APRIL 17, 2019

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by the National MACRA Summit, National ACO Summit,
and the National Bundled Payment Summit.

New Online Tool Helps Providers, Payers with APM Implementation
The Health Care Payment Learning & Action Network (LAN) recently launched an interactive, online tool that aims to help providers, payers, and other healthcare stakeholders identify the challenges and opportunities with alternative payment model (APM) implementation. The Roadmap for Driving High Performance in Alternative Payment Models, or Roadmap, shares key insights from payers and providers who have successfully adopted and implemented APMs. Based on direct conversations with the stakeholders, LAN developed current success strategies and actions payers and providers should know to reduce costs while improving care quality. "For many providers, the transition from fee-for-service to fee-for-value is a journey marked by uncertainty, doubt, and many unanswered questions," Renee McLaughlin, senior medical director for value-based relationships at Cigna and LAN guiding committee member, stated in an emailed press release. "The Roadmap is a valuable tool that can provide insight and guidance to providers new to the field of population health as well as to seasoned experts, easing and accelerating the path to success in value-based care delivery." Healthcare payments are slowly, but surely transitioning away from fee-for-service. In fact, LAN reported in October 2018 that the majority of payments made in 2017 were tied to value and/or care quality to some degree. However, only about one-third of healthcare payments that year were paid under an APM that has some level of financial risk, ranging from upside rewards for appropriate care to integrated finance and delivery systems. LAN intends for the Roadmap to help accelerate the industry's shift to value-based reimbursement that holds providers financially accountable for the care they provide. That means helping providers and payers develop successful APMs and helping the stakeholders implement them appropriately. (RevCycle Intelligence, April 3, 2019)

BPCI Advanced Down to 1,295 Providers as 252 Drop Out
More than 250 providers have dropped out of BPCI Advanced, but despite the 16 percent drop in numbers, the Centers for Medicare and Medicaid Services and two conveners interviewed still call participation in the bundled payment model robust. CMS on Thursday announced 715 acute care hospitals and 580 physician group practices remain in the bundled payments for care improvement advanced program, for a total of 1,295 Medicare providers. This is a loss of 252 providers from the 832 acute care hospitals and 715 physician group practices, a total of 1,547, which began the program in October. A total of 1,086 contracts, that can cover numerous providers, remain as participants for the BPCI Advanced model for year 2. In October 2018, that number was 1,299. "My take is that I'm not surprised, participants were aware of this withdrawal opportunity," said Gina Bruno, vice president clinical strategy, naviHealth. Most providers "saw this as participation at scale. I think knowing that they had that get-out-of-jail free card led some to be more ambitious in participation. I'm also not surprised so many have remained." (Healthcare Finance, March 21, 2019)

Ignore the MIPS Performance Measures at Your Peril
The gist of the new system is that EPs will have to pay seven percent of their Medicare reimbursement back to CMS if they do not report their merit-based incentive payment system (MIPS) performance measures after the 2019 performance year. This bipartisan program was started in 2017 to transform the Medicare payment system from volume-based to value-based. The rationale is that Medicare recognized that paying EPs based solely on the number of patients treated and procedures performed did not ensure quality medical care. MIPS is basically a zero-sum game. High-performing MIPS clinicians get additional reimbursement under Medicare, while low performers have to pay the maximum penalty. To make matters worse, the penalty increases each year. By 2022, EPs who do not participate in MIPS will have to pay nine percent of their Medicare reimbursement. (See diagram.)

An increasingly important determinant of physician reimbursement from Medicare is accurately reporting quality metrics. Qualified Clinical Data Registries (QCDRs) collect clinical information for patient and disease tracking and are key to Medicare's new merit-based payment system. (Emergency Medicine News, April 2019)

Medicare Supplement Insurance Association's Conference to Focus on MACRA Changes
MACRA changes impacting Medicare Supplement insurance next year will be a significant focus of the American Association for Medicare Supplement Insurance's 2019 National Medicare Supplement Insurance Summit. "The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will significantly change Medigap insurance marketplace and will be a major focus of this year's conference," announced Jesse Slome, director of the Association that organizes the industry conference. Signed into law on April 16, 2015 MACRA prohibits the sale of Medigap policies that cover Part B deductibles to "newly eligible" Medicare beneficiaries. "Individuals who turn 65 on or after January 1, 2020 or those who first become eligible for Medicare due to age, disability or end-stage renal disease, on or after January 1, 2020 will be affected notes Slome. MACRA is a most significant change and we'll have experts speaking at the conference who are focused on explaining the latest developments," Slome notes. After January 1, 2020 there are possible fines, imprisonment of not more than five years, and/or civil money penalties of not more than $25,000 for each prohibited act (PR.com, March 29, 2019)

Not Just the "Soft Stuff": How Data Deployment, Artificial Intelligence Can Restore Relationships in Oncology Care
The revolution in cancer care isn't just about the wave of life-saving therapies, or the role of genetics in pinpointing exactly who should get which drug and when. As Ray D. Page, DO, PhD, FACOI, tells it, change also means getting back to the basics, so that the relationship between doctor and patient drives care -- not insurance companies or Medicare or rules from the FDA. The revolution in cancer care isn't just about the wave of life-saving therapies, or the role of genetics in pinpointing exactly who should get which drug and when. As Ray D. Page, DO, PhD, FACOI, tells it, change also means getting back to the basics, so that the relationship between doctor and patient drives care -- not insurance companies or Medicare or rules from the FDA. Giving patients what they need at a fair price -- not care they don't need or can't afford -- is how Page envisions transformation. The president and director of research at The Center for Cancer and Blood Disorders, in Fort Worth, Texas, has plenty to say about the barriers that are preventing shared decision-making -- from the bureaucracy of "Obamacare" to the failed promise of electronic health records (EHRs), which he called, "the number one cause of physician dissatisfaction. "You should be able to negotiate a rate for services at a fair market value price," Page said, as he discussed his challenges with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA),2 which sought to shift healthcare away from fee-for-service (FFS) toward payment based on quality. But Page said much of MACRA has only made things more complex for oncology practices. Given the choice between the Merit-based Incentive Payment System, or MIPS, and an alternative payment model (APM), Page's practice pursued the Oncology Care Model (OCM), an APM regulated by the (American Journal of Managed Care, March 29, 2019)

Free-Market Advocate Slams Independent Practice for NPs; They need to be integrated into physician practice, says Nicole Johnson, MD
The physician shortage will not be solved by allowing nurse practitioners and other advanced practitioners to practice independently without physician supervision, Nicole Johnson, MD, said Monday at a meeting sponsored by the Practicing Physicians of America, a free-market healthcare group. "Twenty-three states [allow] nurse practitioners to practice unsupervised by physicians," said Johnson, a pediatrician in Cleveland. "Nurses are practicing medicine without a license to do so, and it's dangerous and unsafe for patients." In addition, "they have oversaturated their market and we still need physicians -- they haven't improved access to care and haven't improved affordability -- and this is in the face of a nursing shortage. They need to solve that problem [without] bleeding out the nursing population." Instead, nurses "should be integrated into physician-led teams and [not act as] physician substitutes," Johnson said. (MedPage Today, April 1, 2019)

Using the AQUA Registry for MIPS Reporting
The Merit-based Incentive Payment System (MIPS) is a path to participate in the CMS Quality Payment Program (QPP), which was created under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 to combine multiple value-based programs. The AQUA Registry is a "one-stop shop" which reports on measures in all required MIPS categories. The graphic below shows how the AQUA Registry can help streamline your practice's MIPS reporting needs. If you participate in Medicare Part B, you may earn a performance-based payment adjustment through MIPS.

Who is eligible?
Eligible providers must bill Medicare Part B more than $90,000 annually, provide care to more than 200 individual Part B beneficiaries AND provide more than 200 covered professional services under the Physician Fee Schedule. If all three requirements are met, than the clinician must report for the 2019 performance year. Clinicians can check their eligibility status using the CMS Lookup Tool. Additionally, for MIPS you must also be a:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist
  • Occupational therapist
  • Qualified speech–language pathologist
  • Qualified audiologist
  • Clinical psychologist
  • Registered dietician or nutrition professional

(American Urological Association, accessed April 5, 2019)

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Panel II: Making the Business Case for Value-Based Care: Real-World Provider Case Studies Show Evidence that Focusing on Value is a Better Business Model than Maximizing Volume

Karen Conway
Vice President, Healthcare Value, Global Healthcare Exchange

David B. Muhlestein
Chief Research Officer, Leavitt Partners, LLC

Sanjay Doddamani
Senior Director in Population Health, Geisinger Health System

David Nace
Chief Medical Officer, MarkLogic