A proposed rule implementing the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) outlines changes to the Medicare program to migrate from payment for volume to arrangements linked to quality and value. This webinar will review key provisions of the proposed rule and their impact on existing and future payment structures, including key issues, opportunities, and potential areas for comment and modification before the rule is finalized.
On our agenda:
-MACRA background and policy objectives expressed in proposed rule
-Changes to existing Medicare reimbursement programs
-Merit-Based Payment Incentive System (MIPS) program proposals
-Alternative Payment Models (AMP) proposals
-Implications, opportunities, and issues under the proposed rule
The Medicare Aaccess and CHIP Reauthorization Act of 2015 establishes two Quality Payment Programs to transition the U.S. Healthcare System from a Fee-For-Service reimbursement methodology to a Fee-For-Value model. MACRA fundamentally adjusts the Medicare Fee Schedule, forcing healthcare providers to utilize HIT, population health management, and care coordination to receive financial rewards.
MACRA: Restructuring Medicare ReimbursementPaul B. Tripp
Everyone must rethink their approach to the delivery of care. It is no longer a viable option to maintain the fee-for- service (FFS) mindset. New measures from CMS will push healthcare to the next level of reform where the patient is increasingly at the center of care and care payment.
In order to best prepare our clients for CMS' transition from Fee-For-Service to Fee-For-Value physician reimbursement, we have prepared a summary of the Merit Incentive-Based Payment System (MIPS). The MIPS program will consolidate PQRS, Meaningful Use, and the Value-Based Modifier into a single reporting program in which CMS affecting ≈95% of physicians beginning in 2017.
An actionable summary of the MIPS Merit-Incentive Based Payment System, MACRA (or the Quality Payment Program), and how to approach value-based healthcare.
MACRA, MIPS, & APMs: Considerations for 2018 and BeyondPYA, P.C.
Providing an overview of QPP’s second performance year finalized in the 2018 Centers for Medicare & Medicaid Services’ QPP and Medicare Physician Fee Schedule, this presentation highlights changes from last year’s program requirements, identifies key areas of immediate focus relevant to financial risks and outcomes, and provides insights into 2019 planning.
Our Insights webinar this week tackles a little-known program that will have a big impact on fee-for-service Medicare providers. The Value-Based Payment Modifier (or Value Modifier for short) is something every Medicare provider should know about as soon as possible. One way or another, providers will wind up on either the incentive or penalty side of this legislation. Take advantage of our webinar for in-depth information on this complex and far-reaching topic.
The Medicare Aaccess and CHIP Reauthorization Act of 2015 establishes two Quality Payment Programs to transition the U.S. Healthcare System from a Fee-For-Service reimbursement methodology to a Fee-For-Value model. MACRA fundamentally adjusts the Medicare Fee Schedule, forcing healthcare providers to utilize HIT, population health management, and care coordination to receive financial rewards.
MACRA: Restructuring Medicare ReimbursementPaul B. Tripp
Everyone must rethink their approach to the delivery of care. It is no longer a viable option to maintain the fee-for- service (FFS) mindset. New measures from CMS will push healthcare to the next level of reform where the patient is increasingly at the center of care and care payment.
In order to best prepare our clients for CMS' transition from Fee-For-Service to Fee-For-Value physician reimbursement, we have prepared a summary of the Merit Incentive-Based Payment System (MIPS). The MIPS program will consolidate PQRS, Meaningful Use, and the Value-Based Modifier into a single reporting program in which CMS affecting ≈95% of physicians beginning in 2017.
An actionable summary of the MIPS Merit-Incentive Based Payment System, MACRA (or the Quality Payment Program), and how to approach value-based healthcare.
MACRA, MIPS, & APMs: Considerations for 2018 and BeyondPYA, P.C.
Providing an overview of QPP’s second performance year finalized in the 2018 Centers for Medicare & Medicaid Services’ QPP and Medicare Physician Fee Schedule, this presentation highlights changes from last year’s program requirements, identifies key areas of immediate focus relevant to financial risks and outcomes, and provides insights into 2019 planning.
Our Insights webinar this week tackles a little-known program that will have a big impact on fee-for-service Medicare providers. The Value-Based Payment Modifier (or Value Modifier for short) is something every Medicare provider should know about as soon as possible. One way or another, providers will wind up on either the incentive or penalty side of this legislation. Take advantage of our webinar for in-depth information on this complex and far-reaching topic.
This Part D Enhanced Medication Therapy Management (MTM) Model learning event occurred on Tuesday, March 1, 2016. The webinar focused on proposed encounter data specifications.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Quality Payment Program (MACRA) Proposed RuleMick Brown
The Quality Payment Program, established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), began in 2017, known as the transition year. The Program’s main goals are to:
Improve health outcomes.
Spend wisely.
Minimize burden of participation.
Be fair and transparent.
The Quality Payment Program has 2 tracks: (1) The Merit-based Incentive Payment System (MIPS) and (2) Advanced Alternative Payment Models (Advanced APMs).
Because the Quality Payment Program brings significant changes to how clinicians are paid within Medicare, the Centers for Medicare & Medicaid Services (CMS) is continuing to go slow and use stakeholder feedback to find ways to streamline and reduce clinician burden. CMS has engaged more than 100 stakeholder organizations and over 47,000 people since January 1, 2017 to raise awareness, solicit feedback, and help clinicians prepare to participate. Based on stakeholder feedback, CMS established transition year policies from the clinician perspective, such as:
Giving clinicians the option to choose how they’ll participate (also known as Pick Your Pace).
Having a low-volume threshold that exempts many clinicians with a low volume of Medicare
Part B payments or patients.
Allowing flexibilities for clinicians who are considered hospital-based or have limited face-to-
face encounters with patients (referred to as non-patient facing clinicians).
As the Quality Payment Program moves into the second year, CMS wants to ensure that there is meaningful measurement and the opportunity for improved patient outcomes while minimizing burden, improving coordination of care for patients, and supporting a pathway to participation in Advanced APMs.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum covering financial methodology for the 2017 Next Generation Accountable Care Organization Model. The open door forum was held on Tuesday, April 5 from 4:00pm – 5:30pm EDT.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Alphabet Soup of Clinical Quality Measures ReportingBill Presley
CMS is transitioning to what the they call "a new and more responsive regulatory framework" for quality reporting and reimbursement. CMS goals are "…electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people". Over the next couple years, we will see a transformation of fee for service into value-based care models driven by the VBP, Quality Payment Program, MACRA, Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM). Healthcare organizations will no longer be motivated by implementing and meeting Meaningful Use, but instead will be driven by value-based care and risk-based payment models that focus on quality outcomes for reimbursements.
In this Education Session we will review:
• How CMS is aligning clinical quality measures (CQMs) to reduce the reporting burden for healthcare organizations and providers. We will cover the vision and goals for achieving quality alignment for CMS.
• We will dive into the following CMS reporting programs and how they interact with each other: Value-Based Purchasing (VBP), Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payments (MIPS), Hospital Inpatient Quality Reporting (IQR), The Joint Commission (ORYX), Outpatient Quality Reporting (OQR), and Alternative Payment Models (APM).
Revenue at Risk: Understanding Financial Impacts of Quality ReportingBill Presley
Jodi Frei, Northwestern Medical Center Vermont, and I co-presented at the MUSE Executive Institute on Revenue at Risk: Understanding Financial Impacts of Quality Reporting. The Executive Institute featured many amazing CXO's discussing the changing landscape of revenue cycle management and how finance, quality, and IT departments are converging on revenue cycle.
Though pay for performance is the common theme, the logistics of programs including Value Based Purchasing (VBP), Inpatient Quality Reporting (IQR), Hospital Acquired Condition (HAC) Reduction Program, Readmission Reduction, MACRA, MIPS and APMs, are very different. In this session, the specifics of each Quality Program including reporting requirements, scoring methodologies, and associated incentives and penalties will be covered. In addition, tools to track performance and quantify financial risk will be shared.
Reimbursement in this era of health care reform is challenging. We all seek success under this new normal in health care. Optimizing revenue capture in a quality reimbursement model requires acquisition of new knowledge and the use of new tools and strategies. Join us in the conversation; share your strategies; learn from others.
Riding the Rapids of Payment Reform: Downstream Effects of Quality Reporting ...Bill Presley
In this presentation, we highlighted how quality measurement programs impact reimbursement affecting your revenue. The revenue at risk in your organization. We focused on quality programs like Value-Based Purchasing (VBP), Merit-Based Incentive Program (MIPS) and Alternative Payment Models (APM) and their impact on Part A and Part B reimbursements.
It’s no surprise that reimbursement tied to quality performance is quickly becoming a reality for hospitals and physicians. CMS’ aggressive goals aimed at increasing the percentage of Medicare payments associated with quality versus quantity can be achieved through such programs as Value-based Purchasing and MACRA. This session will cover scoring methodologies, reporting requirements, reimbursement impact, infrastructure (and other resource needs), EMR tools and tactics, and workflow modifications.
Prepping for CCJR: Lessons Learned in Physician Alignment and Bundled PaymentsWellbe
With CMS’ recent announcement of its Comprehensive Care for Joint Replacement (CCJR) payment model and its plan to implement in seventy-five geographic areas, hospitals must be prepared to manage the entire episode of care from the time of surgery through ninety days after discharge. CCJR presents both opportunities and challenges for hospitals. In order to achieve success, organizations must manage their system of care delivery, ensure they are aligned with their physicians and post acute providers, and master the analytics necessary for driving high quality, low cost care.
MedAssets has worked with numerous providers to implement alignment models that bring hospitals and their physicians together, evaluate, identify, and implement changes to the care delivery system to improve quality and decrease cost across the continuum, and employ meaningful analytics for managing an episode of care.
Kevin Lieb, Senior Director for MedAssets’ Physician Alignment Solutions division, will share examples demonstrating how organizations have successfully implemented Episodes of Care. Mr. Lieb will also share examples from both hospital led and specialist led programs and provide lessons learned from these experiences.
This webinar will enable attendees to do the following:
• Identify alignment models within bundled payments and understand their applicability to your organization
• Understand the analytic capabilities necessary for success in a bundled payment environment
• Identify opportunities and strategies for cost reduction and quality improvement
About the Speaker:
Mr. Lieb has more than 20 years of healthcare-related experience focusing on quality improvement, market development and cost reduction initiatives for the hospital provider market. Mr. Lieb has worked for a number of well-known healthcare companies including GE Medical Systems, HCIA and LBA in Denver, Colorado. His responsibilities included healthcare consulting with a focus on process improvement and quality initiatives.
Making CJR Work for You: A Roadmap for Successful Implementation of Medicare ...Wellbe
This presentation will describe a structured approach to successfully launching a program for the Comprehensive Care for Joint Replacement (CJR) Model. Based on years of experience with bundled programs, this roadmap provides the basis for developing a targeted plan for your organization as the April 1, 2016 deadline for CJR rapidly approaches.
Key topics to be addressed include:
• Overview of CJR rules and program requirements
• CJR implications for your organization
• Bundle evaluation – financial and clinical issues
• Gainsharing considerations with program collaborators
• Designing an effective post-acute care network
• Using analytics to develop and monitor your program
• Key “must-dos” for an April 1, 2016 launch
Learning Objectives:
1. Describe the rules and requirements of CJR
2. Assess the key success drivers in bundle performance
3. Evaluate where and why organizations fail in bundles
4. Develop strategies and tactics to create a post-acute partnership
5. Illustrate risk stratification factors in bundle design
About the Speaker:
Sheldon Hamburger is an Alternative Payment Model advisor for hospitals and healthcare firms nationally. With a focus on program implementation, he brings extensive knowledge and experience gained from more than 25 years of healthcare financial consulting, technology design and development, and sales & marketing strategy for Fortune 1000 clients. He is a frequently sought-after speaker and writer on regulatory and technology trends affecting hospital operations, provider reimbursement issues, BPCI / CJR, programs and regulations, medical expense strategies and payer-provider dynamics. Residing in Raleigh, he is an active member of HIMSS, HFMA, & ACHE. He earned his B.S.E. in Computer Engineering from the University of Michigan.
Slides presented at the July 13, 2010 press conference announcing the final rules for Meaningful Use. These rules define what qualifies for stimulus incentive payments under the ARRA/HITECH legislation.
The Part D Enhanced Medication Management (MTM) Model team hosted a webinar on Wednesday, October 21, 2015. Attendees received an introduction to the model and related details.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
MIPS APM for ACOs: A Hybrid Reimbursement ModelCitiusTech
CMS announced the Quality Payment Program (QPP) final rule in October 2017, stating how it plans to implement the clinician payment changes to QPP, mandated under the Medicare Access and CHIP Reauthorization (MACRA) act. The implementation of the MACRA act impacts different type of organizations, one such being the Accountable Care Organizations (ACOs). ACOs are evaluated for payments on the basis of quality care and the cost factors associated in achieving their quality goals. Post MACRA implementation, all clinicians will receive payments as per the MIPS (Merit based incentive payments) and Advanced APMs (Advanced alternative payment models). ACO’s can register as APM entities and are eligible to receive payments under Advanced APMs. There is a third category of APM entities which participate in Advanced APMs models but do not meet the threshold of payments and patients set by CMS. Such entities fall into a category that is straddling the line between APM and the MIPS track, called MIPS APM (partially qualifying APM participants). This document discusses about the reporting, scoring and payments for the MIPS APM entities
Modern Relationships Between Physicians, Hospitals, and Long-Term Care Provid...PYA, P.C.
PYA Consulting Manager Aaron Elias co-presented “Modern Relationships Between Physicians, Hospitals, and Long-Term Care Providers in a Time of Risk-Based Contracting,” along with Jeanna Palmer Gunville, a shareholder at Polsinelli.
Implementing Bundled Payments: A Deeper DiveWellbe
A Bundled Payment can be defined as “a single package price that provides a positive margin for a comprehensive and specific set of healthcare services delivered by multiple providers over a specified period of time.”
There is growing consensus that this payment methodology, and the powerful spillover effect from extensive care redesign associated with its implementation, may be the most effective strategy to reduce spiraling healthcare costs.
The secondary hypothesis is that bundled payment creates sufficient financial incentives to encourage multiple stakeholders to re-align and focus on improving the value of healthcare delivered to the patient.
There is data, including from the Connecticut Joint Replacement Institute (CJRI), which supports these hypotheses. Despite growing interest in bundled payment methodology, however, there are numerous upside challenges and downside risks. In this webinar, these issues will be reviewed and a cogent strategy for implementing a bundled payment program presented.
About the Speaker:
Dr. Steven F. Schutzer graduated with Honors from Union College 1974 and then the University of Virginia School Of Medicine in 1978. Dr. Schutzer was a Lieutenant in the Medical Corps of the United States Navy between 1979 and 1981. He did his General Surgical training at the University of Rochester and then completed his Orthopedic Residency at the University of Connecticut in 1985. He was then a Fellow in Adult Hip and Reconstructive Surgery at the Massachusetts General Hospital and entered practice with Orthopedic Associates of Hartford in July 1986.
He is currently on the staff of St. Francis Hospital, Hartford Hospital and the University of Connecticut John Dempsey Hospital. Dr. Schutzer is a Founding Member and the Medical Director of the Connecticut Joint Replacement Institute. He is also President of Connecticut Joint Replacement Surgeons, LLC. Dr. Schutzer is a member of AAOS, AAHKS, and the Orthopedic Research Society.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted the first of two webinars on November 19 to describe the final rule and respond to questions about the Comprehensive Care for Joint Replacement Model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held the fifth in a series of webinars for potential applicants interested in applying to Health Care Innovation Awards Round Two. The webinar held on Wednesday, June 26, 2013 from 1:00–2:00pm EDT, focused on measuring project success and developing an operational plan.
- - -
CMS Innovations
http://innovations.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
OneCare is seeking approval of its $1.43 billion budget. The accountable care organization presented the budget last month, and the Green Mountain Care Board will vote on it in December. It’s also asking for funds that must be approved by the Legislature.
Gov. Peter Shumlin signed a deal with the federal government Thursday that will set up a unified health system in Vermont that officials call an all-payer model.
Shumlin signed the contract in his ceremonial office with watery eyes, and thanked his administration, the Green Mountain Care Board, hospitals, and community health centers for cementing the agreement.
https://vtdigger.org/2016/10/28/shumlin-signs-payer-deal-feds/?is_wppwa=true&wpappninja_cache=friendly
This Part D Enhanced Medication Therapy Management (MTM) Model learning event occurred on Tuesday, March 1, 2016. The webinar focused on proposed encounter data specifications.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Quality Payment Program (MACRA) Proposed RuleMick Brown
The Quality Payment Program, established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), began in 2017, known as the transition year. The Program’s main goals are to:
Improve health outcomes.
Spend wisely.
Minimize burden of participation.
Be fair and transparent.
The Quality Payment Program has 2 tracks: (1) The Merit-based Incentive Payment System (MIPS) and (2) Advanced Alternative Payment Models (Advanced APMs).
Because the Quality Payment Program brings significant changes to how clinicians are paid within Medicare, the Centers for Medicare & Medicaid Services (CMS) is continuing to go slow and use stakeholder feedback to find ways to streamline and reduce clinician burden. CMS has engaged more than 100 stakeholder organizations and over 47,000 people since January 1, 2017 to raise awareness, solicit feedback, and help clinicians prepare to participate. Based on stakeholder feedback, CMS established transition year policies from the clinician perspective, such as:
Giving clinicians the option to choose how they’ll participate (also known as Pick Your Pace).
Having a low-volume threshold that exempts many clinicians with a low volume of Medicare
Part B payments or patients.
Allowing flexibilities for clinicians who are considered hospital-based or have limited face-to-
face encounters with patients (referred to as non-patient facing clinicians).
As the Quality Payment Program moves into the second year, CMS wants to ensure that there is meaningful measurement and the opportunity for improved patient outcomes while minimizing burden, improving coordination of care for patients, and supporting a pathway to participation in Advanced APMs.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum covering financial methodology for the 2017 Next Generation Accountable Care Organization Model. The open door forum was held on Tuesday, April 5 from 4:00pm – 5:30pm EDT.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Alphabet Soup of Clinical Quality Measures ReportingBill Presley
CMS is transitioning to what the they call "a new and more responsive regulatory framework" for quality reporting and reimbursement. CMS goals are "…electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people". Over the next couple years, we will see a transformation of fee for service into value-based care models driven by the VBP, Quality Payment Program, MACRA, Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM). Healthcare organizations will no longer be motivated by implementing and meeting Meaningful Use, but instead will be driven by value-based care and risk-based payment models that focus on quality outcomes for reimbursements.
In this Education Session we will review:
• How CMS is aligning clinical quality measures (CQMs) to reduce the reporting burden for healthcare organizations and providers. We will cover the vision and goals for achieving quality alignment for CMS.
• We will dive into the following CMS reporting programs and how they interact with each other: Value-Based Purchasing (VBP), Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payments (MIPS), Hospital Inpatient Quality Reporting (IQR), The Joint Commission (ORYX), Outpatient Quality Reporting (OQR), and Alternative Payment Models (APM).
Revenue at Risk: Understanding Financial Impacts of Quality ReportingBill Presley
Jodi Frei, Northwestern Medical Center Vermont, and I co-presented at the MUSE Executive Institute on Revenue at Risk: Understanding Financial Impacts of Quality Reporting. The Executive Institute featured many amazing CXO's discussing the changing landscape of revenue cycle management and how finance, quality, and IT departments are converging on revenue cycle.
Though pay for performance is the common theme, the logistics of programs including Value Based Purchasing (VBP), Inpatient Quality Reporting (IQR), Hospital Acquired Condition (HAC) Reduction Program, Readmission Reduction, MACRA, MIPS and APMs, are very different. In this session, the specifics of each Quality Program including reporting requirements, scoring methodologies, and associated incentives and penalties will be covered. In addition, tools to track performance and quantify financial risk will be shared.
Reimbursement in this era of health care reform is challenging. We all seek success under this new normal in health care. Optimizing revenue capture in a quality reimbursement model requires acquisition of new knowledge and the use of new tools and strategies. Join us in the conversation; share your strategies; learn from others.
Riding the Rapids of Payment Reform: Downstream Effects of Quality Reporting ...Bill Presley
In this presentation, we highlighted how quality measurement programs impact reimbursement affecting your revenue. The revenue at risk in your organization. We focused on quality programs like Value-Based Purchasing (VBP), Merit-Based Incentive Program (MIPS) and Alternative Payment Models (APM) and their impact on Part A and Part B reimbursements.
It’s no surprise that reimbursement tied to quality performance is quickly becoming a reality for hospitals and physicians. CMS’ aggressive goals aimed at increasing the percentage of Medicare payments associated with quality versus quantity can be achieved through such programs as Value-based Purchasing and MACRA. This session will cover scoring methodologies, reporting requirements, reimbursement impact, infrastructure (and other resource needs), EMR tools and tactics, and workflow modifications.
Prepping for CCJR: Lessons Learned in Physician Alignment and Bundled PaymentsWellbe
With CMS’ recent announcement of its Comprehensive Care for Joint Replacement (CCJR) payment model and its plan to implement in seventy-five geographic areas, hospitals must be prepared to manage the entire episode of care from the time of surgery through ninety days after discharge. CCJR presents both opportunities and challenges for hospitals. In order to achieve success, organizations must manage their system of care delivery, ensure they are aligned with their physicians and post acute providers, and master the analytics necessary for driving high quality, low cost care.
MedAssets has worked with numerous providers to implement alignment models that bring hospitals and their physicians together, evaluate, identify, and implement changes to the care delivery system to improve quality and decrease cost across the continuum, and employ meaningful analytics for managing an episode of care.
Kevin Lieb, Senior Director for MedAssets’ Physician Alignment Solutions division, will share examples demonstrating how organizations have successfully implemented Episodes of Care. Mr. Lieb will also share examples from both hospital led and specialist led programs and provide lessons learned from these experiences.
This webinar will enable attendees to do the following:
• Identify alignment models within bundled payments and understand their applicability to your organization
• Understand the analytic capabilities necessary for success in a bundled payment environment
• Identify opportunities and strategies for cost reduction and quality improvement
About the Speaker:
Mr. Lieb has more than 20 years of healthcare-related experience focusing on quality improvement, market development and cost reduction initiatives for the hospital provider market. Mr. Lieb has worked for a number of well-known healthcare companies including GE Medical Systems, HCIA and LBA in Denver, Colorado. His responsibilities included healthcare consulting with a focus on process improvement and quality initiatives.
Making CJR Work for You: A Roadmap for Successful Implementation of Medicare ...Wellbe
This presentation will describe a structured approach to successfully launching a program for the Comprehensive Care for Joint Replacement (CJR) Model. Based on years of experience with bundled programs, this roadmap provides the basis for developing a targeted plan for your organization as the April 1, 2016 deadline for CJR rapidly approaches.
Key topics to be addressed include:
• Overview of CJR rules and program requirements
• CJR implications for your organization
• Bundle evaluation – financial and clinical issues
• Gainsharing considerations with program collaborators
• Designing an effective post-acute care network
• Using analytics to develop and monitor your program
• Key “must-dos” for an April 1, 2016 launch
Learning Objectives:
1. Describe the rules and requirements of CJR
2. Assess the key success drivers in bundle performance
3. Evaluate where and why organizations fail in bundles
4. Develop strategies and tactics to create a post-acute partnership
5. Illustrate risk stratification factors in bundle design
About the Speaker:
Sheldon Hamburger is an Alternative Payment Model advisor for hospitals and healthcare firms nationally. With a focus on program implementation, he brings extensive knowledge and experience gained from more than 25 years of healthcare financial consulting, technology design and development, and sales & marketing strategy for Fortune 1000 clients. He is a frequently sought-after speaker and writer on regulatory and technology trends affecting hospital operations, provider reimbursement issues, BPCI / CJR, programs and regulations, medical expense strategies and payer-provider dynamics. Residing in Raleigh, he is an active member of HIMSS, HFMA, & ACHE. He earned his B.S.E. in Computer Engineering from the University of Michigan.
Slides presented at the July 13, 2010 press conference announcing the final rules for Meaningful Use. These rules define what qualifies for stimulus incentive payments under the ARRA/HITECH legislation.
The Part D Enhanced Medication Management (MTM) Model team hosted a webinar on Wednesday, October 21, 2015. Attendees received an introduction to the model and related details.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
MIPS APM for ACOs: A Hybrid Reimbursement ModelCitiusTech
CMS announced the Quality Payment Program (QPP) final rule in October 2017, stating how it plans to implement the clinician payment changes to QPP, mandated under the Medicare Access and CHIP Reauthorization (MACRA) act. The implementation of the MACRA act impacts different type of organizations, one such being the Accountable Care Organizations (ACOs). ACOs are evaluated for payments on the basis of quality care and the cost factors associated in achieving their quality goals. Post MACRA implementation, all clinicians will receive payments as per the MIPS (Merit based incentive payments) and Advanced APMs (Advanced alternative payment models). ACO’s can register as APM entities and are eligible to receive payments under Advanced APMs. There is a third category of APM entities which participate in Advanced APMs models but do not meet the threshold of payments and patients set by CMS. Such entities fall into a category that is straddling the line between APM and the MIPS track, called MIPS APM (partially qualifying APM participants). This document discusses about the reporting, scoring and payments for the MIPS APM entities
Modern Relationships Between Physicians, Hospitals, and Long-Term Care Provid...PYA, P.C.
PYA Consulting Manager Aaron Elias co-presented “Modern Relationships Between Physicians, Hospitals, and Long-Term Care Providers in a Time of Risk-Based Contracting,” along with Jeanna Palmer Gunville, a shareholder at Polsinelli.
Implementing Bundled Payments: A Deeper DiveWellbe
A Bundled Payment can be defined as “a single package price that provides a positive margin for a comprehensive and specific set of healthcare services delivered by multiple providers over a specified period of time.”
There is growing consensus that this payment methodology, and the powerful spillover effect from extensive care redesign associated with its implementation, may be the most effective strategy to reduce spiraling healthcare costs.
The secondary hypothesis is that bundled payment creates sufficient financial incentives to encourage multiple stakeholders to re-align and focus on improving the value of healthcare delivered to the patient.
There is data, including from the Connecticut Joint Replacement Institute (CJRI), which supports these hypotheses. Despite growing interest in bundled payment methodology, however, there are numerous upside challenges and downside risks. In this webinar, these issues will be reviewed and a cogent strategy for implementing a bundled payment program presented.
About the Speaker:
Dr. Steven F. Schutzer graduated with Honors from Union College 1974 and then the University of Virginia School Of Medicine in 1978. Dr. Schutzer was a Lieutenant in the Medical Corps of the United States Navy between 1979 and 1981. He did his General Surgical training at the University of Rochester and then completed his Orthopedic Residency at the University of Connecticut in 1985. He was then a Fellow in Adult Hip and Reconstructive Surgery at the Massachusetts General Hospital and entered practice with Orthopedic Associates of Hartford in July 1986.
He is currently on the staff of St. Francis Hospital, Hartford Hospital and the University of Connecticut John Dempsey Hospital. Dr. Schutzer is a Founding Member and the Medical Director of the Connecticut Joint Replacement Institute. He is also President of Connecticut Joint Replacement Surgeons, LLC. Dr. Schutzer is a member of AAOS, AAHKS, and the Orthopedic Research Society.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted the first of two webinars on November 19 to describe the final rule and respond to questions about the Comprehensive Care for Joint Replacement Model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The CMS Innovation Center held the fifth in a series of webinars for potential applicants interested in applying to Health Care Innovation Awards Round Two. The webinar held on Wednesday, June 26, 2013 from 1:00–2:00pm EDT, focused on measuring project success and developing an operational plan.
- - -
CMS Innovations
http://innovations.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
OneCare is seeking approval of its $1.43 billion budget. The accountable care organization presented the budget last month, and the Green Mountain Care Board will vote on it in December. It’s also asking for funds that must be approved by the Legislature.
Gov. Peter Shumlin signed a deal with the federal government Thursday that will set up a unified health system in Vermont that officials call an all-payer model.
Shumlin signed the contract in his ceremonial office with watery eyes, and thanked his administration, the Green Mountain Care Board, hospitals, and community health centers for cementing the agreement.
https://vtdigger.org/2016/10/28/shumlin-signs-payer-deal-feds/?is_wppwa=true&wpappninja_cache=friendly
The application dev tools market is billions of dollars each year, and COBOL is a big chunk of that. Did you know – the COBOL computer language remains responsible for 2/3 of the world’s business IT systems. Did you know there are many times more COBOL-based transactions executed each day than there are Google & YouTube searches.
If some more recent technology gets more attention and makes more noise, well COBOL is by contrast the silent majority of corporate IT, which quietly, relentlessly gets on with running the world’s economy.
On the IBM mainframe, COBOL is the standard for core business systems. Roughly 5,000 clients on z today, but IBM z Systems represent the majority of all the world’s COBOL. Hundreds of billions of LOCs. Hundreds of thousands of developers.
However elsewhere COBOL is a huge concern and runs across hundreds of distributed platforms.
Also there is a whole segment of proprietary environments where – although the platform itself may no longer be strategic – the applications on those platforms, which are often COBOL, have enduring business value.
And COBOL users comprise the length and breadth of global big business, across a variety of industries.
Over 90% of the fortune100 and fortune 500. a who’s who of big industry. Very strong in FS, insurance, retail, government, auto, and elsewhere. But also major ISVs and smaller organizations too.
Literally thousands of organisations across dozens of countries use the Micro Focus brand to run and modernize their IT systems. If you have checked your bank account, got an insurance quote, booked a vacation, payed your mortgage, shipped a package… you’ve been using COBOL today.
Taking those systems and providing a springboard to future environments, future technology, is what we do. KEEP IT, BUILD IT, RUN IT.
By partnering with the best in today’s operating environments such as SUSE, we are providing efficiency, value and flexibility for our customers.
تعريف الإعلال:
تغيير يطرأ على حروف العلة الثلاثة:
أـ قلب الحرف إلى حرف آخر.
ب ـ بحذف الحركة ( أي تسكين الحرف ).
جـ ـ حذف الحرف
ويكون خاصًّا بحروف العلة الثلاثة.
إذا وقعت الواو أو الياء في المواضع التالية تقلب إلى همزة:
أ ـ إذا وقعت الواو أو الياء متطرفة بعد ألف زائدة: سماء، بناء، دعاء/ أصلها : سماو، دعاو، بناي.( حلاوة، قَاوَل، غزْو).
ب ـ إذا وقعت الواو أو الياء عيناً لاسم فاعل بشرط أن يكون الفعل أجوف. قال/ قائل ، باع/ بائع( عاور).
جـ ـ إذا وقعت الواو أو الياء بعد ألف مفاعيل أو ما يشبه هذا الجمع، بشرط أن تكون الواو أو الياء مدة ثالثة في المفرد. صحيفة / صحائف، عجوز/ عجائز، وتنطبق هذه القاعدة على الألف بهذا الشرط. قلادة/ قلائد.( قساوِر، معايش)، و ( منائر، مصائب).
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In this Education Session we will review:
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• How the Eligible Hospital and Eligible Professional reimbursement models will change in 2017 and going forward.
• Compare and contrast the requirements for quality measure reporting and identify strategies to ensure compliance.
• The potential impact to hospital reimbursement of current and proposed programs that will affect quality reporting for hospitals and providers.
• How to improve efficiency and quality by aligning measures across initiatives.
• Where to find current information (and breaking news) on each of these Quality Initiatives.
In the past, organizations participating in quality reporting initiatives involved abstractors sifting through a small sample set of unstructured data in paper charts to then manually convert their findings to discrete reportable data. This approach is time consuming and requires extensive amount of resources from both IT and Quality staff. Aligning quality initiatives can improve efficiencies and processes, and contribute to population health management efforts, both locally and nationally.
At the conclusion of this presentation, attendees will be able to apply what they’ve learned about aligning Clinical Quality Measures across initiatives specific to their organization to improve reimbursements, reduce their reporting burden, increase efficiencies, and realize the benefits of Population Health Management.
If you are responsible for hospital quality, IT, clinical quality measure initiatives or have a vested interest in making sure your organization is aligning quality measures reporting, this informational session is a must.
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- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
During this webinar the Primary Care First Model Options team provided an introduction to the Primary Care First Model that is geared towards payers, presented and answered questions live on topics related to payer partnership, including the Primary Care First payer alignment framework, benefits of multi-payer partnership, and the payer solicitation elements and selection process.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
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1. MACRA Proposed Rule: Issues &
Opportunities
June 1, 2016
Polsinelli
Reimbursement Institute
Sidney Welch
swelch@polsinelli.com
Bruce A. Johnson
brucejohnson@polsinelli.com
Cybil G. Roehrenbeck
croehrenbeck@polsinelli.com
2. Agenda
MACRA background and policy objectives
Proposed Merit-Based Incentive Payment
System (MIPS)
Proposed Alternative Payment Model (APM)
proposals
Implications, issues, concerns and
opportunities
Q&A
2
3. Physician Payment
3
Based on a complicated formula:
– Facility or Non-Facility Pricing Amount =
[(Work RVU * Work GPCI) +
(Transitioned Facility or Non-Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * Conversion Factor (CF)
Initial conversion factor was created in 1992 and
adjusted annually based on three factors:
– The Medicare Economic Index (MEI)
– RVU budget neutrality
– Medicare expenditures for physician services as
compared to a sustainable growth rate
4. Sustainable Growth Rate
4
For the first few years of SGR, Medicare
expenditures did not exceed targets and
doctors received modest pay increases
In 2002, doctors faced a 4.8% pay cut
Every year since 2002, Congress has
passed legislation to temporarily
defer these physician pay cuts
7. CMS View of the Future
CMS Payment Model Framework
Category 1
Fee for Service
–
No Link to
Quality
• 100%
volume
Category 2
Fee for Service
Link to Quality
• Linkage to
quality
and/or
efficiency
Category 3
Alternative
Payment
Models using
FFS
Architecture
• Track 1 MSSP
ACO
Category 4
Population-
based Payment
• At risk
Pioneer
ACOs and
others
7CMS’ Better Care, Smarter Spending Healthier People (Jan. 2015)
8. MACRA
8
On April 14, 2015, the
U.S. Senate passed the
Medicare Access and
CHIP Reauthorization
Act of 2015 (“MACRA”),
and on April 16, 2015,
the bill became law.
9. Proposed Rule Under MACRA
Notice of Proposed Rule Making
(NPRM) published in the Federal
Register on May 9, 2016 (pre-
publication version posted on April 27,
2016).
Comments on the NPRM are due June
27, 2016.
9
10. MACRA’s Major Changes
10
Repealed the SGR and annual scheduled cuts
Established a path for physician participation
in alternative payment models (“APMs”)
Consolidated penalty programs (MU, PQRS,
VBM)
11. MACRA, MIPS, APMs – Oh My!
Medicare Access & CHIP
Reauthorization Act of 2015 (MACRA)
Ends SGR
Facilitates MIPS & APMs
Merit-Based Incentive Program
Systems (MIPS)
PQRS
VBPM
EHR Incentive Program
Alternative Payment Models (APMs)
Accountable Care Organizations
Patient Centered Medical Homes
Bundled Payments
Medicare Shared Savings Program
11
12. MACRA Options
12
Participate in FFS via the Merit-based Incentive Program (MIPs)
– Subject to reductions or increases in Medicare reimbursement
based on quality performance scores
– Reduced penalty risk
– Statutory updates
– Consolidated reporting
Participate in Advanced Alternative Payment Models (APMs)
– Potential to earn five percent annual bonus
– Subject to financial risk
– Higher updates
– Exempt from MIPs
– Preferred treatment for medical homes
– Specialty models encouraged
13. How will MACRA affect me?
13Source: Centers for Medicare & Medicaid Services
15. 2019 2020 2021 2022 +
beyond
Merit-
Based
Incentive
Payment
System
(MIPS)
Adjusts Medicare FFS
reimbursement based on
performance score linked to:
• Quality
• Resource use
• Clinical practice improvement
• Advancing Clinical
Improvement (formerly EHR
meaningful use)
+-4%* +-5%* +-7%* +-9%*
* Possible 3x
upward
adjustment BUT
unlikely
Alternative
Payment
Models
(APM)
New payment approaches that
incentivize quality and value, such
as:
• CMMI Innovation models
• MSSP ACOs
• Demonstration programs
Most advanced AMPs (those that
bear risk):
• Not subject to MIPS
• 5% lump sum bonus payments
(2019-2024)
• Higher fee schedule update 2026
and beyond
Basic MACRA Framework
Source: Medicare Access and CHIP Reauthorization Act of 2015, Path to Value (CMS) 15
17. MIPS Generally
17
The Merit-Based Incentive Payment System (MIPS) streamlines several
existing Medicare penalty programs, creating a single system with
consolidated reporting and timelines.
MIPS eligible clinicians are:
Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse
Specialists, Certified Registered Nurse Anesthetists, and groups that
include such professionals
After MIPS’ third year, the Secretary has discretion to add more
providers to the list (e.g. physical or occupational therapists, clinical
social workers, etc.)
18. MIPS Excluded Providers
18
Some providers are excluded from MIPS:
Qualifying APM participants
Partial qualifying APM participants who report data under MIPS
Low-volume threshold clinicians (billing ≥ $10,000 & for ≥ 100
beneficiaries)
Newly-enrolled Medicare participants (report following 1st year
enrolled)
Excluded clinicians may “voluntarily report” to gain experience with MIPS
(like eligible clinicians who are new to Medicare program, for example).
CMS defines “non-patient-facing MIPS eligible clinicians” as an individual or
group that bills 25 or fewer patient-facing encounters during a
performance period.
19. MIPS Timeline
19
Fall 2016
MIPS final
regulations
published
Jan. 1 2017
Beginning of
Year 1
performance
period
July 1 2017
Feedback
report
Dec. 31 2017
End of Year 1
performance
period
Jan. 1 2018
Beginning of
Year 2
performance
period
July 1
2018
Feedback
report
Dec. 31 2018
End of Year 2
performance
period
Jan. 1 2019
Year 1
payment
adjustment
20. MIPS Methodology
20
CMS will assign a composite performance score (CPS)
based on performance over a year in:
– Quality (replaces PQRS and some parts of VM)
– Resource Use (replaces cost portion of VM)
– Clinical Practice Improvement Activities (new!)
– Advancing Care Information (formerly EHR
meaningful use)
CMS will also apply an “adjustment factor” to MIPS-
eligible clinicians scores to determine total
performance
24. Quality Performance Category
Improvements to existing quality programs:
– Key change from 9 measures to 6; allows partial credit for
measures.
– CMS tried to address concerns about wading through too
many measures in the PQRS program to find applicable
measures by developing measure sets by specialty.
– MIPS-eligible clinicians will be required to report on one cross-
cutting measure and one outcome measure, but if not
available, another “high priority” measure.
– Acknowledges issues for sub-specialties.
– Provides bonuses for reporting through QCDRs.
24
26. MIPS Resource Use Performance
Category
CMS proposes to use episode-based measures in this category, many of
which are specialty specific, building off of CMS’ sQRUR reports.
26
27. MIPS Clinical Practice Improvement
Activities (CPIA)
MACRA specified that the CPIA performance category must include the
following activities:
Expanded practice access
Population management
Care coordination
Beneficiary engagement
Patient safety and practice assessment
By statute, CMS must give at least a 50% score to APM participants and
100% score for patient-centered medical home participants.
CPIA measured on a “60 point” scale – different CPIAs have different
weights (e.g. “high-level” or “medium-level” activities) that contribute to
an overall score.
Clinicians must perform CPIAs for at least 90 days of the reporting period.
27
28. CPIAs in the Proposed Rule
CMS proposed more than 90 CPIAs, such as:
28
29. Advancing Care Information (ACI) fka
Meaningful Use
ACI replaces EHR Meaningful Use for Medicare
physicians only
Goals:
– Simplify requirements (from 18 measures to 11)
– Increase flexibility (i.e., not “all or nothing”)
– Ease burden
– Facilitate exchange of information, emphasizing
interoperabilitiy
29
30. Extends application to PAs, NPs, CNSs, CRNAs
CMS may reweight ACI portion of MIPS to 0% for
some EPs
– Some hospital-based EPs
– EPs facing significant hardship: (1) Insufficient
internet access; (2) Extreme and uncontrollable
circumstances; (3) Lack of control over availability of
CEHRT; (4) Lack of face-to-face patient interaction
– NPs, PAs, CRNAs, CNSs who submit no data
ACI Application
30
31. Use CEHRT
Report according to objectives and
measures
Support information exchange and
prevention of health information
blocking, and cooperate with
authorized surveillance of CEHRT
ACI Requirements
31Source: Proposed Sec. 414.1375(b)
32. In 2017 reporting year, flexibility to use 2014 or
2015 edition CEHRT
– EPs using only 2015 CEHRT, or a combination of 2014 and
2015 CEHRT can choose between objectives/measures
corresponding to Meaningful Use Stage 3 OR those
corresponding to Meaningful Use Modified Stage 2
– EPs using only 2014 CEHRT should comply with
objectives/measures corresponding to Meaningful Use
Modified Stage 2
Starting in 2018 reporting year, all must use
2015 edition CEHRT, Stage 3
objectives/measures
ACI Reporting
32
33. One-year reporting period
– Different than Meaningful Use 90-day reporting
period for all participants in 2015 and new
participants in 2015 and 2016
– MIPS EPs can submit data even if they do not
have a full year’s data
Group reporting now available
– Not batch reporting with individual assessment,
but assessment as a group
ACI Changes
33
36. Advanced Payment Model
Alternative to MIPS
Eligible Clinicians who participate in certain Alternative
Payment Models are exempt from MIPS
Medicare (only)
Option
(2019 and beyond)
Other Payer
Combination Option
(2021 and beyond)
APMs FFS Reimbursement Implications
(2019-2024)
• Not subject to MIPS
• +5% Lump Sum Incentive
Payment for Part B Prof. Svs.
during Base Period
(2026 and beyond)
• Not subject to MIPS
• Higher Medicare Fee
Schedule updates
Participation in Advanced APM entity sufficient (regardless of
whether APM achieves performance goals)
37. Incentive Payments for
Participation in Advanced APMs
Entities that participate in Alternative Payment
Models (APMs) are eligible to qualify as an
“Advanced APM” where, during the applicable
Performance Period, the entity:
1. Require uses Certified EHR technology
2. Provides for payment for covered professional
services based on quality measures comparable to
measures under the MIPS performance category
3. Bears financial risk under the APM that is in excess
of a nominal amount, or involves a medical home
model
37
38. Eligible APM Entities
Many existing entities participating in CMS
initiatives may qualify as an Advanced APM based
on proposed financial risk criterion including:
– MSSP ACOs in Tracks 2 & 3 (track 1 ACOs would not because
track 1 does not entail any financial risk)
– NextGen ACOs
– Comprehensive Primary Care Plus Program
– Other programs sponsored by CMMI
– Full capitation arrangements
– Not Medicare Advantage organizations (except under Other
Payer Combination Option
38
39. Financial and Nominal Risk
Standards
Financial Risk Requirements Nominal Risk Requirements
Total Risk (total
potential liability)
Marginal Risk
(maximum % in
excess of
expenditure
target)
Minimum Loss
Rate (maximum
loss rate without
triggering
repayment)
General
Standard
AMP payer (e.g., CMS) must
be able to:
• Withhold payment to
AMP Entity or ECs
• Reduce payments to AMP
entity or ECs
• Require AMP Entity to
repay
• 4% or more of
Expected
Expenditures
• Must be at
least 30% of
Expected
Expenditures
• No more
than 4% of
Expected
Expenditures
Medical Home
Model (less
than 50 ECs
assigned to
TIN or
subsidiaries)
All above plus:
• Cause APM Entity to lose
right to all or part of
guaranteed payments
• 2017, 2.5% of APM Entity Medicare Part A & B Revenue
• 2018, 3%
• 2019, 4%
• 2010 and later, 5%
40. Advance APM Illustration
APM Requirements
– Total Risk must exceed 4% (15% in MSSP Track 3)
– Marginal Risk per APM must be 30% (40% minimum in MSSP Track 3)
– Minimum Loss Rate must be no more than 4% (maximum 3.9% in
MSSP Track 3)
MSSP Track 3
Symmetrical Saving/Loss Options
Minimum Savings Rate 0% 0.5% 1.0% 1.5% 2.0% Symmetrical linked to
# of Attributed
BeneficiariesMinimum Loss Rate 0% -0.5% -1.0% -1.5% -2.0%
Shared Savings Maximum 75% of Shared Savings
Loss Rate Minimum and Maximum -40% to -75% of Shared Losses
Maximum Savings (% of Expenditure Benchmark) +20%
Loss Recoupment Limit (Stop loss) (% of Expenditure Benchmark) -15%
41. Becoming a QP or Partial QP
Percentage of Eligible Clinician patients and/or payments through an APM
Entity
Example (patient count method):
– # of APM Entity attributed beneficiaries receiving Part B professional services
during QP Performance Period/ Attribution-eligible beneficiaries receiving Part
B professional services during QP Performance Period
10,000 Attributed Beneficiaries (under applicable attribution rules) = 25.64%
39,000 Attribution-Eligible Beneficiaries (receive 1 E&M Service)
Medicare
Only Option
Threshold 2019-2020 2021-2022 2023 & Later
QP Payment 25% 50% 75%
Patient 20% 35% 50%
Partial QP Payment 20% 40% 50%
Patient 10% 25% 35%
42. Other Payer Advanced APMs
All-Payer
Combination
Option
Threshold 2021-
2022
2023 &
Later
Additional Medicare Option
Requirements
QP Payment 50% 75% Plus 25% payment threshold
Patient 35% 50% Plus 20% payment threshold
Partial QP Payment 40% 50% Plus 20% patient count threshold
Patient 25% 35% Plus 10% patient count threshold
Medicare Only Option counted first. If met, then no consideration of other payers
and All-Payer Combination Option
43. Timeline for APMs & Qualified Participants
2017 2018 2019 2021 2026
Performance
Period
-- Whether
Advanced APM and
QP
Performance
Period for
2019
Performance
Period for
2020
Performance
period for
2021 etc.
Other Payer
Combination
Option
available to
qualify as
APM and QP
QPs eligible
for higher
fee-
schedule
updates
Base Period
-- Determines
incentive payment
amount through EP
TINs
None Base Period
for 2019
incentive
payments
Base Period
for 2021 5%
Part B
incentive
payments
etc.
44. Implications – The Good, Bad and
Ugly
APM strategic choices
– Select model from available options
Complexity
– MIPS replaces existing programs with new
– APMs build on other program infrastructure (e.g.,
MSSP, NextGen, CPC+)
Still fee for service
– Financial incentives with potential to increase spending
“All in” considerations
– Group reporting and evaluation requirements
45. Implications – The Good, Bad and
Ugly
Choices
– Private (physician-owned) practices
• APM participation strategies
• Model selection – single or multispecialty (e.g., physician
focused payment model possibilities)
– Hospital-affiliated practices
• Timing of Advanced AMP engagement
• Model selection (primary care vs. multispecialty models)
– Other (e.g., investor-owned) practices
• Concurrent attention to FFS and risk
46. Implications – The Good, Bad and
Ugly
Challenges
– Migrating from shared savings to at risk
– Risk thresholds
• Expenditure benchmarks
• Medical Homes -- Part A and B revenues
– Risk funding mechanisms
• Withholds
• Repayment arrangements
• APM entities or Eligible Clinicians
– Defining what parties bear risk, relative amount and mechanics
– Operational details of APM and downstream relationships
– APM-specific requirements and other programs (e.g., MSSP
single-purpose entity requirements)
47. Alignment of Strategy and Money
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
Medicare
Physician Fee
Schedule
Updates
0.5% 0.5% 0.5% 0.5% 0% 0% 0% 0% 0% 0% 0./75%
or
0.25%
Merit-Based
Incentive Payment
System (MIPS)
• Quality
• Resource use
• Clinical practice
improvement
• EHR meaningful
use
+-4% +-5% +-7% +-9% +-9% +-9% +-9% +-9%
Alternative
Payment Models
(APMs)
Excluded from MIPS
Source: Medicare Access and CHIP Reauthorization Act of 2015, Path to Value (CMS)
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5% Incentive Payment
FFS UD
48. Implications: For Physicians
For many physicians, some of whom have been waiting for the ACA to
be repealed, MACRA and its proposed rule herald a significant change
conceptually – volume to value – which will require a significant change
in behavior and operations
Disconnect or transitional assistance that payment model is still fee for
service in MIPS?
Death knell” for solo or small providers? 70% of the penalties will be
assessed to provider groups of less than 10.
Will we see increase in acquisitions/collaborations?
Comments/changes to lessen this financial impact?
Start running the numbers now. Don’t wait for the Feedback Report.
Remember data gets reported to Compare and need to know accuracy
and impact.
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49. Implications: MIPS
If specialty physician doesn’t have outcome or high
priority measure, they will be disadvantaged in MIPS
MIPS Quality measures propose administrative claims
based on population health measures part of VBM,
but they are hospital-focused, not physician focused
MIPS resources measures are based on VBM cost, so
not translated to physicians
MIPS Advancing Care changes scoring but not
measures
What happens to physicians who do not qualify as
MIPS eligible clinicians? Impact of fact that APM
bonus is based on Part B billings?
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50. Implications: APMs
Physician participation in more than one APM
Track 1 ACOs withdrawal from program; migration to risk
“Other Entities” in ACOs do not count for attribution, so
will impact ability to use APM
For ACOs, physicians will receive the APM incentive
payment, not the ACO
Does the MIPS “exceptional performance” exceed the
APM bonus?
Won’t know if APM qualifies as an Advanced APM until
after MIPS reporting is due
“Nominal risk” to be defined “over time” with associated
operational issues
Physician ability to control risk in APMs
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51. Implications: TBD
Revisions to payor contracts
Could the changes in models result in revisions in
malpractice policies, premium shifts?
Need to customize HIT to fit needs under new
models, let alone interoperability
Alignment of hospitals meaningful use to physicians’
MD compensation under employment and
professional services agreement will require revision
How to address resource utilization in hospital-
owned physician practices
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52. Questions?
Sidney Welch
Shareholder | Polsinelli PC
Atlanta, GA
404.253.6047
swelch@polsinelli.com
Bruce A. Johnson
Shareholder | Polsinelli PC
Denver, CO
303.583.8203
brucejohnson@polsinelli.com
Cybil G. Roehrenbeck
Counsel | Polsinelli PC
Washington, DC
202.777.8931
croehrenbeck@polsinelli.com
Reimbursement Institute | http://www.polsinelliri.com
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