Payment Reform
Presented By:
Todd Baker, Chief Executive Officer
Southwest Ohio Healthcare
Financial Management Association
May 11, 2017
(Disclaimer: Some of the slides and graphics have been provided to OSMA by CMS.gov)
Overview
• General Overview of Medical Practice Financing
• Payment Reform Overview
• Ohio
• Federal
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Health Financing
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Major Issues
•
•
•
•
Change from fee-for-service to value
Practices will be taking on financial risk
Impact on cash-flow (loan needs)
Opportunities to finance risk
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Payment Reform Update - Ohio
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5-Year Goal for Payment Innovation
Goal
80-90 percent of Ohio’s population in some value-based payment model
(combination of episodes- and population-based payment) within five years
State’s Role
▪
▪
▪
Shift rapidly to PCMH and episode model in Medicaid fee-for-service
Require Medicaid MCO partners to participate and implement
Incorporate into contracts of MCOs for state employee benefit program
Patient-Centered Medical Homes
Year 1
▪ In 2014, focus on Comprehensive Primary ▪ State leads design of five episodes: asthma
▪
▪
Year 3
Year 5
Episode-Based Payments
▪
▪
▪
▪
Care Initiative (CPCi)
Payers agree to participate in design for
elements where standardization and/or
alignment is critical
Multi-payer group begins enrollment
strategy for one additional market
Model rolled out to all major markets
50% of patients are enrolled
Scale achieved state-wide
80% of patients are enrolled
▪
acute exacerbation, perinatal, COPD
exacerbation, PCI, and joint replacement
Payers agree to participate in design
process, launch reporting on at least
3 of 5 episodes in 2014 and tie to payment
within year
▪ 20 episodes defined and launched across
▪
payers
50+ episodes defined and launched across
payers
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Ohio Comprehensive Care Initiative
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Episodes of Care
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Retrospective Episode Model Mechanics
1
Patients and
providers
continue to
deliver care as
they do today
Patients seek care
and select providers
as they do today
4
Calculate
incentive
payments based
on outcomes
after close of
12 month
performance
period
Review claims from
the performance
period to identify a
‘Principal Accountable
Provider’ (PAP) for
each episode
2
3
Providers submit
claims as they do
today
5 Payers calculate average
cost per episode for
each PAP1
Payers reimburse for
all services as they do
today
6 ▪ Providers may:
▪ Share savings: if average
costs below
commendable levels and
quality targets are met
▪ Pay part of excess cost: if
average costs are above
acceptable level
Compare average costs
to predetermined
‘’commendable’ and
‘acceptable’ levels2
▪ See no change in pay: if
average costs are
between commendable
and acceptable levels
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Retrospective Thresholds Reward Cost Efficient,
High-Quality Care
7
Provider
cost distribution (average episode cost per provider)
Eligible for gain sharing based on
cost, didn’t pass quality metrics
Ave. cost per
Episode $
-
Gain sharing
No change
Risk sharing
Risk sharing
Pay portion of
excess costs
No change in payment
to providers
+ Gain sharing
Eligible for incentive payment
Acceptable
Commendable
Gain sharing limit
Principal Accountable Provider
SOURCE: Arkansas Payment Improvement Initiative; each vertical bar represents the average cost for a provider, sorted from highest to lowest average cost
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Ohio’s Episode Timeline
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Ohio’s Episode Timeline
http://medicaid.ohio.gov/PROVIDERS/PaymentInnovation/Episodes.aspx
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How To Read Your Report
•
•
•
•
Summary
Performance
Quality
Cost Types
• http://www.medicaid.ohio.gov/Portals/0/Providers/P
aymentInnovation/HowtoReadYourReport.pdf
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State Payment Reform Resources
Office of Health Transformation:
http://www.healthtransformation.ohio.gov/currentinitiatives/pa
yforvalue.aspx
Medicaid:
http://medicaid.ohio.gov/PROVIDERS/PaymentInnovation.aspx
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Payment Reform Update - Federal
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Fee Schedule Changes
• Eliminates SGR
• Maintains fee-for-service structure, but
transitioning to value-based system
• Annual .5% increases until 2019
• Payment freeze from 2020 to 2025
• 2026 updates depending on provider
participation in alternate structures
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Transition From Fee-For-Service
• Choice of Two Pathways
Merit Based
Incentive
Payment
System
(MIPS)
or
Alternative
Payment
Model
(APMs)
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AMA and CMS MACRA Resources
• http://www.amaassn.org/ama/pub/advocacy/topics/medicarenew-payment-systems.page
• https://qpp.cms.gov/
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Merit-Based Incentive
Payment System (MIPS)
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MIPS
• Merit-Based Incentive Payment System
– Consolidates current measures and creates a
composite performance score
– Resource use not included in Year 1 now
Quality
Year 1 – 60%
Year 2 – 50%
Advancing care
Information
Improvement
Activities
Year 1 – 25%
Year 2 - 25%
Year 1 – 15%
Year 2 – 15%
Cost
Year 1 – 0%
Year 2 – 10%
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MIPS
• Quality Payment Program – 3 Options:
-%
Don’t Participate
Not participating in
the Quality
Payment Program
(negative 4%).
+%
0
+%
Submit Something
Submit Partial Year
Submit Full Year
Partial: If you
submit 90 days of
2017 data to
Medicare, you
may earn a neutral
or positive
payment
adjustment.
Full: If you
submit a full year
of 2017 data to
Medicare, you
may earn a
positive payment
adjustment.
Test: If you submit
a minimum
amount of 2017
data to Medicare,
you can avoid a
downward
payment
adjustment.
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MIPS – Composite Score Adjustments
Based on a MIPS composite performance score, clinicians will
receive + / - or neutral adjustments up to the percentages below
+4%
+5%
+7%
+9%
Adjusted
Medicare Part B
payment to
clinician
+/Maximum
Adjustments
-4%
-5%
-7%
-9%
2019 2020 2021 2022 onward
The potential maximum
adjustment % will
increase each year from
2019 - 2022
Merit-Based Incentive Payment System
(MIPS)
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Benchmarks
• Available from CMS prior to each year
https://qpp.cms.gov/resources/education
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Getting Started
• When does the Quality Payment Program start?
• You get to pick your pace for the Quality Payment Program. If you're
ready, you can begin January 1, 2017 and start collecting your
performance data. If you're not ready on January 1, you can choose
to start anytime between January 1 and October 2, 2017. Whenever
you choose to start, you'll need to send in your performance data by
March 31, 2018. You can also begin participating in an Advanced
APM.
• The first payment adjustments based on performance go into effect
on January 1, 2019.
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Key Dates
Performance year
2017
Performance:
Jan 1 – Dec 31, 2017,
record quality data and
how you used
technology to support
your practice
Payment
Submit
Feedback available
March 31, 2018
2018
January 1, 2019
Send in performance
data: Potentially earn
positive payment
adjustment under
MIPS, send in data
about the care you
provided and how
your practice used
technology in 2017 by
03/31/2018.
Medicare gives you
feedback about your
performance after
you send your data.
Payment: You may
earn a positive MIPS
payment adjustment
for 2019 if you submit
2017 data by
03/31/2018.
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Alternative Payment Models
(APM)
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APM
• Alternate Payment Models
- Option if opting out of MIPS
- 5% annual lump sum bonus
• 2019 – 2020: 25% of Medicare revenue
• 2021 – 2022: 50% of Medicare revenue or 50% of all
payer revenue with 25% being Medicare
• 2023 and beyond: 75% of Medicare revenue or 75% of
all payer revenue with 25% being Medicare
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APM
• Oversight done by Payment Model Technical
Advisory Committee
• Rules will establish review criteria
• Comprehensive list of qualifying APMs
https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf
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Q&A
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