1. 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

2. 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

3. 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

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

5. Federal Payment Reform
Bringing physicians together for a healthier Ohio

6. 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

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

8. 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)

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

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

11. AMA and CMS MACRA Resources
assn.org/ama/pub/advocacy/topics/medicare-new- payment-systems.page

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

13. 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 %
Improvement
Activities
Year 1 – 15%
Year 2 – 15%
Quality
Year 1 – 60%
Year 2 – 50%
Cost
Year 1 – 0%
Year 2 – 10%

14. 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

15. 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.

16. 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.

17. 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).

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

19. MIPS – Composite Score Adjustments
Based on a MIPS Composite Performance Score, clinicians will
receive + / - or neutral adjustments up to the percentages below
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

20. Benchmarks Available from CMS prior to each year

21. 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, Whenever you choose to start, you'll need to send in your performance data by March 31, You can also begin participating in an Advanced APM.
The first payment adjustments based on performance go into effect on January 1, 2019.

22. Key Dates submit Performance year feedback available payment
March 31, 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.

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

24. 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

25. APM Oversight done by Payment Model Technical Advisory Committee
Rules will establish review criteria
Comprehensive list of qualifying APMs
7.pdf

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

27. 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

28. Bringing physicians together for a healthier Ohio

29. 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

30. State Payment Reform Resources
Office of Health Transformation:
atives/payforvalue.aspx
Medicaid:
on.aspx
*Add footers & “Exhibit” references 30

31. How OSMA Can Help Advocate Inform Educate Implement
Partnership with Medical Advantage Group
Grant Opportunities