1. MACRA, TCPI-PTN, SIM/SHIP
What comes after CMMI-
MACRA, TCPI-PTN, SIM/SHIP
William Brien
Director of Practice
Transformation
September 19, 2018

2. The SNMHI Framework: The Change Concepts for Practice Transformation
Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered
Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:

3. What was the SGR? What happened in 2015?
History of the Sustainable Growth Rate
What was the SGR?
The Sustainable Growth Rate (SGR) was the mechanism in the Medicare Physician Fee Schedule implemented in 1997 to control payments based on a formula tied to the GDP
Each year (17 times) Congress suspended or adjusted the rates to prevent cuts to fees resulting in over $150 B in “fixes”
There were many unsuccessful efforts to repeal/replace it over the last decade
What happened in 2015?
Growing consensus of need to shift away from fee-for-service
Strong and uniquely unified push by physician community
Bipartisan, bicameral consensus on the policy with highly committed Congressional leadership
Result: Overwhelming support 92 – 8 Senators; 392 – 37 Representatives
September 19, 2018

4. Extends programs such as CHIP, community health
What does MACRA do?
Eliminates the annual uncertainty and need for “fixes” by stabilizing payment schedules
Combines three physician-level incentive programs (PQRS, Value Based Modifiers and Meaningful Use) into one
Extends programs such as CHIP, community health
centers, and performance measurement.
Meaningful progress toward paying physicians for value, not volume
September 19, 2018

5. Immediately replaces old SGR cycle with short
What does MACRA do?
Immediately replaces old SGR cycle with short
term stable updates, then offers two paths
Establishes a merit based incentive program (MIPS)
Incentivizes the development of, and participation, in alternative payment models (APMs)
September 19, 2018

6. Phases of MACRA
Phase 1 (2015 – 2019): Repeals SGR statute and implements a stepwise adoption of the first overall Physician Fee Schedule increase in over a decade. Consistent payment structure for all physicians.
Phase 2 (2019 – 2025): Begins new payment mechanisms through MIPS and Alternative Payment Mechanisms (APMs)
Phase 3 (2026 and Beyond): All incentives stop. Increase of fees by 0.25% for MIPS providers; increase of 0.75% for APM providers.
September 19, 2018

7. Phases of MACRA Source: The National Partnership for Women & Families
September 19, 2018

8. MIPS Payment Structure
Beginning in 2019 the three quality programs will be merged into a single quality improvement program – Merit-based Improvement Payment System (MIPS
The current penalties for PQRS, VBM and MU will be eliminated and providers will be paid based on there MIPS adjusted rate beginning January 1, 2019
Funds are expanded to provide incentive payments (4% to 9%) for physicians who high performing in EMR implementation, quality reporting resource use and clinical practice improvement. Penalties (-4% to -9%) will also be in place for those providers who fall short.
September 19, 2018

9. MIPS Payment Structure
Meaningful Use
2019: 25%
Quality Reporting
2019: 30%
Resource Use
Clinical Practice Improvement
2019: 15%
Notes
The provider is scored on a scale of 0 – 100 points.
Takes into account both benchmarking against a national average and also against a provider’s own performance from one year to another when compared the baseline.
Combines Meaningful Use with Cost, Quality and “Clinical Practice Improvement;” % can change each year.
Source: Ohio Health Information Partnership

10. Requirements may include three criteria:
APM Participation
Providers participating in an Alternative Payment Model (APM) such as an ACO or advanced PCMHs can choose a different model than MIPS
Requirements may include three criteria:
1. Qualifying Model
2. Quality Measures
Financial Risk
Receive 5% increases in each of years
September 19, 2018

11. What can you do to prepare?
Practices are encouraged to do 3 things:
Join a Practice Transformation Network (PTN)
Join an ACO
Become a PCMH.
PTNs are peer-based learning networks designed to coach, mentor, and assist clinicians in developing core competencies specific to practice transformation. They are part of the CMS's new Transforming Clinical Practices Initiative.
As an ACO or PCMH, practices must establish processes that will help them be successful in the new system. Many ACOs are requiring certified EHRs, quality reporting, and population management. These are areas that will become integral parts of the APMs as they become more fully defined. In addition, many of the requirements to become a PCMH will necessitate that practices transform and use technology in ways that will position them to meet the anticipated requirements of APMs of the future.
September 19, 2018

12. Practice Transformation Networks (PTNs)
Practice Transformation Networks (PTNs) are peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies specific to practice transformation.
Clinician practices can become actively engaged in the transformation and collaborate with a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system.
September 19, 2018

13. Who can participate?
The NYSPTN is for primary care or specialty care practices that want to improve care and prepare for major payment changes.
Eligible practices:
• Use a 2014 Certified Electronic Health Record
• Are not currently participating in a Medicare Shared
Savings Program, Pioneer ACO program, Multi- Payer Advanced Primary Care Program, or Comprehensive Primary Care Initiative
Note: Practices participating in some other practice transformation programs may be excluded from participation.
September 19, 2018

14. PTN Enrollment Benefits
• Skilled technical assistance provided through a combination of remote and on-site training & support
• Assistance with preparing for value based payment as occurs in ACO’s and other evolving models
• Support for PQRS and Meaningful Use programs and adoption of processes that are required for PCMH/APC
• Coaching and mentoring
• Peer-level support
• Practice transformation tools and sample work flows
• Access to national expert faculty through free assistance from Support and Alignment Networks (Ex. ACP, AMA)
• Free CME and MOC credits for most project related educational opportunities
September 19, 2018

15. NYS DOH SIM/SHIP
NYS DOH has recently announced opportunities for funding to support practice transformation through the State Innovation Model (SIM)/State Health Innovation Plan.
This program will provide Practice Transformation Technical Assistance Services beginning in late 2016.
The program is based on development of integrated care system with a foundation in an Advanced Primary Care model premised on primary care’s central role in coordination of care for patients.
This will provide new options for primary care practices to develop patient centered care capabilities and obtaining recognition for participation in value based payment models.
September 19, 2018

16. American College of Physicians:
For more information:
American College of Physicians:
MACRA, MIPS, and APMs - What to Expect from all these Acronyms
MACRA Resources and Information (Medicare)
MACRA Frequently Asked Questions
American Medical Association:
Helping physicians understand the choices they will receive with MACRA
Effects of alternative payment models (APMs) on physician practices
Modules and tools for practice transformation assistance
September 19, 2018

17.
September 19, 2018