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Paying for Quality

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What clinicians need to understand to thrive in the brave new world of MACRA and MIPS
Megan Douglas, JD

Published in: Healthcare
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Paying for Quality

  1. 1. Paying for Quality What Clinicians Need to Understand to Thrive in this Brave New World Megan Douglas, JD – National Center for Primary Care – Morehouse School of Medicine
  2. 2. Overview • Pay for Performance General Overview & Evidence- base • MACRA Overview – Timeline – Eligibility – Composite Performance Score – Impact • Primary care • Emergency Medicine • FQHCs • Small, rural, HPSA • Health equity – Future
  3. 3. Pay for Performance (P4P)
  4. 4. Pay for Performance (P4P) Fee-for- Service Managed Care P4P
  5. 5. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
  6. 6. MACRA • Repeals Sustainable Growth Rate (SGR) • Revenue Neutral – Winners = high performers – Losers = low performers • Shifts clinician responsibility beyond clinical walls • Incentivizes clinical practice transformation, use of health information technology, alternative payment models • Public Reporting – Physician Compare
  7. 7. Trump Administration American Health Care Act
  8. 8. MACRA Merit-based Incentive Payment System (MIPS) Combines: ‒ Physician Quality Reporting System (PQRS)* ‒ Value Modifier (VM or Value-based Payment Modifier) ‒ Meaningful Use Advanced Alternative Payment Model (APM) ‒ Medicare Shared Savings Program (Tracks 2 & 3) ‒ Next Generation Accountable Care Organization (ACO) ‒ Comprehensive End-Stage Renal Disease (ESRD) Care ‒ Comprehensive Primary Care Plus (CPC+) ‒ Oncology Care Model (OCM)
  9. 9. Implementation Timeline
  10. 10. MIPS Reporting Timeline – 2017/2019
  11. 11. Eligibility Low-volume threshold = $30,000 in Medicare claims OR 100 Medicare patients
  12. 12. Merit-based Incentive Payment System (MIPS) https://www.surveyvitals.com/start/quality-payment-program-preparing-for-mips
  13. 13. Composite Performance Score (CPS)
  14. 14. Quality – 60% • Physician Quality Reporting System (PQRS) • 300 Clinical Quality Measures (CQM) to “choose” from – Includes specialty measures sets • Report on 6 CQMs • Opportunities for bonus points for reporting on high priority measures – CAHPS – outcomes
  15. 15. Resource Use (Cost) – 0% • Value-based Payment Modifier (VBPM) • No reporting – claims-based • Total per capita costs & costs per beneficiary • Will include Part D (pharmacy) in the future
  16. 16. Advancing Care Information – 25% • Meaningful Use (MU) • Requires 2015 Certified Electronic Health Record Technology (CEHRT) • Base score & Performance score • Fewer measures than MU • Bonus points for reporting via EHR
  17. 17. Clinical Practice Improvement Activities – 15% • NEW! • 90 activities to “choose” from • Bonus points for high priority activities • Report on 4 medium- or 2 high-weighted activities (2/1 for small, rural, HPSA clinicians) http://www.telligen.com/blog/breaking-down-clinical-practice-improvement-activities-cpia-category-mips
  18. 18. Impact • Family Medicine • Emergency Medicine • Federally Qualified Health Centers • Small, rural, health professional shortage areas (HPSA) • Health Equity
  19. 19. Family Medicine/Primary Care
  20. 20. Emergency Medicine “For example, when a patient is discharged from an emergency department (ED) to a primary care physician office, health care providers on both sides of the transition should have a shared incentive for a seamless transition.” “ED clinicians automatically earn at least a minimum score of one-half of the highest potential score for this performance category simply for providing this access on an ongoing basis, noting that emergency clinicians are one of the few clinician specialties that truly provide 24/7 care” Hospital-based MIPS eligible clinician is a MIPS eligible clinician who furnishes 75 percent or more of his or her covered professional services in sites of service identified by the Place of Service codes used in the HIPAA standard transaction as an inpatient hospital, on-campus outpatient hospital or emergency room setting based on claims for a period prior to the performance period as specified by CMS
  21. 21. Small, Rural, Health Professional Shortage Area • Less than 15 providers • $100 million in technical assistance – Quality Improvement Organizations (QIO) • BIG difference from MU  received support $, now just help • Common questions: – How do I register? – How do I report? – What am I required to report? – Am I eligible? – What CQMs are relevant?
  22. 22. Federally Qualified Health Centers (FQHC) Providers working in FQHCs/RHCs who bill services under FQHC/RHC formula are not eligible for MIPS BUT, services performed in FQHCs and billed under Physician Fee Schedule are subject to MIPS
  23. 23. Health Equity • Overall quality improvement vs. reduction in disparities – Stratification of CQMs by race/ethnicity, disability, SOGI, SES, etc. • “Achieving Health Equity” & “Integrating Mental & Behavioral Health” CPIA – Evaluation: enough of an incentive? • Risk Adjustment – Social Determinants of Health
  24. 24. Future • Loss of solo/small practices – Close/retire – Consolidate with large systems – Join ACO • Quality improvement for reported measures – population-level • Increased health disparities – Cherry-picking of patients – Reduced volume of Medicare patients • LOTS of MACRA consultants
  25. 25. “Nobody knew health care could be so complicated” - POTUS
  26. 26. Questions & Discussion Thank You!! mdouglas@msm.edu @mdouglas1313

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