How did we go from SGR to MACRA - Ohio-ACC · • 'Failure to meet the submission requirements, or...
Transcript of How did we go from SGR to MACRA - Ohio-ACC · • 'Failure to meet the submission requirements, or...
Cathleen Biga, MSN, RN: Disclosures: • Co-chair:ACCCVAdministratorWorkGroup• Member:CardiovascularManagementCouncil• Member:HealthAffairsCommi@ee• Member:BOTWorkGrouponMedicalandProfessionalLiabilityInsurance• Member:CQCAUCImplementaKon&EvaluaKon• Member:CQCFOCUSCommi@ee• Member:PartnersinQualityCommi@ee• Member:TaskForceonMACRA• OwnershipInterest/Partnership/Principal:CardiovascularManagementofIllinois• ConsultantFees/Honoraria:Medaxiom• OrganizaKonal(Non-Commercial):CardiologyAdvocacyAlliance• OrganizaKonal(Non-Commercial):MedaxiomAdvisoryBoard
Whatistheproblem…..
Where are we…..how do we get there
Themarchtovalue……..
ThetrainhasleZthestaKon,anditain’tcomingback
MDRevenueatrisk2017&2018
Source: MGMA
ValueAgenda:Physician• MeaningfulUse• PQRS• ValueModifier• QRUR• S-QRUR• PhysicianCompare
• HelloMACRA• MIPs–Quality60%,Cost0%,ACI25%,CPIA15%
2014
2015
Astheworldturns…..
For more information, visit: ACC.org/CVSummit17
HowdidwegettoMACRA?1997
• MedicareSustainableGrowthRate(SGR)implementedaspartoftheBalancedBudgetControlActof1997
2002-2015
• 17patchestoavertsteepcutstoMedicare• HouseofMedicine,includingtheACC,workswithCongresstocraZMACRA
March24,2015
• H.R.2(MedicareAccessandCHIPReauthorizaLonActof2015)introducedintheHouse
March26,2015
• TheHousepassedH.R.2(392-37)
April14,2015
• TheSenatepassedH.R.2(92-8)
April16,2015
• MACRAsignedintolawbyPresidentBarackObama
TheBasicsofMACRA
• MedicareAccessandCHIPReauthorizaKonAct• EliminateSGR• EffecKve1/1/19• MACRA• APM:baseyearwillbe2017
• Thenewfinalrulehassomechangesin“qualifyingAPM’s”• MIPS:baseyearwillbe2017
Practices will have choices under MACRA"
• Statutory updates"• Consolidated reporting"• Reduced penalty risk"
Fee-for-Service under a “Merit-based Incentive
Payment System” (MIPS)"
• Higher updates"• Exempt from MIPS"• Preferred treatment for medical
homes"• Specialty models encouraged"
Alternative Payment Models"
MUrequirements:25points• Performancescore• BaseScore• 5measures
• Earnfullpoints• Therewere11• TheothersareopKonal
ClinicalPracLceImprovement(15points)• 90acKviKes• Pick4mediumor2high• 40points
Quality/PQRS:60points• 6qualitymeasures• 1sub-specialtymeasure
set• Webinterfacerules
different ResourceUse:0points
• MSPB• Totalcostofcare• Episodesofcare
• Only10vs40• Onlyonesins-QRUR
• 30%by2021
MIPSCompositeScore
Quality50%
QualityUse:60%
Changes• 2017willbeatransiKonyear• QualityisKing• Costiscollectedbutnotscored…..yet• APM• LookingatanACOTrack1+• Detailsnotoutyet• LookingatPrivatepayer&Medicaid
• Excludedproviders:$30Kor100paKents
LatestonMACRA• PickyourPace:PYP• Announced9/8–moredetailstoday• ForreporKngyear2017ONLY
• 1measurefromeachofthe3• NonegaKveadjustment• IfyoudoNOTHING=4%
• OpKon2:ParKcipateforaparKalyear• 90days• Morethan1measurefromthe3categories• CouldgetaposiKveadjustment
PYP:conKnued• OpKon3:ParKcipateforthefullyear• Youcouldbeeligiblefora“modest”posiKvepayment
adjustment• OpKon4:JoinaQualifiedACO• MSSPTrack1,2or3–YEA!!!• 5%bonusIFqualifyingproviderQRURisoutands-QRURshouldbereleasednextweekStaytunedforthefinalMACRAruleinearlyNovember
Pickyourpace:
ACOAlert
• QualifyingAPM• MSSPTrack2&3• NextGen• Pioneer• CPCI+• Oncology• MaybeMSSPtrack1+• ??CMSmandatedbundles
• APM–Doesn’tqualify‘17• MedicareSharedSavings
Track1• BPCI
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Howdowereport
• Individual• Electronichealthrecord• Registry• QCDR:qualifiedclinical
dataregistry• Medicareclaims
process.
• Group• CMSwebinterface• Electronichealthrecord• Registry• QCDR:qualifiedclinical
dataregistry.
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WebinterfaceMUSTapplyby6/30
Quality:60%
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ACI:Required
ACI:Bonus
AdvancingCareInformaKon–25%
• ACIakaMU–131points• ReplacestheMedicareEHRprogram• NewemphasisoninteroperabilityandinformaKonexchange• Eliminatesthecurrentallornothingprogram
• 'Failuretomeetthesubmissionrequirements,ormeasurespecificaKonsforanymeasureinanyoftheobjecKveswouldresultinascoreofzerofortheAdvancingCareInformaKonperformancecategorybasescore
• RemovedeCQM’sfromrequirements• Therewillbeatotalof130pointsavailable–basescore+performance
• +1bonuspointavailable• 100pointswillallowyoutoclaimthe25%ofthiscategory
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ClinicalPracKceImprovement:CPI
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RatedasHighandMedium
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Cost
• 0%foryearone• Threecostmeasures• Totalcostperbeneficiary• MSPB• 10episodesofcareONLYthoseins-QRUR
• OnlyCABGandValvesurgeryinfinallist
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A@ribuKon&Risk
• A@ribuKoniscriKcal• QRUR2stepa@ribuKonmethod• AddingChroniccarecodes• AddingSNFcodes
• PartAandPartBcostsfor1year• RiskscoresarecriKcal
MSPB
• InpaKentonly• A@ribuKon • Pluralityofclaims(asmeasuredbyallowablecharges)
• Cost3dayspreand30dayspost
APMs "• APM is a generic term describing a payment model in which providers
take responsibility for cost and quality performance and receive payments to support the services designed to achieve high value"
• According to MACRA, APMs include:"− Medicare Shared Savings Program ACOs – Track 2 & 3 ONLY"
− CPCI +"
− Pioneer & Next Gen"
− Onc model"
− ??? New CMS Mandated cardiac bundles"
Therearereally3“Buckets”
QualifyingACOANDQualifyingProvider
AreYouMACRAReady?• OrganizaKonalfocus• Physicianledprocess• Currentlysuccessfulin
• PQRS• MU• VM–QRURands-QRUR
• Youhavefoundyourdata• Youknowyournumbers
• Reducingvariabilityincaredelivery–MUSThappen
• Understandingcost• Understandingepisodesof
care• CarecoordinaKonisan
organizaKonalpriority• DocumentaKonisafocus–
clinic&hosp.
2017–NoAdjustment
QualityMeasures
SupplementalQRUR
AnatomyofanEpisode• StructuredpaymentaroundapaKentsTOTALexperienceof
care• Quality–outcome• Cost• Experience
• Preandposthospital• OZen3dayspreand90dayspost
• Be@ercoordinaKonofcare• UlKmatelybe@erpaKentoutcome
Episodesofcare-historical• ACEproject:testedbundledpaymentsinearly2000’s
• Cardiacandortho• Orthowidelysuccessful• Medicaresavingswhilemaintainingquality
• 1990’sBundledpaymentsCABG• Successfulinreducingcost,improvedquality,andprovidedservicesmoreefficiently
• BPCI:CMMIproject• OrthoMandatedbundle
Episodesin2016• Componentofthes-QRUR-64episodes
• CondiKonepisodes• Proceduralepisodes• 40ofthesewilltransfertoMIPscostcategory
• LAN–• Maternity• Orthobundle• CADbundlewithnestedprocedures
• CMSmandatedbundles• 4/1/16–ortho(CJRin67MetropolitanStaKsKcalAreas)• 7/25/16–MI/PCI,CABG,expansionofortho(SHFFT)
Basicepisode
So…..dowerun……or
Thebasics• WillbemandatedinspecificMetropolitanStaKsKcalareas–394naKonally• SpecificAMIcriteriaapplied• 294MSA’sremained• 98MSA’swillbe“selected”–endof2016• 12inIL–only1excluded
• AllMedicareFFSpaKents• 2cardiacbundles–firstKmecondiKon+procedure/surgerycontainedwithin1bundle
Thebasics• MI–includesMIANDMI+PCI
• IncludesbothprimaryANDsecondarydxcode• OutptMI’snotincluded(naKonallythisis6%)
• CABG• Starts7/1/17• Willlastfor5years• PartAandPartBcostincluded(plushospice)• 1/1/17thru12/31/18–2/3localdata+1/3regional
• 2019=yr.3=1/3local+2/3regional• 2020-2021=allregional
CardiacRehabIncenKve• AddiKonalprogram
• 45ofthe98randomlyselected+• 45selectedMSA’sthatarenotpartoftheEPM
• Cardiacrehabandintensiverehabprograms• $25pervisitfrom1-11• $175pervisitfrom12-36• Can’tbeincludedinFSA• Won’tbecountedinreconciliaKonpayments• CanprovidetransportaKon• UseofAPP’s
Andso…..WhatcanYOUdo…• Ensurecodingisaccurate• UnderstandYOURcurrentqualitythresholds• FindyourNCDRdata---reviewit• Knowyourdata–PQRS,MU,QRUR,ands-QRUR• EstablishdataanalyKcsandinformaKonsharing• ReducevariaKonincareacrosstheSystem• CreatetheinfrastructureandexperKsetocoordinatecaretransiKonsandmanagepost-acuteservices
LeadingtheCharge
• Designconsistentcarepathwaysacrossyourhospital–forEVERYONE
• FacilitatecommunicaKonamongsttheteam• ED,PCP,SNFmedicaldirectors,APP’s,hospitalists
• Knowyourcostpercase–leadthechargeincostreducKonthatresultsinexcepKonaloutcomes
• Don’tbeafraidofre-designingyourphysicianworkforce
QuesKons?
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For more information, visit: ACC.org/CVSummit17