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FMCC 2016 MACRA Plenary by Amy Mullins

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FMCC 2016 MACRA Plenary by Amy Mullins

  1. 1. MACRA: Medicare's Shift to Value-based Delivery & Payment Models Presented by Amy Mullins, MD, CPE
  2. 2. 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
  3. 3. 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 202075% Materials herein reflect public law 114-10 dated April 16, 2015
  4. 4. Medicare Access & CHIP Reauthorization Act (MACRA) 4 “To repeal the Medicare SGR and strengthen Medicare access by improving physician payments…” PhotoCourtesyofAmyMullins,MD Materials herein reflect public law 114-10 dated April 16, 2015
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. Merit-Based Incentive Payment System (MIPS) Materials herein reflect public law 114-10 dated April 16, 2015
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. “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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. Alternative Payment Models (APMs) Materials herein reflect public law 114-10 dated April 16, 2015
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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. 31. 31 Yes No Am I in a Qualifying APM? Materials herein reflect public law 114-10 dated April 16, 2015
  32. 32. 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. 33. 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. 34. 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. 35. 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. 36. 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. 37. 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. 38. 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. 39. 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
  40. 40. 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
  41. 41. Technical Assistance 41 • $20 million for Technical Assistance 2016- 2020 Materials herein reflect public law 114-10 dated April 16, 2015
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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

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