1. Medicare: Risks and Opportunities for 2019
Erin Mackay
Associate Director, Health IT Policy & Programs
Families USA Health Action Conference
January 25, 2019

2. About us
The National Partnership for Women & Families is a nonprofit, nonpartisan advocacy group dedicated to promoting fairness in the workplace, access to quality health care, and policies that help women and men meet the dual demands
of work and family.
More information is available at

3. Following the money
Previous physician payment system, the Sustainable Growth Rate (SGR), implemented in 1997
Growing consensus of need to shift away from fee-for-service
MACRA and the Quality Payment Program (passed in 2015)
Eliminated annual uncertainty by repealing the SGR and stabilizing payment updates for physicians
Created two payment tracks for providers:
(1) Merit-Based Incentive Payment System (MIPS)
(2) Alternative Payment Models (APMs)
Why should consumers, advocates care?
Progress toward paying for value, not volume

4. What is value-based care?
A system that rewards and supports providers to:
Deliver high-quality care
Ensure ready access to care
Effectively coordinate care
Meaningfully engage patients and families
Robust use of health information technology
Address non-clinical needs
Promote health equity
Achieve better health outcomes
“Better” as defined by patients/families; reflective of their goals, preferences, needs
Patient-reported outcomes
Patient experience
Reduce health care disparities
Reduce cost

5. MIPS (Merit-based Incentive Payment Program)
Track 1 – (baby) stepping away from Fee-for-Service
MIPS-eligible clinicians receive a composite score based on their performance in four categories:
Quality
Cost
“Meaningful use” of certified EHR technology
Clinical practice improvement activities
Providers began reporting performance data in 2017, with the first payment adjustments going into effect January 01, 2019

6. Promising measures Quality performance category
Average Change in Functional Status Following Total Knee Replacement Surgery
Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls
Cost performance category
Medicare Spending Per Beneficiary (MSPB)
Total Per Capita Cost (TPCC)
8 episode-based cost measures (e.g., Knee Arthroplasty; Simple Pneumonia with Hospitalization)
Technology* performance category
Provide Patients Electronic Access to their Health Information
Support Electronic Referral Loops by Receiving and Incorporating Health Information
Electronic Prescribing bonus - Query of Prescription Drug Monitoring Program (PDMP)
Clinical Practice Improvement Activities
Provide Clinical – Community Linkages
Implement a Patient Navigator Program to Reduce Avoidable Hospital Readmissions
PCP and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients

7. Outstanding questions
How much of health care are we transforming?
“Pick your pace” policies
Number of participating clinicians (exclusions)
Program complexity
What’s the goal of the Patients over Paperwork initiative?
Reduce burden on providers
Add additional flexibility
What does this mean for consumers?
Slower move toward a high-value system
Little progress accessing meaningful quality information
Further delay in technology functions that are a priority

8. Advanced APMs (Alternative Payment Models)
Track 2 – getting closer to value
Providers qualify for the Advanced APM bonus if their payment model meets three criteria:
Use quality measures comparable to MIPS
Use certified EHR technology
Bear at least nominal financial risk (or be a Medical Home Model expanded under CMS Innovation Center authority) 
Advanced APM Potential Benefits:
5 percent bonus
APM-specific rewards
Exclusion from MIPS

9. Examples Qualifying Advanced APMs for 2019 include:
Accountable Care Organizations (ACOs) are most commonly described as groups of physicians, hospitals and other health care providers that join together as one entity to take responsibility for improving the quality of care for their patients.
Bundled payment is a single payment to providers or health care facilities (or jointly to both) for all services to treat a given condition or provide a given treatment.
Oncology Care Model (OCM) is made up of physician practices under a specific payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration for cancer patients.
Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.
Comprehensive ESRD Care (CEC) models aim to identify ways to improve the coordination and quality of care for Medicare beneficiaries living with End Stage Renal Disease (ESRD).

10. Consumer priorities for new payment models
APMs have the potential to provide the comprehensive, coordinated, patient- and family-centered care patients want and need while helping to drive down costs...
If designed and implemented correctly!
Improve delivery of safe, timely, high-quality care
Meaningfully engage with patients and families
Tie payment to quality of care
Ensure health equity becomes an integral component of quality improvement
Protect consumer rights

11. For more information Contact me: Follow us: Find us: Erin Mackay
Associate Director, Health IT Policy & Programs
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