1. THE MACRA JOURNEY TRANSITIONING HEALTHCARE ORGANIZATIONS TO
FEE-FOR-VALUE

2. What is MACRA and MIPS?

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MACRA TIMELINE
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10. How will MACRA and MIPS impact providers?

11. PROVIDER IMPLICATIONS
MACRA is one of many inputs into overall Value Based Programs
Each provider potentially deals with multiple risk-sharing models
Providers are looking for help meeting objectives for each of these models

12. MACRA IMPLICATIONS FOR HOSPITALS Faculty Practice Plan Medical Group
ACO
Community Physicians
Quality
Referrals from wider geographic area and non-aligned primary care networks will make it difficult to manage data to demonstrate quality with high acuity patients.
VBP modifier optimization will be important.
Monitoring of resident activity and documentation becomes important.
Use of APM to qualify will be difficult given the decentralization of clinical departments or divisions.
Quality metrics and outcomes must be aligned through the continuum of ambulatory, acute and post-acute care.
Resource Use
Referring physicians may avoid the academic environment if cost/case is much higher than competitors.
Relatively loose organizational structure of FPP’s may hinder care coordination and cost management across a continuum.
Costs per beneficiary will include inpatient, outpatient and post-acute; thereby stressing coordination of care.
The effect of provider-based reimbursement will need to be considered as that will further increase costs.
CPIA
Expanded practice access, use of telehealth, integration of behavioral health services will be key.
PCMH is high scoring and should be pursued wherever possible.
ACI
Physicians can pick metrics that better reflect their use of technology in daily practice, focus should be on evaluating what technologies have worked best.
Interoperability and patient access to medical records is prioritized.
Implement public health reporting capability to increase potential for bonuses.
CPIA – Clinical Practice Improv. Activities , ACI – Advancing Care Information

13. MACRA IMPLICATIONS FOR MEDICAL GROUPS Faculty Practice Plan
ACO
Community Physicians
Quality
Needs to function as integrated multi-specialty practice referring patients based on quality metrics and outcomes data.
Resource Use
Needs to function as an integrated multi-specialty group to maintain referrals within network and thus control costs of care.
Reconsideration of provider-based revenue implications on Total Cost of Care.
CPIA
PCMH should be pursued wherever possible.
Needs to function as an integrated multi-specialty group maximize care coordination and shared decision-making.
ACI
Target bonus points where use of technology already in place at a provider can make achieving health information exchange and patient experience.
Investing in technology that reduces expenses will be key – areas such as health information exchange and interoperability.
Implement public health reporting capability to increase potential for bonuses.
CPIA – Clinical Practice Improv. Activities , ACI – Advancing Care Information

14. MACRA IMPLICATIONS FOR PROVIDER-LED ACOS Faculty Practice Plan
Medical Group
ACO
Community Physicians
Quality
Quality reporting and review must drive network selection for referrals
Consolidate and offer resources for standardization metrics, care management and patient navigation
CAHPS can be used for MIPS survey
Develop and leverage as APM
Resource Use
Continued efforts to improve efficiencies and quality become increasingly important
CPIA
PCMH’s will receive full credit
Provide framework for shared decision-making, care coordination, patient safety efforts
ACI
In general, ACO programs focus on ACI should be to invest in technologies that improve possibilities for bonus points and involve some level of investment risk that can be quantified as reducing cost/increasing revenue. Examples would be:
Integrating clinical and claims data into a population health platform
Platform for timely notification of transitions of care
CPIA – Clinical Practice Improv. Activities , ACI – Advancing Care Information

15. Implications for the Community Physicians
MACRA IMPLICATIONS FOR COMMUNITY PHYSICIANS
Implications for the Community Physicians
Faculty Practice Plan
Medical Group
ACO
Community Physicians
Quality
Quality metric data capture and reporting may be a challenge.
EHR capture and reporting capability.
Clinically Integrated Network can align interests and capabilities of community physicians.
Resource Use
Coordination of care will be new to most community physicians.
Additional cost of patient navigation and data reporting.
A Clinically Integrated Network can align the interests and capabilities of community physicians.
CPIA
CPIA activities and requirements will be new to most community physicians and they will require education and support.
PCMH should be encouraged.
A Clinically Integrated Network can educate, align and provide capabilities needed.
ACI
Dependent on group size, consider use of virtual groups once CMS has released guidance in final MACRA rule.
Focus on clinical network integration, specifically metrics that support interoperability and health information exchange.
Implement public health reporting capability to increase potential for bonuses.
CPIA – Clinical Practice Improv. Activities , ACI – Advancing Care Information

16. Challenges in dealing with MACRA and MIPS

17. SURMOUNTING PRESSURES FROM MACRA – WORKING TOGETHER
Alignment and Innovation for Providers and Payers
Alignment of Fee Schedules and Medicare Advantage
Helping clinicians succeed with MACRA while avoiding expensive cost-shifting measures
Aligning current accountable care contracts to MIPS and looking at opportunities for fee schedule simplification
Care Continuum
Evaluating each payment model approach (such as MACRA) as an input to a larger healthcare transformation
Finding areas of alignment across payment models where providers and payers can innovate and differentiate
Patient Driven Ecosystem
Internal and external stakeholders within the U.S. healthcare system are becoming factors in a patient’s care and provider’s prospective payment
Data sharing is becoming paramount in differentiating provider and payer performance
Provider Perception
MACRA is perceived as adding the potential for another layer of administrative burden to providers
Providers are looking for services and support to their physicians, groups and hospitals in meeting MACRA/MIPS

18. MACRA Challenges and Key Considerations
MACRA CHALLENGES WE HEAR FROM PROVIDERS
MACRA Challenges and Key Considerations
CHALLENGE
DESCRIPTION
KEY CONSIDERATIONS
Determining measures to report
Selecting quality measures in which a provider does not just perform well, but performs well compared to its peers that submit on the same quality measure
Need to evaluate measures both on achievability and difficulty
ID opportunity to achieve extra credit or ways to increase performance in this category
Achieving balance in quality measurement
Provider’s choice of submitted quality metrics can significantly affect the relative score for this category because all measures are scored on a relative basis and “graded on a curve.”
ID potential thresholds for provider competition
Providers need to have a good understanding of whether they can report on a measure and if they have the right data
Understanding the network
Provider network mapping is important for patient attribution and to determine the right network of providers to maintain a high score under the MIPS scoring system.
Physician compensation arrangements, as well as professional services agreements, will need to include physician incentives that reflect those being implemented by CMS.
Provider networks must collaborate to manage a patient’s overall resource use. Over utilizing providers in a group will negatively impact the overall score for the group
Ongoing Risk Calculation
MACRA states that to qualify as an APM, a medical group will have to take on more than nominal downside risk
Providers will likely think about moving from Track 1 to more risk-bearing to qualify as an APM

19. What are current industry responses to MACRA and MIPS?

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A SPECTRUM OF FEE-FOR-VALUE APPROACHES
Payers and non-traditional players have had varying responses to Alternative Payment Arrangements
Partnership Models
Collaborative relationships
Joint ventures
Provider integration
Ex: Aetna, Highmark, Presbyterian Health
Targeted Tools and Services
Engaging in metric rationalization that aligns with CMS
Offering population health and care management services to high-performing providers
Builds, operates, measure, optimizes value based care models
Ex: Evolent Health, Lumeris
Level of Specificity in Offering
Alignment of Fee for Value Approaches
Targeting performance measures to provider workflows
High-performance provider network aggregation
Robust clinical data capabilities (data governance, capture, collection, validation and reporting)
Ex: Massachusetts Blue AQC contract, Humana (Metric Rationalization)
Humana – metric rationalization – proactive, designing metrics to fit CMS
MIDDle proactive – working with providesr
Optum – waiting, see if MACRA/CMS works with them
Initial Assessment
Initial IT system and service assessments with MACRA as an input
Evaluate how the shift of patients and revenue to risk-based contracts will change financial projections
Ex: Cigna, UnitedHealth
Degree of Business Impact to Providers
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MACRA VENDOR MARKET
Non traditional players focus expertise around consulting, analytics, population health and outsourcing / aggregators ??
Consulting
Outsourcing/
Aggregators
Population
Health
Provider Health Plan/ Risk Turnkey solutions
Assorted ACO companies
Humana – metric rationalization – proactive, designing metrics to fit CMS
MIDDle proactive – working with providesr
Optum – waiting, see if MACRA/CMS works with them
Outsourcing
Analytics
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22. EMERGING VENDOR TARGETS
Dealing with Quality
Measure Madness
Financial Risk and
Provider Network Analysis
Data Aggregation
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23. Conclusions

26. Accenture’s POV on the Impact of MACRA
Accenture POV - How will MACRA/MIPS impact providers?
Accenture’s POV on the Impact of MACRA
We believe MACRA is one of many inputs into the overall move into fee-for-value
We expect MACRA to significantly impact health systems: 1
MACRA’s goals include the expansion of patient-centered approaches, advancing Alternative Payment Model participation, creation of meaningful incentives to drive multi-payor reform. There will be considerable discussion of the right “grouping” for clinicians to report within: group practice, APM entity, or individually. For those in groups, composite scores will reflect group performance, reflecting the need to coordinate practice performance in new ways. 2
Resource use will be calculated as total per costs capita for all attributed beneficiaries and Medicare Spending per Beneficiary (inpatient episode). In addition, episode-based measures, as applicable to the MIPS eligible clinician will be utilized. Thus, physicians will have the incentive as never before to monitor the use of resources across specialties and services. Expect provider-based pricing to come under scrutiny as well. 3
The law’s incentives for clinicians to enter into risk-bearing, coordinated care models could create opportunities for health systems and health plans to enter into new arrangements with clinicians under Medicare and beyond, setting the stage for similar initiatives with health plans, employers, etc. We also expect that physicians will further seek to consolidate, or align, with entities that can help them report and perform better on measures and reduce the cost to serve Medicare beneficiaries.

27. Alternative Payment Models (APMs) and MACRA

28. Approved APMs APPROVED APMS Accountable care organization
A hospital-led program that increases collaboration among a patient’s health care team and aims to improve member health and satisfaction. It reduces costs by avoiding unnecessary hospital admissions, readmissions, emergency room visits and duplicate services.
Models in scope – Medicare Shared Savings Program (MSSP) Track 3 and Next Gen, Advance Payment ACO Model, Pioneer ACO Model , Other Payer Advanced APM’s (2021 based on 2019 performance)
Patient-centered medical home
A program designed for primary care physicians that is comprehensive, team-based, and focused on quality and safety. The medical home aims to deliver care in the right place, at the right time, and in the manner that best suits a patient's needs. Also qualifies for 100% score in CPIA under MIPS.
BUNDLED PAYMENTS
A payment strategy that defines the reimbursement of health systems on the basis of expected costs for clinically-defined episodes of care.
Models in scope - Bundled Payments for Care Improvement Initiative (BPCI) and Comprehensive Joint Replacement (CJR)

29. Am I exempt from MIPS requirements if I already participate in an APM?
MIPS EXEMPTIONS FOR APMS
Am I exempt from MIPS requirements if I already participate in an APM?
Only Qualifying APM Participants (QPs) and Partial Qualifying APM Participants (Partial QPs) are exempt from MIPS.
MACRA sets thresholds for the level of participation in Advanced APMs that are required for an eligible clinician to become a QP or Partial QP for a given year.
CMS does not communicate thresholds have been met until after the performance year ends. Providers could be subject to the payment penalties in 2019 if they do not prepare for 2017 MIPS reporting and don’t end up meeting the QP or Partial QP requirements.
Clinicians who are participating in an Advanced APM can use the APM Scoring Standard under MIPS in order to reduce the reporting burden required by MIPS and the APM.
QP Threshold
Partial QP Threshold*
Medicare Payment Amount
25%, 50% (2021), 75% (2023)
20%
Medicare Patient Count
20%, 35% (2021), 50% (2023)
10%
* Partial QPs will have the option to elect whether or not
to report under MIPS, which determines whether or not they will be subject to MIPS adjustments.

30. 1 2 3 ACO AND APM ELIGIBILITY UNDER MACRA
3 Financial tests must be passed for the advanced APMs: 1
Marginal risk rate must be at least 30% of any negative variance to expected expenditures 2
Loss protection in the form of a minimum loss rate must be 4% or less 3
Conversely, loss protection must expose the organization to at least paying 4% of the denominator in question (total cost of care or target price) to CMS
For example, if an ACO splits losses 50/50 with CMS then the stop loss would need to be at least 8%. Under these definitions all two sided tracks of MSSP would meet the definition.
Entity must be on the hook to pay back at least 30% of the losses that are greater than 4% of the target to qualify, or
Entity must be on the hook to pay back losses totaling 4% or more of the target