Sustainable Growth Rate? Goodbye for Good!
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PYA Staff Consultant Aaron Elias spoke to attendees of the Georgia Healthcare Financial Management Association’s (HFMA) Spring Institute May 6, 2015, on the implications of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
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Sustainable Growth Rate? Goodbye for Good!
- 1. Page 0May 6, 2015 Georgia HFMA Spring Institute Sustainable Growth Rate? Goodbye for Good! Implications of the 2015 SGR Bill (H.R. 2) Aaron Elias Georgia HFMA Spring Institute May 6, 2015
- 2. Page 1May 6, 2015 Georgia HFMA Spring Institute Only Months into the 2015 PFS… This was all holding true…until suddenly, it wasn’t. 2015 MPFS Final Rule • No payment updates, only changes to payment policies • Still anticipate 20.9% reduction in payments without Congressional action (Sustainable Growth Rate)
- 3. Page 2May 6, 2015 Georgia HFMA Spring Institute
- 4. Page 3May 6, 2015 Georgia HFMA Spring Institute Timeline of Medicare Payments 1997 • Introduction of Balanced Budget Act to Amend the Social Security Act • Specified formula for calculating SGR 17 Short- Term Patches 2014 SGR Repeal and Medicare Provider Payment Modernization Act of 2014 2015 Medicare Access and CHIP Reauthorization Act of 2015
- 5. Page 4May 6, 2015 Georgia HFMA Spring Institute History of Patches 21% With no Congressional action, Physician Fee Schedule payments would have been cut by 21% beginning April 1, 2015. Since 1997, a total of 17 “short-term” SGR patches have been enacted by Congress, delaying Medicare Payment Cuts. Total Cost = $175 Billion1 1 Source: Committee for a Responsible Federal Budget, The Prep Plan: A Permanent Fix For The Sustainable Growth Rate, March 9, 2015.
- 6. Page 5May 6, 2015 Georgia HFMA Spring Institute H.R.2 Medicare Access and CHIP Reauthorization Act of 2015 Removes SGR Methodology Development of MIPS Alternative Payment Models Plan for Quality Measure Development Expands Use of Medicare Data
- 7. Page 6May 6, 2015 Georgia HFMA Spring Institute
- 8. Page 7May 6, 2015 Georgia HFMA Spring Institute SGR Payment Updates Permanently repeals the 21% reduction to MPFS payments in 20151 MPFS rates increase by 0.5% annually beginning June 1, 2015, through 2019 2 MPFS rates remain constant from 2019 to 20253 Again, in 2026, MPFS rates increase by 0.5% annually4 Removes SGR methodology
- 9. Page 8May 6, 2015 Georgia HFMA Spring Institute The SGR Solution Benefits: Certainty of payments for the next 10 years No annual fear of unrealistic payment cuts Concerns: Does 0.5% keep up with medical inflation (plus the inherent costs of participation in quality programs)? Removes SGR methodology
- 10. Page 9May 6, 2015 Georgia HFMA Spring Institute Centralized Quality Reporting? Merit- Based Incentive Payment System = MIPS Quality Efficiency Meaningful Use Clinical Process Improvement Development of MIPS
- 11. Page 10May 6, 2015 Georgia HFMA Spring Institute The Current Reporting “System” PQRS • Reporting of quality measures as individual providers or as group • Penalty for not reporting Value Modifier • Two composite measures: • Cost (Efficiency) • Quality • Payment adjustment based on performance Meaningful Use • Use of an EHR in a meaningful way • Penalty for not reporting Development of MIPS
- 12. Page 11May 6, 2015 Georgia HFMA Spring Institute The Current Reporting “System” Program Applicable to Adjustment Amount Program Participation Year (PY) PQRS All eligible professionals (EPs) (Medicare physicians, practitioners, therapists) -2.0% adjustment 2015 Medicare EHR Incentive Program Medicare physicians (if not a meaningful user) -3.0% adjustment 2015 Value-Based Payment Modifier All Medicare physicians and non-physician EPs in groups with 2+ EPs and solo practitioners Non-PQRS reporters: Automatic - 4.0% VM downward adjustment (in addition to PQRS penalty) Groups with 2-9 EPs and solo practitioners: Upward or neutral VM adjustment based on quality tiering Groups with 10+ EPs: Upward, neutral, or downward VM adjustment based on quality tiering 2015 Development of MIPS
- 13. Page 12May 6, 2015 Georgia HFMA Spring Institute What’s the Problem With Current System? Current Value-Based Payment Programs: Good intentions, but… Complicated Requirements Confusing Timing Overlap in Requirements Wasted Resources Inconsistent Measurement and Payment Adjustments Development of MIPS
- 14. Page 13May 6, 2015 Georgia HFMA Spring Institute Merit-Based Incentive Payment System Harmony Development of MIPS
- 15. Page 14May 6, 2015 Georgia HFMA Spring Institute MIPS – the Details • Repeals PQRS and MU penalties and VM program effective December 31, 2018; replace with MIPS. • Providers will receive a composite score from 1 to 100 based on quality measures, efficiency measures, meaningful use of electronic health records, and clinical practice improvement activities; score will be made publicly available. • Each year, CMS will establish a threshold score based on median/mean composite performance scores of all providers measured during previous performance period. Development of MIPS
- 16. Page 15May 6, 2015 Georgia HFMA Spring Institute MIPS Scoring System 0 100 Quality Efficiency Meaningful Use Clinical Process Improvement 78 National Median Composite Provider Score = Medicare Provider = National Median Composite Score Development of MIPS
- 17. Page 16May 6, 2015 Georgia HFMA Spring Institute …More MIPS • Providers scoring below threshold subject to payment cuts capped at 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022. • Providers scoring above threshold will receive bonus payments, up to three times the annual penalty cap. • Providers scoring above “stretch” performance score will receive an additional bonus payment allocated from a $500 million annual pool. • Providers participating in alternative payment mechanisms (APMs) may opt out of MIPs in favor of annual 5% bonus payment. Development of MIPS
- 18. Page 17May 6, 2015 Georgia HFMA Spring Institute Raising the Stakes Implications for Providers • Over time, the MIPS penalties become substantially greater than those contemplated in existing CMS programs. This, coupled with the fact private payers are likely to “piggy-back” on the MIPS program, make the push for quality and efficiency simply too strong for providers to ignore. • Just as before, there would be winners and losers in this program • The legislation is very broadly defined, CMS will have to fill in the details… Development of MIPS
- 19. Page 18May 6, 2015 Georgia HFMA Spring Institute Alternative Payment Models Accountable Care Organizations Primary Care & Medical Home Models Bundled Payment Initiatives Integrated Care & Care Management Alternative Payment Models
- 20. Page 19May 6, 2015 Georgia HFMA Spring Institute
- 21. Page 20May 6, 2015 Georgia HFMA Spring Institute Alternative Payment Models Medicare FFS Payments, 2016 Medicare FFS Payments, 2018 Alternative Payment Models All Medicare FFS (100%)FFS linked to Quality Alternative Payment Models 85% of all Medicare FFS 30% of All Medicare FFS 90% of all Medicare FFS 50% of all Medicare FFS
- 22. Page 21May 6, 2015 Georgia HFMA Spring Institute Alternative Payment Models CMS Announcement on January 26, 2016… Alternative Payment Models Health Care Payment Learning and Action Network
- 23. Page 22May 6, 2015 Georgia HFMA Spring Institute Health Care Payment Learning and Action Network Actions: • Facilitate implementation of new payment models • Identify areas for payment improvement • Develop new approaches to core issues Stakeholders involved: • Payers • Providers • Employers • States • Consumer Groups • Individual Consumers Goal of Network in two words: SMARTER SPENDING Alternative Payment Models
- 24. Page 23May 6, 2015 Georgia HFMA Spring Institute Alternative Payment Models Incentive payments to participate in Alternative Payment Models (5%) 1 Ability to opt-out of other MACRA payment requirements (MIPS)2 Increased APM promotion; establishment of Technical Advisory Committee 3 Alternative Payment Models
- 25. Page 24May 6, 2015 Georgia HFMA Spring Institute Quality Measure Development Continued funding of NQF review, endorsement, and maintenance of quality/efficiency measures. Additional funding in 2015, extends funding for 2016 and 2017. $15,000,000 $30,000,000 Draft plan by January 1, 2016 for development of quality measures for application, followed by comment period. (Bill mentions inclusion of measures used by private payers.) Plan for Quality Measure Development
- 26. Page 25May 6, 2015 Georgia HFMA Spring Institute Quality Measure Development What Does this Mean? • Finalization of plan by May 2016 (with annual updates) • Meant to address current scrutiny on available measures (challenges for specialists) Plan for Quality Measure Development
- 27. Page 26May 6, 2015 Georgia HFMA Spring Institute Use of Medicare Data Expanded use of Medicare Data by “Qualified Entities” Provide or Sell Data to Authorized Users Assist providers with improvement activities Expands use of Medicare data
- 28. Page 27May 6, 2015 Georgia HFMA Spring Institute Use of Medicare Data • Certain restrictions still remain in place: – Cannot use data for marketing – Must abide by all privacy and security laws – Must enter into a data use agreement – No re-disclosures of analyses Better Data Better Decisions Better Outcomes In general… Expands use of Medicare data
- 29. Page 28May 6, 2015 Georgia HFMA Spring Institute Other Key Components
- 30. Page 29May 6, 2015 Georgia HFMA Spring Institute EHR Interoperability EHR 1 Current state of EHR systems… Data Sharing
- 31. Page 30May 6, 2015 Georgia HFMA Spring Institute EHR Interoperability EHR 1 Data Sharing Mandated state of EHR systems by 2018
- 32. Page 31May 6, 2015 Georgia HFMA Spring Institute Global Payments 2014 and Prior Years • 10- and 90-Day Global Surgical Payments 2015 MPFS Final Rule • Removal of 10- and 90- Day Global Surgical Payments H.R. 2 • 10- and 90-Day Global Surgical Payments Reinstated Keep in mind… • CMS will begin collecting data on global payments and number of visits furnished beginning in 2017 • Reassessment every 4 years
- 33. Page 32May 6, 2015 Georgia HFMA Spring Institute Children’s Health Insurance Program • 2-Year Extension of CHIP – No new funding available after FY 2015 – Without action, the current CHIP program is funded through FY 2017
- 34. Page 33May 6, 2015 Georgia HFMA Spring Institute Two-Midnight Rule MAC “probe and educate” program will continue through September 30, 2015.
- 35. Page 34May 6, 2015 Georgia HFMA Spring Institute Medical Liability Cases Medicare quality program standards cannot be used as standard or duty of care Medical professionals will continue to be held to community standards rather than those defined by CMS quality programs
- 36. Page 35May 6, 2015 Georgia HFMA Spring Institute Smart Cards? CMS to consider use of smart card technology for beneficiaries and providers.
- 37. Page 36May 6, 2015 Georgia HFMA Spring Institute What’s Next?
- 38. Page 37May 6, 2015 Georgia HFMA Spring Institute Offsetting the Bill One source… you! • Income-related premium adjustments for Part B and Part D • Higher income beneficiaries now pay higher percentage Other Funding
- 39. Page 38May 6, 2015 Georgia HFMA Spring Institute Fundamental Challenges Remain…
- 40. Page 39May 6, 2015 Georgia HFMA Spring Institute Increasing Transparency
- 41. Page 40May 6, 2015 Georgia HFMA Spring Institute “Our goal is to have 85% of all Medicare fee-for- service payments tied to quality or value by 2016, and 90% by 2018.” “Our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.” Here to Stay Source: HHS Secretary Sylvia Burwell (January 30, 2015)
- 42. Page 41May 6, 2015 Georgia HFMA Spring Institute In Closing Removes SGR methodology Development of MIPS Incentives for Alternative Payment Models Plan for Quality Measure Development Expanded use of Medicare data
- 43. Page 42May 6, 2015 Georgia HFMA Spring Institute Additional PYA Resources Providing and Billing Medicare for Chronic Care Management http://www.pyapc.com/white-paper-details-new-medicare-payment-chronic-care- management/ Practical Guide to the Medicare Physician Value Modifier Program http://www.pyapc.com/pya-offers-guide-medicare-physician-value-modifier-program/ Healthcare 2015: Turning the Corner http://www.pyapc.com/pya-white-paper-healthcare-2015-turning-the-corner/
- 44. Page 43May 6, 2015 Georgia HFMA Spring Institute Thank You!Thank You! Aaron Elias Consultant Pershing Yoakley & Associates, P.C. (404) 266-9876 aelias@pyapc.com www.pyapc.com
Editor's Notes
- Poll Title: How many short term fixes has Congress enacted relating to the Sustainable Growth Rate? https://www.polleverywhere.com/multiple_choice_polls/p3OW42UEj65XdoK
- Tip of the iceberg…….
- Poll Title: Who do you think will be most impacted by this legislation? https://www.polleverywhere.com/free_text_polls/UAIwCpWufAVEA2V
- Place to plug healthcareloop.com – lots of information, listserv to push out information on relevant info (internal, daily) We’ve seen specialty-specific quality programs from private payers
- Are you engaging with leadership and physician groups on these APMs? Have you thought about it? Once you’ve thought about it strategically, have you considered how you’ll operationalize this?
- Poll Title: Are you currently participating in an "Alternative Payment Model"? https://www.polleverywhere.com/multiple_choice_polls/I0smWeF14RnfUnB
- PYAA – examples from ACOs, etc. You also want to be able to test what is being measured about you…