1. Viewing MACRA Through a Medicaid Lens
R. Shawn Martin Senior Vice President, Advocacy, Practice Advancement, and Policy American Academy of Family Physicians

2. Current State Over Utilization Volume over Value Silos of Care
This is the current fee for service state we are all familiar with… because we live in it every day. It is not set up to reward value or quality and, in many cases;… it promotes over utilization and fragmented care.
Fee for Service

3. The Medicare Access and CHIP reauthorization Act (MACRA) is the key legislative piece that moves the healthcare system closer to meeting the goals laid out by the Secretary.
The first line in the legislation is spelled out here, and it states clearly what the law is intended to do…To repeal the Medicare Sustainable Growth Rate (the SGR) and strengthen Medicare access by improving physician payments
If only the law were this simple!

4. What Does MACRA Do? Consolidates quality programs
Merit-Based Incentive Payment System (MIPS)
Potential for bonus payment for participation
Advanced Alternative Payment Models (AAPM)
As we mentioned previously, MACRA introduces two new payment tracks:
One that consolidates quality programs –the Merit Based Incentive Payment System (MIPS)
And Alternative Payment Models (APMs) - which have the potential for bonus payments for participation
We anticipate many of our members will move through MIPS into the alternative payment model track.

5. Here is a graphical representation of the MACRA path you will be venturing on.

6. Merit-Based Incentive Payment System
(MIPS)
Lets take a look at MIPS in more detail

7. “Consolidates” Old New Meaningful Use =MU
VBPM
PQRS
“Consolidates”
Old
New
Meaningful Use =
Advancing Care Information (ACI)
Value-Based Payment Modifier
Cost
PQRS
Quality
Advancing
Care Information
What actually happened is the current programs went into the funnel and came out as three moderately changed programs with new names.
Meaningful Use is now Advancing Care Information, Value-based Payment Modifier is now Resource Use, and PQRS is now Quality.
The proposed rule has done little to consolidate or reduce the administrative burden associated with these programs as initially indicated.
Cost
Quality

8. What’s it called? Value Modifier Cost MACRA – April 2015
Proposed Rule – April 2016
Final Rule– October 2016 MU
Advancing
Care Information
Advancing
Care Information
Value
Modifier
PQRS
Resource Use
Quality
Cost
Quality
CPIA IA
Advancing
Care Information
CPIA

9. Weighting by Category - 2017
This is a breakdown of year 1 scoring. The four categories above contribute points, in a weighted fashion, to make up the performance score. The total number of points scored will range from 0-100, with each category weighted as established in statue.
Quality 60%
Cost 0%
IA 15
ACI 25
This is a breakdown of year 1 scoring. The four categories above contribute points, in a weighted fashion, to make up the MIPS Composite Performance Score. The total number of points scored will range from 0-100, with each category weighted as established in statue.
You will notice there is a footnote for CPIA. Specifically, a “Certified” patient centered medical home will receive the full 15 points for this category. Those in alternative payment models who do not qualify for the alternative payment model bonus, will get half the credit for the CPIA category. We will discuss this more in the alternative payment model section.
“Certified” patient centered medical home is defined in the proposed rule as those recognized by NCQA, the Joint Commission, URAC, and AAAHC. The AAFP is advocating for state-based and payer programs to be included in this definition as well.

10. Advanced Alternative Payment Models
(AAPMs)
Let’s move on to APMs

11. Definitions Qualifying APM Based on existing payment models
Advanced APM
Based on criteria of the payment model
Qualifying AAPM Participant
Based on individual physician payment or patient volume
As we’ve mentioned, most providers will move through MIPS as they prepare to enter the Alternative Payment Model track.
At the highest level, MIPS is based on existing activities with few entry requirements or exceptions making it easy to become a participant.
Conversely, in the APM track, you must meet specific qualification and eligibility criteria. Let’s talk about what each of these mean.

12. Qualifying APMs Qualifying APMs MSSP (Medicare Shares Savings Program)
Expanded under CMS Innovation Center Model*
Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration
“Demonstration required by Federal Law”
Qualifying APMs
The goal is for you to be a Qualifying APM Participant.
The first step to get there is to be practicing in a “qualifying” payment model defined in the law. MACRA is very specific about which models qualify, and they are listed here.
Although this is a wide net cast for qualification it does get smaller as we move through the next steps of eligibility and further qualification.

13. Advanced APM Eligibility
Qualifying APMs
Advanced APMs
Quality measures comparable to MIPS
Use of certified EHR technology
More than nominal risk OR Medical Home model expanded under CMMI authority
Step two in the process is for qualified APMs to meet eligibility criteria, listed here. Let’s take a closer look.
First, Advanced APMs must report measures comparable to those in MIPS.
Second, they must use certified EHR technology
And, this last bullet is interesting. The APM needs to either 1) bear more than nominal financial risk for monetary losses, OR 2) be a medical home model expanded under CMMI authority.
Nominal financial risk has been defined in the proposed rule and it is very complicated. The AAFP is advocating the definition be simplified.

14. Qualifying APM Participant
Qualifying APMs
Advanced APMs
Percentage of patients or payments thru eligible APM
In 2019, the threshold is 25% of Medicare payments or 20% of beneficiaries
QP status will be determined at the group level
Qualifying APM Participant
The last step after the payment model has been identified as an Advanced APM, is for the participants within the model to be qualified.
Qualifying Participants (QPs) are physicians and practitioners who have a certain percentage of their patients or payments coming through an Advanced APM.
In 2019 and 2020, the threshold for claims is 25% of payments made by CMS for part B services to Medicare attributed beneficiaries paid through the Advanced APM.
The patient threshold is 20% of Medicare unique attributed beneficiaries. This is not a total percentage of your patient panel, this is just a percentage of your Medicare attributed patients.
Beginning in 2021, the threshold percentage may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid

15. Key Concerns Administrative complexity Lack of alignment
Availability & affordability of staff
Poor data or no data
And let us not forget – EMRs

16. Practice Characteristics

17. Value-based Payment Utilization

18. Barriers to Value-based Payment
Physicians see as a barrier to implementing value-based care delivery (multiple selection)
Lack of staff time to implement care functions that support value-based payment
91%
No uniform payer reports on performance
75%
Lack of standardization of performance measures and metrics

19. Barriers to Value-based Payment
Physicians see as a barrier to accepting more financial risk value-based payment (multiple selection).
Lack of resources to report, validate, and use data
81%
Unpredictability of revenue stream
Administrative complexity and cost needed to understand financial risk
80%

20. EMR’s & IT Systems Must Work for & With Everyone

21. Success Factors Conflict with Barriers
Lack of staff time 91%
Lack of resources to report, validate, and use data 81%
Unpredictability of revenue stream 81%
Administrative complexity and cost needed to understand financial risk 80%
Practice Sustainability
Lack of evidence that using performance measures results in better patient care 62%
Will increase workload without improving patient care 59%
Insufficient training on advanced care delivery functions 61%
Patient Outcomes
Lack of interoperability between types of health care providers 76%
Untimely data 63%
Lack of information available on cost of health care services provided for appropriate referrals 76%
Lack of transparency between payers and providers 77%
Coordination of Patient Care

22. Keys To Successful Multi-Payer VBP Programs
Language
Alignment
Administrative Burden
Pace of Implementation

23. Value-based Payment Utilization
What is your current status or strategy towards value-based payment?
Actively pursue VBP opportunities today
33%
Develop capabilities, but wait until the results are better known before fully pursuing
19%
Hold off on making changes, focus on optimizing under fee-for-service
15%
Participated in VBP previously, but dropped out 1%
Other 8%
Don’t know/not sure
25%
52%

24. Factors for Value-based Payment Success
Physicians who feel factor is important to success of VBP models (multiple selection)
Practice sustainability
92%
Clinical outcomes
91%
Physician and staff morale
87%
Coordination of patient care
86%
Cost savings for my practice
84%
Patient satisfaction
82%
Population health management
72%

25. Partnering for Success
Comprehensive Primary Care Initiative
State Innovation Models
Accountable Care Organizations
Comprehensive Primary Care Plus Program
Insurance Industry Transformation Projects

27. Advocacy, Practice Advancement, & Policy
R. Shawn Martin
Senior Vice President
Advocacy, Practice Advancement, & Policy
@rshawnm