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Health DataPalooza PreconferenceMay 8, 2016
Alternative Payment Models and Health IT
Kelly Cronin, MS, MPH, Director, Office of Care Transformation, ONC/HHS
In January 2015, the Department of Health and Human Services announced
new goals for value-based payments and APMs in Medicare
2
HHS Goals for Medicare Payment Reform
3
Medicare Met the Goal of 30% of Payments in APMs 1 Year EARLY2014 2015 2016 2017 2018
ESRD Prospective Payment System*ESRD Prospective Payment System*
Maryland All‐Payer Hospital Payments*Maryland All‐Payer Hospital Payments*
Comprehensive ESRD Care ModelComprehensive ESRD Care Model
Medicare Shared Savings Program ACO*Medicare Shared Savings Program ACO*
Pioneer ACO*Pioneer ACO*
CMS will continue to test new models and will
identify opportunities to expand existing models
Major APM Categories
* MSSP started in 2012, Pioneer started in 2012, BPCI started in
2013, CPC started in 2012, MAPCP started in 2011, Maryland All Payer started in
2014 ESRD PPS started in 2011
Bundled Payment for Care Improvement*Bundled Payment for Care Improvement*
Oncology CareOncology Care
Comprehensive Primary Care*Comprehensive Primary Care*
Multi‐payer Advanced Primary Care Practice*Multi‐payer Advanced Primary Care Practice*
Model completion or expansion
Next Generation ACONext Generation ACO
Comprehensive Care for Joint ReplacementComprehensive Care for Joint Replacement
4
First step to a fresh startWe’re listening and help is availableA better, smarter Medicare for healthier peoplePay for what works to create a Medicare that is enduringHealth information needs to be open, flexible, and user-centric
Medicare Quality Payment Program
The Merit-based Incentive
Payment System (MIPS)
Advanced Alternative
Payment Models (APMs)
or
Repeals the Sustainable Growth Rate (SGR) FormulaStreamlines multiple quality reporting programs into the new Merit-based Incentive Payment System (MIPS)Provides incentive payments for participation in Advanced Alternative Payment Models (APMs)
Most clinicians will be subject to MIPS.
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Not in APM In non-advanced APM
QP in advanced APM
Note: Figure not to scale.
Subject to MIPS
Some people may be in advanced APMs but not have enough payments or patients through the advanced APM to be a
QP.
In advanced APM, but not a QP
Quality Resource use
Clinical practice
improvement activities
Advancing care
information
A single MIPS composite performance score will factor in performance in 4 weighted performance categories on a 0-100 point scale:
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MIPS Performance Categories
MIPS Composite
Performance Score (CPS)
Year 1 Performance Category Weights for MIPS
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QUALITY50%
ADVANCING CARE INFORMATION
25%
CLINICAL PRACTICE IMPROVEMENT
ACTIVITIES15%
COST10%
+/- MaximumAdjustments
Adjusted Medicare
Part B payment to
clinician
Merit-Based Incentive Payment System (MIPS)
+4%+5%+7%+9%
2019 2020 2021 2022 onward
Based on a CPS, clinicians will receive +/- or neutral adjustments up to the percentages below.
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How much can MIPS adjust payments?
-4%The potential maximum
adjustment % will increase each year from
2019 to 2022
- 5%
- 7%
- 9%
The Quality Payment Program provides additional rewards for participating in APMs.
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Not in APM In APM In Advanced APM
MIPS adjustments
APM-specific rewards
5% lump sum bonus
APM-specific rewards
+MIPS adjustments
+If you are a
Qualifying APM Participant (QP)
Potential financial rewards
The APM requires participants to use certified EHR technology.
The APM bases payment on quality measures comparable to those in the MIPS quality performance category.
The APM either: (1) requires APM Entities to bear more than nominal financial risk for monetary losses; OR (2) is a Medical Home Model expanded under CMMI authority.
Advanced APMs meet certain criteria.
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As defined by MACRA, advanced APMs must meet
the following criteria:
NOTE: MACRA does NOT change how any particular APM functions or rewards value. Instead, it
creates extra incentives for APM participation.
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PROPOSED RULE Advanced APM Criterion 1: Requires use of Certified Health IT
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An Advanced APM must require at least 50% of the eligible clinicians in each APM Entity to use Certified Health IT to document and communicate clinical care. The threshold will increase to 75% after the first year.
For the Shared Savings Program only, the APM may apply a penalty or reward to APM entities based on the degree of Certified Health IT use among its eligible clinicians.
Certified EHR use
Example: An Advanced APM has a provision in its participation
agreement that at least 50% of an APM Entity’s eligible clinicians must use Certified Health IT.
APM Entity
Eligible Clinicians
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Shared Savings Program (Tracks 2 and 3)
Next Generation ACO Model
Comprehensive ESRD Care (CEC) (large dialysis
organization arrangement)
Comprehensive Primary Care Plus (CPC+)
Oncology Care Model (OCM) (two-sided risk track
available in 2018)
Proposed RuleAdvanced APMs
Based on the proposed criteria, which current APMs will be Advanced APMs in 2017?
What about private payer or Medicaid APMs? Can they help me qualify to be a QP?
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Starting in 2021, some arrangements with other non-Medicare payers can count toward
becoming a QP.
IF the “Other Payer APMs” meet criteria similar to those for Advanced APMs, CMS will consider them “Other Payer Advanced APMs”:
“All-Payer Combination
Option”
Quality Measures
Financia l Risk
Certified EHR use
201 6
201 7
201 8
201 9
202 0
202 1
202 2
202 3
202 4
202 5
2026 & on
Fee Schedule
Putting it all together:
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+0.5% each year
No change +0.25%or
0.75%
MIPS
APMQP in
Advanced
4 5 7 9 9 9 9
Max Adjustment
(+/-)
+5% bonus(excluded from MIPS)
Next Generation ACO Model builds upon successes from Pioneer and MSSP ACOs
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Designed for ACOs experienced
coordinating care for patient
populations
21 ACOs will assume higher levels of financial risk and reward than the Pioneer or MSSP ACOS
Model will test how strong financial incentives for ACOs can improve health outcomes and reduce expenditures
Greater opportunities to coordinate care (e.g., telehealth & skilled nursing facilities)
Model Principles• Prospective
attribution
• Financial model for
long‐term stability
(smooth cash flow,
improved
investment
capability)
• Reward quality
• Benefit
enhancements that
improve patient
experience &
protect freedom of
choice
• Allow beneficiaries
to choose alignment
Next Generation ACO Pioneer ACO
21 ACOs spread among 13 states 9 ACOs spread among 7 states
Comprehensive Primary Care
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7 regions (AR, OR, NJ, CO, OK, OH/KY, NY) encompassing 31 payers, nearly 500 practices, and approximately 2.5 million multi‐payer patients
CPC+ just announced could expand participation across 20 regions in the US with up to 5000 practices
CMS convenes Medicaid and commercial payers to
support primary care practice transformation through
enhanced, non‐visit‐based payments, data feedback,
and learning systems
$14 or 2%* reduction part A and B expenditure in year 1 among all 7 CPC regions
Reductions appear to be driven by initiative‐wide impacts on hospitalizations, ED visits, and unplanned 30‐day readmissions
* Reductions relative to a matched comparison group and do not include the care management fees (~$20 pbpm)
HIT Vendor Partnership with CMS and CPC practices – vendors sign a MOU with CMS and will develop advanced HIT functionalities for practices in Track 2
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Health IT Capabilities Expected in CPC+ Track 2
Empanel patients to the practice site care team
Screen for social and community support needs and link the identified need(s) to practice identified resourcesProduce and display eCQM results at the practice level to support continuous feedback
Risk stratify the practice site patient population
Establish patient focused care plans to guide care management
Document and track patient reported outcomes
Optional: Practice site care delivery and care touch documentation
Bundled Payments for Care Improvement is also growing rapidly
19
The bundled payment model targets 48 conditions with a single payment for an
episode of care
Incentivizes providers to take accountability for both cost and quality of care
Four Models ‐
Model 1: Retrospective acute care hospital stay only
‐
Model 2: Retrospective acute care hospital stay plus post‐acute care
‐
Model 3: Retrospective post‐acute care only
‐
Model 4: Prospective acute care hospital stay only
337 Awardees and 1237 Episode Initiators as of January 2016
Duration of model is scheduled for 3 years:Model 1: Awardees began Period of Performance in April 2013Models 2, 3, 4: Awardees began Period of Performance in October 2013
Comprehensive Care for Joint Replacement (CJR) is testing a bundled payment model across a cross-section of hospitals
20
The model tests bundled payment of lower extremity joint replacement (LEJR) episodes and includes approximately 20% of all Medicare LEJR procedures
The model will have 5 performance years, first year started April 1, 2016
Participant hospitals that achieve spending and quality goals will be eligible to receive a reconciliation payment from Medicare or will be held accountable for spending above a pre‐determined target beginning in Year 2
Pay‐for‐performance methodology will include 2 required quality measures and voluntary submission of patient‐reported outcomes data
~800
Inpatient
Prospective Payment
System Hospitals
participating
67selected
Metropolitan
Statistical Areas
(MSAs)
where 30%U.S.
population
resides
in
Medicare Payment Reform alone will not drive interoperability
• APMs offer a number of opportunities to reinforce the adoption of health information exchange capabilities and HIT tools that are instrumental to providers succeeding within these models.
• Advanced Medicare APMs will require use of certified health IT among eligible clinicians
• Multi-payer alignment of incentives or requirements for interoperability will drive provider behavior and uniform adoption of standards through certification.
• State policies will also reinforce interoperability through Medicaid waivers, State Plan Amendments (e.g., health home requirements), Managed Care Contract requirements, Medicaid matching fund policies, and other state driven mandates or incentives
HIT Capabilities for APMs – where are the gaps?
• Based on an extensive literature review, interviews, and input from
Technical Expert Panel participants, ONC has identified several market
gaps around health IT capabilities, including:– Up to date care plan in standardized format with patient goals and
results accessible by providers & case managers– Receive and incorporate notifications of referral status, including if
appointment is not kept.– Identify providers by specialty, commitment to care coordination,
patient preference, patient’s health plan network– Ability to cross reference the organization’s preferred providers to
provider networks identified by the patient, health plan, or provider
system.
HIT Modular Functions for Value Based Payment
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Data Quality & Provenance
ID Management
Data Extraction
Data Transport and Load
Analytics Services
Security
Provider Portal
Consent Mngt
PD/Registry
Notification Services
Consumer Tools
Reporting Services
Governance
Financing
Policy/Legal
Business Operations
Data Aggregation
Exchange Services Patient Attribution
Health Care Provider Systems
Registries
EHR
Providers &Data Sources
Claims Data
Clinical Data
Information
Other Non- Health Care
Provider Systems
Other Non- Provider Systems
Private Purchasers
Medicaid & Other State
Agencies
CMS & Other Federal
Agencies
Payers and Other VBP
Stakeholders
ACOs – MCOs - APMs
Public Health
VariousReporting Formats
Other
Key Insights from States on Multi-Stakeholder Collaboration for APM
Data Infrastructure• Focus on 1-2 high value use cases valuable to providers and
payers, i.e., improve measurement, reporting and performance • Assess existing data assets statewide (APCD, HIEs, CDRs,
Medicare QEs, etc.) to determine if they meet requirements• Need a neutral convener and facilitator
• Starting with a multi-payer process with provider input has been effective
• Find the right committed partners at the right level in respective payer organizations (senior level clinician managers)
• State shouldn’t necessarily lead but definitely be at the table and fully engaged
• Keep process nimble, flexible, informal initially• Get front line clinician input into user design of reporting tools to
ensure value and usability in practices• CMS Data Use Agreement can permit access to Medicare data
for APMs like CPC
5/8/2016 Office of the National Coordinator for Health Information Technology 24
