Pharmacists, Physicians, and Value-Based Payments: WHY THEY NEED US MORE THAN THEY MAY KNOW

Rebecca Snead EVP/CEO National Alliance of State Pharmacy Associations (NASPA)

Disclosure I do not have (nor does any immediate family member have) actual or potential conflict of interest, within the last twelve months; a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity; or any affiliation with an organization whose philosophy could potentially bias my presentation.

Acknowledgements Much of the content of this presentation is being used with permission from: Daniel E. Buffington, PharmD, MBA, FAPhA University of South Florida Colleges of Medicine and Pharmacy Clinical Pharmacology Services, Inc. Tampa, FL and The Pharmacy Quality Alliance

Objectives Outline how the National Quality Strategy is shaping health care objectives centered on team-based care Describe how healthcare quality measures are redefining care delivery including the impact on the role of pharmacists and; the impact on other healthcare professionals Review the changing professional dynamics between pharmacists, physicians and health plans in both in-patient and community settings Define how quality measures are refocusing on patients and caregivers

The Shift to Value-Driven Healthcare The U.S. health care system is rapidly moving to value-based purchasing or “value-driven healthcare” Value is the balance of quality and costs, thus we can optimize value by improving quality while reducing costs One of the biggest challenges in driving better quality is that we can’t always agree on how to define and measure quality

The Triple Aim Better Care Healthy People/ Communities Affordable Care

Clinical quality of care HHS primary care and CV quality measures Prevention measures Setting-specific measures Specialty-specific measures Care coordination Transition of care measures Admission and readmission measures Population/community health Measures that assess health of the community Measures that reduce health disparities Access to care and equitability measures Efficiency and cost reduction Spend per beneficiary measures Episode cost measures Quality to cost measures Safety Health Care Acquired Conditions(HCACs) including HAIs All cause harm Person and Caregiver centered experience and outcomes CAHPS or equivalent measures for each settings Functional outcomes The Six National Quality Strategy Priorities

Federal Value-based Payment Goals Sylvia Burwell Jan 26, 2015 HHS Announcement--NEJM Article/Meeting/Press Release Sylvia M. Burwell. N Engl J Med 2015; 372: Jan DOI: /NEJMp

Value-Based Payments CMS CMMI Value QualitySavings Cost

Transition in Payment Models Fee-for- Service Pay-for- Performance Value-Based Payment Alternate Payment Models (APM) Alternate Payment Models (APM) Historical Recent Future Patient- Centered Medical Homes (PCMH) Accountable Care Organizations (ACO)

Alternate Payment Model Journey AMA CPT Current Procedural Terminology Product or Service AMA RUC Relative Value Scale (RVS) Update Committee CMS / CMMI Healthcare Payment Modeling & Improvement Future Alternate Payment Models (APM) Value-Based Payment FFS & APM RUC Valuation Analysis or Market Valued Healthcare Reform a)Market & Exchange b)Payment Models c)Quality & Safety Improvement Physician-Focused Technical Advisory Committee

Health Care Payment LAN HHS has set a goal (PDF) of tying 30 percent of Medicare fee-for-service payments to quality (PDF) or value through alternative payment models by 2016 and 50 percent by HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by To support these efforts, HHS has launched the Health Care Payment Learning and Action Network to help advance the work being done across sectors to increase the adoption of value-based payments and alternative payment models.

Where is innovation happening in GA? (accessed 5/28 – select GA and all)

Physician Quality Reporting System (PQRS) 284 measures on the 2016 Measure List Review of the first 50 measures, there were 18 (36%) associated with appropriate medication use Instruments/PQRS/MeasuresCodes.html

PQRS – Georgia As of 2014 there were close to 105,000 physicians voluntarily reporting to PQRS 26,708 from Georgia 26,708 who could benefit from YOUR services

Meaningful Use

Quality and Resource Use Report (QDUR) QDUR identifies performance in terms of cost and quality so physicians can prioritize potential areas for improvement. Payment/PhysicianFeedbackProgram/2013-QRUR.html

Chronic Care Management CMS’s decision to pay separately for care management of beneficiaries with two or more chronic conditions came from the agency’s stated belief about resource use and the CPT evaluation and management (EM) codes; that is, EM codes describe face-to-face visits and do not reflect any of the time spent managing chronic conditions when the patient is not physically present. Monthly fee for services provided. Provider-Calls-and-Events-Items/ Chronic-Care-Management- new.html

Healthcare Payment Reform Merit-Based Incentive Payment System (MIPS) $ $$$$$ Medicare Access & CHIP Reauthorization Act (MACRA) SGR Alternate Payment Models (APM) Physician Quality Reporting System (PQRS) Value Modifiers Resource use Clinical practice improvement Meaningful use of certified EHR technology Notice of Proposed Rulemaking April 27, 2016

Quality Focus within MACRA (2015) Medicare Access and CHIP Reauthorization Act (MACRA) Paying physicians: the old way ◦Medicare Physician Fee Schedule (MPFS) ◦Sustainable growth rate (SGR) formula ◦Ensure that Medicare increases did not exceed growth in GDP ◦Resulted in frequent “Doc fixes” by congress New method: Merit-based Incentive Payments (MIPs) ◦MPFS increased by 0.5% ◦PQRS, Value-based Modifier, Meaningful Use in effect ◦MIPs go into effect 2019

MIPS Consolidates three existing quality reporting programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBPM), and meaningful use (MU). The system also adds a new program, called clinical practice improvement activities (CPIA). The four programs establish a composite performance score (0-100) used to determine physician payment. The categories are: Quality – based on PQRS; Resource use – based on VBPM; Meaningful use of certified electronic health record (EHR) technology – based on MU; and Clinical practice improvement activities – new program

MIPS Physicians who score at the threshold will receive no payment adjustment. Physicians whose composite score is above the mean will receive a positive payment adjustment on each Medicare Part B claim for the following year. Physicians whose composite score is below the mean will receive a negative payment adjustment on each Medicare Part B claim for the following year.

MIPS Physicians given a publicly reported score of ◦Quality measures (PQRS) ◦Efficiency measures (Value-based Modifier) ◦Meaningful use of electronic health records (MU) ◦Clinical practice improvement activities

MIPS Physicians performance rewarded or penalized ◦Thresholds established based on mean performance composites ◦Providers scoring below threshold subject to payment reductions ◦-4% in 2019, -5% in 2020, -7% in 2021, and -9% in 2022 ◦Providers scoring above threshold receive bonuses (funded by penalties) ◦+12% in 2019, +15% in 2020, +21% in 2021, +27% in 2022 ◦$500M bonus pool for “best of best” Providers in alternative models may opt out

Exemptions from MIPS Providers in their first year billing Medicare; Providers whose volume of Medicare payments or patients fall below the threshold (not yet defined); and Providers who qualify for payment under APMs with the associated bonuses exempt from MIPS. Additionally, it is anticipated that providers practicing in rural health clinics or Federally Qualified Health Clinics (FQHCs) are also exempt from MIPS

Pharmacy Quality Alliance Develops measures of safe and appropriate medication use Consensus-based, non-profit alliance with >180 member organizations, including: ◦Health Plans & PBMs ◦Pharmacies & professional associations ◦Federal agencies (CMS, FDA) ◦Pharmaceutical manufacturers ◦Consumer advocates ◦Technology & consulting groups ◦Universities

Summary United States has significant healthcare quality gaps US has a National Quality Strategy for improving health Federal government is shifting risk from itself to healthcare providers Primary vehicle for accomplishing this is through quality measurement and value based payment There are many types of quality measures, with emphasis being placed now on outcome measures and patient-level measures Market forces related to quality measurement are eliciting strong responses across healthcare settings Pharmacists are critical member of the team.

Rebecca Snead Visit GPhAconvention.com/grow to download materials from this and other presentations.