Advocacy and Healthcare Reform Update Presented By: Todd Baker, Chief Executive Officer Southern Ohio Medical Center (SOMC) King’s Daughters Medical Center Ohio (KDMC) Feb. 15, 2017 (Disclaimer: Some of the slides and graphics have been provided to OSMA by CMS.gov) *Add footers & “Exhibit” references 1

Overview State Advocacy Overview Federal Payment Reform MACRA, MIPS, and APM State Payment Reform Ohio CPC Episodes of Care Bringing physicians together for a healthier Ohio

Why what happens in Ohio’s legislature and regulatory bodies impacts how you provide care every day, regardless of whether you practice in a large hospital system or are in solo practice. Clinical Practice Health Policy Clinical Practice Health Policy Bringing physicians together for a healthier Ohio

Advocacy Overview Price Transparency Prior Authorization Health Insurance Mergers Regulatory Issues Opiate Prescribing (SmartRx) Marijuana One-Bite Rule Tort Reform

Federal Payment Reform Bringing physicians together for a healthier Ohio

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

Transition From Fee For Service Choice of Two Pathways Merit Based Incentive Payment System (MIPS) Alternative Payment Model (APMs) or

Eligible Providers Physician PA NP CRNA Clinical Nurse Specialist If you bill Medicare more than $30,000 a year, and provide care for more than 100 Medicare patients a year (must meet both criteria)

Exclusions Billing Thresholds ($30,000 or 100 patients) Patient Facing Encounters (less 25) Rural Health / FQHCs New to Medicare

Reporting Options Individual or Groups For quality and other measures can be reported through qualified registries and vendors

AMA and CMS MACRA Resources http://www.ama- assn.org/ama/pub/advocacy/topics/medicare-new- payment-systems.page https://qpp.cms.gov/

Merit Based Incentive Payment System (MIPS) *Add footers & “Exhibit” references Bringing physicians together for a healthier Ohio 12

MIPS Merit-Based Incentive Payment System Consolidates current measures and creates a composite performance score Resource use not included in Year 1 now Advancing care Information Year 1 – 25% Year 2 - 25% Improvement Activities Year 1 – 15% Year 2 – 15% Quality Year 1 – 60% Year 2 – 50% Cost Year 1 – 0% Year 2 – 10%

MIPS Quality Payment Program – 3 options: - % + % + % - % Not participating in the Quality Payment Program (negative 4%) Test: If you submit a minimum amount of 2017 data to Medicare, you can avoid a downward payment adjustment. 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. Don’t Participate Submit Something Submit partial year Submit full year

Quality System (PQRS) Replaces the Physician Quality Reporting Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days. Report 15 quality measures for a full year. https://qpp.cms.gov/measures/performance

Advancing Care Information Replaces the Medicare EHR Incentive Program (aka Meaningful Use) Fulfill the required measures for a minimum of 90 days: Security Risk Analysis e-Prescribing Provide Patient Access Send Summary of Care Request/Accept Summary of Care Choose to submit up to 9 measures for a minimum of 90 days for additional credit. https://qpp.cms.gov/measures/aci

Improvement Activities Activities that best fit your practice Attest that you completed up to 4 improvement activities for a minimum of 90 days. Attest that you completed up to 2 activities for a minimum of 90 days (fewer than 15 participants). https://qpp.cms.gov/measures/ia

Cost Replaces Value Based Modifier No data submission required – calculated from adjudicated claims.

MIPS – Composite Score Adjustments Based on a MIPS Composite Performance Score, clinicians will receive + / - or neutral adjustments up to the percentages below 2019 2020 2021 2022 onward Merit-Based Incentive Payment System (MIPS) Adjusted Medicare Part B payment to clinician +4% -4% +5% +7% +9% -9% -7% -5% + / - Maximum Adjustments The potential maximum adjustment % will increase each year from 2019 - 2022

Benchmarks Available from CMS prior to each year https://qpp.cms.gov/resources/education

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.

Key Dates submit Performance year feedback available payment 2017 March 31, 2018 2018 January 1, 2019 Performance: Jan 1 – Dec 31, 2017, record quality data and how you used technology to support your practice 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.

Alternative Payment Models (APM) *Add footers & “Exhibit” references Bringing physicians together for a healthier Ohio 23

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

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_201 7.pdf

State Payment Reform Bringing physicians together for a healthier Ohio *Add footers & “Exhibit” references Bringing physicians together for a healthier Ohio 26

5-Year Goal for Payment Innovation Patient-centered medical homes Episode-based payments Goal 80-90 percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years Year 1 In 2014 focus on Comprehensive Primary 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 Year 3 Year 5 State leads design of five episodes: asthma 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 Model rolled out to all major markets 50% of patients are enrolled 20 episodes defined and launched across payers Scale achieved state-wide 80% of patients are enrolled 50+ episodes defined and launched across payers 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 Overall, the 5-year focus at the state level is on PCMH and episodes. For immediate term, the focus is on CPCI for PCMH and development of 5 episode models (with the goal to launch reports in November 2014). Bringing physicians together for a healthier Ohio

Bringing physicians together for a healthier Ohio

Retrospective episode model mechanics Patients seek care and select providers as they do today Providers submit claims as they do today Payers reimburse for all services as they do today 1 2 3 Patients and providers continue to deliver care as they do today 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 See no change in pay: if average costs are between commendable and acceptable levels Review claims from the performance period to identify a ‘Principal Accountable Provider’ (PAP) for each episode 4 5 6 Calculate incentive payments based on outcomes after close of 12 month performance period Payers calculate average cost per episode for each PAP1 Compare average costs to predetermined ‘’commendable’ and ‘acceptable’ levels2 Ohio episode model is RETROSPECTIVE, not prospective. To repeat, there is not pre-set price for a bundle in the retrospective model. Patients seek care and providers bill and are reimbursed as they do today. After the fact, claims data is analyzed to: - identify the principal accountable provider, or PAP, who is held accountable for all episode costs, not just those he/she directly bills for - calculate the average episode code per PAP and compare to set “commendable” and “acceptable” thresholds to determine any gain or risk sharing Bringing physicians together for a healthier Ohio

State Payment Reform Resources Office of Health Transformation: http://www.healthtransformation.ohio.gov/currentiniti atives/payforvalue.aspx Medicaid: http://medicaid.ohio.gov/PROVIDERS/PaymentInnovati on.aspx *Add footers & “Exhibit” references 30

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