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HL7 Payer Summit Keynote: Overview of MACRA and MIPS for Health Insurers

Shahid N. Shah
January 16, 2017
250

HL7 Payer Summit Keynote: Overview of MACRA and MIPS for Health Insurers

Keynote on the current status and plans for MACRA and MIPS, delivered on January 16, 2017 at the HL7 Payer Summit.

Shahid N. Shah

January 16, 2017
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Transcript

  1. Overview of MACRA and MIPS
    for Health Insurers
    Shahid N. Shah
    Strategist, Entrepreneur-in-Resident
    AHIP Innovation Lab

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  2. www.netspective.com 2
    @ShahidNShah HealthcareGuy.com
    Who is Shahid?
    • Technology Strategist and Entrepreneur in
    Residence (EiR) for AHIP’s Innovation Lab
    • Chairman of the Board of Netspective
    Communications, Publisher at Netspective Media
    and serial entrepreneur.
    • Angel investor, board member, in several digital
    health and Internet startups.
    • 25 years of software engineering and multi-site
    healthcare system deployment experience in
    Fortune 50 and public sector (Fed 100 winner).
    • 15 years of healthcare IT and medical devices
    experience (blog at http://healthcareguy.com)
    • 15 years of technology management experience
    (government, non-profit, commercial)
    Engineer, strategist, entrepreneur,
    investor, author, and journalist

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  3. www.netspective.com 3

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  4. “Culture eats strategy
    for breakfast”
    Peter Drucker

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  5. “What's not going to change
    in the next 10 years?”
    Jeff Bezos

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    There will be no disruption of
    the healthcare industry.

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  7. www.netspective.com 7
    @ShahidNShah HealthcareGuy.com
    Why is disruption in healthcare so hard?
    This is $1 Trillion and the Healthcare
    Market is about $3 Trillion
    This is $1 Billion

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  8. What's not going to change in healthcare?
    Do no harm, safety
    first, and reliability
    effect on standard of
    care
    Statutory cruft &
    regulatory burdens
    increase over time
    Government as
    dominant purchaser
    Outcomes based
    payments
    intermediation &
    pricing pressure
    Eminence & consensus
    driven decisions as
    collaboration increases
    Increased use of
    alternate sites of care

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    Payment model innovation is determined by intermediation … what
    statutory or regulatory modifications will really drive changes?

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  10. What will change
    in healthcare?
    Shifting risks

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  11. Financial Risk is shifting from payers more to providers and patients
    Utilization Risk is being shared
    More performance Risk is now borne by providers

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  12. www.netspective.com 12
    @ShahidNShah HealthcareGuy.com
    Past Present Emerging Future Utopia
    Volume  Value is driving MACRA and MIPS
    Fee for Service (FFS)
    FFS + Bundled
    Payments
    Shared Risk
    Integrated Health
    Plan & Care Delivery
    Ecosystem
    Full Risk
    Episodic Care
    Coordination
    Risk based
    Managed Care
    Population
    Management
    Personalized
    Medicine
    Wellness
    Management
    FFS tied to incentives for Quality +
    Effectiveness + Efficiency
    Managed Care
    0% 30%? 50% 90% 100%
    % FFS
    Payments tied
    to Quality
    SGR rate cuts
    ACOs

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  13. www.netspective.com 13
    @ShahidNShah HealthcareGuy.com
    MACRA is implemented as QPP
    What is MACRA?
    Congress enacted Medicare Access and CHIP
    Reauthorization Act (“MACRA”) in 2015 to:
    • Repeal the Sustainable Growth Rate (“SGR”)
    formula based physician payment rate cuts
    • Set annual FFS increases of 0.5% through
    2019
    • Establish new physician payments based on
    quality performance and value through:
    – Merit-Based Incentive Payment System (“MIPS”)
    – Advanced Alternative Payment Models (“APMs”)
    CMS implemented the MACRA statutes in
    regulations through the Quality Payment
    Program (QPP): https://qpp.cms.gov/education
    Is it likely to be repealed or replaced?
    Because MACRA was enacted very recently with
    broad bipartisan agreement, including support
    by Tom Price (DHHS Secretary nominee), it’s not
    likely to be repealed or replaced.
    Tom Price, if confirmed, and the Republican
    Congress will be friendlier to provider
    community so the problems identified in the
    2016 comment period of the proposed rules will
    probably get new attention:
    • Not enough implementation time
    • Reporting and administrative burdens too
    high
    • Participation in Advanced APMs too hard
    • QPP is detrimental to solo/small practices

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  14. www.netspective.com 14
    @ShahidNShah HealthcareGuy.com
    “Pick your pace” provider participation in 2017
    Alternative Payment
    Model
    • An APM is an incentive
    based payer/provider
    collaboration applied to
    a specific clinical
    condition, a care
    episode, or a
    population.
    • An “Advanced APM” is a
    collaboration with a
    downside risk
    component tied to
    outcomes
    Test Pace
    • Submit minimum 2017
    data (one quality
    measure or one
    improvement activity) to
    avoid penalty
    Partial Year
    • Submit 90 days of 2017
    data to earn a small
    payment increase
    • Choose to start anytime
    between now and
    October 2, 2017 and
    send in performance
    data by March 31, 2018
    Full Year
    • Submit full year of 2017
    data to earn a moderate
    payment increase. The
    largest positive
    adjustments go to
    participants submitting
    information in all the
    MIPS performance
    categories
    Positive adjustments (payment increases) in MIPS are based on the performance data on
    the performance information submitted, not the amount of information or length of time
    submitted
    APM MIPS MIPS MIPS
    Advanced APM
    Advanced APM-specific
    rewards + 5% lump sum
    incentive

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  15. www.netspective.com 15
    @ShahidNShah HealthcareGuy.com
    MIPS isn’t really new, it’s unifying legacy initiatives
    • Quality replaces/uses PQRS measures
    – Report on 6 quality measures, including at least
    one outcome measure
    – Example: Controlling High Blood Pressure
    • Advancing Care Information replaces/uses
    Meaningful Use measures; report on the 5
    required:
    – Security Risk Analysis
    – e-Prescribing
    – Provide Patient Access
    – Send Summary of Care
    – Request and Accept Summary of Care
    • Improvement Activities is a new category
    – Report on 4 clinical improvement activities
    – Example: Care coordination
    • Cost replaces Value Based Payment
    Modifiers (VBM), compares against peers
    – Calculated using adjudicated claims
    Quality
    60%
    Improveme
    nt Activities
    15%
    Advancing
    Care
    Information
    25%
    Cost
    0%

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  16. www.netspective.com 16
    @ShahidNShah HealthcareGuy.com
    You already know the 2017 Advanced APMs
    Comprehensive End
    Stage Renal Disease
    Care Model (Two-Sided
    Risk Arrangements)
    Comprehensive Primary
    Care Plus (CPC+)
    Shared Savings Program
    Track 2
    Shared Savings Program
    Track 3
    Next Generation ACO
    Model
    Oncology Care Model
    (Two-Sided Risk
    Arrangement)
    List of Advanced APMs is available at http://qpp.cms.gov

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  17. www.netspective.com 17
    @ShahidNShah HealthcareGuy.com
    Future Advanced APMs are being discussed
    Comprehensive Care
    for Joint Replacement
    (CJR) Payment Model
    (CEHRT)
    New Voluntary
    Bundled Payment
    Model
    Advancing Care
    Coordination through
    Episode Payment
    Models Track 1 (CEHRT)
    Vermont Medicare
    ACO Initiative (as part
    of the Vermont All-
    Payer ACO Model)
    ACO Track 1+

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    Payment adjustments
    landscape through
    2022
    No changes until 2019.
    Advanced APMs get
    their standard benefits
    plus lump sum 5%
    incentive each year.
    Annual baseline adjustment

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    Eligible clinicians declining to
    participate in QPP may be docked 4%
    of their Medicare payments in 2017.
    “If the implementation costs of QPP for a particular practice is less
    than 4%, that penalty payment may not matter.” – Shahid Shah
    Physicians, PAs, NPs, CNSs, and CRNAs are eligible to participate in the MIPS if they bill more than $30,000 to
    Medicare and provide care to more than 100 Medicare patients per year. If 2017 is a provider’s first Medicare year,
    they are not required to participate.

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    Participation in an APM that qualifies
    for scoring benefits under MIPS
    might be better than Advanced APM
    for most providers.
    The 5% bonus payment may outweigh the risks because
    many organizations aren’t ready to move to APMs, let
    alone advanced APMs.

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  23. Visit
    http://www.netspective.com
    http://www.healthcareguy.com (personal blog)
    http://www.healthcareguys.com (collaborative blog)
    E-mail [email protected]
    Follow @ShahidNShah @HealthcareGuys @Netspective
    Call 202-713-5409
    Thank You! Need help?

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