Medicare: Risks and Opportunities - PowerPoint Presentation

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Medicare: Risks and Opportunities for 2019

Erin Mackay Associate Director, Health IT Policy & Programs

Families USA Health Action ConferenceJanuary 25, 2019

About usThe 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 www.NationalPartnership.org.2

Previous physician payment system, the Sustainable Growth Rate (SGR), implemented in 1997 Growing consensus of need to shift away from fee-for-serviceMACRA 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 volumeFollowing the money 3

A system that rewards and supports providers to: Deliver high-quality careEnsure ready access to care Effectively coordinate care Meaningfully engage patients and familiesRobust use of health information technology

Address non-clinical needsPromote 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 What is value-based care?4

MIPS (Merit-based Incentive Payment Program) 5Track 1 – (baby) stepping away from Fee-for-Service

MIPS-eligible clinicians receive a composite score based on their performance in four categories: QualityCost“Meaningful use” of certified EHR technologyClinical practice improvement activitiesProviders began reporting performance data in 2017, with the first payment adjustments going into effect January 01, 2019

Promising measures 6Quality performance category

Average Change in Functional Status Following Total Knee Replacement SurgeryFalls: Screening, Risk-Assessment, and Plan of Care to Prevent Future FallsCost performance categoryMedicare Spending Per Beneficiary (MSPB) Total Per Capita Cost (TPCC) 8 episode-based cost measures (e.g., Knee Arthroplasty; Simple Pneumonia with Hospitalization) Technology* performance categoryProvide Patients Electronic Access to their Health InformationSupport Electronic Referral Loops by Receiving and Incorporating Health InformationElectronic Prescribing bonus - Query of Prescription Drug Monitoring Program (PDMP)Clinical Practice Improvement ActivitiesProvide 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

Outstanding questions 7How 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 providersAdd additional flexibility What does this mean for consumers?Slower move toward a high-value systemLittle progress accessing meaningful quality informationFurther delay in technology functions that are a priority

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 MIPSUse certified EHR technologyBear at least nominal financial risk (or be a Medical Home Model expanded under CMS Innovation Center authority)

 Advanced APM Potential Benefits:5 percent bonusAPM-specific rewardsExclusion from MIPSAdvanced APMs (Alternative Payment Models)8

Examples 9Qualifying 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).

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 careMeaningfully engage with patients and familiesTie

payment to quality of careEnsure health equity becomes an integral component of quality improvementProtect consumer rightsConsumer priorities for new payment models10

For more information

Find us:www.NationalPartnership.orgwww.GetMyHealthData.org Follow us:www.facebook.com/nationalpartnershipwww.twitter.com/npwf

Contact me:

Erin Mackay

Associate Director, Health IT Policy & Programs

emackay@nationalpartnership.org

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