sustainable growth rate? goodbye for good!
TRANSCRIPT
Page 1May 6, 2015
Georgia HFMA Spring Institute
Sustainable Growth Rate? Goodbye for Good!
Implications of the 2015 SGR Bill (H.R. 2)
Aaron Elias Georgia HFMA Spring Institute
May 6, 2015
Page 2May 6, 2015
Georgia HFMA Spring Institute
Only Months into the 2015 PFS…
This was all holding true…until suddenly, it wasn’t.
2015 MPFS Final Rule• No payment updates, only
changes to payment policies• Still anticipate 20.9%
reduction in payments without Congressional action (Sustainable Growth Rate)
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Georgia HFMA Spring Institute
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Georgia HFMA Spring Institute
Timeline of Medicare Payments
1997
• Introduction of Balanced Budget Act to Amend the Social Security Act
• Specified formula for calculating SGR
17 Short-Term
Patches2014
SGR Repeal and Medicare Provider
Payment Modernization Act of
2014
2015
Medicare Access and CHIP
Reauthorization Act of 2015
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Georgia HFMA Spring Institute
History of Patches
21%
With no Congressional action, Physician Fee Schedule payments would have been cut by 21% beginning April 1, 2015.
Since 1997, a total of 17 “short-term” SGR patches have been enacted by Congress, delaying Medicare Payment Cuts.
Total Cost = $175 Billion1
1 Source: Committee for a Responsible Federal Budget, The Prep Plan: A Permanent Fix For The Sustainable Growth Rate, March 9, 2015.
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Georgia HFMA Spring Institute
H.R.2Medicare Access and CHIP Reauthorization Act of 2015
Removes SGR Methodology
Development of MIPS
Alternative Payment Models
Plan for Quality Measure
Development
Expands Use of Medicare
Data
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Georgia HFMA Spring Institute
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SGR Payment Updates
Permanently repeals the 21% reduction to MPFS payments in 20151
MPFS rates increase by 0.5% annually beginning June 1, 2015, through 2019
2
MPFS rates remain constant from 2019 to 20253
Again, in 2026, MPFS rates increase by 0.5% annually4
Removes SGR methodology
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Georgia HFMA Spring Institute
The SGR Solution
Benefits: Certainty of payments for
the next 10 years
No annual fear of unrealistic payment cuts
Concerns: Does 0.5% keep up with
medical inflation (plus the inherent costs of participation in quality programs)?
Removes SGR methodology
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Georgia HFMA Spring Institute
Centralized Quality Reporting?
Merit-Based
Incentive Payment System =
MIPS
Quality
Efficiency Meaningful Use
Clinical Process
Improvement
Development of MIPS
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Georgia HFMA Spring Institute
The Current Reporting “System”
PQRS• Reporting of
quality measures as individual providers or as group
• Penalty for not reporting
Value Modifier• Two composite
measures:• Cost
(Efficiency)• Quality
• Payment adjustment based on performance
Meaningful Use• Use of an EHR
in a meaningful way
• Penalty for not reporting
Development of MIPS
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Georgia HFMA Spring Institute
The Current Reporting “System”Program Applicable to Adjustment Amount
Program Participation
Year (PY)
PQRSAll eligible professionals (EPs) (Medicare physicians, practitioners, therapists)
-2.0% adjustment 2015
Medicare EHR Incentive Program
Medicare physicians (if not a meaningful user)
-3.0% adjustment 2015
Value-Based Payment Modifier
All Medicare physicians and non-physician EPs in groups with 2+ EPs and solo practitioners
Non-PQRS reporters: Automatic -4.0% VM downward adjustment (in addition to PQRS penalty) Groups with 2-9 EPs and solo practitioners: Upward or neutral VM adjustment based on quality tieringGroups with 10+ EPs: Upward, neutral, or downward VM adjustment based on quality tiering
2015
Development of MIPS
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What’s the Problem With Current System?
Current Value-Based Payment Programs:
Good intentions, but…
Complicated Requirements
Confusing Timing
Overlap in Requirements
Wasted Resources
Inconsistent Measurement and Payment Adjustments
Development of MIPS
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Merit-Based Incentive Payment System
Harmony
Development of MIPS
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Georgia HFMA Spring Institute
MIPS – the Details• Repeals PQRS and MU penalties and VM program effective
December 31, 2018; replace with MIPS.• Providers will receive a composite score from 1 to 100 based
on quality measures, efficiency measures, meaningful use of electronic health records, and clinical practice improvement activities; score will be made publicly available.
• Each year, CMS will establish a threshold score based on median/mean composite performance scores of all providers measured during previous performance period.
Development of MIPS
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Georgia HFMA Spring Institute
MIPS Scoring System
0 100
Quality Efficiency Meaningful Use
Clinical Process
Improvement
78
National Median Composite Provider Score
= Medicare Provider
= National Median Composite Score
Development of MIPS
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Georgia HFMA Spring Institute
…More MIPS• Providers scoring below threshold subject to payment cuts
capped at 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022.
• Providers scoring above threshold will receive bonus payments, up to three times the annual penalty cap.
• Providers scoring above “stretch” performance score will receive an additional bonus payment allocated from a $500 million annual pool.
• Providers participating in alternative payment mechanisms (APMs) may opt out of MIPs in favor of annual 5% bonus payment.
Development of MIPS
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Georgia HFMA Spring Institute
Raising the StakesImplications for Providers
• Over time, the MIPS penalties become substantially greater than those contemplated in existing CMS programs. This, coupled with the fact private payers are likely to “piggy-back” on the MIPS program, make the push for quality and efficiency simply too strong for providers to ignore.
• Just as before, there would be winners and losers in this program
• The legislation is very broadly defined, CMS will have to fill in the details…
Development of MIPS
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Alternative Payment Models
Accountable Care
Organizations
Primary Care & Medical
Home Models
Bundled Payment Initiatives
Integrated Care & Care Management
Alternative Payment Models
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Alternative Payment ModelsMedicare FFS Payments, 2016 Medicare FFS Payments, 2018
Alternative Payment Models
All Medicare FFS (100%)FFS linked to Quality
Alternative Payment Models
85% of all Medicare FFS
30% of All Medicare FFS
90% of all Medicare FFS
50% of all Medicare FFS
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Alternative Payment Models
CMS Announcement on January 26, 2016…
Alternative Payment Models
Health Care Payment Learning and Action Network
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Health Care Payment Learning and Action Network
Actions:
• Facilitate implementation of new payment models
• Identify areas for payment improvement
• Develop new approaches to core issues
Stakeholders involved:
• Payers• Providers• Employers• States• Consumer Groups• Individual Consumers
Goal of Network in two words: SMARTER SPENDING
Alternative Payment Models
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Georgia HFMA Spring Institute
Alternative Payment Models
Incentive payments to participate in Alternative Payment Models (5%)1
Ability to opt-out of other MACRA payment requirements (MIPS)2
Increased APM promotion; establishment of Technical Advisory Committee
3
Alternative Payment Models
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Georgia HFMA Spring Institute
Quality Measure Development
Continued funding of NQF review,
endorsement, and maintenance of
quality/efficiency measures.
Additional funding in 2015, extends funding for 2016
and 2017.
$15,000,000
$30,000,000
Draft plan by January 1, 2016 for
development of quality measures for application,
followed by comment period.
(Bill mentions inclusion of measures used by private
payers.)
Plan for Quality Measure
Development
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Georgia HFMA Spring Institute
Quality Measure Development
What Does this Mean?
• Finalization of plan by May 2016 (with annual updates)
• Meant to address current scrutiny on available measures (challenges for specialists)
Plan for Quality Measure
Development
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Georgia HFMA Spring Institute
Use of Medicare Data
Expanded use of Medicare Data by “Qualified Entities”
Provide or Sell Data to
Authorized Users
Assist providers with improvement
activities
Expands use of Medicare data
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Georgia HFMA Spring Institute
Use of Medicare Data
• Certain restrictions still remain in place:
– Cannot use data for marketing
– Must abide by all privacy and security laws
– Must enter into a data use agreement
– No re-disclosures of analyses
Better Data
Better Decisions
Better Outcomes
In general…
Expands use of Medicare data
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Georgia HFMA Spring Institute
Other Key Components
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Georgia HFMA Spring Institute
EHR Interoperability
EHR 1
EHR 2
EHR 3
EHR 4
EHR 5
Current state of EHR systems…
Data Sharing
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Georgia HFMA Spring Institute
EHR Interoperability
EHR 1
EHR 2
EHR 3
EHR 4
EHR 5
Data Sharing
Mandated state of EHR systems by 2018
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Georgia HFMA Spring Institute
Global Payments
2014 and Prior Years• 10- and 90-Day Global
Surgical Payments
2015 MPFS Final Rule• Removal of 10- and 90-
Day Global Surgical Payments
H.R. 2• 10- and 90-Day Global
Surgical Payments Reinstated
Keep in mind…
• CMS will begin collecting data on global payments and number of visits furnished beginning in 2017
• Reassessment every 4 years
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Georgia HFMA Spring Institute
Children’s Health Insurance Program
• 2-Year Extension of CHIP
– No new funding available after FY 2015
– Without action, the current CHIP program is funded through FY 2017
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Two-Midnight Rule
MAC “probe and educate” program will continue through September 30, 2015.
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Georgia HFMA Spring Institute
Medical Liability Cases
Medicare quality program standards cannot be used as standard or duty of care
Medical professionals will continue to be held to community standards rather than those defined by CMS quality programs
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Smart Cards?
CMS to consider use of smart
card technology for beneficiaries and providers.
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What’s Next?
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Offsetting the Bill
One source… you!
• Income-related premium adjustments for Part B and Part D
• Higher income beneficiaries now pay higher percentage
Other Funding
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Fundamental Challenges Remain…
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Increasing Transparency
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“Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018.”
“Our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.”
Here to Stay
Source: HHS Secretary Sylvia Burwell (January 30, 2015)
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Georgia HFMA Spring Institute
In Closing
Removes SGR methodology
Development of MIPS
Incentives for Alternative Payment Models
Plan for Quality Measure Development
Expanded use of Medicare data
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Georgia HFMA Spring Institute
Additional PYA Resources
Providing and Billing Medicare for Chronic Care Management
http://www.pyapc.com/white-paper-details-new-medicare-payment-chronic-care-management/
Practical Guide to the Medicare Physician Value Modifier Program
http://www.pyapc.com/pya-offers-guide-medicare-physician-value-modifier-program/
Healthcare 2015: Turning the Corner
http://www.pyapc.com/pya-white-paper-healthcare-2015-turning-the-corner/
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Georgia HFMA Spring Institute
Thank You!Thank You!
Aaron Elias
Consultant
Pershing Yoakley & Associates, P.C.
(404) 266-9876
www.pyapc.com