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Cashing in on Value Based Reimbursement
The document discusses projected Medicare fee-for-service payment cuts and emphasizes the shift from volume-driven to value-driven healthcare. It highlights the roles of various incentive programs and the financial stakes for different medical practices under the changes in reimbursement models. It also details the importance of coordinated care and quality-based payments, with statistics on Medicare beneficiaries and penalties for non-compliance with the established healthcare standards.
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Cashing in on Value Based Reimbursement
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- 3. 3 Projected Medicare Fee-for- servicePayment Cuts per the ACA 2014 2015 2016 2017 2018 2019 2020 Projected number of Medicare beneficiaries 54M 56M 57M 59M 61M 63M 64M -14B -21B -25B -32B -42B -53B -64B Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf
- 4. FFS versus FFV Eliminatesincentive to increase volume Eliminates incentive to provide high-cost services over equally effective low-cost services Quality-based incentives Shared risk Emphasizes the role of primary care providers Encourages coordination of care Fees billed per units of service Income maximized through volume No penalty for poor quality Providers lose money if they reduce unnecessary services Volume Driven Health Care Value Driven Health Care Fee-for-service Value-based payments
- 5. 2018: 90% of Medicare payments tiedto quality. 2020: 75% of commercial plans will be value-based. Jan 2015. http://www.hhs.gov/news/press/2015pres/01/20150126a.html
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- 8. 2007 PQRI starts 2016 PQRS VM appliesto all HCPs 2011 Meaningful Use Stage 1 2014 Meaningful Use Stage 2 2017 Start MIPS or APM 2015 Meaningful Use penalties hit 2015 ICD-10 2015 PQRS penalties hit
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- 11. Two options todemonstrate value SOURCE: The Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board analysis. Merit-Based Incentive Payment System1 2020: -5% to +15% 2019: -4% to +12% 2022 and on: -9% to +27% 2021: -7% to +21% 2018: Last year of separate MU, PQRS, and VBM penalties 1. Positive adjustments may be scaled by a factor of up to 3 times the negative adjustment to ensure budget neutrality. Actual positive adjustments may be lower than numbers shown here. In addition, top performers may earn additional adjustments of up to 10 percent. 1 2. APM participants who are close to but fall short of APM bonus requirements will not qualify for bonus but can report MIPS measures and receive incentives or can decline to participate in MIPS. 2019 - 2024: 5% participation bonus 2019 - 2020: 25% Medicare revenue requirement 2021 and on: Ramped up Medicare or all-payer revenue requirements Advanced Alternative Payment Models22
- 12. Cashing in on VBRtoday.
- 13. 13 Revenue Threats MU + PQRS + VM Revenue Opportunities CCM TCM PCMH New Modelsfor Reimbursement MSSP Bundles ACO
- 14. 14 1 MD Solo FamilyPractice 1,410 Patients per year $909,322 Annual revenue 12% OF TOTAL 2016 ANNUAL REVENUE $119,144 AT STAKE 800K 860K 920K 980K 1.04M 1.1M $35,532 CCM (1 month) $42,540 TCM (avg. complexity) $26,578 VM & HCC $104,650 REWARD MU $7,247 PQRS & VM $7,247 PENALTY $14,494
- 15. 15 5 MDs Group FamilyPractice 4,078 Patients per year $3,299,569 Annual revenue 13% OF TOTAL 2016 ANNUAL REVENUE $426,542 AT STAKE 3M 3.2M 3.4M 3.6M 3.8M 4M $102,766 CCM (1 month)** $123,033 TCM (avg. complexity)1 $129,903 VM & HCC* $355,702 REWARD MU $35,420 PQRS & VM $35,420 PENALTY $70,840
- 16. 16 10 MDs Orthopedic Practice 5,920 Patients peryear $11,621,454 Annual revenue 9% OF TOTAL 2016 ANNUAL REVENUE $1,094,736 AT STAKE 11M 11.4M 11.8M 12.2M 12.6M 13M $178,606 TCM (avg. complexity)t $5,000 Bundles $646,651 VM & HCC* $830,257 REWARD MU $105,792 PQRS & VM $158,687 PENALTY $264,479
- 17. 17 30 MDs Multi-Specialty Practice 14,876 Patients peryear $11,196,511 Annual revenue 18% OF TOTAL 2016 ANNUAL REVENUE $2,021,573 AT STAKE 10M 10.8M 11.6M 12.4M 13.2M 14M $374,863 CCM (1 month)** $448,794 TCM (avg. complexity)t $1,250 Bundles $849,303 VM & HCC* $1,674,210 REWARD MU $138,945 PQRS & VM $208,418 PENALTY $347,363
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- 20. MU versus PQRS Eligibleproviders PQRS Meaningful Use MEDICARE PHYSICIANS Doctor of Medicine X X Doctor of Osteopathy X X Doctor of Podiatric Medicine X X Doctor of Optometry X X Doctor of Oral Surgery X X Doctor of Dental Medicine X X Doctor of Chiropractic X X PRACTITIONERS Physician Assistant X Nurse Practitioner X Clinical Nurse Specialist X Certified Registered Nurse Anesthetist X Certified Nurse Midwife X Clinical Social Worker X Clinical Psychologist X Registered Dietician X Nutrition Professional X Audiologists X THERAPISTS Physical Therapist X Occupational Therapist X Qualified Speech-Language Therapist X
- 21. PQRS versus MU Numberof measures 9 out of 287 measures PQRS Meaningful Use 20 out of 23 measures
- 22. PQRS versus MU Measurementstyle Report first. Then, performance against your peers. PQRS Meaningful Use Measure thresholds.
- 23. Value-Based Payment Programuses data in PQRS to rate practices on cost & quality 23 (above average) COST (below average) QUALITY
- 24. 0% +2% +4% -2%0% +2% -4% -2% 0% Rewards and penalties are based on how practices perform relative to the nation 24 (above average) COST (below average) QUALITY
- 25. PQRS versus MU Practicesfacing penalties in 2015 Nearly 40% of eligible providers face a payment reduction for not reporting in 2013. PQRS Meaningful Use More than 30%will be penalized for not meeting requirements in 2013 and 2014.
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- 28. Transitional Care Management paysfor the work of reducing re-hospitalization Medicare Physician Reimbursement: Evaluation & Management versus TCM Moderate Complexity High Complexity $300 $200 $100 $0 $111 $239 $75 $171 E&M TCM
- 29. 29 During the first30 days after discharge… • Interactive communication between patient and caregiver within 2 business days of discharge • Non-face-to-face services, such as reviewing discharge information or assisting in follow-up with other providers • A face-to-face visit within either 7 or 14 calendar days of discharge
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- 32. 32 Chronic care managementpays for care between visits for chronic conditions $42.60 Medicare Payment 20+ Minutes per month Patients with 2 or more Chronic Conditions Aimed at PCPs, open to any specialty
- 33. 33 • Alzheimer’s diseaseand related dementia • Arthritis (osteoarthritis and rheumatoid) • Asthma • Atrial fibrillation • Autism spectrum disorders • Cancer • Chronic Obstructive Pulmonary Disease • Depression • Diabetes • Heart failure • Hypertension • Ischemic heart disease • Osteoporosis Examples of eligible Chronic Conditions
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- 35. 35 EHR Connectivity & Interoperability DataRegistries Patient & Provider Portals Data Warehousing & Mining Acute Care PHARMAC Y SPECIALT Y CARE PATIENT/FAMILY SUPPORTS HOME CARE ACUTE CARE EMERGENCY CARE SUPPORTIVE /PALLIATIVE CARE TELEHEAL TH LONG TERM CARE Medical Home PCMH helps provide better access to and more coordinated primary care
- 36. PCMH Recognition ThroughNCQA 36 Three Levels of Recognition ✔ ✔ ✔ Level 1: 35-59 points Level 3: 85-100 points Level 2: 60-84 points
- 37. A partner forVBR: athenahealth’s Full Value Program
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- 46. 46 Our clients arealready performing better… Meaningful Use Stage 2 attestation % of HCPs avoiding PQRS penalties in 2015 NATIONAL AVERAGE 60% ATHENAHEALTH CLIENTS 93.6% NATIONAL AVERAGE 33% ATHENAHEALTH CLIENTS 98.2%
- 47. 47 Our PCMH programwas the first of its type, and remains the best in the business 85 35.25 45.5 0 20 40 60 80 100 Minimum amount of points for NCQA Level 3 Practice Responsibility 4.25 athena-Enabled Auto Credits*NCQA Level 1 NCQA Level 2 *pre-validated NCQA points *practice support points athenahealth PCMH Accelerator Program NCQA Level 3
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- 50. 50 OUR VISION: Build thehealth information backbone that makes health care work as it should. Practice management system Patient Portal (ambulatory) Most usable EHR #1 #1 #1
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Editor's Notes
- #3 Why is VBR even happening? What is starting all of these changes? Well, the government is dramatically changing the way doctors are getting paid. Why is that?
- #4 It’s because the number of Medicare beneficiaries has been and will continue to increase exponentially over the next five to ten years, mostly driven by the “baby-boomers” hitting the retirement age. So as to not bankrupt the country, the Medicare fee cuts have to be cut just as much to compensate.
- #5 The big shift is moving from what is known as a “fee-for-service” environment to a “fee-for-value” environment, or “value based”. These value based payments are very different in that they really incentivize quality based care. Instead of high volume where money is made form providing more care, it is all about high quality, where payments come from the type of care that is provided.
- #6 As of January of this year, the government has committed that 90% of their Medicare payments will be tied to quality by 2018. The commercial payers have followed this example and have committed that at least 75% of their plans will be value-based by 2020.
- #7 This leads a lot of practices to feeling like they’ve hit the end of the trail and may not quite know where to go from here or even how to navigate through all these governmental changes going forward, what path to take, so to speak. ------------------------------------- 2015 is a year of intense change. New legislation, rulings, announcements, proposals, and constant changes from the government surrounding the healthcare community have been especially noticeable this year just by the sheer amount coming from the capitol. Much of the changes are pushing aggressively toward reworking payment systems into exclusively quality based programs and unfortunately a lot of the resulting work will fall at the feet of healthcare professionals. Keeping up with all these recent developments can feel a bit like hiking out into uncharted territory, especially now that you’re put in the position of needing to know more about new reporting and documentation measures than ever before. Image source: https://www.flickr.com/photos/33346716@N03/8036177029
- #8 For many practices or small practices in the country, VBR can feel like one more thing to juggle in addition to all the other change facing them over the last few years, and VBR is definitely a big change. It’s really hard to get your head around and it’s a big umbrella for a lot of programs, making it a good one to really buckle down and focus on. Plus, the fact that it comes with some very significant fee cuts, starting actually based on your performance this year, a practice could see a 4% fee cut in years ahead. ---------------------------- Note: you can’t talk about everything and all the buckets but you might want to pick out a few so as they appear so you can narrate along as they pop up: “PCMH, ACO, Self-Pay, ICD-10, Meaningful Use….” It’s already difficult enough with all the changes to payers, hospitals, patients and government. Patients are more involved today and payers are coming up with new strategies like ACOs, hospitals are acquiring practices, etc, etc. So it can feel like trying to run your practice is like walking a tightrope, trying to balance all this change while you keep getting handed more to juggle, more things that can upset your balance ----- Meeting Notes (9/2/15 12:37) ----- revenue hit - make more clear 16, 17, 18 (-10) no dark version
- #9 In order to set some context, let’s talk about the history of those programs. PQRS started back in 2007 then called PQRI. Meaningful Use was introduced in 2011 as part of the American Recovery and Reinvestment Act. In 2014, Meaningful Use Stage 2 went into effect, it was delayed a couple of years but many providers have since attested for Stage 2. In this year, 2015, it’s the first year that your performance is going to be directly tied to quality of care, in other words if you don’t perform well you could see a penalty associated with your Medicare payments. 2015 is also the same year you have to successfully transition over to ICD-10 so it’s a pretty full year. Then next year in 2016, PQRS will apply to all health care professionals. Up until now, it’s only been for about six providers or more but in 2016 the value-based modifier will apply to everyone which will make it a lot more complicated. In 2017, this is the part of the SGR Repeal bill that was written into law, Meaningful Use and PQRS will actually go away and be recreated as a new program called MIPS. Hopefully this means it will all be simplified although CMS has not yet revealed all the details of that program.
- #10 Before getting into the details of the here and now and what you should be thinking about when it comes to value-based reimbursement, I want to give you a quick update of what’s been going on in Washington, D.C. Many of you are aware that the sustainable growth rate repeal bill passed back in April. In the bill, there was a small line item that is causing some very big ripples by changing the way Meaningful Use and PQRS programs are going to exist in the future.
- #11 Even so, the idea behind MIPS is to take Mr. Potato head and make him look a little simpler and less intimidating if not just less jumbled.
- #12 The line item included in the SGR Repeal bill is called MACRA basically has two parts. You can either join MIPS, the merit-based incentive payment system, it starts in 2015 and is essentially fee-for-service with incentives and penalties depending on how you do with your reporting of quality and cost. Or you can become an alternative payment model and substantially change how you practice medicine. An example of an alternative payment model is a patient centered medical home and if you become a PCMH you could see a 5% bonus in your Medicare payments. -------------------------------- To dive a little deeper, per MACRA, providers will have two Medicare value-based reimbursement options, starting in the 2017 reporting year to impact reimbursement in 2019: the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). Furthermore, under MIPS, the swing in Medicare FFS rates will increase to 36% by the year 2022. These are big variants with real revenue impact. However, providers have another option – those that can successfully participate in an alternative payment model or “APM” are exempt from MIPS (though many APMs also require quality reporting, but that quality reporting is taken care of as part of the participation in the APM, so MIPS would be kind of redundant. With MACRA, legislators have made it clear that they want to offer significant incentive for practices to make the move to providing care through APMs, some of which have proven to bring about greater levels of care coordination and patient-center health management, such as PCMH. The bill proposes that starting in 2019, providers receive an automatic 5% participation bonus simply for proving that they are participating in an APM.
- #13 All of that is in the future, though not the very distant future. However you still need to be aware of value based reimbursement programs today and making sure you’re a) avoiding the penalties and b) cashing in on all the incentive payments that are out there between now and 2018.
- #14 To simplify it a little bit for you we like to group all these programs into three buckets. There are the programs that come with revenue threats, Medicare fee cuts if you don’t preform well. There are the programs that come with incentives if you participate. Then there are the programs that are essentially a new way of how you get reimbursed which we’re not going to talk about today but many of you are aware of accountable care organizations and similar models that are typically for larger organizations that are taking on risk.
- #15 For practices like yours, let’s talk a little about what next year might look like. Here’s an example of a one doctor solo family practice who sees approximately 1,410 patients a year and your annual revenue is a little under a million dollars you essentially have about 120,000 dollars at stake or in play so that is 14,000 in Meaningful Use and PQRS penalties on the downside and over 100,000 in incentives payments coming from programs like Chronic care management, transitional care management, and the value based modifier associated with PQRS. ----- Meeting Notes (9/2/15 12:37) ----- Add poll questions????
- #17 10 doctor orthopedic practice – are eligible for bundled payments ----- Meeting Notes (9/2/15 12:37) ----- should it say "2016" show the red first. then the green.
- #19 How do you avoid the ax or avoid the penalties associated with Meaningful Use and PQRS?
- #20 Let’s first talk a little bit about what these two programs are.
- #21 Almost every health care professional is eligible for PQRS. With Meaningful Use there is a lot, roughly 300,000 but way more with PQRS.
- #22 With PQRS as we said there are almost 300 measures which you only have to report out on 9 of them but the trick is finding which 9 measures out of the 300 are best for your practice to be successful in and report out on so it’s pretty complicated in terms of picking those 9 measures. Meaningful Use it’s a little easier to pick since you’re only picking out of 23 but you actually have to report on double the number of measures and be successful in all 20
- #23 When it comes to how you get measured, with PQRS you submit a report with all your data and then CMS measures you against your peers to see how you did so essentially you’re measured on a curve. With Meaningful Use you just have to hit thresholds so you have to be good enough at the measures you selected to hit the thresholds set out by CMS
- #24 To explain how the PQRS value based modifier works, this is your patient panel. Some of your patients cost more, some cost less, some received really great quality, some maybe didn’t which puts you at an average, about where that red dot is.
- #25 CMS then takes your data and compares you to other practices, or the other red dots on this grid. In this case, looks like you did about average which means that you won’t get hit with a payment reduction but you also won’t get an additional payment incentive. If you had done better and ended up in the upper right quadrant you might have seen as much as 4% bump on your Medicare payments.
- #26 Nationally the providers have really struggled with both programs. In 2013 40% of eligible providers did not do well enough to avoid the payment reduction. With Meaningful use that was more that 30% 9% 10% 2018
- #27 That’s it for the penalty programs, now let’s talk about the additional revenue or incentive programs.
- #28 The first one is Transitional Care management or TCM
- #29 A program that gives you extra money for doing the work of reducing hospital admissions. Siginifact increase oin your Communication between patient and provider within 2 business days of discharge Non-face-to-face services, such as reviewing discharge information or assisting in follow-up Face-to-face visit within either 7 or 14 calendar days of discharge 20% of discharged patients are readmitted within 30 days* 78% of hospitals penalized in 2015 due to readmission rates** $12B in preventable readmission costs per year*
- #32 For chronic care management this pays for the work done between visits for patients with chronic conditions, at least two chronic conditions
- #33 CCM reimbursement was finalized by Medicare in the 2015 Physician fee schedule final rule and the AMA created a new CPT code 99490 also effective 1/1/15 that Medicare decided to use for these services. So what is CCM? CCM is a payment for non-face to face care coordination services. CCM services include developing and revising a patient’s care plan, communicating with other treating health professionals, and medication management. The 99490 code can be billed once per calendar month if the requirements are met and at least 20 min of care coordination was provided. Patients eligible must have 2 or more chronic conditions expected to last at least 12 months, place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Remember that 65% of Medicare beneficiaries have 2 or more chronic conditions. While there is no requirement that CCM services be billed by a patient’s PCP, CMS expects the “chronic care management code to be billed most frequently by primary care physicians.” The Medicare payment for these services each calendar month is around $40 and is subject to patient cost sharing like coinsurance and the beneficiaries deductible.
- #35 The last one I’m going to talk to you about is an alternative payment model the Pat
- #36 The primary care is at the center of care coordinating care for their patients, specialists, long term care, whatever they become the sort of quarterback for their patients PCMH helps to provide better access to care and service by promoting a more coordinated approach to managing patients, with an emphasis on the integration of key new technologies and teamwork in support of that coordination. This then leads to returns on an improved patient experience and ultimately improved health. While the number of medical homes with payment initiatives have grown substantially, more providers must show support for this model to achieve its consistency in the health care community and continue to increase recognition and financial reward for PCMH success. Sources: http://www.bostonherald.com/news_opinion/opinion/op_ed/2015/06/as_you_were_sayingfinding_care_close_to_home http://www.washingtonmonthly.com/magazine/july_august_2013/features/first_teach_no_harm045361.php?page=1 https://www.pcpcc.org
- #37 In order to become recognized as a PCMH, you need to go through a certification board. The most popular is NCQA which offers three levels of recognition. Most PCMHs try to get to level three because the return on investment is much higher. A measurable points system goes along with each (click) of the three levels of recognition. Six of six elements are required at each level, and the score for each “Must-Pass” element must be greater than or equal to 50%. (click) athenahealth has the NCQA pre-validated auto-credits and approved “practice support” points needed to automatically get your practice above the 35-point Level 1 threshold and to make getting your practice across the line to achieve Level 3 much easier. We’ll talk more about athena’s support in a moment. Source: http://www.ncqa.org/Portals/0/Events/BehindtheEnhancements_FINAL.pdf Animation: Click for all check marks, click again for dotted line and logo
- #38 So those are all the programs which might be slightly overwhelming. I’d like to spend the rest of my time just quickly talking about what a partner can look like in order to avoid penalties and secure incentives. At athenahealth, this is our approach:
- #39 We at athena have three teams that are tracking over 100 different reimbursement programs Government affairs team go down to Washington D.C. to monitor changes Payer performance team, tracking every measure in every program to make sure we are embedding it in the right way in our software
- #40 We have a quality management engine that sorts though more that 1,700 clinical rules that works for you
- #41 Those measures are surfaced at a point that is not disruptive but it is specific to the patient that comes into the office that is most appropriate to so you can satisfy those measures at the moment of care
- #42 We provide real time visibility into how you’re doing
- #48 When a practice uses our proven, cloud-based EHR and patient engagement services, achieving PCMH Level 3 recognition is within reach. Follow our simple workflows and you’ll automatically receive 35.25 pre-validated points. Combine those points with our NCQA approved “practice support” appoints, and athenaOne clients are only 4.25 points away from achieving Level 3, the highest level of NCQA PCMH recognition.
- #49 We offer a cloud-based integrated service for practices like yours.
- #50 Aside from our scale and open platform what makes use unique is our business model. Unlike other vendors, we sell results, not software. We promise clinical and financial results to health care providers and align our incentives with theirs. We then combine the work of expert service teams with the power of an always-on, up-to-date information platform to deliver on that promise. By combining cloud-based software, network knowledge, and robust services we’re able to markedly improve clinical and financial results for our clients, year over year. So what are the results of the software, knowledge, and services that athenaHealth products can provide? What goes on, both on your computer screen and behind the scenes at athenaHealth, from before a patient enters your office to the moment you get paid?
- #51 Today we are…
- #52 At the end of the day, all the work we do to keep our clients on top of change and support them with the technology and services they need to be successful with VBR is to unburden the skilled physician of tedious, time-consuming and unfulfilling administrative work, so they can get back to doing what they want to be doing, what they were trained to do, which is managing patient health through great care.