Holy MACRA, this is how we get paid? September 17, 2017 Lawrence Cowsill, D.O., FACOI

President Trump said… “Nobody knew health care could be so complicated.”

MACRA Current State MACRA Future State Quality Payment Program Buzz Discussion Menu MACRA Current State MACRA Future State Quality Payment Program Buzz

Things I Should Confess… A practicing internist and Senior Medical Director of McLaren Physician Partners An urban doctor with no hidden agenda Fortunate to have a practice partner who shares a passion for change No allegiance except to my patients, the health care system and collaborative physicians

Perfect Storm of Change Replace SGR with MACRA…WHY? Move from volume-based payment to value-based payment. Reward high performance providers. Sunset programs like PQRS, MU and VBM. Move physicians to taking risk and managing risk. To formulate a simple, transparent value based payment process.

MACRA Future State

Proposed Rule for QPP Year 2 Transition Year (2017) Policies: Pick your Pace Minimum amount of data 90 days of data One year of data Having a low-volume of MA payments/patients – EXEMPT Flexibilities for physicians who are hospital-based or limited face-to-face encounters.

Proposed Rule for QPP Year 2: MIPS For Quality & Cost categories increase the performance period to include full year of data. For Improvement Activities and Advancing Care Information categories increase performance period to 90 days of data.

Proposed Rule for QPP Year 2: MIPS Offer “Virtual Groups” participation. Increase the low-volume threshold to help exemptions Continue to allow the use of 2014 edition CEHRT. Add bonus points for: Caring for complex patients Use of 2015 edition CEHRT Use facility-based scoring for facility- based physicians

Proposed Rule for QPP Year 2: MIPS Flexibilities for small practice providers: Hardship exception in the Advancing Care Information category Bonus points to the final score for small practices providers Award small practices 3 points for measures in the Quality category that don’t meet data completeness

Comparison of current policy to proposed policies Transition Year – FRCY 2017 Low Volume Threshold Year 2 – PRCY 2018 Low Volume Threshold Exclude MIPS ECs or GRPs with less/equal $30,000 in Part B allowed charges Less/equal 100 Part B beneficiaries in a year Increase threshold to exclude MIPS ECs or GRPs with less/equal $90,000 in Part B allowed charges Less/equal 200 Part B beneficiaries in a year Starting in 2019 MIPS Perform period – let docs opt-in to MIPS if exceed 1 or 2 of the above components.

Comparison of current policy to proposed policies Transition Year – FRCY 2017 Non-Patient Facing Year 2 – PRCY 2018 Non-Patient Facing Individuals: 100 or less patient facing encounters Groups: > 75% NPIs billing under group’s TIN during a performance period are labeled as non-patient facing. No change in how CMS is defining non-patient facing clinicians. Proposing same definition for Virtual Groups.

Comparison of current policy to proposed policies Transition Year – FRCY 2017 Facility-Based Measurement Year 2 – PRCY 2018 Facility-Based Measurement Not available in 2017. Optional, voluntary FB scoring mechanism based on Hospital V-B Purchasing Program FB clinicians at least 75% of professional services in inpatient setting or ED. FB option converts a hospital Total Performance Score into MIPS Quality & Cost score

Quality Payment Program Buzz

Major Problems with MIPS Incentives for clinicians to reduce services are weak. Incentives for providers to improve quality are weak. Providers can choose measures Limited number of measures Risk adjustment Clinical performance influenced by patient factors rather that quality of care Providers bear cost of performing well on high risk patients when risk comes from non-medical factors Attract low-risk patients J. Michael McWilliams, MD, PhD Annals of Internal Medicine, July 2017

MACRA, in passing… Good to merge diverse programs, to many nuisance or nuance? Road map to success is not clear All theory Not providing consistent answers Designed for family practice/internal medicine Effects small portion – MAFFS, Railroad

Cost of Advancing Care Information The Application Programing Interface(provide Patient Access) Certified EHR (2014 or 2015 edition or combo) Vendor relationship Security Risk Analysis and Security Updates The cost of the Interface (Summary of Care)

MIPS APM, Simply Put… (A program of flexibility or nuance?) Check to see if eligible participant in MIPS Cost domain – not included for 2017 and 2018 Not PCMH, but in ACO – require MIPS participation No EHR – no reporting Advancing Care Information Re-weighting PCMH overrides Improvement category.

MACRA, not so fast…

MACRA vs SGR… Unless significant bonuses earned in MIPS Part B payment will not keep up with inflation Some long term projections indicate physician payment under MIPS will be worse than under SGR

What keeps post-acute care directors up at night? Regulations – federal, state and local STAR ratings Relationships – where is my next patient coming from?

Spotlight on the SNF Use of 4 or 5 STAR facility Medical Oversight Length of Stay Expectations of Care Communication with next provider Transition of Care

Healthcare Future…. Universal coverage? Single Payer? Limited Healthcare Vision?