MACRA and the Future of Primary
Care: Strategic Preparation for
Success
John D. Goodson, MD
Associate professor of medicine
Harvard Medical School
Massachusetts General Hospital
Boston
How are doctors paid?
Payment Policies
Congress with Executive Approval
Medicare (1965)
Medicaid (1965)
RBRVS (1989)
HITECH (2009)
Affordable Care Act (2010)
MACRA (2015)
Policy Implementation
Executive branch: Center for Medicare
and Medicaid Services (CMS)
RBRVS Physician Fee Schedule, 1992
Sustainable Growth Formula, 1997
Meaningful Use, 2011
Health Care Exchanges, 2012
Value-based Purchasing, 2019
CMS makes the rules
CMS issues the “Final Rule” January 1st, each year.
These are the rules of payment.
Baseball is a
game of rules
Basic terminology
What we do: CPT (Current Procedural
Terminology): What we do, descriptions of
services. Proprietary to the AMA.
Why we do it: ICD (International
Classification of Diseases): The diagnostic
code assigned to each disease or condition,
ICD 10
We are paid in RVUs (Relative Value Units,
the “coin of the realm”) for each CMS
service with an RVU value
RBRVS is at the core of the MPFS
We are paid in RVUs (Relative Value Units, the “coin
of the realm”) for each CMS service
Resource-based relative value scale (RBRVS)
Assigns worth = “RVUs” to each CPT code
Conversion factor 2016 = $ 35.80
3 components: Total RVUs = W + P + M
»
»
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Work “…Clinical work…” (52%)
Practice Expense “overhead” (44%)
Malpractice “liability insurance” (4%)
How are services defined and
valuated?
AMA’s
CPT Editorial Panel
and CMS
define services
CMS
assigns value =
Medicare
Physician
Fee
Schedule
(MPFS)
AMA’s Relative value
Update Committee
(RUC)
Congressional mandates
IPPE, AWVs, TCMs
CCM
Professional societies
MACRA: Beginning or ending?
What is MACRA?
Medicare Access and CHIP
Reauthorization Act, MACRA
(April 16, 2015)
MACRA
• Ended the SGR
• A poorly conceived health care cost containment
strategy that plagued professional payments with an
annual downgrade without additional funding.
• 12 years, 2013-15, 17 patches, $169.5 Billion
• Consolidated many overlapping and redundant
reporting requirements from MU to PQRS.
MACRA’s “value proposition”
Health care costs will “bend” down
• Payment incentives for “quality” will improve
the value of health care expenditures
• Payment incentives for doctors to accept more
than “nominal risk”
• Large organizations will agree to administer
and doctors will be willing to be aggregated
Where to small and independent practices
fit into MACRA thinking?
MACRA Payment Options
Alternative Payment Models for those
qualified (likely only enterprises)
The Merit-based Incentive Payment
System (MIPS) for everyone else.
MACRA is built on the current Medicare
Physician Fee Schedule(MPFS) with
powerful incentives.
APMs (Alternative Payment Models)
Eligible APMs
Base payment on quality measures comparable
to those in MIPS
Require use of certified EHR technology
Risk defined:
Bear more than “nominal” financial risk for
monetary losses OR
Be a medical home model expanded under
CMMI authority
Qualifying APM participants
Physicians and other clinicians who have a
certain % of patients or payments through an
eligible APM
MIPS changes how Medicare links
performance to payment
Physician
Quality
Reporting
Program
(PQRS)
Value-based
Payment
Meaningful
Use
Merit-Based Incentive Payment System
(MIPS)
Source: www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf
How will Physicians and Clinicians
be Scored Under MIPS?
Quality
0-30
Resource
Use
0-30
Clinical
Meaningful
practice
use of
improvement certified EHR
activities
technology
0-15
0-25
MIPS
Composite
Performance
Score
0-100
0-100 Points, < 25 points is penalty threshold
Source: www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf
MIPS Timeline
2016 November 1: MIPS reporting expectations
2017 July 1: Initial feedback from CMS on MIPS scores
2018 July 1: CMS establishes attribution models
January 1, 2019: MIPS and APMs start
MIPS Adjustments UP OR DOWN:
4% in 2019 >> 5% in 2019 >> 7 % in 2020
>> 9% in 2021
Bonus adjustment (not budget neutral, 2019
through 2025, $500 M allocated).
APMs: 5% upward adjustment for 5 years
MIPS penalties and APM incentives
AMP 5 year 5 % incentive and MIPS 5 year
reductions in Medicare payments for
MDs with composite scores < 25
2017 2018 2019 2020 2021 2022 2023
+ 5%
APMs
MIPS adjusted
- 4%
30 months
- 5%
-7%
- 9%
How Much Can MIPS Adjust
Payments Upward?
MAXIMUM Adjustments
4%
5%
-4% -5%
7%
9%
Adjustments to
provider’s base
rate of Medicare
Part B payment
-7%
In addition, those who score
-9%
2019 2020 2021 2022 onward
in top 25% are eligible for an
additional annual performance
adjustment of up to 10%,
2019-24 (NOT budget neutral).
Source: www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf
Details unclear
Quality (0-30 points)
Disease treatment
CV: Hypertension (<140/90), Beta blocker for 6 mos. post
acute MI
Diabetes care: HbA1c <9%, foot care, eye, nephropathy
Asthma: Persistent on controller medications
Prevention
Ischemic vascular disease on ASA
Tobacco cessation screening and cessation
Screening
Cervical CA screening
Breast CA screening, 50-74, biannual
Colorectal CA screening
BMI screening and follow up
Patient experience (CAHPS)
Meaningful Use (0-25 points)
Clinical Functionality – 15 Criteria
Care Coordination & Clinical Quality measures (CQM) –
13 Criteria
Privacy and Security – 11 Criteria
Design and Performance – 9 Criteria
Patient electronic Access and Secure Messaging – 9
Criteria
Public Health Reporting – 7 Criteria
Resource Use (0-30 points)
Your clinical Care
No cervical CA screening, <21 yrs
No imaging for LBP
Avoidance of antibiotics in bronchitis
But what about…
Clinical care delivered by colleagues
Clinical care driven by patient demands
Practice Improvement (0-15 points)
Access
Same day appointments
Care delivery
Medication reconciliation
Population management
Communication
Test results communication
Plan of care (POC) for complex patients
Shared decision-making
“MOC assessments”
APMs vs. MIPS FFS?
Surviving and thriving
•
•
•
•
•
•
High quality primary care
Patient engagement
Optimize charting
Use the Primary Care codes
Panel management
Find your allies
High quality Primary Care
• A clinical interface to support key workflows
• Clinical encounters
• Communication, internal and external
• Non face-to-face care management
• Results management and disposition
• Decision support resources
• Clinical decision support
• Crowd sourcing
• Education and learning
Patient Engagement
• Portal
• Previsit work
• Intervisit communication
• Devices
• Communication
• Open scheduling
• After hours coverage
Optimize Charting
• Organize clinical thinking to support the
complexity of your work
• Chronic care management
• Problem orientation
• Risk adjustment
Problem oriented charting
• Problems become the indexing tool for
clinical care
• Documentation of medical decision making
related to each problem
• Linkages to outputs
• Testing
• Referrals
• Billing
• Prior approvals
Use the Primary Care Codes
• Evaluation and Management (E/M)
•
•
•
•
Welcome to Medicare (IPPE)
Annual Wellness Visits
Transitional Care Management
Chronic Care Management
Service Codes: Know your RVUs
2000
2005 2010 2015
IPPE, 2005 (4.70)
2020
2025 2030
AWV codes, 2011 (4.85/3.26)
TCM codes, 2013 (6.79/4.82)
CCM code, 2015 (1.19)
E/M codes (99214=3.13)
Panel Management
• Reporting
• Find outliers
• Clinical management tools for: Hypertension,
Diabetes, Hypercholesterolemia, Depression
• Coaching
• Portals
• Educational resources (“health literate”)
Find Your Allies
• Professional societies
• AAFP
• ACP
• AOA
• Congress
• EHR vendors that anticipate the future
• Agile
• Responsive
• Service oriented
Can the MPFS be changed?
NEJM OnLine
March 9, 2016
Berenson and Goodson
The call to action:
“Implementing new incentives and quality
measures in new payment models while maintaining
broken fee schedule is a prescription for failure.”
Write a letter
“There is no way from me as an active
primary care physician to achieve the goals
of MACRA for improved value from
Medicare payments unless there is a
substantial and meaningful increase in the
valuation of the core outpatient established
patient service codes, 99213, 99214 and
99215.”
Bottom line
1.
2.
3.
4.
MACRA will ripple through MD payments for
the years to come. Ignore at your own peril.
MIPS is a FFS adjuster with opportunities for
improved patient care and better
compensation
Dates to remember:
July 2016: Composite metrics defined
July 2017: MIPS scores reported
July 2018: Attribution model established
Begin planning
Plan for success
Thank you
Questions?