A. MD, Chair, ACC Board of Governors - The...9/17/2016 1 The Alphabet Soup of Cardiology: Current...

9/17/2016

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The Alphabet Soup of Cardiology: Current Advocacy Issues

September 17, 2016

A. Allen Seals, MD, FACCChair, ACC Board of Governors

More than 85 percent of U.S. cardiologists are ACC members

48 Domestic Chapters52,000+ members across the entire cardiovascular care team

10 NCDR Registries

36 International Chapters

ACC by the Numbers

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ACC in 2000 (26,000 Members) ACC in 2016 (52,000+ Members)

Source (Right): Data compiled from 2015 Year End Official Member Count

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ACC Communications Journal American College of Cardiology ACC.ORG Website

Best Practices on the ACC.org

BOG Leadership Portal

http://www.acc.org/about‐acc/leadership/features/leadership‐portal/board‐of‐governors‐portal/best‐practices

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Medicare Access and CHIP Reauthorization Act of 2015

(MACRA)

MACRA Impact on Health Care Delivery Will be Profound

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MACRA Payment Adjustments

2015 2016 2017 2018 2019 2020 2021 2022+

PQRS+VM+MU Adjustments(combined)

~+ 5%3.5%

TBD‐ 6%

TBD‐9%

TBD‐10% or more

PQRS+Value Modifier+Meaningful Use Replaced by MIPS

MIPS Bonus/Penalty (max)

+4%*

‐4%+5%*

‐5%+7%*

‐7%+9%*

‐9%

APM Bonus^+5% +5% +5% +5%

* May be increased by up to 3 times to incentivize performance$500 mil funding for bonuses allocated through 2024

^ APM Bonus funded through 2024

Benchmark

Neutral Adjustment

High Performance

Positive Adjustment

Low Performance

Negative Adjustment

PQRS+Value Modifier+Meaningful Use

MACRA Taskforce

• Paul N. Casale, MD, MPH, FACC, Chair

• Thad F. Waites, MD, FACC

• Linda D. Gillam, MD, FACC

• James B. Powers, MD

• Richard J. Kovacs, MD, FACC

• William Borden, MD, FACC

• Michael K. Shroyer, RN, AACC

• Michael J. Wolk, MD, MACC

• Ralph G. Brindis, MD, MPH, MACC

• Michael J. Mirro, MD, FACC

• Cathleen Biga, MSN, RN

• Steven A. Farmer, MD, FACC

• Robert A. Shor, MD, FACC

• Fred A. Masoudi, MD, MSPH, FACC

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What Did MACRA Do?

• Repealed the flawed

Sustainable Growth Rate (SGR)

• Established framework for moving Medicare from a VOLUME to a VALUE‐BASED system

Background: Creation of the SGR

• The sustainable growth rate (SGR) was created by theBalanced Budget Act of 1997 as a means to control Medicarespending by tying Medicare clinician payments to increases inthe gross domestic product (GDP).

• When health spending outpaced GDP, negative paymentupdates were threatened as a result.

• Due to the inability to find sufficient offsets, the SGR wasunable to be repealed for nearly two decades.

Congress passed 17 patches to avoid cuts (implementing cuts twice)

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Elimination of the SGR

• Early 2014: Congressional leaders from the House and Senate, inclose collaboration with the physician community, draftedlegislation which would repeal the SGR and reward physiciansfor the value of the services they provided.

• Spring 2015: Speaker of the House John Boehner and MinorityLeader Pelosi struck a deal on the offsets and the Medicare andCHIP Reauthorization Act of 2015 (MACRA) was born.

Virtually the entire House of Representatives united to pass MACRA, followed by the Senate.

President Obama signed the now‐law on April 16, 2015.

Encourage Alternative Payment Model

participation

Improve Medicare quality reporting systems

MACRA

Recognize quality based on clinically, relevant

evidence‐based measures

Improving Population Health

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• Broadly Written Directions, Implementation Details Unclear

What About the Details of the Law?

• CMS released first proposed regulations in April 2016 – currently open for public comment

• Repeal not likely

Medicare and CHIP Reauthorization Act of 2015

• Delayed enforcement of the “two‐midnight” rule until October 1, 2015

• Extends the Children’s Health Insurance Program (CHIP) for two years (until 2017)

• Extends the Teaching Health Center Graduate Medical Education Program (THCGME) for two years (until 2017)

• Declares a national objective to achieve interoperable electronic health records by December 31, 2018

• Prevents quality program standards and measures (such as PQRS/MIPS) from being used as a standard or duty of care in medical liability cases

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Changing the Payment Landscape

Pre‐MACRA

• 21% payment cut in 2015, continued uncertainty

• Separate quality reporting programs

• Incentives for alternative payment model participation mainly from savings

Post‐MACRA

• Eliminates SGR; implements stable payment increases

• Streamlined quality reporting program

• Incentives for alternative payment model participation built into payment system

Annual Payment Updates

Mid 2015‐2019

• 0.5% annual payment update

2020‐2025

• 0% annual payment update

• Introduction of Merit‐Based Incentive Payment System

2026 and After

• 0.75%: Alternative Payment Model participants

• 0.25%: All other professionals

Averts a 21% payment cut in 2015 and future uncertainty

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Merit‐Based Incentive Payment SystemMIPS

Quality

(PQRS)

Meaningful Use (EHR Incentive)

Resource Use (Value Modifier)

Clinical Practice Improvement

• Individual programs continue through 2018

• MIPS begins in 2019 for physicians and most mid‐level clinicians

– 2017 performance

• Eligible professionals scored against benchmark based on prior year’s performance

• Low‐volume providers and some APM participants may be exempt from MIPS requirements

MIPS Composite(subject to CMS adjustment)

• PQRS measures• eCQMs• QCDR measures• Risk-adjusted outcome

measures

• Value-Based Modifier measures

• Risk-adjusted outcome measures

• Part D drug cost (if feasible)

• Expanded Practice Access• Population Management• Care Coordination• Beneficiary Engagement• Patient Safety • Practice Assessment (ex. MOC)• Patient-Centered Medical Home or

specialty APM

• Meaningful Use requirements

• Meaningful Use weight may be adjusted down to 15 percent if 75% or more EPs are meaningful users

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Alternative Payment Model

• 2019‐2024: 5% bonus

• CMS/CMMI models (except Healthcare Innovation Awards)

• Other eligible models

– Requires CEHRT

– Payment based on quality measures

– Financial risk or a Patient Centered Medical Home

• APM participants meeting threshold are MIPS‐exempt2023 and Beyond

> 75% of total Medicare revenue

> 75% of all‐payer, plus


2021 and 2022




2019 and 2020


Measure Development Plan & Funding

By Jan 2016

• HHS Secretary and stakeholders must develop and publish a draft plan for MIPS and APM measure development

By Mar 2016

• Close of public comment period

By May 2016

• Final plan published on HHS website

May 2017 & beyond

• Annual progress report, including a listing of each measure developed or in development

• $15 mil each fiscal year 2015 to 2019

• Prioritize measure gaps

– outcome, patient experience, care coordination, and appropriate use measures

• Incorporation of private payer and delivery system measures

• Coordination across stakeholders

• Utilization of clinical best practices and practice guidelines

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2015 2016 2017 2018 2019 2020 2021 2022+


~+ 5%3.5%

TBD‐ 6%

TBD‐9%

TBD‐10% or more



+4%*

‐4%+5%*

‐5%+7%*

‐7%+9%*

‐9%

APM Bonus^+5% +5% +5% +5%



Benchmark

Neutral Adjustment

High Performance

Positive Adjustment

Low Performance

Negative Adjustment


Small Practice Assistance

• $20 mil allocated to help practices of ≤ 15, rural, and underserved areas

• Allow “virtual groups”

• All Eligible Professionals will need to receive quality and resource use feedback at least quarterly

9/17/2016

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Public Reporting

• Continued expansion of Physician Compare

– 2016: volume of services, submitted charges, and payments

– MIPS composite and category scores

2016 Medicare Physician Fee Schedule

• Defining MIPS‐exempt professionals based on “low volume threshold”

• Identifying activities to meet the Clinical Practice Improvement component of MIPS

• Designing the elements of a physician‐focused payment model

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Considerations

Increased awareness between payment

and quality

Increased focus on alternative payment

models

Opportunities to impact quality improvement

Value of registries and meaningful

measures

How will ACC ensure members have the resources to meet new requirements?

CMS has incorporated recommendations made by the ACC and other societies in to the proposed rule. Examples include…

• Advancing Care Information component of Merit‐Based Incentive Payment System

• Reporting requirement of National Quality Strategy Domains

• Menu approach for clinical practice improvement

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ACC Action on MACRA• The ACC responded to CMS’ Request for Information on MACRA

Implementation. The ACC emphasized the importance of a system that is focused on:

– evidence‐based patient care

– measures quality in an accurate and transparent manner

– is not administratively burdensome

• The ACC worked with the AMA and other specialty societies to form common principles on how CMS should implement the new payment system under MACRA.

Challenges Ahead, Engagement Necessary

• Early years of implementation will post challenges to those accustomed to the current system

• ACC working with HHS and CMS to minimize these challenges to support evidence‐based, cost‐effective, high quality care.

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Recognizing NCDR Participation

• NCDR registries as a way to meet reporting requirements under three MIPS components:

– Quality

– Advancing care information

– Clinical practice improvement activities

• ACC staff is working towards creating specific NCDR Registry‐based solutions to the performance Improvement participation requirement.

• CMS Announcement on BUNDLES

• CMS Announcement on Pick Your Pace (PYP)

• “FINAL RULE” now expected on November 1 with implementation Jan 1, 2017

• Rep Pete Sessions (TX) proposes a 6‐12 month delay

• Fasten your seat belts…...

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Latest on MACRA• Pick your Pace: PYP

– Announced 9/8

– For reporting year 2017 ONLY

– Option 1: Submit something – Option 2: Participate for a partial year

• Not really well defined yet

• Probably something from each of the 4 categories

• Could receive a “small positive adjustment”

PYP: continued– Option 3: Participate for the full year

• You could be eligible for a “modest” positive payment adjustment

– Option 4: Join a Qualified ACO• MSSP Track 2 or 3• 5% bonus IF qualifying provider

QRUR and s‐QRUR should be released 9/16/16Stay tuned for the final rule in early November

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Episodes are…everywhere• In MIPs cost allocation

– 13 cardiac– Acute and Chronic– Condition and procedure

• CMS recently released– AMI/PCI– CABG– Cardiac rehab incentive program

35

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Bundled Payment Model: Key Elements

• Quality‐adjusted target episode price for each facility based on historic costs. – Performance based on average episode costs for reporting

period. – Costs in excess of quality‐adjusted target price must be paid

back. Savings will be shared. [may have 1.5‐3% inc]• All Medicare costs included (e.g., post‐acute facilities, physician

payments, etc.); hospital assumes risk.– Hospital can enter into risk/gain sharing agreements with

other providers. What is this going to mean for private practice?

– Physicians may get advanced APM credit under MACRA.– Downside risk begins in 2Q 2018

Bundled Payment Model: Opportunities

• Represents continued movement towards a value‐based payment system that focuses on improved quality and value – key elements of ACC’s strategic plan.

• Reflects CMS’ continued efforts to find new ways for specialists to be rewarded for delivering quality care

• May qualify as Advanced Alternative Payment Models (APMs) under MACRA.

– HHS goal to have 50% of Medicare payments tied to APMS by end of 2018.

• Cost‐saving opportunities lie in lowering readmissions, home health and SNF utilization

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Bundled Payment Model: Challenges

• Different from previous CMS bundles payment models:

– Higher‐risk patients

– Surgeries are not elective (Physicians have less control over timing/planning)

• Some hospitals have had experience with APM models, while others have not. Those without experience will have little time to adapt or plan in advance.

• Changes in payment structures in health care can pose significant challenges to clinicians and must be driven by clinical practices that improve patient outcomes.


• AMI model combines medical management and revascularization procedures in one condition‐based bundle

• AMI model includes heterogeneous population, patients discharged under relevant PCI MS‐DRGs with a principal and secondary diagnosis of AMI

• Full benefits of participation in Advanced APM may not be achievable unless threshold to meet QP status under MACRA is lowered

• Quality Performance Weighting for Risk‐Standardized Mortality Rate is high and may not be achievable

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Bundled Payment Model: Next Steps

• ACC will review and provide recommendations to CMS in comment period (due October 3)– Health Affairs/Partners in Quality have the lead on

comments, with input from other committees.– Consultation with CV subspecialties and other important

stakeholders (e.g., hospitals) in progress.

• Opportunity to extend value of NCDR (ACTION, Cath‐PCI) and ACC quality programs.

There Will Be Opportunities for ACC to Provide Input Into How the Law Will Function

MACRA

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More information is available on the ACC’s online MACRA hub at www.ACC.org/MACRA

Updates are provided via the hub and through the ACC’s Advocate newsletter.

ACC MESSAGE ON MACRA

Congress and CMS should work with medical specialty societies to ensure that MACRA implementation is not

administratively burdensome and doesn’t interfere with the delivery of high-quality cardiovascular care.

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ACC MESSAGE ON MACRA • CMS must provide effective resources and assistance to small and/or

private practices

• CMS should continue to explore options to accept multiple performance data submission files from a practice reporting as a group so clinicians report and be scored on the most meaningful measures to their clinical practice.

• While the ACC is not advocating for a delay to the Jan. 1, 2017, reporting period start date, we urge Congress and CMS to consider a “hold‐harmless” year and/or phasing in requirements over time.

Source: 2014 PQRS Experience Report: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Experience_Rpt.pdf

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ACC Advocacy Update

Our Mission

Transform cardiovascular care and improve heart health through interactions with Congress, federal

government agencies, state legislative and regulatory bodies, private insurers, and other

policy making groups.

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Our Vision• ACC is a leading voice in shaping

health policy to put patients first and support CV professionals’ commitment to high quality care.

• Every ACC member is an advocate for patients and for CV medicine.

ACC Advocacy Priorities

Create a value driven health care

system

Ensure access to care and CV

practice stability

Promote use of clinical data to improve care

Foster research and innovation in

CV care

Improve population health and prevent CV

disease

Engage members to shape health

policy

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ACC Advocacy TargetsFederal

• U.S. Congress

• White House/Executive Office of the President

• HHS (CMS, FDA, CDC, NIH, ONC)

• MedPAC

• GAO

• USDA

State

• Legislature

• Governor/Lt. Governor

• Health Department (or equivalent)

• Insurance Commissioner or equivalent

• State medical board

• Medicaid program

Non‐Government

• Health plans

• Think tanks (e.g., Brookings, Pew)

• National Quality Forum

• Healthcare Transformation Learning and Action Network

Save the Date!

Leadership Forum and CV Summit 2017

January 25 – 28, 2017

Hilton Bonnet Creek Resort Orlando, FL

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I hope this is the sun rising and not setting on the practice of Cardiology in the US.

More to follow!

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Maintenance of Certification and the ABIM

ACC Input to ABIM Has Created Change:

• Reversal of the double jeopardy provision

• Decoupling of the initial board exam from MOC participation

• Streamlining the ability for practitioners to get both CME and MOC Part II credit

• Suspending MOC Part IV requirement

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The BIG Announcement:

ABIM will begin offering physicians a new MOC assessment option in January 2018.

NOTE: ABIM's current 10‐year exam will remain available as a second assessment option.

Additional ACC Asks: – Allow the ACC, other professional societies and qualified entities

to put forth standards‐based processes that would be certified by the ABIM.

– Undertake research to test the outcome of MOC activities on actual improvement in patient care and outcomes.

– Enable diplomates to seamlessly receive credit for activities in which they lead and participate in on behalf of hospitals, health care systems, payers and state medical boards.

– Permanently eliminate practice improvement (“Part‐IV”) activities as an MOC requirement.

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Recent ACC Activities

• ACC's accounting staff have reviewed and discussed the ABIM’s publically available financial statements with an outside accounting firm.

• Dual CME/MOC activities were offered for the first time at ACC.16 in Chicago. (All MOC activities are free for ACC members.)

• As of September, JACC Journals will offer dual CME/MOC credit for online activities. Visit www.onlineJACC.org.

• Continued updates to ACC’s online MOC Hub (www.ACC.org/MOC)

Accreditation

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Critical need:

To provide hospitals, health systems and other facilities with an integrated, holistic approach to quality improvement across the cardiovascular care spectrum.

>2,500 hospitals>3,500 cardiologists>40 million clinical records

LAAO Registry – Q1 2016AF Ablation Registry – Spring 2016

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The New Entity Will Benefit from a Convergence of a Wealth of Experience

ACC65 years of leadership in CV

education, guideline development, clinical data

registries and quality improvement

SCPC18 years of accrediting more than 1,000 hospitals and other facilities to improve clinical processes for the early assessment, diagnosis, and treatment of CV disease

Understanding the Medicare Access and CHIP Reauthorization Act of 2015

(MACRA)

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MACRA Impact on Health Care Delivery Will be Profound

What Did MACRA Do?

• Repealed the flawed

Sustainable Growth Rate (SGR)

• Established framework for moving Medicare from a VOLUME to a VALUE‐BASED system

9/17/2016

35

Background: Creation of the SGR

• The sustainable growth rate (SGR) was created by theBalanced Budget Act of 1997 as a means to control Medicarespending by tying Medicare clinician payments to increases inthe gross domestic product (GDP).

• When health spending outpaced GDP, negative paymentupdates were threatened as a result.

• Due to the inability to find sufficient offsets, the SGR wasunable to be repealed for nearly two decades.

Congress passed 17 patches to avoid cuts (implementing cuts twice)

Elimination of the SGR

• Early 2014: Congressional leaders from the House and Senate, inclose collaboration with the physician community, draftedlegislation which would repeal the SGR and reward physiciansfor the value of the services they provided.

• Spring 2015: Speaker of the House John Boehner and MinorityLeader Pelosi struck a deal on the offsets and the Medicare andCHIP Reauthorization Act of 2015 (MACRA) was born.

Virtually the entire House of Representatives united to pass MACRA, followed by the Senate.

President Obama signed the now‐law on April 16, 2015.

9/17/2016

36

Encourage Alternative Payment Model

participation

Improve Medicare quality reporting systems

MACRA

Recognize quality based on clinically, relevant

evidence‐based measures

Improving Population Health

• Broadly Written Directions, Implementation Details Unclear

What About the Details of the Law?

• CMS released first proposed regulations in April 2016 – currently open for public comment

• Repeal not likely

9/17/2016

37

Medicare and CHIP Reauthorization Act of 2015

• Delayed enforcement of the “two‐midnight” rule until October 1, 2015

• Extends the Children’s Health Insurance Program (CHIP) for two years (until 2017)

• Extends the Teaching Health Center Graduate Medical Education Program (THCGME) for two years (until 2017)

• Declares a national objective to achieve interoperable electronic health records by December 31, 2018

• Prevents quality program standards and measures (such as PQRS/MIPS) from being used as a standard or duty of care in medical liability cases

Changing the Payment Landscape

Pre‐MACRA

• 21% payment cut in 2015, continued uncertainty

• Separate quality reporting programs

• Incentives for alternative payment model participation mainly from savings

Post‐MACRA

• Eliminates SGR; implements stable payment increases

• Streamlined quality reporting program

• Incentives for alternative payment model participation built into payment system

9/17/2016

38

Annual Payment Updates

Mid 2015‐2019

• 0.5% annual payment update

2020‐2025

• 0% annual payment update

• Introduction of Merit‐Based Incentive Payment System

2026 and After

• 0.75%: Alternative Payment Model participants

• 0.25%: All other professionals

Averts a 21% payment cut in 2015 and future uncertainty

Merit‐Based Incentive Payment System

MIPS

Quality

(PQRS)

Meaningful Use (EHR Incentive)

Resource Use (Value Modifier)

Clinical Practice Improvement

• Individual programs continue through 2018

• MIPS begins in 2019 for physicians and most mid‐level clinicians

– 2017 performance

• Eligible professionals scored against benchmark based on prior year’s performance

• Low‐volume providers and some APM participants may be exempt from MIPS requirements

9/17/2016

39

MIPS Composite(subject to CMS adjustment)

• PQRS measures• eCQMs• QCDR measures• Risk-adjusted outcome

measures

• Value-Based Modifier measures

• Risk-adjusted outcome measures

• Part D drug cost (if feasible)

• Expanded Practice Access• Population Management• Care Coordination• Beneficiary Engagement• Patient Safety • Practice Assessment (ex. MOC)• Patient-Centered Medical Home or

specialty APM

• Meaningful Use requirements

• Meaningful Use weight may be adjusted down to 15 percent if 75% or more EPs are meaningful users

Alternative Payment Model

• 2019‐2024: 5% bonus

• CMS/CMMI models (except Healthcare Innovation Awards)

• Other eligible models

– Requires CEHRT

– Payment based on quality measures

– Financial risk or a Patient Centered Medical Home

• APM participants meeting threshold are MIPS‐exempt2023 and Beyond




2021 and 2022




2019 and 2020


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Measure Development Plan & Funding

By Jan 2016

• HHS Secretary and stakeholders must develop and publish a draft plan for MIPS and APM measure development

By Mar 2016

• Close of public comment period

By May 2016

• Final plan published on HHS website

May 2017 & beyond

• Annual progress report, including a listing of each measure developed or in development

• $15 mil each fiscal year 2015 to 2019

• Prioritize measure gaps

– outcome, patient experience, care coordination, and appropriate use measures

• Incorporation of private payer and delivery system measures

• Coordination across stakeholders

• Utilization of clinical best practices and practice guidelines


2015 2016 2017 2018 2019 2020 2021 2022+


~+ 5%3.5%

TBD‐ 6%

TBD‐9%

TBD‐10% or more



+4%*

‐4%+5%*

‐5%+7%*

‐7%+9%*

‐9%

APM Bonus^+5% +5% +5% +5%



Benchmark

Neutral Adjustment

High Performance

Positive Adjustment

Low Performance

Negative Adjustment


9/17/2016

41

Small Practice Assistance

• $20 mil allocated to help practices of ≤ 15, rural, and underserved areas

• Allow “virtual groups”

• All Eligible Professionals will need to receive quality and resource use feedback at least quarterly

Public Reporting

• Continued expansion of Physician Compare

– 2016: volume of services, submitted charges, and payments

– MIPS composite and category scores

9/17/2016

42

2016 Medicare Physician Fee Schedule

• Defining MIPS‐exempt professionals based on “low volume threshold”

• Identifying activities to meet the Clinical Practice Improvement component of MIPS

• Designing the elements of a physician‐focused payment model

Considerations

Increased awareness between payment

and quality

Increased focus on alternative payment

models

Opportunities to impact quality improvement

Value of registries and meaningful

measures

How will ACC ensure members have the resources to meet new requirements?

9/17/2016

43

CMS has incorporated recommendations made by the ACC and other societies in to the proposed rule. Examples include…

• Advancing Care Information component of Merit‐Based Incentive Payment System

• Reporting requirement of National Quality Strategy Domains

• Menu approach for clinical practice improvement

ACC Action on MACRA• The ACC responded to CMS’ Request for Information on MACRA

Implementation. The ACC emphasized the importance of a system that is focused on:

– evidence‐based patient care

– measures quality in an accurate and transparent manner

– is not administratively burdensome

• The ACC worked with the AMA and other specialty societies to form common principles on how CMS should implement the new payment system under MACRA.

9/17/2016

44

Challenges Ahead, Engagement Necessary

• Early years of implementation will post challenges to those accustomed to the current system

• ACC working with HHS and CMS to minimize these challenges to support evidence‐based, cost‐effective, high quality care.

Recognizing NCDR Participation

• NCDR registries as a way to meet reporting requirements under three MIPS components:

– Quality

– Advancing care information

– Clinical practice improvement activities

• ACC staff is working towards creating specific NCDR Registry‐based solutions to the performance Improvement participation requirement.

9/17/2016

45

There Will Be Opportunities for ACC to Provide Input Into How the Law Will Function

MACRA

More information is available on the ACC’s online MACRA hub at www.ACC.org/MACRA

Updates are provided via the hub and through the ACC’s Advocate newsletter.

9/17/2016

46

Maintenance of Certification and the ABIM

What 2014 Brought…

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Your ACC Listened …and developed a three‐pronged approach focused on –

• Serving as a source of information about the changes for members

• Providing tools and resources to help members more easily meet the new requirements

• Advocating on behalf of members for changes to the MOC process

CardiologyMagazine, January 2015

Your ACC Listened …and developed a multitude of educational products

• Full one‐third of all FACCs have taken advantage of these free resources since 2014

CardiologyMagazine, January 2015

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ACC Continuing to Work With ABIM to Meaningfully Change the MOC Process

• Alternative options have been investigated (Possible new certification/recertification process)

• However…none are ideal

Thanks to physician input and organizations like the ACC…

ABIM has made substantial changes

9/17/2016

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ABIM Actions:The “We’re Sorry” E‐mail Heard ‘Round Internal

Medicine

ABIM’s Assessment 2020 Task Force Report Developed to:

• Develop a vision for future of assessment

• Stimulate discussion among stakeholders

In line with many of the ACC’s recommendations!

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ACC Input to ABIM Has Created Change:

• Reversal of the double jeopardy provision

• Decoupling of the initial board exam from MOC participation

• Streamlining the ability for practitioners to get both CME and MOC Part II credit

• Suspending MOC Part IV requirement

The ACC is seeking the following from ABIM:

– Model the new, more frequent, focused assessments of cognitive skills on the “SAP” model and use the “2016 ACC Lifelong Learning Clinical Competencies for General Cardiologists” as the basis for these assessments.

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– Consideration of an open‐book format for those members choosing to take the 10‐year exam. Allow access to all resources during exam (I.e., not limited to Up‐to‐Date)


– Allow the ACC, other professional societies and qualified entities to put forth standards‐based processes that would be certified by the ABIM.

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– Enable diplomates to seamlessly receive credit for activities in which they lead and participate in on behalf of hospitals, health care systems, payers and state medical boards.


– Permanently eliminate practice improvement (“Part‐IV”) activities as a requirement for MOC. Practice improvement activities are important and will soon be required of all providers by Federal law (MACRA).

– Appropriate practice improvement activities should be acceptable for fulfillment of MOC participation, but a specific minimum level of Practice Improvement activities should not be returned to the list of MOC requirements.

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– Undertake research to test the outcome of MOC activities on the actual improvement in patient care and outcomes in order to provide an evidence‐base for the value of MOC.

ABIM’s Recent CommunicationRegarding Maintenance of

Certification

May 5, 2016

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“ABIM announces plans to offer options for MOC assessment that

reflect physician input”

Email sent on May 5 from:

Richard J. Baron, MD, MACP

Clarence H. Braddock III, MD and Jeanne M. Marrazzo, MD

The BIG Announcement:

The ABIM will begin offering physicians a new MOC assessment option

in January 2018.

NOTE: ABIM's current 10‐year exam will remain available as a second assessment option.

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The new assessment option will:• Take the form of shorter assessments that doctors can choose to take on

their personal or office computer—with appropriate identity verification and security—more frequently than every 10 years but no more than annually;

• Provide feedback on important knowledge gap areas so physicians can better plan their learning to stay current in knowledge and practice; and

• Allow physicians who engage in and perform well on these shorter assessments to test out of the current assessment taken every 10 years.

“Both options will reflect the input ABIM has received from you, your colleagues, medical societies and other stakeholders over the past year.”

ABIM is Listening!

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Important Notes:• Initially, this new option will be available for physicians maintaining certification in

internal medicine, and, possibly, one or two subspecialties.

• Physicians with certificates that expire before the new assessment option is offered in their subspecialty will still need to take and pass the current exam in order to maintain their certification. They will then not have to take another assessment for 10 years.

• During the coming months, ABIM will continue to work with physicians and societies to refine the assessment options, testing these elements and others, and they will provide more specific details no later than Dec. 31, 2016.

The final ABIM plan must have an ultimate goal to find a solution(s) that best allow clinicians to maintain and demonstrate competence related to:

• patient outcomes• quality care • cost‐effectiveness

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The ACC's accounting staff have reviewed and discussed the ABIM’s publically available financial statements with an outside accounting firm and have found the statements to be in compliance with Generally Accepted Accounting Principles (GAAP), as utilized by not‐for‐profit organizations in the United States.

The ACC’s online MOC hub at www.ACC.org/MOC and ACC in Touch Blog at blog.acc.org contain the latest MOC resources and updates, including free MOC activities.

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ACC’s Health System Strategy and Accreditation

ACC Adopts and Conforms to a Principle of Accountability for access to care, quality of outcomes, and cost of the delivery of cardiovascular care for populations served by cardiovascular specialists.

ACC Overriding Principle on Population Health Management

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Rapid Pace of Change Continues

• MACRA

– APM

– MIPS

• Pick your pace

• CMS mandated bundle

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MACRA Highlights• MACRA & ACO’s

– Proposed in the PFS• Allow providers to separately report quality• Further highlight the need to know YOUR data

– Remember the rules change depending on your ACO

• Will the new mandated cardiac bundles qualify as a qualifying ACO…..? What will the thresholds be in order to be a qualifying provider?

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Latest on MACRA• Pick your Pace: PYP

– Announced 9/8

– For reporting year 2017 ONLY

– Option 1: Submit something – Option 2: Participate for a partial year

• Not really well defined yet

• Probably something from each of the 4 categories

• Could receive a “small positive adjustment”

PYP: continued– Option 3: Participate for the full year

• You could be eligible for a “modest” positive payment adjustment

– Option 4: Join a Qualified ACO• MSSP Track 2 or 3• 5% bonus IF qualifying provider

QRUR and s‐QRUR should be released 9/16/16Stay tuned for the final rule in early November

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Episodes are…everywhere• In MIPs cost allocation

– 13 cardiac– Acute and Chronic– Condition and procedure

• CMS recently released– AMI/PCI– CABG– Cardiac rehab incentive program

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Bundled Payment Model: Key Elements

• Quality‐adjusted target episode price for each facility based on historic costs. – Performance based on average episode costs for reporting

period. – Costs in excess of quality‐adjusted target price must be paid

back. Savings will be shared. [may have 1.5‐3% inc]• All Medicare costs included (e.g., post‐acute facilities, physician

payments, etc.); hospital assumes risk.– Hospital can enter into risk/gain sharing agreements with

other providers. What is this going to mean for private practice?

– Physicians may get advanced APM credit under MACRA.– Downside risk begins in 2Q 2018

Bundled Payment Model: Opportunities

• Represents continued movement towards a value‐based payment system that focuses on improved quality and value – key elements of ACC’s strategic plan.

• Reflects CMS’ continued efforts to find new ways for specialists to be rewarded for delivering quality care

• May qualify as Advanced Alternative Payment Models (APMs) under MACRA.

– HHS goal to have 50% of Medicare payments tied to APMS by end of 2018.

• Cost‐saving opportunities lie in lowering readmissions, home health and SNF utilization

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• Different from previous CMS bundles payment models:

– Higher‐risk patients

– Surgeries are not elective (Physicians have less control over timing/planning)

• Some hospitals have had experience with APM models, while others have not. Those without experience will have little time to adapt or plan in advance.

• Changes in payment structures in health care can pose significant challenges to clinicians and must be driven by clinical practices that improve patient outcomes.


• AMI model combines medical management and revascularization procedures in one condition‐based bundle

• AMI model includes heterogeneous population, patients discharged under relevant PCI MS‐DRGs with a principal and secondary diagnosis of AMI

• Full benefits of participation in Advanced APM may not be achievable unless threshold to meet QP status under MACRA is lowered

• Quality Performance Weighting for Risk‐Standardized Mortality Rate is high and may not be achievable

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Bundled Payment Model: Next Steps

• ACC will review and provide recommendations to CMS in comment period (due October 3)– Health Affairs/Partners in Quality have the lead on

comments, with input from other committees.– Consultation with CV subspecialties and other important

stakeholders (e.g., hospitals) in progress.

• Opportunity to extend value of NCDR (ACTION, Cath‐PCI) and ACC quality programs.

▪ MIPS similarities to current programs

▪ Recognition of registries and QI initiatives

▪ Flexibility for non-patient facing, low-volume clinicians, and APM participants

▪ Do proposals go far enough to improve current programs?

▪ Limited opportunities for specialty Advanced APM involvement

▪ Flexibility created complexity

MACRA Proposed Rule Released April 2016

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Interna

International Outreach of the ACC

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Growth of FACC/MACC Members Since 2000

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Other Membership Category Growth Since 2000

A. MD, Chair, ACC Board of Governors - The...9/17/2016 1 The Alphabet Soup of Cardiology: Current...

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