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, carrie.nixon@nixonlawgroup.com, 703-795-9763 • Mark Engelen, mark.Engelen@greenwayhealth.com, 919-593-1196