCMSwillbelessflexible–nowistheNmetolearn!

•  Geteducated!LotsofinformaNonatwww.qpp.cms.gov

•  UnderstandyourchoicesandpickapathforparNcipaNon

•  Choosemeasures:pickfromlistsatwww.qpp.cms.gov

•  Reviewyourpastyears’QRURs

•  LookyourselfuponPhysicianCompare

GetReadyNowforMIPS

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OpNonsforNextStepsforCongress:•  ConNnuetonegoNaterepealandreplacelegislaNon

–  DratnewreplacementbillperhapswithDemocraNcsupport?

•  UseAdministraNveauthoritytoloosenregulaNons(ie.workrequirementsinMedicaidexpansion)

•  MoveindividualcomponentsofrepealandreplacethathavebiparNsansupport(ie.medicaldevicetaxrepeal)

•  PuntACArepealandreplaceandfocusontaxreform,Dodd-Frankreform,budget,PrescripNonDrugUserFeeAct(PDUFA),etc.(makingACArepeala2018elecNonissue)

FocusshitsbacktoHHS

What’sNextAberDeathofAHCA?

•  MedicarePaymentReformo  Price:bundledpayments“makealotofsense”forcertainpopulaNonso  VermasupportsMedicareAccessandCHIPReauthorizaNonAct(MACRA)-

benercareoutcomesandneedforstakeholderengagementduringMACRAimplementaNon

!  CentersforMedicareandMedicaidInnovaNonCenter(CMMI)

o  PricesupportsdemonstraNonsthatpromoteinnovaNonbutthinksCMMI“hasgonenofftrack”

o  VermasupportstesNnginnovaNvepaymentmodelsbutnotmandaNngindividualstoparNcipateinthem

o  VermasupportsevaluaNononsmallpopulaNonsbeforegoingfull-scaleandshareresultswithstakeholders

Administra6onMedicareOutlook

SecretaryDepartmentofHealthandHumanServicesTomPrice

CentersforMedicareandMedicaidServices(CMS)AdministratorSeemaVerma

Episode-basedPaymentIni6a6ves•  Hospitalheldaccountableforqualityandcostofcare

providedduringepisode–  Beginswithhospitaladmissionandends90dayspost-discharge–  Involuntary;allhospitalsinselectedgeographicareaparNcipatefor

admissionswithspecificdiagnosis

•  ComprehensiveCareforJointReplacement(CJR)Model(hipandkneereplacements)underwaysinceApril2015

•  ObamaAdministraNonplannedaddiNonalepisodemodelstostartJuly1,2017–  AMI–  CABG–  SurgicalHipandFemurFractureTreatment(SHFFT)

•  TrumpAdministraNondelayedstartdateunNlOctober1,2017andfutureofmodelsisunclear

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Thank You •  Paul Rudolf, MD, JD

– Email: paul.rudolf@aporter.com – Tel: 202-942-6426

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