MACRA: New Opportunities For Medicare Providers Through Innovative Payment Systems

Patrick H. Conway, Tim Gronniger, Hoangmai Pham, Kate Goodrich, Amy Bassano, JP Sharp,Alison Falb, and Molly MacHarris

oday, almost 60 million Americans are covered by Medicare — and 10,000 become eligible for Medicare every day.

For many years, Medicare was primarily a pure fee-for-service (FFS) payment system that paid health care providers based on the volume of services they delivered, not the value of those services. Over time, this contributed to increased costs with little improvement in the quality of care.

However, that system is changing as we work to improve our nation’s health care delivery system to ensure patients and their families receive the best care possible. And, we want to hear from you. Today, the Centers for Medicare & Medicaid Services (CMS) released a Request for Information (RFI) to seek public comment related to new provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): Merit-based Incentive Payment System (MIPS), Alternative Payment Models (APMs), and a physician-focused payment model (PFPMs).

Driven by the Affordable Care Act, CMS has taken substantial steps toward this better, smarter, and healthier system through quality improvement programs, promotion of electronic health record use, Accountable Care Organizations (ACOs), Patient Centered Medical Homes, bundled payment models, and other Alternative Payment Models (APMs) developed at CMS.

Driving CMS further along the path to value, in January 2015, Secretary Burwell set goals for 30 percent of traditional Medicare payments to be tied to APMs, such as bundled payments, ACOs, or medical homes, by the end of 2016, and 50 percent of such payments to be tied to these models by the end of 2018.

The Department of Health and Human Services (HHS) has already made significant progress in reaching these goals. In 2011, no Medicare payments were made through APMs; by 2014, approximately 20 percent of payments were made through these APM arrangements. And, HHS continues to catalyze stakeholders across the health care spectrum to join in the path to value. In March 2015, HHS launched the Health Care Payment Learning and Action Network to bring together stakeholders in the public and private sector to accelerate adoption of value-based payments and APMs.

The MACRA: A New Opportunity

On April 14, 2015, a large bipartisan majority in Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). President Obama signed the MACRA into law on April 16, 2015. The MACRA permanently repeals the flawed Sustainable Growth Rate formula for determining Medicare payments for clinicians’ services, establishes a new framework for rewarding clinicians for value over volume, and streamlines other existing quality reporting programs into one new system.

The MACRA was passed with bi-partisan support and will help accelerate paying for and rewarding value. Implementation of the MACRA is a major opportunity to put a broad range of health care providers on the path to value through the new Merit-Based Incentive Payment System (MIPS) and incentive payments for participation in certain Alternative Payment Models (APMs).

Path #1: MIPS

The MACRA sunsets the payment adjustments associated with the Physician Quality Reporting System, the Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) incentive program for Eligible Professionals. The MIPS combines those efforts into a single consolidated program with four weighted performance categories upon which eligible professionals (EPs) will be assessed: Quality; Resource Use; Clinical Practice Improvement Activities; and Meaningful Use of Certified EHR Technology.

MIPS requires the Secretary to develop and provide clinicians with a Composite Performance Score that incorporates MIPS EP performance on each of these categories. Based on this Composite Performance Score, EPs may receive an upward, downward, or no payment adjustment. MIPS offers an opportunity for EPs to achieve significant financial incentives for providing health care that advances the goals of a better, smarter, and healthier system.

Path #2: APMs

The MACRA also provides incentives for participation in certain APMs. “Qualifying APM participants” will not be subject to MIPS adjustments and will receive a lump sum incentive payment equal to 5 percent of the prior year’s estimated aggregate expenditures under the fee schedule. The 5 percent incentive payment is available from 2019 to 2024, but beginning in 2026, the fee schedule growth rate will be higher for qualifying APM participants than for other practitioners.

The MACRA also encourages expansion of the APM options available to physicians, especially specialists, through physician focused payment models (PFPMs). The law requires the establishment of a Technical Advisory Committee that will assess PFPM proposals submitted by stakeholders and make recommendations to the Secretary about which models to consider testing. This is a valuable opportunity for stakeholders to participate in delivery system reform by developing and submitting their ideas for APMs.

Request For Information

We encourage you to read the RFI and submit comments to CMS within the next 30 days. Your input is very important to us.

As we implement this historic legislation and continue to advance along the path to value in health care, we hope stakeholders will take this opportunity to provide input through the RFI. These new programs afford providers the opportunity to be rewarded for providing high quality care at lower costs, and our goal is to help providers be successful while reducing administrative burden. Together, we can create a health care system that delivers better care and healthier people and spends health care dollars more wisely.

MACRA: New Opportunities For Medicare Providers Through Innovative Payment Systems

Beyond the Buzz: The Myths and Realities of Consumer and Patient Engagement | EMR and HIPAA

Peter Edelstein  Medical Director at Elsevier

Today’s healthcare reform world is filled with buzzwords.  “Population Health Management.”  “Value-Based Care.”  “Patient Engagement.”  I am in no way suggesting that these topics do not play critical roles if we are to realize the enormous potential of healthcare reform.  However, if you ask ten people to define any one of these buzzwords, you’ll receive twelve different definitions.  And in a world of threatening reimbursement penalties and expanding healthcare legislation, the sooner that we come to some consensus on the basic meaning of these terms, the sooner we can understand the associated myths and realities.

Relative to the patient population (that is, the general population), the population of providers (doctors, nurses, and other clinicians) represents a fairly homogeneous and small group to target with initial reform efforts.  In addition, we are all painfully aware of the unacceptable number of preventable deaths and complications which occur at the hands of providers each and every day.  Thus reform legislation has first focused on reducing variability, elevating quality, and controlling the cost of care delivery through programs focused on providers (hospitals and healthcare systems, as well as the physicians, nurses, other clinicians who work in such institutions). 

Again, this makes sense as a starting point.  That said, to believe that we will achieve our ultimate goals of evolving into a system dominated by preventative care and outpatient and home health maintenance (leaving hospitals to serve only those whose chronic conditions can no longer be controlled in the outpatient setting) solely by changing how providers deliver care is a myth of epic proportions.  Far-and-away our greatest opportunity to shift our population’s health from reactive, acute, and expensive to proactive, preventative, and cost-efficient is by directly engaging and educating and empowering the general population of patients and future patients themselves. 

This perspective is based on two major realities.  First, studies (as well as our own experience) confirms that even individuals with chronic conditions spend on average only a handful of hours annually in front of a professional care provider.  (How many hours did you or your spouse spend under the direct care of a provider in the previous twelve months?  For the overwhelming majority of you, the answer is less than a couple.)  Second, patients who demonstrate interest in and ownership of their health have better clinical outcomes and reduced costs of care.  In a nutshell, people spend virtually all of their lives away from doctors, nurses, and hospitals, and as with virtually any complex processes, those who are more involved and knowledgeable have better outcomes.

Now we come up against another reality:  limited resources.  Hospitals and healthcare systems have limited staff and finances, and Patient Engagement often draws the short straw when competing with electronic health records, computerized order sets, and other provider-specific support solutions.  But, as I’ve suggested, de-prioritizing Patient Engagement as “less important” or “less impactful” is a myth which greatly limits our potential to increase the value (elevate quality/reduce costs) of healthcare delivery.  Thus, the most important first step for healthcare stakeholders to accept is the reality that assigning resources to Patient Engagement must be as great a priority (if not greater) as allocating staff and money to products and solutions which target only traditional providers.

Once healthcare leaders accept the critical importance of Patient Engagement, they again have to consider their limited resources.  It is another common and perilous myth when trying to allocate resources and develop and implement Patient Engagement strategies to consider all patients within a healthcare system’s catchment area as a homogeneous population.  The reality here is that not all individuals have the same potential for or barriers to becoming engaged patients.  And understanding with which patient subpopulations you can get “the most bang for your buck” is a necessity which is often overlooked. 

Beyond the Buzz: The Myths and Realities of Consumer and Patient Engagement | EMR and HIPAA

Age-Related Macular Degeneration

Normal healthy retinal fundus image

Age-related macular degeneration (ARMD) is the most common cause of severe vision loss in elderly persons in developed countries and accounts for one-third of cases of untreatable vision loss. ARMD is a painless, irreversible, degenerative eye condition associated with the damage and ultimate death of photoreceptors. There are two types of ARMD, dry and wet; dry ARMD is far more common, but wet ARMD is usually a more advanced disease state and is associated with rapid distortion and sudden loss of central vision. Various agents are used for treatment, and lifestyle changes and dietary constituents are important for preventing ARMD and halting its progression. As new therapies become available, early identification of patients with risk factors for ARMD will be increasingly important.

Introduction

Age-related macular degeneration (ARMD) is the leading cause of irreversible visual impairment in the elderly.^[1] ARMD is a degenerative disease of the central part of the retina— known as the macula—that results in a loss of central vision, which is essential for most daily activities.^[2] It is characterized by a loss of visual acuity caused by degeneration of the choriocapillaris, retinal pigment epithelium (RPE), and photoreceptors, usually beginning with drusen and pigmentary changes in Bruch's membrane.^[1,3]

^{Wet Age Related Macular Degeneration/Hemorrhage}

The condition, which affects 30 million to 50 million people worldwide, is the leading cause of irreversible blindness in developed countries in people aged 50 years and older.^[1,2] More than 1.75 million persons in the United States were reported to have ARMD in the year 2000, and it is thought that the incidence will increase to almost 3 million by 2020.^[2]

^{Progression of Age Related Macular Degeration}

The prevalence of ARMD increases exponentially every decade after age 50.^[4] In many Western countries, the prevalence of ARMD in individuals older than 55 years is 1.6% and increases to about 13% in persons older than 84 years.^[2] The loss of central visual acuity leads to a reduction in activities of daily living, as well as to mobility problems and an increased risk of falls, fractures, and depression in the elderly.^[5]

 

Age-Related Macular Degeneration

Precision Medicine, Patient Engagement Focus of Medicine 3.0

Precision Medicine, Patient Engagement Focus of Medicine 3.0

Texas Attorney General Defends Medical Board's Telehealth Limits - iHealthBeat

Texas Attorney General Defends Medical Board's Telehealth Limits - iHealthBeat

Lawmakers Call on HHS, OMB To Delay Final Stage 3 Rule - iHealthBeat

Lawmakers Call on HHS, OMB To Delay Final Stage 3 Rule - iHealthBeat

Necessary Medicare Fraud Alerts:

Medicare Fraud and Abuse perpetrators are inventive...to say the least.  How much of it is intentional or pre-meditated.

http://www.beckershospitalreview.com/legal-regulatory-issues/physician-who-billed-medicare-for-24-hour-workdays-convicted-of-fraud.html

http://www.beckershospitalreview.com/legal-regulatory-issues/5-recent-stark-law-settlements-september23.html

http://www.beckershospitalreview.com/legal-regulatory-issues/government-claims-hospital-owner-charged-medicare-for-bmws.html

http://www.beckershospitalreview.com/legal-regulatory-issues/prime-healthcare-sues-california-attorney-general-over-failed-hospital-deal.html

http://www.beckershospitalreview.com/legal-regulatory-issues/adventist-health-to-pay-record-breaking-118-7m-to-settle-improper-physician-compensation-claims.html

http://www.beckershospitalreview.com/legal-regulatory-issues/florida-hospital-district-to-pay-69-5m-to-settle-stark-law-false-clams-act-allegations.html

http://www.beckershospitalreview.com/legal-regulatory-issues/vanguard-health-systems-to-pay-2-9m-to-resolve-false-claims-kickback-allegations.html

Regulators to Shut Down Health Republic Insurance of New York - WSJ

It all started with great expectations.  Health Republic Insurance of New York  the largest COOP and fastest growing USA insurance company (0 to 215K members in 18 months) with over 42% year over year growth.  A health plan with the mission of providing high quality and affordable care .

The insurer lost about $52.7 million in the first six months of this year, on top of a $77.5 million loss in 2014, according to regulatory filings. The move to wind down its operations was made jointly by officials from the federal Centers for Medicare & Medicaid Services; New York’s state insurance exchange, known as New York State of Health; and the New York State Department of Financial Services.

In a statement, Health Republic said it was “deeply disappointed” by the outcome, and pointed to “challenges placed on us by the structure of the CO-OP program.”

Health Republic has about 215,000 members, with about half holding individual plans and half under small-business coverage, a spokesman for the insurer said.

The regulators said they chose to take action before the exchange’s November open enrollment period, when individuals can choose coverage with a new insurer. Health Republic policies will remain in effect amid “an orderly wind down” of the insurer’s operations, they said. In a statement, Kevin Counihan, the CMS official who oversees insurance marketplace operations, said the move came “because of the likelihood that Health Republic Insurance of New York would become financially insolvent.”

The shuttering of Health Republic, at least the fourth to falter among the ACA’s original 23 co-ops around the country, reflects the losses many insurers are seeing in their business related to the health law’s exchanges, which are particularly acute for small plans without deep pockets or diversified lines of business.

In Health Republic’s case, its premiums appeared not to be set high enough to cover members’ health expenses and its own costs, said Deep Banerjee, an analyst with Standard & Poor’s Ratings Services. “They are paying out in claims and expenses a lot more than they are getting in the door,” he said.

A Health Republic spokesman said the insurer didn’t receive the full rate increases it requested from state regulators for 2015, and “we didn’t feel as if we got rate adequacy” for this year’s plans.

The situation was complicated by programs created under the health law to ease risks for insurers that signed up a lot of sicker, more-costly enrollees. Under one of those programs, Health Republic had expected to break even, but instead it was assessed to pay around $80 million into the program’s pool, likely reflecting that it enrolled a relatively healthier clientele compared with competitors. Health Republic also expected to receive $147 million under another one of those programs, known as risk corridors, the insurer said. Because of a tweak to a federal spending bill, insurers may not get as much as they have projected, Mr. Banerjee said—an issue that could squeeze other companies.

The co-ops were set up as nonprofit insurance entities governed by their members, and analysts have said several of those that remain are in challenging financial straits. Health Republic’s membership is far larger than the next-biggest co-op, which had around 131,000 enrolled, according to Mr. Banerjee.

The Iowa insurance regulator said in January that it would shut down CoOportunity Health. At least two other co-ops, in Nevada and Louisiana, have said they won’t offer plans next year.

Regulators to Shut Down Health Republic Insurance of New York - WSJ

Dr Jay Lee Keynote at 2015 APAMSA Conference

Collaboration has become essential for progress and growth of health care. Silos are nothing new and it began with Abraham Flexner's report over 10 years ago. It is based  upon scientific approach to medicine.  Flexner's model was a sea-change in medicine creating a scientific methodology to diagnosis and treatment of patients based upon science, such as pathology, physiology, anatomy and other disciplines.


Dr. Jay Lee, President of the California Academy of Family Physicians, gives keynote at 2015 Asian Pacific American Medical Student Association…D. Jay Leno points out that we have outgrown Flexner's model. Medicine has grown vertically and horizontally. 



Dr. Lee covers the span of four generations in health care changes. No longer do we need to demonstrate in front of the White House, we can make a presence on facebook twitter, google, and blogs.

The triple AIM has become a goal. Donald Berwick coined tthe term. Today's trainees are in a 'golden moment' of medicine. The Affordable Care Act jolted the system...not as an end point but like a lottery basket it has stirred the mix and created change and the ability and necessity of using the ACA as a catalyst.

Physicians must be at diverse industry events in HIT and technology otherwise innovators do not have the knowlege or  guidance. Expositions such as those at SXSW and the CES afford this opportunity.  Many current common place technical devices were previously shown at these forums and later adopted my medicine by a physician entrepeneur.

Physicians need to become process engineers rather than medical directors.   Medical directors follow an established framework, engineers design a new system. 

Innovation and technology are not just about shiny new things, but also "blowing up the system, and creating new ideas for the system, work flows, application of population management for individuals.  We need to create a new system capable of managing many more patients to continue to provide personalized and patient centered care..  If we do not accomplish this end our healthcare will deteriorate into an even more impersonal encounter for ourselves and our patients.We need to  change from a  health system that innovates to a culture of innovators that deliver health care.  Innovation is  not going faster.....it is about changing direction.

Most of the content is attributable to Jay Lee, M.D. he is a family practitioner, President of the California Academy of Family Practice.

An Aging Population, Without the Doctors to Match -

We are already at the beginning of a new crisis in American Health Care. For those entering their senior years, according to Dr. David Reuben, a leading geriatrician at the U.C.L.A. Medical Center, a true national crisis is brewing.

Our average population age has gradually drifted up, due to longer life spans, the elimination of death from infectious diseases and cause of death from life-long chronic illness

Many people age prematurely or develop premature neurologic disease from stroke, heredity and chronic disease. The affordable care act will broaden coverage and add previously uniinsured to the insurance roles. Most  patient who are 65 or over and the disabled are covered by Medicare and/or Medicaid.

Venture capitalist and entrepeneurs are investing in long term homes for the aged. National franchises are appearing.

The missing link is the absence of geriatricians.

Currently there are fewer than 8,000 geriatricians in practice nationwide — and that number is shrinking. “We are an endangered species,” said Dr. Rosanne Leipzig, a geriatrician at Mt. Sinai Medical Center in New York.

At the same time, the nation’s fastest-growing age group is over 65. Government projections hold that in 2050 there will be 90 million Americans 65 and older, and 19 million people over age 85. The American Geriatrics Society argues that, ideally, the United States should have one geriatrician for every 300 aging people. But with the looming shortage of geriatricians, the society projects that by 2030 there will be only one geriatrician for every 3,798 older adults.
A vast majority of Americans have no conception of what lies ahead and — without geriatricians available to provide their health care — how substantially their lives will be affected. I know. It means that soon we may all soon be in the land of the pink bibs.

How will we solve this shortage ?  .....to be continued

An Aging Population, Without the Doctors to Match - The New York Times

The ACP Advocate Blog: What do doctors really think of Obamacare? (It’s not what critics have told you).

The ACP Advocate Blog: What do doctors really think of Obamacare? (It’s not what critics have told you).

America's Health Care-Cost Slowdown Goes Kaput; What Should Republicans Say (And Do) About It? - Forbes

America's Health Care-Cost Slowdown Goes Kaput; What Should Republicans Say (And Do) About It? - Forbes

Report: After two years, mHealth apps have evolved but majority are still lame - MedCity NewsMedCity News

Report: After two years, mHealth apps have evolved but majority are still lame - MedCity NewsMedCity News