Evolving Business Models: Preparing for Value-Based Payments

Evolving Business Models: Preparing for Value-Based Payments
Virginia MGMA September 26, 2016 Presented by: Pamela Ballou-Nelson, RN, MSPH, PhD, PCMH CCE Senior Consultant, MGMA Health Care Consulting Group Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Objectives At the end of this session, you should be able to:
Examine your theoretical framework: view your practice through a new lens Ask what am I doing with my population: population health management is here to stay Understand the CMS terms of payment reform Discuss the key components of value-based practice models Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 3

Theoretical Framework
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Imperative for Change Just because you need to change doesn’t mean you will change, even if you want to change Understand your theoretical frameworks in place today See healthcare, patients, through a “different lens” Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 5

Thank you for your cartoon request and payment of $40
Thank you for your cartoon request and payment of $40.00 authorizing one time permission to use 2 cartoons in a presentation, specifically as requested. The cartoon may also be used in handouts, providing the material is the printed version of your original PowerPoint slide. No additional or subsequent usage of any kind is authorized by this transaction. Please print and save this and receipt as record of your payment and authorization. It contains all the details of your transaction Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 6

Here to stay — value-based model of care population health
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Collaboration Working together is success Keeping together is progress
Coming together is a beginning Keeping together is progress Working together is success - Henry Ford Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 8

Population Health is an Outcome
Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as insurance attributions, employees, ethnic groups, disabled persons, prisoners, or any other defined group. Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93, Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Managing Services for a Population

Population Selection How will you know which segments to choose?
Large gaps in health outcomes Size of population Organization or community alignment with the work Resources available for this work Can you build a sustainable financial model for this population Adequate return on investment Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 11

Getting to Know Populations
It is not enough to choose populations. You need to understand the needs and assets of the population you have chosen. As you get to understand your population, better projects will naturally arise from a better understanding. Attribution is key and often challenging Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Here to stay — Payment reform
Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Payment Models Will Demand New Care Models
Used with permission from Deloitte Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 14

Commercial Plans Included
75% of business in value-based payment arrangements by 2020 – Health Transformation Alliance United will double value-based contracts by 2018 — this includes self-funded plans Humana anticipates half of its Medicare Advantage membership will be enrolled in full-risk-bearing accountable care organizations by 2017 Aetna currently has 22% of spend running through contracts with a value-based component Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 16

What is Value? Outcomes + Patient Experience
Since value is defined as outcomes relative to costs, it encompasses efficiency. Cost reduction without regard to the outcomes achieved is dangerous and self-defeating, leading to false “savings” and potentially limiting effective care. Outcomes + Patient Experience (safety, patient satisfaction outcome metrics) Value = _____________________ Cost Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

How Do We Get There? From FFS to performance-based payment
New measures — quality and cost New shared data infrastructure New incentives Transparency Alignment across payers New care models New community partners New relationships Clinical tied with business No silos Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 18

Value-based practice models
Key components of Value-based practice models Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

A wise lumberjack once said that if he were given five minutes to chop down a tree or lose his life if he failed to do so, he’d spend three minutes sharpening his axe. Take your time to prepare, sharpen your skills evaluate. Conduct an assessment of your practice Don’t panic BUT prepare Don’t follow the herd; unless it is your herd. Before a health system starts that journey from volume to value, it must plan the transition, especially considering that the provider will have to run its business for a time with a mixed payment model, “That’s why you need a road map,”. “You can’t just feel your way into it.” Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 20

Volume to Value OLD SUCCESS – Volume NEW SUCCESS – Value High volume
High compensation High independence NEW SUCCESS – Value Outcomes to value (volume) Modified compensation plans Partnerships/teamwork Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 21

Practice Assessment Examine your theoretical frameworks
Educate internally Understand your contracts/risk Manage total cost of care Improve operational efficiency New budget models Create community and health system partnership The focus of VBM should not be on methodology. It should be on the why and how of changing your corporate culture. A value-based manager sees the difference from 1960s-style planning systems. It focuses on better decision making at all levels in an organization. It recognizes that top-down command-and-control structures cannot work well Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 23

Practice Assessment 8. Optimize provider network, manage care transitions, and expand disease management to full attributable population 9. Invest in interventions in the high-acuity, post-acute population 10. Develop care pathways for consistency, continuity and effectiveness 11. Automated process to address prevention and wellness 12. Coding and documentation effectiveness: maximize ICD-10, continue on path to clinical documentation (care management codes) Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 24

Value and Uses of TCOC Data

Work Flow Redesign – Traditional Method
Courtesy of Bon Secours health system in Richmond Virginia Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 26

Care Team: New Workflow Redesign
Delivery System: The Care Team Division of Labor: Use every member of team to highest level of training/licensure/ability Move all possible interventions away from the physical visit – Pre and post-visit encounter Everything comes to the patient Use of nursing-driven protocols Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 27

MACRA The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, What does MACRA do? MIPS & APM called Quality Payment Program Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 29

50% 10% 15 % 25 %

Exceptions to MIPS In order to determine whether clinicians met the requirements for the Advanced APM track, all clinicians will report through MIPS in the first year. New as of 4/28/2016 Low volume defined MIPS applies to Medicare Part B clinicians, including physicians, physician assistants, nurse practitioners, clinical nurse specialist, and certified registered nurse anesthetists. All Medicare Part B clinicians will report through MIPS during the first performance year, which begins January Medicare Part B clinicians may be exempted from the payment adjustment under MIPS if they: Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 32

Domain One Quality Measures 50% - Year 1
Not just for Medicare: multi payer applicability MACRA identifies five quality domains (i.e., clinical care; safety; care coordination; patient and caregiver experience; population health and prevention ECs select six measures, as opposed to the currently required nine measures under PQRS, to satisfy the Quality category. CMS proposed expanded measure options to allow ECs to select the six measures that are most applicable to their specialty. Multi-Payer Applicability Overview – MACRA requires consideration of how to incorporate measures used by private payers and integrated delivery systems within Medicare quality reporting programs. The creation and use of measures applicable across payers can lessen provider burden and contribute to improved health outcomes by improving data capture and reducing measure variation. Strategic Approach – CMS will leverage the Measure Applications Partnership (MAP), the Core Quality Measures Collaborative, the Health Care Payment Learning and Action Network, and other multi-stakeholder groups to identify creative solutions for the use of measures across multiple payers and delivery systems from both the private and public sectors to streamline clinician reporting. Coordination and Sharing Across Measure Developers Overview – Measure developers are required, to the extent possible, to coordinate across CMS programs, as well as with initiatives in other public programs and in the private sector, to seek alignment of related measures and promote broader efficiency and consistency in measure development processes. Strategic Approach – CMS will eliminate inefficiencies in the measure development process through the application of process improvements (e.g., the use of Lean principles), build upon the successful foundation of collaboration across measure developers and broaden stakeholder participation, and implement new ways to foster communication and knowledge sharing. CMS coordinates measure development efforts across federal agencies through the HHS Measure Policy Council. With the Office of the National Coordinator for Health Information Technology (ONC), CMS also jointly hosts an interagency forum for electronic clinical quality measure (eCQM) developers and stewards, known as the eCQM Governance Group. The National Quality Forum (NQF) routinely convenes developers through monthly conference calls and webinars to promote knowledge sharing, efficiency, and consistency across CMS measure development efforts. Clinical Practice Guidelines Overview – MACRA requires the MDP to take into account how clinical practice guidelines and best practices can be used in the development of quality measures. The MACRA ends the PQRS adjustment after CY 2018 and provides for the inclusion of various aspects of PQRS in MIPS as part of the quality component of the overall performance score. practices can choose from over 200 quality measures to report, 80 percent of which are tied to specialty care. What’s more, an eligible provider must report on at least six measures and at least one of those measures must address what are called “cross cutting measures,” such as preventive care and screening, patient satisfaction or advanced directives. Another quality measure must be tied to outcomes, or in the case of specialty care, what’s called a high-priority measure. In addition, for individual clinicians and small groups (two to nine clinicians), MIPS calculates two population measures based on claims data, meaning there are no additional reporting requirements for clinicians for population measures.2

The law requires MIPS to be budget neutral, so EC scores will either be
positive, negative or neutral adjustments to their Medicare Part B payments, based on the four performance categories. Each year, the maximum payment adjustments will increase until 2022, when they will level out at 9 percent. An additional bonus, up to 10 percent higher than the respective positive payment, is also permitted for exceptionally high performers in the first five years of the program. ECs are scored on a 100-point scale, with each performance category accounting for a specific percentage of points. CMS will calculate the total performance score for each EC, then stack it against all other ECs participating in MIPS to determine the respective Medicare Part B payment adjustments. Quality Performance Category Scoring:Converting Measure to Points Based on Deciles Each measure is converted to points(1-10) For each measure: •CMS publishes deciles based on national performance in a baseline period (2-yearsprior to the performance period).•Exception –Performance period is used if a baseline benchmark is not available •Eligible clinician’s performance is compared to the published decile breaks. •Points are assigned based on which decile range the performance data is located. Allscored measures receive at least 1 point.•Partial points are assigned within deciles based on percentile distribution. •Rules for special cases:•Eligible clinicians with performance in the top decile will receive the maximum 10points. •Eligible clinicians who do not report enough measures will receive 0 points for each measure not reported, unless they could not report these measures due to insufficient applicable measures.

What Can You Do Now? Practice managers can go through the list of proposed quality measures on the CMS website and identify which measures your practice can meet. Measures for all specialties. Going forward, physician practices should strive to remain informed about this evolving field by checking the CMS website. Pediatrics Measures Children's Health Insurance Program Reauthorization Act (CHIPRA)

Domain Two Resource Use-Cost 10% - Year1
CMS will compare your practice’s resource use, or cost of care, for specific episodes, to other practices in your region. There is no need to report this measure; CMS will calculate it automatically using claims data. CMS proposes to calculate several episode-based measures for inclusion in the resource use performance category. While this one is calculated for you there is a great deal a practice can do to impact this score at the practice level While it is only 10% now it will grow As noted earlier, we have provided performance information on episode-based measures to MIPS eligible clinicians through the Supplemental Quality and Resource Use Reports (sQRURs), which are released in the Fall. The sQRURs provide groups and solo practitioners with information to evaluate their resource utilization on conditions and procedures that are costly and prevalent in the Medicare FFS population. To accomplish this goal, various episodes are defined and attributed to one or more groups or solo practitioners most responsible for the patient's care. The episode-based measures include Medicare Part A and Part B payments for services determined to be related to the triggering condition or procedure. The payments included are standardized to remove the effect of differences in geographic adjustments in payment rates and incentive payment programs and they are risk adjusted for the clinical condition of beneficiaries. Although the sQRURs provide detailed information on these care episodes, the calculations are not used to determine a TIN's VM payment adjustment and are only used to provide feedback. We propose to include in the resource use performance category several clinical condition and treatment episode-based measures that have been reported in the sQRUR or were included in the list of the episode groups developed under section 1848(n)(9)(A) ) Attribution for Individual and Groups In the VM and sQRUR, all resource use measurement was attributed at the solo practitioner and group level, as identified by TIN. In MIPS, however, we are proposing to evaluate performance at the individual and group levels. For MIPS eligible clinicians whose performance is being assessed individually across the other MIPS performance categories, we propose to attribute resource use measures using TIN/NPI rather than TIN. Attribution at the TIN/NPI level allows individual MIPS eligible clinicians, as identified by their TIN/NPI, to be measured based on cases that are specific to their practice, rather than being measured on all the cases attributed to the group TIN. For MIPS eligible clinicians that choose to have their performance assessed as a group across the other MIPS performance categories, we propose to attribute resource use measures at the TIN level (the group TIN under which they report). The logic for attribution would be similar whether attributing to the TIN/NPI level or the TIN level. Non facing We therefore anticipate that, similar to MIPS eligible clinicians or groups that do not meet the required case minimum for any resource use measures, many non-patient facing MIPS eligible clinicians may not have sufficient measures and activities available to report and would not be scored on the resource use performance category under MIPS. We refer readers to section II.E.6.b.2. of this proposed rule where we discuss how we would address performance category weighting for MIPS eligible clinicians or groups who do not receive a performance category score for a given performance category. We also intend to work with non-patient facing MIPS eligible clinicians and specialty societies to propose alternative resource use measures for non-patient facing MIPS eligible clinicians and groups under MIPS in future years. Lastly, we seek comment on how best to incorporate appropriate alternative resource use measures for all MIPS eligible clinician types, including non-patient facing MIPS eligible clinicians.

What Can You Do Now? Review practice clinical guidelines used by your clinicians for consistency around evidence based disease management Engage/ activate patients and families for self-management Review your total cost of care QRUR reports Review ED visits and readmission data Automating the practice functions and streamline workflow Know your payer contracts for expected measure compliance – practice facilitators can assist the practice Business office functions and clinical functions merge together in a value based world. Data Dive can be useful to benchmark your expenses, staffing create budgets. Rachel Weber with MGMA is here today to answer your questions during lunch break about datadive. Less activated patients need more frequent interventions to avoid hospital Ed visits and to improve self-management can’t treat all the patients the same.

Domain Three Clinical Practice Improvement Activities 15% -Year 1
Clinical practice improvement activities are meant to improve the physician practice for patients. Each practice can select activities from a list of more than 90 options that includes flexible office hours and patient scheduling, care coordination, population health management and patient safety. Providers can submit this data in a variety of ways. Expanded practice access, such as same day appointments for urgent needs and after-hours access to clinician advice. Population management, such as monitoring health conditions of individuals to provide timely health care interventions or participation in a QCDR. Care coordination, such as timely communication of test results, timely exchange of clinical information to patients and other MIPS eligible clinicians or groups, and use of remote monitoring or telehealth. Beneficiary engagement, such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training, and using shared decision-making mechanisms. Patient safety and practice assessment, such as through the use of clinical or surgical checklists and practice assessments related to maintaining certification. Participation in an APM, as defined in section 1833(z)(3)(C) of the Act. In the MIPS and APMs RFI, we requested recommendations on the inclusion of the following five potential new subcategories: Promoting Health Equity and Continuity, including (a) serving Medicaid beneficiaries, including individuals dually eligible for Medicaid and Medicare, (b) accepting new Medicaid beneficiaries, (c) participating in the network of plans in the Federally Facilitated Marketplace or state exchanges, and (d) maintaining adequate equipment and other accommodations (for example, wheelchair access, accessible exam tables, lifts, scales, etc.) to provide comprehensive care for patients with disabilities. Social and Community Involvement, such as measuring completed referrals to community and social services or evidence of partnerships and collaboration with the community and social services. Achieving Health Equity, as its own performance category or as a multiplier where the achievement of high quality in traditional areas is rewarded at a more favorable rate for MIPS eligible clinicians or groups that achieve high quality for underserved populations, including persons with behavioral health conditions, racial and ethnic minorities, sexual and gender minorities, people with disabilities, people living in rural areas, and people in geographic HPSAs. Emergency preparedness and response, such as measuring MIPS eligible clinician or group participation in the Medical Reserve Corps, measuring registration in the Emergency System for Advance Registration of Volunteer Health Professionals, measuring relevant reserve and active duty military MIPS eligible clinician or group activities, and measuring MIPS eligible clinician or group volunteer participation in domestic or international humanitarian medical relief work. Integration of primary care and behavioral health, such as measuring or evaluating such practices as: Co-location of behavioral health and primary care services; shared/integrated behavioral health and primary care records; or cross-training of MIPS eligible clinicians or groups participating in integrated care. This subcategory also includes integrating behavioral health with primary care to address substance use disorders or other behavioral health conditions, as well as integrating mental health with primary care.

What Can You Do Now? Become a PCMH Medical Home 2017 standards improved Review the list of Clinical practice Improvement Activities on the CMS website and understand what activities your practice can qualify. Stephanie share with us how these measures cross over into SIM TCPI and Evidence Now

Domain Four ADVANCING CARE INFORMATION 25% - Year 1
Overall, scoring will be based on the degree to which a practice performs in the following areas: Electronic prescribing Patient electronic access Health information exchange Care coordination through patient engagement Participation in public health immunization and clinical data registries Protection of patient health information Advancing Care Information is the federal government’s new name for meaningful use, and it makes up 25 percent of a practice’s score. The new measure emphasizes interoperability and information exchange, CMS says, and providers will no longer be required to report on clinical decision support and computerized provider order entry.

What Can You Do Now? Map your practice’s progress towards achieving Meaningful Use stage 3 requirements and make sure you are using a certified EHR. (Base Score) Providers/clinicians may have the opportunity for bonus points for submitting quality measure data using certified EHR technology. Develop encourage your patient portal ECs could potentially be measured on how the use of health IT contributes to the overall health of their patients i.e. tie patient health outcomes with the use of health IT. Remember activation levels less activated need assistance and guidance to use portal We have learned from this feedback that clinicians desire flexibility to focus on health IT implementation that is right for their practice. We have also learned that updating software, training staff and changing practice workflows to accommodate new technology can take time, and that clinicians need time and flexibility to focus on the health IT activities that are most relevant to their patient population. Clinicians also desire consistent timelines and reporting requirements in order to simplify and streamline the reporting process. Recognizing this, we have worked to align the advancing care information performance category with the other MIPS performance categories, which would streamline reporting requirements, timelines and measures in an effort to reduce burden on MIPS eligible clinicians. The implementation of the advancing care information performance category is an important opportunity to increase clinician and patient engagement, improve the use of health IT to achieve better patient outcomes, and continue to meet the vision of enhancing the use of certified EHR technology as defined under the HITECH Act. As discussed later in this section, we are proposing in section II.E.5.g.6.a. new flexibility in how we would assess MIPS eligible clinician performance for the advancing care information performance category. We propose to emphasize performance in the objectives and measures that are the most critical and would lead to the most improvement in the use of health IT and health care quality. We intend to promote innovation so that technology can be interconnected easily and securely, and data can be accessed and directed where and when it is needed to support patient care. These objectives include Patient Electronic Access, Coordination of Care Through Patient Engagement and Health Information Exchange, which are essential to leveraging certified EHR technology to improve care. At the same time, we propose to eliminate reporting on objectives and measures in which the vast majority of clinicians already achieve high performance—which would reduce burden, encourage greater participation and direct MIPS eligible clinicians' attention to higher-impact measures. Our proposal balances program participation with rewarding performance on high-impact objectives and measures, which we believe would make the overall program stronger and further the goals of the HITECH Act.

Base score for this domain
Beyond the base score In addition to the base score, which includes submitting each of the objectives and measures in order to achieve 50 percent of the possible points within the advancing care information performance category, we propose to allow multiple paths to achieve a score greater than the 50 percentage base score. The performance score is based on the priority goals established by CMS to focus on leveraging certified EHR technology to support the coordination of care. A MIPS eligible clinician would earn additional points above the base score for performance in the objectives and measures for Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange. These measures have a focus on patient engagement, electronic access and information exchange, which promote healthy behaviors by patients and lay the ground work for interoperability. These measures also have significant opportunity for improvement among eligible clinicians and the industry as a whole based on adoption and performance data. We believe this approach for achievement above a base score in the advancing care information performance category would provide MIPS eligible clinicians a flexible and realistic incentive towards the adoption and use of certified EHR technology.

APM = Alternative Payment Models
Comprehensive ESRD Care Model (Large Dialysis Medicare Shared Savings Program—Track 3 Organization arrangement) Next Generation ACO Model Comprehensive Primary Care Plus (CPC+) Oncology Care Model Two-Sided Risk Arrangement (available in 2018) Medicare Shared Savings Program—Track 2 Advanced Alternative Payment Models (APMs) Clinicians who take a further step towards care transformation—participating to a sufficient extent in Advanced Alternative Payment Models—would be exempt from MIPS payment adjustments and would qualify for a 5 percent Medicare Part B incentive payment. To qualify for incentive payments, clinicians would have to receive enough of their payments or see enough of their patients through Advanced APMs. The participation requirements are specified in statute and increase over time. Under the new law, Advanced APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily-required demonstrations where clinicians accept both risk and reward for providing coordinated, highquality, and efficient care. These models must also meet criteria for payment based on quality measurement and for the use of EHRs. The proposed rule lays out specific criteria for determining what would qualify as an Advanced APM. These include criteria designed to ensure that primary care physicians have opportunities to participate in Advanced APMs through medical home models. The proposed rule includes a list of models that would qualify under the terms of the proposed rule as Advanced APMs. These include: • Comprehensive ESRD Care Model (Large Dialysis • Medicare Shared Savings Program—Track 3 Organization arrangement) • Next Generation ACO Model • Comprehensive Primary Care Plus (CPC+) • Oncology Care Model Two-Sided Risk Arrangement • Medicare Shared Savings Program—Track 2 (available in 2018) Under the proposed rule, CMS would update this list annually to add new payment models that qualify to be an Advanced APM. CMS will continue to modify models in coming years to help them qualify as Advanced APMs. In addition, starting in performance year 2019, clinicians could qualify for incentive payments based, in part, on participation in Advanced APMs developed by non-Medicare payers, such as private insurers or state Medicaid programs. The proposed rule also establishes the Physician-Focused Payment Technical Advisory Committee to review and assess additional physician-focused payment models suggested by stakeholders. Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 33

How to Prepare My Practice for VBPM
Understand how your practice will be affected Participate in PQRS. Participation is required, as the VBPM relies on PQRS measures reported by physicians for quality performance analysis. This also means that those providers who are impacted by the VBPM and do not participate as required in PQRS will see a double penalty — one reduction for non-PQRS participation as well as an additional reduction under the VBPM for not participating in quality reporting. PQRS and the VBPM are inter-related, but distinct programs and criteria must be satisfied in each separate program. Access your practice’s QRUR. Authorized representatives of groups can access their QRURs using valid Enterprise Identity Management System (EIDM) log-in credentials to the CMS Enterprise Portal. Copyright Medical Group Management Association® (MGMA®) . All rights reserved. 37

References Centers for Medicare & Medicaid Services. CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Baltimore, MD: Centers for Medicare & Medicaid Services;

References Federal Registry Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models A Proposed Rule by the Centers for Medicare & Medicaid Services on 05/09/2016

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