1. Holy MACRA, this is how we get paid? September 17, 2017
Lawrence Cowsill, D.O., FACOI

2. President Trump said…
“Nobody knew health care could be so complicated.”

3. MACRA Current State MACRA Future State Quality Payment Program Buzz
Discussion Menu
MACRA Current State
MACRA Future State
Quality Payment Program Buzz

4. Things I Should Confess…
A practicing internist and Senior Medical Director of McLaren Physician Partners
An urban doctor with no hidden agenda
Fortunate to have a practice partner who shares a passion for change
No allegiance except to my patients, the health care system and collaborative physicians

5. Perfect Storm of Change
Replace SGR with MACRA…WHY?
Move from volume-based payment to value-based payment.
Reward high performance providers.
Sunset programs like PQRS, MU and VBM.
Move physicians to taking risk and managing risk.
To formulate a simple, transparent value based payment process.

63. MACRA Future State

64. Proposed Rule for QPP Year 2
Transition Year (2017) Policies:
Pick your Pace
Minimum amount of data
90 days of data
One year of data
Having a low-volume of MA payments/patients – EXEMPT
Flexibilities for physicians who are hospital-based or limited face-to-face encounters.

65. Proposed Rule for QPP Year 2: MIPS
For Quality & Cost categories increase the performance period to include full year of data.
For Improvement Activities and Advancing Care Information categories increase performance period to 90 days of data.

66. Proposed Rule for QPP Year 2: MIPS
Offer “Virtual Groups” participation.
Increase the low-volume threshold to help exemptions
Continue to allow the use of edition CEHRT.
Add bonus points for:
Caring for complex patients
Use of 2015 edition CEHRT
Use facility-based scoring for facility- based physicians

67. Proposed Rule for QPP Year 2: MIPS
Flexibilities for small practice providers:
Hardship exception in the Advancing Care Information category
Bonus points to the final score for small practices providers
Award small practices 3 points for measures in the Quality category that don’t meet data completeness

68. Comparison of current policy to proposed policies
Transition Year – FRCY 2017
Low Volume Threshold
Year 2 – PRCY 2018
Low Volume Threshold
Exclude MIPS ECs or GRPs with less/equal $30,000 in Part B allowed charges
Less/equal 100 Part B beneficiaries in a year
Increase threshold to exclude MIPS ECs or GRPs with less/equal $90,000 in Part B allowed charges
Less/equal 200 Part B beneficiaries in a year
Starting in 2019 MIPS Perform period – let docs opt-in to MIPS if exceed 1 or 2 of the above components.

69. Comparison of current policy to proposed policies
Transition Year – FRCY 2017
Non-Patient Facing
Year 2 – PRCY 2018
Non-Patient Facing
Individuals: 100 or less patient facing encounters
Groups: > 75% NPIs billing under group’s TIN during a performance period are labeled as non-patient facing.
No change in how CMS is defining non-patient facing clinicians.
Proposing same definition for Virtual Groups.

70. Comparison of current policy to proposed policies
Transition Year – FRCY 2017
Facility-Based Measurement
Year 2 – PRCY 2018
Facility-Based Measurement
Not available in 2017.
Optional, voluntary FB scoring mechanism based on Hospital V-B Purchasing Program
FB clinicians at least 75% of professional services in inpatient setting or ED.
FB option converts a hospital Total Performance Score into MIPS Quality & Cost score

72. Quality Payment Program Buzz

73. Major Problems with MIPS
Incentives for clinicians to reduce services are weak.
Incentives for providers to improve quality are weak.
Providers can choose measures
Limited number of measures
Risk adjustment
Clinical performance influenced by patient factors rather that quality of care
Providers bear cost of performing well on high risk patients when risk comes from non-medical factors
Attract low-risk patients
J. Michael McWilliams, MD, PhD
Annals of Internal Medicine, July 2017

74. MACRA, in passing…
Good to merge diverse programs, to many nuisance or nuance?
Road map to success is not clear
All theory
Not providing consistent answers
Designed for family practice/internal medicine
Effects small portion – MAFFS, Railroad

75. Cost of Advancing Care Information
The Application Programing Interface(provide Patient Access)
Certified EHR (2014 or 2015 edition or combo)
Vendor relationship
Security Risk Analysis and Security Updates
The cost of the Interface (Summary of Care)

76. MIPS APM, Simply Put… (A program of flexibility or nuance?)
Check to see if eligible participant in MIPS
Cost domain – not included for 2017 and 2018
Not PCMH, but in ACO – require MIPS participation
No EHR – no reporting Advancing Care Information
Re-weighting
PCMH overrides Improvement category.

77. MACRA, not so fast…

78. MACRA vs SGR…
Unless significant bonuses earned in MIPS Part B payment will not keep up with inflation
Some long term projections indicate physician payment under MIPS will be worse than under SGR

79. What keeps post-acute care directors up at night?
Regulations – federal, state and local
STAR ratings
Relationships – where is my next patient coming from?

80. Spotlight on the SNF Use of 4 or 5 STAR facility Medical Oversight
Length of Stay
Expectations of Care
Communication with next provider
Transition of Care

81. Healthcare Future…. Universal coverage? Single Payer?
Limited Healthcare Vision?