MACRA: An Overview and Implications for Your Organization. Patrick J. Hurd, Esq. March 30, 2017 VASHRM

Transcription

1 MACRA: An Overview and Implications for Your Organization Patrick J. Hurd, Esq. March 30, 2017 VASHRM

2 MACRA: How Did We Get Here?

3 MACRA: How Did We Get Here? Medicare Access and CHIP Reauthorization Act of 2015 Eliminates the Flawed SGR Payment System Consolidates 3 Existing Quality-Based Dr. Payment Programs into MIPs Value Modifier ( VM ) Physician Quality Reporting System ( PQRS ) Meaningful Use ( MU ) Provides Incentives for APMs

4 MACRA Basics MIPS APMs

5 MACRA Basics Merit Based Incentive Payment System ( MIPS ) A modified fee-for-service model Retains some performance-based payments Adds performance improvement & innovation component Greater flexibility and wider selection of quality measures

6 MACRA Basics ( MIPS ) Quality Reporting (was PQRS) Cost (was Value-based Modifier) MIPS Advancing Care Information (was MU) Improvement Activities From AMA 01/2017 Presentation

7 MIPS Participants in MIPS Medicare Part B clinicians billing more than $30,000 a year and providing care for more than 100 Medicare patients a year. (MDs/DOs, PAs, NPs, CNSs & CRNAs) Clinicians exempt from MIPS First year of Part B participation Medicare allowed charges < $30K or < 100 patients Advanced APM participants

8 MIPS: 2017 transitional performance reporting options* *Table from AMA 01/11/2017 AMA MACRA Presentation MIPS Testing Partial MIPS reporting Full MIPS reporting Advanced APM participation Report some data at any point in CY 2017 to demonstrate capability 1 quality measure, or 1 improvement activity, or 4/ 5 required ACI measures No minimum reporting period No negative adjustment in 2019 Submit partial MIPS data for at least 90 consecutive days 1+ quality measure, or 1+ improvement activities, or 4/ 5 required ACI measures No negative adjustment in 2019 Potential for some positive adjustment ( < 4%) in 2019 Meet all reporting requirements for at least 90 consecutive days No negative adjustment in 2019 Maximum opportunity for positive 2019 adjustment ( < 4%) Exceptional performers eligible for additional positive adjustment (up to 10%) No MIPS reporting requirements (APMs have their own reporting requirements) Eligible for 5% advanced APM participation incentive in

9 MIPS Performance Categories Category CY 2019 CY 2020 CY 2021 and beyond Quality 60% 50% 30% Resource use (Cost) NA 10% 30% Clinical practice improvement activities Advancing Care Information (i.e., Meaningful Use) 15% 15% 15% 25% 25% 25%

10 When Does MIPS Begin?

11 MIPS

12 Advanced APMs Advanced APMs greatest risks but offer potential for greatest rewards Qualified Medical Homes different risk structure but otherwise treated as Advanced APMs MIPS APMs participants receive favorable MIPS scoring Physician-focused APMs--TBD

13 Advanced APM Incentives MACRA provides incentives for qualifying professionals Lump-sum bonus payment of 5% of Part B payments for professional services Exemption from MIPS reporting requirements and payment adjustments Higher base rates beginning in 2026 Incentives in 2019 based on 2017 APM participation

14 Advanced APM Criterion 1: Use of Certified EHR Technology Requires that at least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other health care professionals.

15 Advanced APM Criterion 2: MIPS- Comparable Quality Measures Bases payments on quality comparable to those used in MIPS quality performance category. Ties payment to quality measures that are evidence-based, reliable, and valid. At least one of these measures must be an outcome measure if an appropriate outcome measure is available on the MIPS measure list.

16 Advanced APM Criterion 3: Bear More than Nominal Amount of Financial Risk If actual expenditures exceed expected expenditures, Advanced APM may: Withhold payment for services to the APM Entity and/or the APM Entity s eligible clinicians Reduce payment rates to the APM Entity and/or the APM Entity s eligible clinicians Require direct payments by the APM Entity to CMS.

17 Advanced APM Total Amount of Risk The total amount of risk must be equal to at least either: 8% of the average estimated total Medicare Parts A and B revenues of participating APM Entities; OR 3% of the expected expenditures for which an APM Entity is responsible under the APM.

18 Advanced APMs For 2017, Models are: Comprehensive End Stage Renal Disease Care Model Shared Savings Program Track 2 & Track 3 Next Generation ACO Model Oncology Care Model Comprehensive Primary Care Plus (CPC+)

19 MACRA & The Role of Healthcare Risk Managers Fundamental Basis of MACRA: Financial Risk Sharing Adverse Outcomes = Increased Risk Core Healthcare Risk Manager Expertise: Management of Risk Guiding Principles of Enterprise Risk Management: Translate to MACRA

20 MACRA: Financial Risk Sharing Old Days: Volume of Services Less Financial Risk More Uncertainty Due to SGR Today: Outcomes Measures Financial Incentives for Improved Quality Some Penalties for Lack of Improvement Tomorrow: Improve Quality while Controlling Costs Greater Rewards for Greater Risk Significant Penalties for Failing to Participate

21 MACRA: Adverse Outcomes = Increased Financial Risk

22 MACRA and ERM ASHRM ERM Principles Advance safe and trusted healthcare Manage uncertainty Maximize value protection and creation Encourage multidisciplinary accountability Optimize organizational readiness Promote positive organizational culture which will impact readiness and success Utilize data/metrics to prioritize risks Align risk appetite and strategy

23 Other Impacts of MACRA Hospital and Health System Employed Physicians vs. Private Medical Staff Significance of Incident Reports, RCA s, FMEA s Risk Management Data & Quality Reporting System Effectiveness Evolution of Physician Compensation Structure

24 QUESTIONS?