JULY 31, 2019

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

Advanced APM Participation Almost Doubled from 2017 to 2018
Participation in APMs through QPPís other track -- the Merit-Based Incentive Payment System (MIPS) -- also grew in 2018, increasing from 341,200 eligible clinicians in 2017 to 356,828 in 2018, the federal agency reported. "I am excited about this progress, as it is a critical indicator we are succeeding in our goal of maximizing participation in MIPS APMs and Advanced APMs," CMS Administrator Seema Verma stated in the blog post. "This increase in APM participation supports the evolution of the program and incentives towards a system of value that puts patients first." A major goal for QPP implementation is to move clinicians to APMs that hold providers financially and clinically accountable for the care they deliver to patients. To incentivize participation in such models, MACRA implementation rules state that eligible clinicians do not have to participate in MIPS and they can earn a five percent bonus by joining an approved APM. Advanced APM participation rates exceeded CMS goals for the first QPP performance year, according to the 2017 Quality Payment Program Reporting Experience report recently published by CMS. The federal agency only expected about 70,000 eligible clinicians to participate in the models in 2017. Verma pointed out that the statistic is "a strong sign that our incremental approach and flexible options lead to clinician success in MIPS." CMS also saw MIPS performance scores increase, with the largest gain in the Quality performance category. Additionally, MIPS final scores rose for all practice sizes and types of participation (i.e., individual, group, and clinicians participating in MIPS through an APM), the blog post stated. In particular, small practices scored higher in 2018 versus 2017, with nearly 85 percent surpassing the scoring threshold for a positive MIPS payment adjustment. Only about one-quarter (74 percent) of small practices achieved that in 2017. (RevCycle Intelligence, July 16, 2019)

2019 Promoting Interoperability Changes and the Impact on your MIPS Score
CMS has revamped the MIPS Promoting Interoperability (PI) category for the 2019 performance year, focusing more on interoperability and patient access to their health information. Beginning this year, 2015 Edition Certified Electronic Health Record Technology (CEHRT) is required to attest to the PI category. Additionally, the PI measures have been modified and MIPS eligible clinicians and groups will be scored solely on their performance on the measures. Making sense of all of the requirements can be challenging, so in this blog we will examine the major changes and how they could impact MIPS scores. (MDInteractive, July 21, 2019)

Value Based Care and the Evolution of Health Payment Models
The shift to value-based care has been a positive one for both patients and the healthcare system. But, itís left many physicians, particularly nephrologists, with a lot of questions about how they can be reimbursed for their services. In this article, we aim to demystify the ever-changing reimbursement landscape for nephrologists. Enacted in 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) did three important things from the perspective of the nephrologist:

  1. Repealed the sustainable growth rate (SGR), eliminating the flawed formula used to establish annual updates to the Medicare physician fee schedule (PFS)
  2. Sunset the three stand-alone CMS incentive programs (Physician Quality Reporting System or PQRS, Meaningful Use and the Physician Value-Based Payment Modifier or VBPM)
  3. Created the Quality Payment Program (QPP), which replaces the programs outlined above in 1 and 2

The QPP, now in its second year, represents a generational change with respect to the way Medicare pays physicians. The QPP effectively creates two physician payment tracks. Unless you are excluded, due to low volume or because it is your first year billing Medicare, you are either subject to the Merit-based Incentive Payment System (MIPS), or you are a Qualifying Participant (QP) within an Advanced Alternative Payment Model (Advanced APM or AAPM). (Fresenius Medical Care, accessed July 21, 2019)

CMS Issues Final Coverage Policy For TAVR
On June 21, the Centers for Medicare and Medicaid Services (CMS) released the final national coverage determination that will govern TAVR services to Medicare patients. The final policy is largely consistent with the draft NCD issued in March. The final coverage includes some familiar elements from the existing NCD that has been in place since 2012, while also taking new approaches to facilitate access to this therapy.

Under the final NCD, coverage would be contingent upon:

  • Care of the patient by an interdisciplinary heart team that includes a cardiac surgeon and interventional cardiologist;
  • Facility infrastructure and volume standards;
  • Interventional cardiologist and cardiac surgeon experience and volume standards;
  • Joint interventional cardiologist and cardiac surgeon participation in intraoperative technical aspects of the procedure; and
  • Data collection through a national registry to allow continued study of key research questions through the tracking of procedural and post-procedural outcomes.

These coverage criteria incorporate some themes and specifics from the 2018 AATS/ACC/SCAI/STS Expert Consensus Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement. The societies previously commented to CMS on the draft NCD that certain criteria to establish and maintain TAVR programs are necessary to optimize quality outcomes and patient safety, though CMS chose not to implement those exact recommendations. (American College of Cardiology, June 21, 2019)

Hundreds of New ICD-10-CM Codes Effective Oct. 1
The Centers for Medicare & Medicaid Services (CMS) released on June 20 the ICD-10-CM code descriptions, tables and index, and addendum for fiscal year 2020. There are 273 additions, 21 deletions, and 30 revisions, effective Oct. 1, 2019, which will increase the code set from 71,932 to 72,184 diagnoses. The majority of changes to ICD-10-CM for 2020 are seen in Chapters 9, 12, 17, 19, and 20 -- adding a considerable number of new codes, mainly to improve data specificity. (American Academy of Family Practice, June 21, 2019)

Intermountain Healthcare Announces New Company to Elevate Value-Based Care Capabilities
Intermountain Healthcare has formed a new comprehensive health platform company focused on elevating value-based care capabilities with providers, payers, healthcare systems, and accountable care organizations. The new company, named Castell, will enable other organizations to accelerate their transition from volume to value-based systems of care, while keeping care more affordable and accessible. "Intermountain Healthcare's mission is to help people live the healthiest lives possible. This commitment is the same no matter where, when, or with whom people get care," said Marc Harrison, MD, Intermountain president and CEO. "Castell is a critical component of Intermountain's broad vision for healthier communities. It creates a new path for providers to access the support they need to provide high quality, affordable care to their patients across the nation." Rajesh Shrestha has been named as the president and CEO of Castell. In addition to leading Castell, Shrestha serves as vice president and chief operating officer of Community Based Care for Intermountain Healthcare. He has more than two decades of experience accelerating other health companies move from fee-for-service to value-based care. "Healthcare's ongoing shift from volume to value-based systems of care enables providers, health systems, and payers to take a more holistic approach to managing the health of their patients, but also creates more financial risk or rewards," said Shrestha. "The health platform capabilities, tools, and resources that Castell provides will strengthen the ability of the health ecosystem to thrive in a value-based care environment." (TMC News, July 18, 2019)

Investing in Primary Care: A State-Level Analysis
In a first-of-its-kind study, this yearís report examines statesí primary care spending patterns, including spending across payer types, and considers the implications of these results for select patient outcomes.

The PCPCC 2019 Executive Report provides quantitative data and analysis of primary care spend at the state and payer levels, as well as a window into the association between primary care spend and key patient outcomes. In short, the report shows that primary care investment as a percentage of total health care expenditures was low between 2011 and 2016, and it varied considerably across states and across payers. The analysis also shows an association between more primary care investment and better patient outcomes. Finally, the report includes a description of legislative/regulatory efforts in 10 states to measure and report on primary care spend and to shift more resources into primary care.

(Patient-Centered Primary Care Collaborative, July 2019)

MACRA MIPS/APM Update e-Newsletter is one of a family of free e-Newsletters providing a complimentary video presentation and regularly updated news and key resources on major health care issues such as ACOs, patient safety, pay for performance, bundled payment, readmissions, and Medicaid. To view and subscribe to other e-Newsletters go to healthcareeNewsletters.com.

Seven Considerations in the Financial Modeling of Value-based Payment Arrangements

Charlie Brown
Associate Principal, ECG Management Consultants

Mark J. Carley
President, Colorado Health Neighborhoods Value Based Care Delivery

Jim Ryan
Manager, ECG Management Consultants

Terri Welter
Principal, ECG Management Consultants