physician adoption of value based care
TRANSCRIPT
Carol Vargo, MHS, Director, Physician Practice Sustainability
Montgomery County Medical Society
May 4, 2016
Physician Adoption of Value Based Care
© 2015 American Medical Association. All rights reserved.
Agenda
• Background on AMA Strategic Focus on Physician Professional
Satisfaction and Practice Sustainability
• Research Overview of Impact of New Payment Models on Physician
Practices
• Overview of MACRA
• AMA Tools and Resources to Assist Physicians in New Payment
Adoption
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© 2015 American Medical Association. All rights reserved.
AMA Physician Satisfaction and Practice Sustainability
Goals and Objectives
AMA’s goal is to identify, support, and grow the
evidence-based models of care delivery and
payment that promote the long-term sustainability
of and satisfaction with medical practice, and lead
to improvement in the cost and quality of American
health care.
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© 2015 American Medical Association. All rights reserved.
Internal to Physician Practices External to Physician Practices
Practice
Transformation
(STEPSForward)
Physician
Payment
Professional Satisfaction and Practice Sustainability
Digital
Health
Public Policy/Advocacy
Physician
Organizational
Relationships
Physician
Leadership
Training
Research
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Creating Thriving Physician Practices
© 2015 American Medical Association. All rights reserved.
Physician Payment Models
A proliferation of new payment models impacting physician practices…
– Global payment (a.k.a., capitation)
– Shared savings (e.g., ACO)
– Medical home
– Bundled payments
…How these practices are reacting remains a black box
AMA/Rand “Effects of Health Care Payment Models
on Physician Practice in the United States”
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Payment
models
Physician
practicesPatient care
– Hospital-physician gainsharing
– Pay-for-performance
– Subscription/retainer models
© 2015 American Medical Association. All rights reserved.
Organizational level, alternative payment models have…
• encouraged practices to consider merging or become affiliated with large provider or hospital organizations
• encouraged practices to develop team approaches to care management and new modes of patient access
to care. Relationships between physicians (e.g., referral patterns) have changed.
• increased the importance of data and data analysis, highlighting data deficiencies and inaccuracies
• conflicted with each other and with government regulations, complicating practices’ abilities to respond in a
constructive manner
Features of payment model implementation
Problems in data integrity and timeliness, errors in payment model execution (including inaccurate
measure specification and patient attribution), incomprehensible incentives, and concerns about
measure validity.
Key Findings
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Implications
• Physician practices need support and guidance to optimize the quantity and
content of physician work under alternative payment models
• Challenge: manage multiple simultaneous changes without burning out physicians
• Addressing physicians’ concerns about the operational details of alternative
payment models could improve their effectiveness
• To succeed in alternative payment models, physician practices need data and
resources for data management and analysis
• Harmonizing key components of alternative payment models, especially
performance measures, would help physician practices respond constructively
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© 2015 American Medical Association. All rights reserved.
Next Steps
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AMA/Rand “Effects of Health Care
Payment Models on Physician Practice
in the United States” Report
Influence
Public Payment Policy
Influence
Private Payment Policy
Offer Information, Tools,
and Resources
to Physicians/Practices
The Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA)
© 2015 American Medical Association. All rights reserved.
MACRA
• P.L. 114-10 (H.R. 2) the Medicare Access and CHIP Reauthorization Act
of 2015 (MACRA)
• Developed in bipartisan, bicameral process over 2+ years
• Supported by over 750 national and state-based physician
organizations
• Passed House of Representatives March 26, 392-37
• Passed Senate April 14, 92-8
• Permanently eliminates the SGR, which has been producing Medicare
physician payment cuts annually since 2002
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© 2015 American Medical Association. All rights reserved.
MACRA improvements over current law
Negative Updates for foreseeable future (-21.2% in 2015)
Multiple overlapping, rigid, and sometimes contradictory reporting and penalty programs
Little support for new payment and delivery models outside CMMI and ACO programs
Modest but positive updates for 5 years, and then again in 2026 and beyond
Consolidated Merit-based Incentive Payment System (MIPS) with greater alignment and flexibility, potential for significant bonuses
Technical and financial support for small practices, transitional payments for new models, funding for measure development, more timely physician access to data
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Then Now
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Physicians will have choices
FFS (MIPS)
• Statutory updates
• Former reporting programs consolidated into MIPS with greater flexibility
• Penalty risks reduced, more opportunity for bonuses
• Benchmarks set prospectively, more timely feedback on performance
APMs
• Physicians’ role in creating new models specified
• 5% update bonuses for 5 years aides transition to new 2-sided risk models
• Demonstrated savings will produce higher payments
• Participants exempt from MIPS
Primary Care Support
• PCMH models assume cost savings, so 2-sided risk not required
• Specialty practice PCMHs may be designated
• Permanent coverage of chronic care management services with no annual wellness or preventive examination
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© 2015 American Medical Association. All rights reserved.
MACRA Encourages Physicians to Participate in APMs
Significant Incentives for Participation in APMs Under MACRA
• Lump Sum Bonus = 5% of FFS revenues from 2019 to 2024
• Higher Annual FFS Update (0.75% vs. 0.25%) starting in 2026
• Exemption from MIPS
Flexibility in Minimum Participation Requirements to Receive Incentives
• 2019: 25% of Medicare payments through APMs
• 2021: 50% of Medicare payments through APMs
or 25% Medicare & 50% of total payments in APMs
• 2023: 75% of Medicare payments through APMs
or 25% Medicare & 75% of total payments in APMs
• Option to count % of patients instead of % of payments
• Ability for those just under these thresholds to Partially Qualify
© 2015 American Medical Association. All rights reserved.
What Does MACRA Require for an APM?
• Requirements for Alternative Payment Entity
– Participate in an Alternative Payment Model
– Bear financial risk for monetary losses under APM “in excess of a nominal amount”
OR
be designated as a medical home expanded by the Innovation Center
• Requirements for an Alternative Payment Model
– Be a model defined in the Innovation Center language under ACA, be part of the
shared savings (ACO) program, or be a Medicare demonstration
– Require participants to use certified EHR technology
– Base payment on quality measures “comparable” to MIPS
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© 2015 American Medical Association. All rights reserved.
Milestone events
2016•Proposed and final regulations issued for MIPS and APMs (April and September?)
2017
•First performance measurement year for MIPS
•APM criteria set, proposals accepted on ongoing basis
2018
•First performance measurement year for APMs
•Separate PQRS, MU, and VBM programs/ adjustments sunset Dec. 31
•Deadline for achieving EHR interoperability Dec. 31
2019
•First MIPS payment adjustments implemented, maximum penalties 4% (phases up to 9% in 2022)
•First APM performance assessed, 5% bonus payments made to “qualifying participants”
•HHS reports if EHR interoperability achieved, penalties and decertification criteria may be recommended
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© 2015 American Medical Association. All rights reserved.
AMA plans
AMA’s goal: To proactively shape MACRA implementation so that all physicians can succeed under the practice model of their choice
Ongoing consultation with other physician organizations
Outreach to other influential stakeholders
Securing needed technical expertise
Developing decision making and planning resources and tools for physicians
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© 2015 American Medical Association. All rights reserved.
Critical elements in AMA’s MACRA strategy
• Tools for physicians and practice managers to facilitate their
transition/adoption of new payment models
• Correct problems with existing incentive programs (MU, PQRS, VBM)
• Maximize alignment (or minimize disconnect) between public and
private sector models
• Comprehensive and well coordinated communication and education
network including physicians and practice managers
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© 2015 American Medical Association. All rights reserved.
Tools and Resources Under Development
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TIMELINEWHY
MACRA
WHAT IS
MACRA
MACRA
101
MIPS
DETAILS
APM
DETAILS
DECISION
POINTS
MACRA Evaluator will educate, assess practice readiness, and provide
implementation resources for MIPS and APMs
Initial Educational Content Will Address
V.1 Launch Summer 2016; Future versions after final MACRA regulation
© 2015 American Medical Association. All rights reserved. 18
© 2015 American Medical Association. All rights reserved.
CMS – Transforming Clinical Practices Initiative (TCPI)
AMA SAN Awardee
Work Tracks
Market
Awareness
Promote the goals of the TCPI to the
broad healthcare community through
meetings and digital communications
Online
Education
Develop and digitally host training for
TCPI clinician participants on AMA’s
STEPS Forward™ platform
Registry
Advancement
Accelerate maturation of clinical data
registries through multiple educational
strategies, tools, and resources
Collaborative
Events
Elevate the capabilities of the PTNs
and SANs through developing and
leading four learning events per year
• Practice Transformation Networks (PTN)
• 29 awardees, ~$658M (e.g. Mayo, New
York eHealth Collaborative, Univ. of
Washington, others)
• Provide technical assistance and peer-
level support to assist clinicians in
transforming practices
• Support and Alignment Networks (SAN)
• 10 awardees, ~$27M (e.g. AMA, ACP,
ACEP, ABFM, ACR, others)
• Provide CME, disseminate practice
guidelines, share best practices, provide
access to registry data, provide coaching,
and assist with emerging alternative APMs
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