FMCC 2016 MACRA Plenary by Amy Mullins
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FMCC 2016 MACRA Plenary by Amy Mullins
- 1. MACRA: Medicare's Shift to Value-based Delivery & Payment Models Presented by Amy Mullins, MD, CPE
- 2. Current State Over Utilization Volume over Value Silos of Care 2 Materials herein reflect public law 114-10 dated April 16, 2015 2 Fee for Service
- 3. Push Toward Value & Quality 3 • Medicare payments tied to quality or value by end of 2018 • Of those through alternative payment models (APMs) by end of 2016 • Private payer business through value-based arrangements by 202075% Materials herein reflect public law 114-10 dated April 16, 2015
- 4. Medicare Access & CHIP Reauthorization Act (MACRA) 4 “To repeal the Medicare SGR and strengthen Medicare access by improving physician payments…” PhotoCourtesyofAmyMullins,MD Materials herein reflect public law 114-10 dated April 16, 2015
- 5. What is MACRA? • Signed into law April 16, 2015 • Passed 392 to 37 in the House and 92 to 8 in the Senate 5 Materials herein reflect public law 114-10 dated April 16, 2015
- 6. What Does MACRA Do? • Repeals the Sustainable Growth Rate (SGR) • Extends Children’s Health Insurance Program (CHIP) funding for 2 years • Creates 2 payment tracks • Provides Annual Baseline Fee Schedule Updates 2016-2018 6 Materials herein reflect public law 114-10 dated April 16, 2015
- 7. MACRA Timeline 2016 2017 2018 2019 2020 2021 2022- 2024 2025 2026 Medicare Part B Baseline Payment Updates -.27% +0.5% +0.5% +0.5% 0% 0% 0% +0.25%* +0.75%** *Non-qualifying APM Conversion Factor **Qualifying APM Conversion Factor +0% 7 Materials herein reflect public law 114-10 dated April 16, 2015
- 8. Payment Models • Consolidates quality programs Merit-Based Incentive Payment System (MIPS) • Potential for bonus payment for participation Alternative Payment Model (APM) 8 Materials herein reflect public law 114-10 dated April 16, 2015
- 9. Merit-Based Incentive Payment System (MIPS) Materials herein reflect public law 114-10 dated April 16, 2015
- 10. MIPS Highlights Consolidates existing quality and value programs • To ease administrative burden Establishes a Performance Score • Adds a category for Clinical Practice Improvement Activities Opportunity for payment adjustments • Both positive and negative 10 Materials herein reflect public law 114-10 dated April 16, 2015
- 11. Consolidates Quality & Value Programs 11 • Physician Quality Reporting System • Value Based Payment Modifier • Meaningful Use MIPS MU VBPM PQRS Materials herein reflect public law 114-10 dated April 16, 2015
- 12. Establish Composite Performance Score 12 Quality Resource Use Clinical Practice Improvement Activities Meaningful Use Materials herein reflect public law 114-10 dated April 16, 2015
- 13. Clinical Practice Improvement Activities (CPIA) • Access • Population Management • Care Coordination • Beneficiary Engagement • Patient Safety • Participation in an Alternative Payment Model 13 Materials herein reflect public law 114-10 dated April 16, 2015
- 14. Weighting by Category 2019 2020 2021 Quality 50% 45% 30% Resource Use 10% 15% 30% EHR MU 25% 25% 25% CPIA1 15% 15% 15% 1 - “Certified” patient-centered medical home will receive the full 15 points for CPIA 14 Materials herein reflect public law 114-10 dated April 16, 2015
- 15. “Certified” Patient-Centered Medical Home (PCMH) 15 • Not defined in law • Joint Principles of PCMH • Functions of Comprehensive Primary Care (CPC) – Risk-Stratified Care Management – Access and Continuity – Planned Care for Chronic Conditions and Preventive Care – Patient and Caregiver Engagement – Care Coordination Across the Medical Neighborhood Materials herein reflect public law 114-10 dated April 16, 2015
- 16. Annual Performance Threshold • Established by Secretary years 1 and 2 • Mean or median of previous year’s MIPS scores • Below = negative payment adjustments • Above = positive payment adjustments 16 Materials herein reflect public law 114-10 dated April 16, 2015
- 17. Adjust Payments -4% -5% -7% -9% 4% 5% 7% 9% 2019 2020 2021 2022 onward “With respect to positive MIPS adjustment factors…the Secretary shall increase or decrease such adjustment factors by a scaling factor in order to ensure that the budget neutrality requirement …is met” 17 Materials herein reflect public law 114-10 dated April 16, 2015
- 18. Adjust Payments 18 -4% -5% -7% -9% 12% 15% 21% 27% 4% 5% 7% 9% 2019 2020 2021 2022 onward Adjustment to provider’s base rate of Medicare Part B payment Maximum Adjustments Materials herein reflect public law 114-10 dated April 16, 2015
- 19. Exemptions 19 • Year 1 Medicare • Eligible APMs with Bonus • Below low volume threshold • Federally Qualified Health Clinics and Rural Health Clinics Materials herein reflect public law 114-10 dated April 16, 2015
- 20. Adjustment Summary 20 Performance Score Payment Adjustment Lowest quartile = Maximum negative adjustment At threshold = No adjustment “Exceptional Performers” = Eligible for up to 10% positive adjustment “Exceptional Performers” has yet to be defined Materials herein reflect public law 114-10 dated April 16, 2015
- 21. MACRA Timeline 2016 2017 2018 2019 2020 2021 2022- 2024 2025 2026 Medicare Part B Baseline Payment Updates -.27% +0.5% +0.5% +0.5% 0% 0% 0% +0.25%* +0.75%** *Non-Qualifying APM Conversion Factor **Qualifying APM Conversion Factor Merit-Based Incentive Payment System (MIPS) PQRS, Value-based Modifier, & Meaningful Use Quality, Resource Use, Meaningful Use, & Clinical Practice Improvement Activities -6% -9% -9%? +/-4% +/-5% +/-7% +0% +/-9% 21 Materials herein reflect public law 114-10 dated April 16, 2015
- 22. MIPS Summary Composite Performance Score • Consolidates existing quality reporting programs in Medicare Part B with Clinical Practice Improvement Activities Positive payment adjustments • Includes the potential for significant adjustments for “Exceptional Performers” Risk of payment penalty • Risk of negative payment adjustment if performance below threshold 22 Materials herein reflect public law 114-10 dated April 16, 2015
- 23. 10 or fewer Combined score Geography or Specialty Written agreement One year commitment “All or nothing” 23 Virtual Groups Materials herein reflect public law 114-10 dated April 16, 2015
- 24. Alternative Payment Models (APMs) Materials herein reflect public law 114-10 dated April 16, 2015
- 25. Definitions Qualifying APM • Based on existing payment models Eligible APM • Based on criteria of the payment model Qualifying APM Participant • Based on individual physician payment or patient volume 25 Materials herein reflect public law 114-10 dated April 16, 2015
- 26. Qualifying APMs 26 • MSSP (Medicare Shares Savings Program) • CMS Innovation Center Model* • Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration • “Demonstration required by Federal Law” Qualifying APMs Materials herein reflect public law 114-10 dated April 16, 2015
- 27. Eligible APMs 27 • Quality measures comparable to MIPS • Use of certified EHR technology • More than nominal risk1 OR Medical Home model under CMMI authority 1 – Not yet defined Qualifying APMs Eligible APMs Materials herein reflect public law 114-10 dated April 16, 2015
- 28. Qualifying APM Participant 28 • Percentage of patients or payments thru eligible APM • In 2019, the threshold is 25% of Medicare payments. Patient threshold is yet to be determined. Qualifying APMs Eligible APMs Qualifying APM Participant Materials herein reflect public law 114-10 dated April 16, 2015
- 29. Additional Rewards for Qualifying Participants 29 • Not subject to MIPS • 5% bonus 2019-2024 • Higher fee schedule update 2026 Materials herein reflect public law 114-10 dated April 16, 2015
- 30. Summary of APMs Qualifying APMs • AAFP advocates for CMMI expansion to allow greater participation Eligible APMs • “nominal financial risk” Qualifying Participants • Potentially more financial certainty with a 5% annual bonus (and no potential for penalty) 30 Materials herein reflect public law 114-10 dated April 16, 2015
- 31. 31 Yes No Am I in a Qualifying APM? Materials herein reflect public law 114-10 dated April 16, 2015
- 32. 32 Yes No Am I in an eligible APM? Yes No Am I in a Qualifying APM? Materials herein reflect public law 114-10 dated April 16, 2015
- 33. 33 Yes No Am I in an eligible APM? Enough payments or patients? Yes No Yes No Am I in a Qualifying APM? Materials herein reflect public law 114-10 dated April 16, 2015
- 34. 34 Yes No Am I in an eligible APM? Enough payments or patients? Yes No Yes No Am I in a Qualifying APM? Qualifying APM Participant 5% bonus payment 2019-2024 Higher fee schedule 2026+ APM-specific rewards Excluded from MIPS Materials herein reflect public law 114-10 dated April 16, 2015
- 35. 35 Yes No Am I in an eligible APM? Enough payments or patients? Yes No Yes No Am I in a Qualifying APM? Subject to MIPS Favorable MIPS scoring APM-specific rewards Materials herein reflect public law 114-10 dated April 16, 2015
- 36. 36 Yes No Am I in an eligible APM? Subject to MIPS Favorable MIPS scoring APM-specific rewards Yes No Am I in a Qualifying APM? Materials herein reflect public law 114-10 dated April 16, 2015
- 37. 37 Yes No 1st year in Medicare OR below low-volume threshold? Not subject to MIPS Yes No Am I in a Qualifying APM? Materials herein reflect public law 114-10 dated April 16, 2015
- 38. 38 Yes No 1st year in Medicare OR below low-volume threshold? Subject to MIPS Yes No Am I in a Qualifying APM? Materials herein reflect public law 114-10 dated April 16, 2015
- 39. 39 Yes No Am I in a Qualifying APM? Yes No Am I in an eligible APM? Enough payments or patients? Yes No Qualifying APM Participant 5% bonus payment 2019-2024 Higher fee schedule 2026+ APM-specific rewards Excluded from MIPS Yes No 1st year in Medicare OR below low-volume threshold? Not subject to MIPS Subject to MIPS Subject to MIPS Favorable MIPS scoring APM-specific rewards Materials herein reflect public law 114-10 dated April 16, 2015
- 40. MACRA Timeline 2016 2017 2018 2019 2020 2021 2022- 2024 2025 2026 Medicare Part B Baseline Payment Updates -.27% +0.5% +0.5% +0.5% 0% 0% 0% +0.25%* +0.75%** *Non-qualifying APM Conversion Factor **Qualifying APM Conversion Factor Merit-Based Incentive Payment System (MIPS) PQRS, Value-based Modifier, & Meaningful Use Quality, Resource Use, Meaningful Use, & Clinical Practice Improvement Activities -6% -9% -9%? +/-4% +/-5% +/-7% Qualifying APM Participant 5% Incentive payment Excluded from MIPS +0% +/-9% 40 Materials herein reflect public law 114-10 dated April 16, 2015
- 41. Technical Assistance 41 • $20 million for Technical Assistance 2016- 2020 Materials herein reflect public law 114-10 dated April 16, 2015
- 42. Payment Reform Is Here • Final regulations in 2016 • 2017 likely performance year for MIPS – Advocating for 2018 • Help is available 42 Materials herein reflect public law 114-10 dated April 16, 2015
- 43. What Can I Do Right Now? 1. Evaluate your practice – Are you submitting PQRS? – Have you reviewed your QRUR? – Attested for Meaningful Use? – Ask the Expert - aco@aafp.org 43 Materials herein reflect public law 114-10 dated April 16, 2015
- 44. What Can I Do Right Now? 2. Find a PTN – Go to aafp.org/tcpi – Click “Find a PTN” to find a practice transformation network in your area – Email tcpi@aafp.org with any questions. 44 Materials herein reflect public law 114-10 dated April 16, 2015
- 45. Family Practice Management Articles 45 FPM Journal Article - http://www.aafp.org/fpm/2015/1100/p19.pdf FPM Journal Article - http://www.aafp.org/fpm Materials herein reflect public law 114-10 dated April 16, 2015
- 46. AAFP.ORG/MACRA • FAQs • Timeline • MIPS/APM Comparison table • Related articles • Related links 46 Materials herein reflect public law 114-10 dated April 16, 2015