Navigating the Health IT Policy Landscape with New Payment Models: A Primer
March 1st 2016
Carrie Nixon, CEO/Partner, Healthcare Solutions Connection/Nixon Law Group,
Mark Engelen, Sr. Director Marketing Strategy & Government Affairs, Greenway Health
Conflict of Interest Carrie Nixon, Esq Mark Engelen, MBA Has no real or apparent conflicts of interest to report.
Agenda • How did we get here • Civics lesson • Deciphering the alphabet soup • Getting involved and building a plan
Learning Objectives • Identify which value-based programs will impact your organization in 2016 • Determine the potential revenue and cost implications these programs will
have on your income statement in 2016 • Identify the types of tools organizations can use to get involved in the policy
discussion and ensure your voice is heard
Speakers Carrie Nixon is Co-Founder and CEO of Healthcare Solutions Connection and Managing Member of Nixon Law Group. She is an expert in healthcare law and policy issues relating to the Affordable Care Act reforms, including Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMHs), public and private Health Insurance Exchanges (HIX and PHIX), Health Information Exchanges (HIE), and mobile health/telemedicine. Carrie provides counseling in governance and regulatory compliance matters such as HIPAA/privacy and fraud and abuse restrictions. She represents hospitals and health systems, health plans, individual physicians and physician groups, labs, pharmacies, post-acute care providers, tele-health companies and startups in the healthcare space.
Speakers Mark is the Sr. Director of Marketing Strategy for Greenway Health where he is responsible for product marketing, market intelligence, and government affairs. Mark has spent his entire career in healthcare, working in strategy and marketing roles across multiple market segments including HealthIT, pharmacy benefit management, specialty pharmacy, and public health policy. Mark received a BA in Economics and a BS in Chemistry from the University of North Carolina at Chapel Hill, as well as an MBA from the Harvard Business School.
Poll 1
• Who are you? – Provider or Other Clinical Staff – IT Executive – Other Executive – Vendor, Other Roles
Poll 2
• What type of organization do you come from? – Small practice (1-3 Providers) – Medium practice (4-25 Providers) – Large Practice (25+ Providers) – Hospital/Health System – Other
To Start …Recent News
• Is MU Going Away? • MACRA Physician Focused Payment Model Technical Advisory
Committee Announcement
Healthcare of the Past
How did we get from there to here??
Insurance and Fee-for-Service Reimbursement
Skyrocketing Cost of Healthcare
The Shift from Volume to Value
Courtesy of Center for Healthcare Quality and Payment Reform
Poll 3
• How do your providers feel about quality reporting requirements – Love it – Like it – Meh – Not a fan – Hate it
Poll 4
• Have you seen any benefits in patient care or outcomes as a result of quality reporting?
– Lots – Some – Neutral – Made things worse – It has been terrible for patient care
Timeline: Healthcare Reform
Legislation 2006 PQRS Reporting under Tax Relief and Healthcare
Act
2008 Value-based
Payment Modifiers
under Medicare
Improvements for Patients
and Providers Act
2009 Meaningful Use under
HITECH Act
2010 Affordable Care Act
gives teeth to reporting
requirements
2015 Merit-based
Incentive Payment
System under Medicare
Access and CHIP
Reauthorization Act
How a Bill becomes a Law (a.k.a. How sausage is made)
The Basics
PROVIDERS IMPLEMENT CHANGES
Where the rubber meets the road!
REGULATORY AGENCY PROMULGATES AND ENFORCES REGULATIONS Agency issues Proposed Rule and requests
comments Agency issues Final Rule
BILL IS PROPOSED AND PASSED Bill is introduced in House or
Senate Bill is passed by both Chambers President Signs or Vetos Bill
Outside Influences
Poll 5
• Do you feel like these organizations are acting as your advocates today? – Absolutely – Kinda – Meh – Not Really – Absolutely Not
PQRS
• Physicians, Practitioners, and Therapists who bill Medicare, either individually or as a group (via Group Practitioner Reporting Option) MUST report quality measures in order to avoid a negative adjustment to Medicare reimbursement.
• To avoid downward adjustment in 2015, providers must have successfully reported one Quality Measure in 2013.
• To avoid downward adjustment in 2017, providers must successfully report nine Quality Measures (out of 254) across three quality domains in 2015.
How are we doing?
• Out of 1.25 million eligible providers, 460,000 (almost 40%) did not submit PQRS data in 2013, resulting in a loss of 1.5% total reimbursments.
• The 642,000 providers who met PQRS criteria will receive a 0.5% increase in CMS reimbursements.
2016 Physician Fee Schedule
• Final Rule released on Oct. 30, 2015 • To avoid downward adjustment in 2018, providers must successfully
report nine Quality Measures (out of 281) across three domains in 2015. • Failure to successfully report will result in 2% downward payment
adjustment in 2018. • 2018 is last PQRS payment adjustment year before transition to Merit-
based Incentive Payment System (MIPS)
Value-Based Payment Modifier
• Differential payments to physicians or practice groups based on quality of care as compared to cost of care for Medicare FFS beneficiaries.
• Adjustments are upwards, downwards, or neutral, and are separate and apart from PQRS adjustments.
• Phase-In: – 2015 (for performance year 2013): 100 or more physicians – 2016 (for performance year 2014): 10 or more physicians – 2017 (for performance year 2015): Solo practitioners and up
Meaningful Use • Final Rule issued in October. • Stage 2:
– # objectives reported reduced from 18 to 10 – Quality measures reporting remains the same – 90-day reporting period in 2016 for new attesters (previously 365) – Hardship exemption for problems with EHR
• Stage 3: – Optional in 2017, but mandatory in 2018
Current MU situation Most practices are participating and plan to continue participating in meaningful use in 2016.
40%
36%
17%
7%
45%
36%
15%
5%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
We have attested for MU Stage 2 andplan to attest again in 2016
We have attested for MU Stage 1 andplan to attest further
We have attested for MU Stage 1 anddon't plan to attest any further
We have attested for MU Stage 2 anddon't plan to attest any further
Customer Marketn = 415 n = 183
Stage 3 familiarity “Top box” familiarity among the respondents was similar. Slight difference on the not familiar side of the scale.
8%
5%
10%
13%
23%
31%
19%
27%
40%
23%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Customer
Market
Please select how familiar you are with the provider objectives for Stage 3 on the scale below.
1 - Very familiar 2 3 4 5 - Not at all familiar
n = 415
n = 181
Stage 3 participation Of those who are already planning to attest for MU Stage 2 in 2016, most are likely to voluntarily start Stage 3 in 2017.
39%
45%
24%
27%
24%
14%
6%
8%
6%
6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Customer
Market
Please select how likely it is that your practice will start Stage 3 voluntarily in 2017 on the scale below.
1 - Very likely 2 3 4 5 - Not at all likely
n = 157
n = 62
Agreement with Stage 3 Timelines
Most agree that there needs to be changes to the meaningful use timeline – however, movement officials might disagree.
61%
56%
33%
32%
28%
19%
14%
19%
34%
19%
37%
54%
25%
25%
33%
50%
36%
27%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Stage 3 should be pushed back 1 year and eliminate some of the provisions
Stage 3 should be pushed back a year
We should push Stage 3 to 2018 start date, without a voluntary year
We should merge Stage 3 with MARCA in 2019
We should keep Stage 3 as it is but eliminate some of the provision
The current timeline is alright
Please select whether you agree or disagree with the following statements about meaningful use:
Agree Disagree Don't know
n = 560
Not Feeling the Benefits While IT has to be certified, most aren’t seeing a strong clinical or financial benefit for attesting for the meaningful use program.
4%
4%
50%
11%
13%
26%
38%
51%
14%
28%
22%
6%
20%
11%
4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
How much financial benefit/loss have you seenby participating in the meaningful use program
at your practice?
How much clinical benefit/harm have you seenby participating in the meaningful use program
at your practice?
When considering a health IT system topurchase, how much of a priority is a health IT
system that is certified for meaningful use?
1 - Positive 2 3 4 5 - Negative
n = 481
A losing game?
A losing game?
• Embedded I love Lucy Video (Chocolate Conveyor Belt Scene)
Poll 6 • What programs are you participating in today?
– Chronic Care Management (CCM) – Patient Centered Medical Home (PCMH) – Accountable Care (ACO) – Physician Quality Reporting System (PQRS) – Value-base payment modifiers
Continuing the push towards quality and value
January 2015: HHS announces big goals for value-based payments and Alternative Payment Models (APMs)
• 30% of Medicare payments tied to quality
or value through APMs by end of 2016 • 50% by end of 2018 • 85% of Medicare FFS payments tied to
quality or value by end of 2016 • 90% by end of 2018
MACRA and MIPS: Where it all comes
together… Repeal of the Sustainable Growth Rate (SGR) formula!
MACRA law familiarity Very few are familiar with MACRA law – giving us an opportunity to add value by educating the marketplace.
3%
3%
8%
12%
20%
25%
18%
25%
51%
35%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Customer
Market
How familiar are you with the MACRA law?
1 - Very familiar 2 3 4 5 - Not at all familiar
n = 410
n = 173
What else does MACRA do? Introducing the Merit-based Incentive Payment System
MIPS
VPM PQRS
Meaningful Use
MIPS Payment Adjustments
• Composite Performance Score based on: – Quality – Resource Use – Clinical Practice Improvement Activities – Meaningful Use of Certified EHRs
• Positive, Negative, or Neutral adjustments: – 2019: +/- 4% – 2020: +/- 5% – 2021: +/- 7% – 2022 onward: +/- 9%
Bonus Payments for participation in Eligible Alternative Payment
Models Eligible APMs bear more than nominal financial risk, use quality measures, have certified EHRs
– CMS Innovation Center Model – Medicare Shared Savings
Program – Demonstration pilot
“Qualifying Participant"
• “QPs” with a certain percentage of patients participating in the most advanced payment models
– Are not subject to MIPs – Receive 5% lump bonus payments from 2019-
2024 – Receive a higher fee schedule update for 2026
and beyond
Law making involvement Greenway needs to communicate better about it’s role on the hill. Our customers aren’t being heard and we need to let them know we have the opportunity to help them with their frustration.
31%
32%
4%
30%
34%
12%
19%
17%
4%
8%
8%
35%
11%
9%
45%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
If given the appropriate tools, how willing wouldyou be to contact your nationally elected official
about healthcare policy?
If given the appropriate tools, how willing wouldyou be to contact your congressional
representatives about healthcare policy?
Please move the slider to show how happy youare with your voice and opinions being heard
currently by policy makers in Washington?
1 - Positive 2 3 4 5 - Negative
n = 452
Physician-Focused Payment Model Technical Advisory
Committee
Submit proposals to PFPM TAC Physicians
•Review Proposals •Submit recommendations to HHS
PFPM TAC •Comments on Proposals
•May test proposals
HHS Sec. and CMS
What’s your game plan?
Poll 7 • Do you have a plan?
– Nope – free in the wind man … – Kinda – but its in my head – Yup – but not a formal one – Detailed PowerPoint!
How can small or solo practices get in the
game?
Independent Physician Association (IPA) Clinically Integrated Network (CIN)
Demonstrate Your Value: It’s All About Quality and
Data!
The Big Takeaway
Questions
• Carrie Nixon, [email protected], 703-795-9763 • Mark Engelen, [email protected], 919-593-1196
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