(+)William P. Jaquis, MD, FACEP
Chief, Department of Emergency Medicine,
LifeBridge Health, Baltimore, Maryland; Vice
President, ACEP Board of Directors
Reimbursement: Trends &
Strategies in Emergency Medicine
Palm Springs, CA
Alternative Payment Models: Salvation From MIPS
or a Sentence of Hard Times to Come?
CMS has a 5 percent bonus available for those meeting
the tough APM requirements, with an added incentive of
being excused from the MIPS complexities. Gear up to
understand your group’s options.
Objectives:
 Discuss the alternative payment model design
process.
 Review the impact of federal regulations that
will define APMs.
 Identify successful possible APM programs and
todays models being developed.
 Develop strategies to optimize success under
APMs.
MO-8
(+) No significant financial relationships to disclose
2/7/2017
Alternative Payment Models
Salvation from MIPS or a Sentence of Hard Times
William Jaquis MD, FACEP
Chief, Dept. Emergency Medicine
Sinai Hospital
Michael Granovsky MD, CPC, FACEP
President, LogixHealth
The Quality and Payment Timeline
$35.8043
MIPS
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What Is an APM?
Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high‐quality and cost‐efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
What is an Advanced APM?
Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patientsʹ outcomes.
•
Uses CEHR technology
•
Requires ”more than nominal” financial risk
•
Applicable to specific care models, though expanding by year
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MACRA: Alternative Payment Model Thresholds 2019 – 2025 potential 5% lump sum bonus
▪
2019-2020: 25% of Medicare revenues furnished as part
of an eligible APM
▪
2021-2022: 50% of Medicare revenues from APMs
Or 25% of Medicare revenues from APMs
AND 50% of all payer revenues from APMs
▪
The professional “is willing to provide the data to CMS”
▪
2023+- 75% of Medicare revenues from APMs or 25% of
Medicare revenues from APMs and 75% of all payer
revenues from APMs
Example Alternative Payment Models
▪
Certain clinicians participating in Advanced APMs are
exempt from MIPS
▪
Current potential Advanced APMs
‒
Comprehensive ESRD Care (CEC) - Two-Sided Risk
• 13 nationwide
‒
Comprehensive Primary Care Plus (CPC+)
‒
Next Generation ACO Model
• 18 nationwide
‒
Shared Savings Program - Track 2 and 3
‒
Oncology Care Model (OCM) - Two-Sided Risk
CONFIDENTIAL
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AMA APMs Under Development
▪
Angina (Stable)
‒
▪
Asthma
‒
▪
Help patients quickly and accurately determine the
causes of chest pain and their risk of a heart attack
Reduce emergency visits and hospitalizations due to
asthma exacerbations
Cancer
‒
Improve cancer outcomes through accurate
diagnosis and staging, as well as appropriate use of
treatments
AMA APMs Under Development
▪
Chronic Kidney Disease
‒
▪
Diabetes
‒
▪
Improve patient understanding and selfmanagement of their condition
Epilepsy
‒
▪
Slow progression to end stage renal disease
Reduce frequency and severity of seizures
Pregnancy
‒
Deliver babies in lower-cost settings
Almost All of them have as a goal: reduce emergency
department visits
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Do APMs Matter to Emergency Medicine
▪
Yes- we need Emergency Medicine specific APMs
‒
they take a while to develop
▪
Most ED physicians will satisfy MACRA requirements
initially through MIPS
▪
Advanced APMs described in the MACRA
proposed rule require very substantial infrastructure
▪
ACEP has a deeply resourced expert group working
to design sensible APMs for Emergency Medicinechallenging!
Elements of APMs
CMS
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Quality Payment Program (QPP)
Element 1
What type of Alternative
Payment Model would
your design be?
▪
APM
▪
AAPM
▪
PFPM
CMS QPP
QPP
Element 2
How will your Alternative Payment Model result
in clinical practice transformation?
• Change in delivery?
• Change in payment methodology?
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QPP
Element 3
What is the rationale for your Alternative Payment
Model?
CMS QPP
QPP
Element 4
What is the scale of your Alternative Payment Model?
CMS QPP
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QPP
Element 5
How does your Alternative Payment Model
align with other payers and CMS programs?
• Are enough payers aligned to make
the business case a strong one?
QPP
Element 6
How is improved clinical quality or better patient
experience of care measured under your Alternative
Payment Model?
CMS QPP
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QPP
Element 7
How easy would it be for participants to
implement your Alternative Payment Model?
• Are the systems and processes in place
to operate the APM?
Alternative Payment Models: Project Flow: 1 of 2
Federal
Gov’t
CMS
• Legislative Imperative (MACRA)
April
2015
ACEP
• ACEP evaluation &
response
• Presidential
appointment of
APM Task Force
• Engagement of
staff & consultative
expertise
Summer
2015
APM Task
Force
• Understanding &
assessment
• Ideation &
brainstorming
• Initial assessment
of APM options
• Selection of initial
APM models (3)
• Initial (conceptual)
feedback on 3
initial APMs
Fall
2015
APM
Technical
Subgroups
• Detailed build out of
3 APM objectives,
mechanisms. Data
issues
• Refinement, further
vetting, &
articulation of
risks/benefits
• Presentation to full
Task Force
Spring
2016
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Alternative Payment Models: Project Flow: 2 of 2
APM
Task
Force
Reg.
Comments
ACEP
Board of
Directors
• Rec’s on initial 3
APMs (keep,
modify/ abandon
or develop
additional)
• Detailed analytics
& testing of APMs
(requires
consultants)
• Final rec’s to ACEP
BOD
• MIPS/APM draft
rule released April
2016 – comments
due June 27, 2016
• Consideration and
actions as
appropriate
Summer
2016
June 27,
2016
CMS &
Private
Payor
Process
• Submit APMs to
PTAC* and/or
CMS or Private
Payors 2017
• Approval
EM
Community
• Rollout to members
• Implementation
• Utilization
October
2016
2017
ACEP APM Model 1‐ DC Planning ▪
ED physicians bear the cost of hiring DC planning
FTEs in order to decrease preventable admissions
‒
The economic risk component
▪
ED physicians bill using new CPT codes for DC
planning services for appropriate patients
▪
If minimum regulatory thresholds hit could receive
5% lump sum bonus
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PTAC will assess the extent to which each submitted proposal meets criteria for PFPMs established by the Secretary of HHS in regulations at 42 CFR §414.1465
Physician‐Focused Payment Model
Technical Advisory Committee
Criteria
▪
Value over volume
▪
Flexibility
▪
Quality and cost
▪
Payment methodology
▪
Scope
▪
Ability to be evaluated
▪
Integration and Care Coordination
▪
Patient Choice
▪
Patient Safety
▪
Health Information Technology
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Evaluation Criteria ▪
Addressing an issue in payment policy in a new way
▪
Including APM Entities whose opportunities to participate
in APMs have been limited
▪
Improve health care quality at no additional cost
▪
Maintain health care quality while decreasing cost
▪
Both improve health care quality and decrease cost
Evaluation Criteria ▪
Pays APM Entities with a payment methodology
designed to achieve the goals
▪
Payment methodology differs from current payment
methodologies
▪
How the model is intended to affect practitioners’
behavior to achieve higher value care through the
use of payment and other incentives
▪
How the proposed payment model could
accommodate different types of practice settings
and different patient populations
▪
Have evaluable goals for quality of care and cost
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Supporting Information:
Health Information Technology ▪
Encourage use of health information technology to
inform care
▪
Describe how information technology will be utilized
to accomplish the model’s objectives with an
emphasis on any innovations that improve
outcomes, improve the consumer experience and
enhance the efficiency of the care delivery process
▪
Describe goals for better data sharing, reduced
information blocking and overall improved
interoperability
Evaluation Criteria: Integration and Care Coordination ▪
Encourage greater integration and care
coordination among practitioners and
across setting where multiple practitioners or
settings are relevant to delivering care to
the population
▪
Improve care coordination for patients
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Supporting Information: Patient Safety ▪
Aims to maintain or improve standards of patient
safety
▪
How patients would be protected from potential
disruption in health care delivery brought about by
the changes in payment methodology and
provider incentives
▪
Describe how disruptions in care transitions and
care continuity will be addressed
Many APM Model 1 Challenges
▪
How to identify appropriate patients for DC
planning- GSW to chest, simple rash, mild CHF,
COPD exacerbation on home oxygen
▪
What is my appropriate baseline admission ratesites vary immensely in presenting acuity
▪
‒
How to risk stratify 4,000 hospitals
‒
What abut night shifts?
How about other cost curve bending services:
ICU admission rate, use of telemetry, step down,
Observation status
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APM WG 1 Future Steps ▪
WG 1 Proposal submitted to CPT for a potential APM
code and presented to the RUC as a model for
consideration
▪
The APM Task force will continue to meet as the
MACRA environment becomes more focused
APM WG 2
▪
An emergency physician group and hospital
participating in this APM would agree to jointly
manage the total costs associated with ED visits
within a pre-defined ED Case Rate
budgets/payments for each eligible patient who
presents to the ED.
▪
The budget/payment amount for an ED Case Rate
would be designed to support the average cost of
the services that patients needed during an ED visit.
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APM WG 3
Participants in this APM would agree to manage the
costs of ambulatory acute care visits for a defined
population of people, such as the individuals who are
under the care of a primary care practice, the
residents of a nursing home or assisted living facility,
the members of a health plan, an Accountable Care
Organization (ACO), the assigned members of a
capitated Independent Practice Association, the
employees of a self-insured business, etc.
APM Current State
▪
Conceptual models developed
▪
Reviewing data sources to determine how to model
the APMs
▪
Project management consultant has been added
to the team to continue moving the projects
forward
▪
Looking to submit APMs for approval in mid 2017
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2/7/2017
What About Accountable care organizations and bundled payments? Not All ACOS Are Win‐ Win
Dartmouth’s ACO reduced Medicare costs on
hospital stays, tests, imaging and other
procedures…
And was still penalized by the federal
government for not reaching cost savings
benchmarks, which prompted it to exit the
program.
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2/7/2017
Bundled Payments Update: Slow Growth
July 25th, 2016 The CMS proposed new models that continue the
Administration’s progress to shift Medicare payments from quantity to quality
by creating strong incentives for hospitals to deliver better care at a lower cost.
▪
Expanded bundled payment programs for; cardiac care
and hip surgeries- including outpatient post op rehab
▪
Expansion of hip and knee bundles to include hip/femur
fractures beyond joint replacement
▪
Pathway for physicians to qualify for advanced payment
model bonuses
The hospital in which a Medicare patient is admitted for care for a heart
attack or bypass surgery would be accountable for the cost and quality of
care provided to Medicare beneficiaries during the inpatient stay and for 90
days after discharge.
The expansion of bundled payments is moving slowly starting with big ticket surgical items. In most programs ED still bills fee for service.
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Contact Information
Michael A. Granovsky MD, CPC, FACEP
President, LogixHealth
[email protected]
William Jaquis, MD, FACEP
Chief, Dept. Emergency Medicine
Sinai Hospital
[email protected]
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