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MACRA:Medicare’s Shift to Value-based
Delivery & Payment ModelsRobert Hall, JD
Director, Government Relations
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https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjJsbHdyfTPAhXHzz4KHRaKB80QjRwIBw&url=https://missamberlong.com/2016/02/03/learning-to-share-a-drink-and-other-things-that-made-me-grow-up/thelist-how-did-i-get-here-dorothy-100568058-large-idge/&psig=AFQjCNEvEjc6KiXYPQKlGd2HHwGWY0BiHA&ust=1477437466086994
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The US has a Budget Problem
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The driver is health costPe
rcen
t of
US
GD
P
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$210bnUnnecessary Services
$190bnAdministrative Costs
$130bnInefficient
Delivery of Care
$55bnPrevention
Failures
$105bnInflated Prices $75bn
Fraud
U.S. HEALTHCARE WASTE = NETHERLANDS GDP
$765bnin wasted spending
Source: Institute of Medicine (2009 data); The World Bank (2009
data)
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Healthcare Expenditures vs. Outcomes
Healthcare Expenditures as % of GDP, 2005*
757677787980818283
USA Sweden France Canada Japan UK
Average life expectancy, 2007
*Bradley EH, et al. Health and Social Services Expenditures:
Associations with Health Outcomes. BMJ Qual Saf (2011). *McGinnis
JM, Russo PG, Knickman JR. The case for more active policy
attention to health promotion. Health Aff (Millwood)
2002;21(2):78–93
Chart1
USA
Sweden
France
Canada
Japan
UK
Column1
16
12.1
12
10.3
8.6
8.2
Sheet1
Column1
USA16
Sweden12.1
France12
Canada10.3
Japan8.6
UK8.2
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range.
Chart1
USA
Sweden
France
Canada
Japan
UK
Column1
77.9
81
80.9
80.7
82.6
79.7
Sheet1
Column1
USA77.9
Sweden81
France80.9
Canada80.7
Japan82.6
UK79.7
To resize chart data range, drag lower right corner of
range.
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Pay Now … Or Pay Later
Hospital inpatient 27%
Hospital outpatient visits/other 28%
Professional procedures (non-
hospital) 30%
Drugs 16%
Primary Care 6%
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Source: RWJF/UWPHI.
GENETICS DIET & EXERCISE
TOBACCO USEALCOHOL &
DRUG USESLEEP SEXUAL
ACTIVITYACCESS TO CARE
QUALITY OF CARE
EDUCATION EMPLOYMENT INCOME SOCIAL SUPPORT
COMMUNITY SAFETY
AIR QUALITY
WATER QUALITY
HOUSING TRANSIT
THE FUTURE HEALTH ECOSYSTEM WILL FOCUS ON THE TRUE DRIVERS OF
OUTCOMES
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Current State
Over Utilization
Volume over Value
Silos of Care
1010
Fee for Service
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Sustainable Growth Rate2002-2015
Chart1
20022002
20032003
20042004
20052005
20062006
20072007
20082008
20092009
20102010
20112011
20122012
20132013
20142014
20152015
SGR Payments
Cumulative SGR Payments
Percentage
-5
-5
1.4
-3.6
1.5
-2.1
1.5
-0.6
0.2
-0.4
0
-0.4
0.5
0.1
1.1
1.2
2.2
3.4
0
3.4
0
3.4
0
3.4
0.5
3.9
-22
-18.1
Sheet1
YearSGR PaymentsCumulative SGR Payments
2002-5-5
20031.4-3.6
20041.5-2.1
20051.5-0.6
20060.2-0.4
20070-0.4
20080.50.1
20091.11.2
20102.23.4
201103.4
201203.4
201303.4
20140.53.9
2015-22-18.1
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“The difference between what’s made available to me as a surgeon
and what’s made available to our internists or pediatricians (or
family physicians) or HIV specialists is not just shortsighted –
it’s immoral”
Atul GawandeThe Heroism of Incremental CareAnnals of Medicine,
January 23, 2017
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MACRA Legislative Timeline
MACRA enacted
Request for Information
Proposed Rule released
Final Rule w/ comment
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*Medicare physician fee schedule published separately
April 16, 2015 October 1, 2015 April 27, 2016 October 14,
2016
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What Does MACRA Do?• Repeals the Sustainable Growth Rate
(SGR)
• Extends Children’s Health Insurance Program (CHIP) funding for
2 years
• Provides Annual Baseline Fee Schedule Updates 2016-2018
• Creates 2 payment pathways
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What Does MACRA Do In Medicare?
• Consolidates quality programs
Merit-Based Incentive Payment System (MIPS)
• Potential for bonus payment for participation
Advanced Alternative Payment Models (AAPM)
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17
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QPP Participants
Physicians (MD/DO)
Physician Assistant
Nurse Practitioner
Clinical Nurse
Specialist
Certified Registered
Nurse Anesthetist
MACRA defines eligible clinicians as:
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Merit-Based Incentive Payment System
(MIPS)
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MIPS HighlightsConsolidates existing quality and value programs•
Adds a category for Improvement Activities
Establishes a Final Score• Weighted scoring by category
Provides opportunity for payment adjustments• Both positive and
negative
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What’s it called?
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ValueModifier
MU
PQRS Resource Use
AdvancingCare
Information
Quality Cost
AdvancingCare
Information
Quality
MACRA – April 2015 Proposed Rule – April 2016 Final Rule–
October 2016
AdvancingCare
InformationIA
CPIACPIA
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MIPS Final Score
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Quality Cost Improvement Activities
Advancing Care
Information (ACI)
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Improvement Activities – New! • Expanded Practice Access•
Population Management• Care Coordination• Beneficiary Engagement•
Patient Safety and Practice Assessment• Achieving Health Equity•
Emergency Response and Preparedness• Integrated Behavioral and
Mental Health
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**2018 Proposed Rule – More Options added included Performance
CME and Appropriate Use Criteria
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Weighting by Category - 2017
Quality, 60%
Cost, 0%
Improvement Activities1, 15%
Advancing Care Information,
25%
1 - “Certified” PCMH receives the full credit for IA; APM
Participants receive half credit
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Proposed Weighting for 2018
Quality, 50 or 60%
Cost, 0% or 10%???
Improvement Activities1, 15%
Advancing Care Information,
25%
1 - “Certified” PCMH receives the full credit for IA; APM
Participants receive half credit
Jumps to 30% in 2019,as required by statue
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Weighting Progression2019 2020 2021
Quality 60% 50% 30%
Cost 0% 10% 30%
Advancing Care Information 25% 25% 25%
Improvement Activities 15% 15% 15%
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‘Pick Your Pace’
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Test Partial ParticipationFull
ParticipationAdvanced
APM
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‘Pick your Pace’ Options for 2017Test
• Submit some data to QPP
• No negative adjustment
Partial Participation• Report
minimum 90 days
• Smallpositive adjustment
Full Participation• Report 90
days up to full year
• Modest positive adjustment
Advanced APM
• Qualifying Program & Qualified Participant
• 5% incentive payment
NO NEGATIVE PAYMENT ADJUSTMENTS
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“Pick Your Pace” Reporting
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• Report one quality measure, one improvement activity, or all
four of the required measures within the advancing care information
(ACI) category
Test
• Report a minimum of 90 days for more than one quality measure,
more than one improvement activity, or more than four of the
measures within the ACI category.
Partial Participation
• Report to MIPS for a full 90-day period or full year
Full Participation
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Annual Performance Threshold• Established by Secretary years 1
and 2
– For transition year 2017, threshold is 3– For 2018, proposed
threshold is increased 15
• Below = negative payment adjustments
• Above = positive payment adjustments
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Adjust Payments
-4% -5% -7% -9%
4%5% 7%
9%
2019 2020 2021 2022 onward
*Adjustment to provider’s base rate of Medicare Part B
payment
*Potential for
3Xadjustment
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Adjustment Summary
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Performance Score Payment Adjustment
Exceptional Performers (Final Score over 70) =
Eligible for up to 10% positive adjustment in
2019
25th Percentile or below = Maximum negativeadjustmentAt
threshold = Stable Payment
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MIPS Exemptions
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• Year 1 Medicare• Eligible Advanced Alternative Payment Model
with Bonus• Below low volume threshold
– Less than or equal to $30,000 Medicare payments; or less than
or equal to 100 Medicare beneficiaries
– PROPOSED FOR 2018 – less than or equal to $90K Medicare
payments; or less than or equal to 200 Medicare beneficiaries
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Advanced Alternative Payment Models
(AAPMs)
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DefinitionsQualifying APM• Based on existing payment models
Advanced APM• Based on criteria of the payment model
Qualifying AAPM Participant• Based on individual physician
payment
or patient volume
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Qualifying APMs
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• MSSP (Medicare Shares Savings Program)
• Expanded under CMS Innovation Center Model*
• Demonstration under Medicare Healthcare Quality Demonstrations
(MHCQ) or Acute Care Episode Demonstration
• “Demonstration required by Federal Law”
Qualifying APMs
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Advanced APM Eligibility
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• Quality measures comparable to MIPS
• Use of certified EHR technology
• More than nominal risk OR Medical Home model expanded under
CMMI authority
Qualifying APMs
Advanced APMs
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Primary Care Advanced APMs
• Shared Savings Program (Tracks 2 & 3)• Next Generation ACO
Model• Comprehensive Primary Care Plus (CPC+)
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Qualifying APM Participant
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• Percentage of patients or payments thru eligible APM
• In 2019, the threshold is 25% of Medicare payments or 20% of
beneficiaries
• QP status will be determined at the group level
Qualifying APMs
Advanced APMs
Qualifying APM
Participant
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Additional Rewards for Qualifying Participants
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• Not subject to MIPS• 5% bonus 2019-2024• Higher fee schedule
update to 0.75% 2026
QPAdvanced APM
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MACRA Timeline2017 2018 2019 2020 2021 2022-2024 2025 2026
Medicare Part B Baseline Payment Updates
+0.5% +0.5% +0.5% 0% 0% 0% +0.25%*+0.75%***Non-qualifying APM
Conversion Factor**Qualifying APM Conversion Factor
Merit-Based Incentive Payment System (MIPS)PQRS, Value-based
Modifier, & Meaningful Use Quality, Cost, Advancing Care
Information, & Improvement Activities
-9% -9%? 0 or +/-4%*“Pick Your Pace”
+/-5% +/-7%
Qualifying APM Participant5% Incentive payment
Excluded from MIPS
+0%
+/-9%
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Proposed Changes for 2018• Virtual Groups will begin in 2018 –
more details to come• ACI – allowing use 2014 or 2015 Edition
CEHRT; new
hardship exemption for small practices • New Small Practice
Bonus (15 or less physicians will get 5 bonus
points added to final score if they submit data for at least one
performance category)
• New Complex Patient Bonus (3 points added to final score for
caring for complex patients)
• Performance Period now 12 months for Quality and Cost/ 90
minimum for ACI and Improvement Activities
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Performance year
2017
Submit
March 31, 2018
Feedback available Adjustment
2018 January 1, 2019
Performance: The first performance period opens January 1, 2017
and closes December 31, 2017. During this period, providers will
record quality data and how they used technology to support their
practices
Submit data: To qualify for a positive payment adjustment under
MIPS, providers must send in data by March 31, 2018. To earn the 5%
incentive payment for participating in an Advanced APM, providers
must send quality data through their Advanced APM
Feedback: Medicare will give providers performance feedback
after the submission of data
Payment: A provider may earn a positive MIPS adjustmentpayment
beginning on January 1, 2019 if it submits 2017 data by the
deadline. Those participating in an Advanced APM in 2017 may earn a
5% incentive payment in 2019
2017 Performance Period Timeline
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Getting Started
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Assistance is Available
• Find a PTN– Go to aafp.org/tcpi
– Click “Find a PTN” to find a practice transformation network
in your area
– Email [email protected] any questions.
mailto:[email protected]
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Questions?
Robert Hall, JDAAFP, Director of Government Relations
[email protected], ext. 2510
mailto:[email protected]
MACRA:�Medicare’s Shift to Value-based Delivery & Payment
ModelsSlide Number 2The US has a Budget ProblemThe driver is health
costU.S. HEALTHCARE WASTE = NETHERLANDS GDPHealthcare Expenditures
vs. Outcomes Pay Now … Or Pay Later �THE FUTURE HEALTH ECOSYSTEM
WILL FOCUS ON THE TRUE DRIVERS OF OUTCOMESSlide Number 9Current
StateSustainable Growth Rate�2002-2015Slide Number 12Slide Number
13MACRA Legislative TimelineWhat Does MACRA Do?What Does MACRA Do
In Medicare?Slide Number 17QPP ParticipantsMerit-Based Incentive
Payment System MIPS HighlightsWhat’s it called?MIPS Final
ScoreImprovement Activities – New! Weighting by Category -
2017Proposed Weighting for 2018Weighting Progression‘Pick Your
Pace’‘Pick your Pace’ Options for 2017“Pick Your Pace” Reporting
Annual Performance ThresholdAdjust PaymentsAdjustment SummaryMIPS
ExemptionsAdvanced Alternative Payment ModelsDefinitionsQualifying
APMsAdvanced APM EligibilityPrimary Care Advanced APMsQualifying
APM ParticipantAdditional Rewards for �Qualifying ParticipantsMACRA
TimelineProposed Changes for 2018Slide Number 43Getting
StartedAssistance is AvailableSlide Number 46Questions?
