How to Succeed in Alternative Payment Models -...

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How to Succeed in Alternative Payment Models

Shannon Calhoun

Regional Vice President, Caravan Health

Caravan Health

23 MSSP ACO’s

• 6,000 Clinicians

• 55 PPS Hospitals

• 92 Critical Access Hospitals

• 168 Rural Health Clinics

• 39 FQHC’s

• 500,000 Medicare lives

• 32 states

1 Practice Transformation Network

• 11,000 Clinicians

• 800 Independent Practices

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Caravan Health Services and Programs

• Establish Care Coordination programs

• Establish Wellness and Prevention programs

• Population Health Management software and analysis

• Evidence-based medicine programs

• 24/7 Access program

• Patient Satisfaction program

• Clinically integrated networks

• Advocacy

• Legal and financial services

3

Overview and Learning Objectives

• Learn about MACRA and Alternative Payment Models

• Understand the implications for your organization

• Consider what changes you will need to make to be successful

• Hear about opportunities to engage in alternative payment models

• Learn about tools and resources funded by Medicare and available to you now!

www.CaravanHealth.com | Proprietary & Confidential, Not for Distribution 4

MACRA: Engage Now for the Future of

Health Care


The Big Picture-Results Matter

6

CMS uses cost and quality data to show results inPrograms.

• It matters that every beneficiary/patient has access to quality care.

• It matters that cost is controlled.

• It matters what your claims and quality submissions say about your practice.

$586 $597 $615 $671 $695 $722

$794 $849

$911

$1,018 $1,064

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

SOURCE: Congressional Budget Office (CBO) Medicare Baseline, May 2013.

Projected Medicare Spending, 2013-2023

In billions:

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012 2014 2016 2018 2020 2022 2024 2026SOURCE: 2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

Medicare Part A Trust Fund Balance at Beginning of the Year, as a Percentage of Annual Expenditures, 2012-2026

In billions:

Why Quality Matters: Disparities in Quality of Care Between Rural and Urban


2 2 1

13 14

25 15 16

42

17 11 9

0%

20%

40%

60%

80%

100%

Patient Safety(n=19)

Person-Centered Care

(n=16)

EffectiveTreatment

(n=44)

Healthy Living(n=27)

Access (n=25)

Better Same Worse

Disparities in Life Expectancy Between Rural and Urban are Wide and Growing

50,000,000 Rural Americans x 2.4 years lost = 120 million years lost by today’s rural residents.

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Rural vs. Urban Death Rate per 100,000

Quality Payment Program:

Merit Based Incentive Payment System

andAlternative Payment

Models


Alphabet Soup: A Guide

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Confidential, Not for Distribution

1

3

• PFS: Physician Fee Schedule. Medicare payment program for clinician rates effective through CY2018.

• MACRA: Medicare Access and CHIP Reauthorization Act. Legislation passed in 2015 replacing the PFS with the QPP.

• QPP: Quality Payment Program. New Medicare payment program for clinician rates effective beginning CY2019.

• MIPS: Merit-based Incentive Payment System. One of two QPP tracks.

• A-APM: Advanced Alternative Payment Model. One of two QPP tracks.

The Speed of Change is Increasing

Secretary Burwell’s historic announcement:

“Our first goal is for 30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide – and to do it by 2016. Our goal would then be to get to 50% by 2018.

Our second goal is for virtually all Medicare fee-for-service payments to be tied to quality and value; at least 85% in 2016 and 90% in 2018.”

Only 36 percent of the 1,201,363 professionals who were eligible to participate in 2012 participated in PQRS, so how is that going to happen?


Payment Roadmap

Quality Payment ProgramProviders Choose Between Two Tracks


Merit Based Incentive

Payment System (MIPS)

Advanced Alternative

Payment Models (Advanced APM)

Two Tracks; Four Buckets


Quality Payment Program

(QPP)

Merit-based Incentive

Payment System

(MIPS)

Advanced Alternative

Payment Model

(A-APM)

Other Payer

APMA-APM`MIPS APMMIPS`

Who Is Included in the QPP?


Physician

Physician Assistant

Nurse Practitioner

Clinical Nurse Specialist

Certified Registered Nurse Anesthetist

Physical Therapist

Occupational Therapist

Clinical Social Workers

Speech-Language Pathologist

Others…To be considered2019+

Providers in first year of Medicare Part B participation

Providers below the low patient volume threshold

o Medicare charges less than $30k OR

o Fewer than 100 Medicare beneficiaries annually

Providers that bill through a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC)

All eligible clinicians may voluntarily report

Who Is NOT in the QPP?



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9

What Is An Advanced Alternative Payment Model (A-APM)?


1. Use certified electronic health record technology

• At least of clinicians 50% in 2017

2. Payment based in part on quality measure results

• Comparable measures to MIPS, including at least one outcome measure

3. Accept financial risk

• Be a CMMI Medical Home Model; OR

• Bear more than a nominal amount of risk (3% of expected expenditures)

To be a qualifying A-APM, the clinician or group must have a “significant” investment in the A-APM

• 2017 & 2018: +25% of Medicare Part B payments OR +20% of patients

• Increasing to +75% of payments OR +50% of patients

What It Means To Be A Qualifying A-APM


Exempt from MIPS (can opt in)

Receive a 5% lump sum incentive payment CY2019-2024

Beginning in CY2026, will receive higher annual updates on fee schedule rates

MIPS APMs


Shared Savings Program Track 1 Participants are considered “MIPS APMs”

Subject to MIPS performance categories and payment adjustment

Alternative scoring of performance categories

• No cost measure

Streamlined data submission

• ACO quality data automatically rolls over (no separate submission needed)

• Automatically receive credit for Improvement Activities that are part of the MSSP (full credit in 2017)

• ACO Participation Improves all MIPS performance

• All providers billing under ACO TIN’s will get the ACO quality score unless they choose to report both.

• All Participants must submit data individually for Practice Improvement and Advancing Healthcare Information.

Performance Year 2017 Data Submission

Test the Quality Payment Program. Submit a minimum amount of data to avoid a downward payment adjustment (one quality measure, one improvement activity, OR advancing care information)


Participate for the full calendar year. Report all of the required MIPS data

for the full year to be eligible for the maximum incentive adjustment

Participate for part of the calendar year. Report all of the required MIPS

data for a 90 day period to earn a neutral to small positive payment

adjustment

Do not participate. Submit no data for 2017; receive a negative 4% payment adjustment in 2019

Merit-Based Incentive Payment System

MIPS Payment

Adjustment

Advancing Care

Information (Meaningful Use)

Quality (PQRS)

Cost or Resource Use

(Value Modifier)

Clinical Practice Improvement

Activity(new)


Notable Changes from Current Programs


• Quality Reporting

• Reduces measures from 9 to 6

• Report one outcome measure

• Report for a minimum of 90 days

• Advancing Care Information

• Renames program from EHR/ Meaningful Use to “Advancing Care Information”

• Security Risk Analysis, Electronic Rxing, Patient Access, Provide Summary of Care

• Improvement Activities (NEW)

• Self-attestation of 2-4 Activities for a minimum of 90 days (Rural vs Non-Rural)

• PCMH, comparable specialties or APM designated as Medical Home= 100% Credit

• Track 1 ACO (New in 2017= 50%+ Credit, Established=100% Credit)


Source: CMS MACRA LAN Powerpoint, October 2015

Quality Payment Program Timeline


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Key Considerations

• Final Rule announced Friday October 14, 2016

• CMS estimates more than 125,000 providers will participate in Advanced APMs and qualify for the 5% incentive payment.

• RHCs and FQHCs are exempt from reporting – can do so on a voluntary basis

• Solo practitioners and most small group practices are not exempt from reporting

• Performance periods start 2017 for payment adjustments in 2019


Advanced APMs or MIPS APMs Which is Right for You?

Requires Risk

Up to 10% loss 5% Max Bonus

Does Not Require Risk

27% Max Bonus

4-9% Max Penalties


Advanced

APM

MIPS APM

Value-Based Payments• Medicare Incentive Payment System (Starts 2017)

• Up to 9% penalty or 27% bonus by 2022

• $3- $9 PMPM

• Medicare Shared Savings Program (Open)

• Average Payment = $7.34 PMPM

• AIM Funding = ~$7.50 PMPM

• Comprehensive Primary Care Plus (Regional-FFS only)

• Average Payment = $16.50-$32 PMPM

• NextGen ACO Shared Savings Program (Open)

• $8 PMPM

• Million Hearts (closed)

• $10 PMPM for 30% of Medicare patients

• Humana Medicare Advantage Shared Savings Program (New!)

CONFIDENTIAL | 30

MIPS Alternative Payment Models

• MIPS APMs: e.g., Track 1 Medicare Shared Savings Program

• ACO Participation Improves MIPS performance.

• All providers billing under ACO TIN’s will get the ACO quality score, which are generally higher than MACRA scores.

• MIPS APMs are exempt from the Resource Utilization metric.

• You automatically get 100% credit for Clinical Practice Improvement.

• All Participants must submit data individually for Advancing Healthcare Information, but ACO has one score.

• Most ACO Participants will not be penalized and can earn high bonuses if they pay attention to EHR issues.

• Most specialists in an ACO will not have to report quality.


MSSP Program Elements

• All reimbursement stays the same for all providers

• Quality reporting and care coordination is required

• If savings are realized, payor will share savings with the provider

• Bonus payments are adjusted downward based on quality scores

• All claims data is provided to participants

• Waivers of Stark, Anti-trust, Anti-Kickback and Patient Inducement regulations

• Patients have full choice on where to go for care.

• Cost: $5 PMPM + 10% SS (AIM funding may be available)


Proprietary & Confidential, Not for Distribution

www.NationalRuralConsortium.org

Practice Transformation

Network (PTN): Getting

Ready for Value-Based

Payments

The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the

U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Its

contents are solely the responsibility of the authors and do not necessarily represent the official

views of HHS or its agencies.



HOW DO WE TRANSITION FROM

VOLUME TO VALUE ?

E & M AWV

Procedures TCM - CCM

20192015

2016

2017

2018


www.nationalruralaco.com

Common Elements of Success

Prevention: • Annual Wellness Visits

• Chronic Care Management

• Advanced Care Planning

• Behavioral Counseling

• Depression Screening

• Mental Health Support

• 24/7 Access

Coding:

• Complete and accurate

documentation of all chronic

conditions is key to correct

payment under value-based

models.

Quality: • Process

• Pre-visit Planning

• Patient Satisfaction

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Current Revenue Opportunities

Fee Schedule: • Annual Wellness Visits

• Chronic Care Management

• Advanced Care Planning

• Behavioral Counseling

• Depression Screening

Value-Based

Payments:• Medicare Incentive Payment

System

• Medicare Shared Savings Program

• NextGen ACO Shared Savings

Program

• Mandatory or Voluntary Bundled

Payments

• Comprehensive Primary Care Plus

• Million Hearts

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What Are We Trying To Improve?• Quality

• Most practices do not have processes in place to promote wellness and

address gaps in care – which are key quality measures.

• We need to establish the processes and workflow to address these

issues.

• Cost

• Reduce unnecessary care

• In value-based payments, payments are multiplied times HCC scores.

• We need to improve our coding to get paid what we are worth.

• Practice Economics

• We need to spend an extra hour with each of our Medicare patients

each year to address prevention, care gaps and appropriate coding.

How do you pay for that?

• We will need to fund the staff to do this work in order to be sustainable.

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Two-Thirds of Medicare Spending Is for People With Five or More Chronic Conditions

Percentage of Medicare Expenditures• Ninety-nine percent of

Medicare expenditures are

for beneficiaries with at least

one chronic condition.

• Ninety-eight percent of

Medicare expenditures

involve individuals with

multiple chronic conditions.

Source: Medicare Standard Analytic File, 2007



Chronic Care Management Reduces Cost• At risk patients with 2+ chronic conditions expecting to last

for the following 12 months or until death of the patient

• Explanation of CCM with written consent

• Incident to Primary Care providers

• General Supervision except RHC, FQHC

• 20 minutes per month

• 24/7 access to care team with access to electronic care

plan

• Shown to reduce cost by 20-60%

• Generates an average of $20,000/year in profit

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Quality Varies but Problem Areas are the Same

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Value of Wellness Visit in Population HealthealthValue of Wellness Visit in

Population HealthGather as much data as possible

on lives

Find patients who are “at risk”

Refer for appropriate follow-

up services

Develop a consistent primary care relationship

Refer patients to Care Coordinator



Our Version of the Wellness Visit

• Documentation of all drugs to support ongoing Medication Reconciliation.

• Documentation of all co-morbidities to support accurate risk coding.

• Perform PHQ-9 Depression Screen, Mini-COG, Fall Risk.

• Documentation of all interventions to support quality scores.

• Maximize number of patients who get the service.

• Maximize revenue to support staff needed for population health activities.

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Wellness Visit Risk Adjustment Impact

• Value-based payments are based on expected cost multiplied by

HCC risk scores. Providers will be penalized for falsely low

scores. For example:

• A hospital who has a joint replacement bundle expected cost of

$20,000 will get paid the following:

• $20,000 for a patient with an HCC score of 1.0



• HCC risk scores are calculated from all diagnoses listed on bills

sent to CMS in the prior calendar year – no institutional memory.

• DOCUMENT ALL SIGNIFICANT CHRONIC CONDITIONS ON

THE BILL FOR THIS VISIT. ASK PATIENT ABOUT EACH ONE

AND DOCUMENT IN SOAP NOTE. PRIORITIZE IF NECESSARY.

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Mandate to Improve Coding

• Value-based payments are based on allowed charges divided by

HCC risk scores.

• Cost/HCC score = adjusted cost

• E.g., a beneficiary who had $10K in claims last year and an

HCC score of 0.9 = $10,000 x .9 = $9,000 risk-adjusted cost

used for value-based payments.



• Rural typically under-codes because it does not generally affect

our payments.

• This makes our higher costs look even worse.

• Most providers can increase their risk scores by at least 10%.

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Mandate to Improve Coding

• Value-based payments are based on allowed charges divided by

HCC risk scores.

• Cost/HCC score = adjusted cost

• E.g., a beneficiary who had $10K in claims last year and an

HCC score of 0.9 = $10,000 x .9 = $9,000 risk-adjusted cost

used for value-based payments.



• Rural typically under-codes because it does not generally affect

our payments.

• This makes our higher costs look even worse.

• Most providers can increase their risk scores by at least 10%.

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AWV as Key to Quality

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25% Wellness Visits=20%Improvement

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Pre-AWV Post-AWV



Wellness Visits Generate Income

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Fee-for-Service(+$225-$300/visit)

• Wellness Visit

• Depression Screen

• Advanced Care Plan

• Smoking Cessation

• Obesity Counseling

• Substance Abuse Intervention

• Immunizations

• + E&M visit if needed

RHC (?)

• Can only bill All Inclusive Rate (AIR), but can add cost of staff to do work to cost report for reimbursement.

• Cannot bill for more than one visit.

FQHC (~+$60/visit)

• Can bill for the Wellness Visit (but not for the follow up or add-ons) for 1.3416 times FQHC PPS rate (including regular visit).

• Cannot bill for separate visit

What Should You Do Now?• Perform wellness visits on all of your patients.

• Embed a care coordinator in your practice.

• Start working on integrating behavioral health.

• Prepare to be flexible. This takes trial and error.

• Join a non-risk bearing Clinically Integrated Network.

• Keep up with your EHR.

• Code Baby Code! Get your HCC scores right.

• Join/Form an ACO.

• Get value-based payments from other payers.

• Keep up with announcements of new models.

• Get free training, software and support by joining National Rural Accountable Care Consortium Practice Transformation Network.



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Join Our PTN:• Set up Care Coordination Services

• Maximize Wellness Visits

• Increase your Medicare revenue by $20 PMPM

• Increase your quality by 20% or more

• Provide 24 hour advice nurses for your patients

• Get help implementing new programs discussed today.

IT’S FREE• Go to www.nationalruralaco.com and click on “Apply Now”

• Or email [email protected]

Learn More

http://www.nationalruralaco.com/

mailto:[email protected]

51

Questions?


Thank You

Shannon Calhoun, Regional Vice President

[email protected]

[email protected]

916-542-4707

www.CaravanHealth.com

916.500.4777





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Practice Transformation Network

Establish Your Value-Based Infrastructure at No Cost.



Step One: Set up your Care Coordination Program

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• Certify your coordinators with the Clinical Health

Coach (CHC) Training program offered by the Iowa

Chronic Care Consortium.

• A 26 hours on-line and self-paced program.

• Participate in hands-on Regional Workshops held

quarterly.

EDUCATION: Attend Care Coordination Webinar

ACTION: Designate a Care Coordinator



Step Two: Develop Your Billable Chronic Care Management (CCM) Service

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• Train and Certify your Care

Coordinators as Clinical Health

Coaches (CHC)

• Implement the necessary IT

infrastructure for access to Care

plans in Lightbeam

• Provide a federally-funded 24/7 nurse

advice hotline

• Bill Medicare $42 PMPM

EDUCATION: Attend Chronic Care Management Webinar

ACTION: Download Consent Form and Support Materials



Lightbeam Data Support

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Lightbeam Health Data Software

• for 24/7 access to your patient’s care plan

Action for Success: Designate a person as Super User for

Lightbeam – Webinar training instruction for Care Planning.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwja6-7Pqp_JAhUHx2MKHaQUB3UQjRwIAw&url=http://www.greenwayhealth.com/marketplace/partners/lightbeam-health-solutions/&psig=AFQjCNEgnHdDWvfa69QtKaN5Ac5_KyPHrg&ust=1448120295856454



Step Three: NurseWise/Evolve

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• 24-hour telephonic access to

medical advice for Medicare

patients.

• Necessary for your billable care

coordination program’s after-

hours coverage.

EDUCATION: Attend 24hr Nurse Advice Hotline Webinar

ACTION: Complete Nursewise Survey on PTN website

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwizp5utrZ_JAhVG7WMKHXK8DaoQjRwIBw&url=http://www.nationalruralaco.com/partners.shtml&psig=AFQjCNEaFufffnxyt00n3CS9EDFgy1ap1A&ust=1448121027233410



Step 4: Point-of-Service Patient Satisfaction Survey Tool and Tablet

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• Each practice is eligible to

receive single use tablet for

patients to complete satisfaction

survey & receive feedback.

• Tablets will be deployed within

60 days of enrollment.

EDUCATION: Attend webinar about survey tool and tablet.

ACTION: Complete Survey posted on PTN webpage.



Step 5: Preparing to become a Patient-Centered Medical Home (PCMH)

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ACTION: Complete Practice Baseline Assessment

EDUCATION: Attend webinar about PCMH.

ACTION: Complete Plan-Do-Study-Act activities.

• Assessment is aligned with PCMH goals and

track’s your practice performance.

• Conducted by NRACC Quality Specialist or your

state’s QIO/QIN with your leadership.

• Lays the foundation to apply for certification as a

PCMH. PCMH elements are built into quarterly

training workshops in a Plan, Do, Study, Act

(PDSA) format.



Step 6: Practice Workflow Redesign

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• Your practice will receive easy-to-

implement workflow tools.

• We will work together to create custom

implementation plan – tailored to your

practice’s needs and challenges

• Regional Workshop will be held in

Savannah on October 18th and in Atlanta

on October 21st.

EDUCATION / ACTION:

Schedule staff to attend one Regional Workshop per quarter.



OUTCOMES: Redesign Your Practice to Better Manage Population Health

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• Modify clinic workflow to address

care gaps

• Provide data to identify cost-savings

opportunities

• Report and improve ambulatory

quality scores

• Measure patient satisfaction at the

point of care (Tablet)

• Get paid quality bonuses



OUTCOMES: Improved Billing and New/Increased Revenue Streams

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• Program activities designed to

reduce cost and improve quality.

• Maximize additional population

health payments

• Prevent value-based payment

penalties

• Improve financial stability of local

health systems.

Action for Success: Actively participate in program activities –

PDSAs, Workflows, Trainings, and Workshops.



Eligibility

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• PHYSICIANS, PA’s and NP’s

• Rural PPS Hospitals

• Critical Access Hospitals (CAHs)

• RHCs, FQHCs

• Rural Fee-for-Service Clinics

• Urban rural network providers

• Not already part of any Medicare Shared Savings

program (MSSP, CPCI, etc.)



Participation Requirements

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• Participants must appoint or hire an in-house care

coordinator (will bill Medicare for new services)

• Active participation in the program, including attendance at:

• Training webinars

• Regional workshops

• Divisional workshops, and

(Travel for regional & divisional workshops is reimbursed through the grant)

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