New Payment Models Ahead What’s on the horizon for the Medicare payment landscape Harold With the U.S. health care system undergoing a momentous transition from a volume-based fee-for-service model to one focused on value and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) initiating new payment pathways, Medicare reimbursement is a hot topic across the health care spectrum. During several sessions at ACC.16, experts walked through what’s on the horizon for the Medicare payment landscape and how physicians should prepare for the changes. A session co-chaired by Paul N. Casale, MD, MPH, FACC, and Karen E. Joynt, MD, MPH, zoomed in on what new payment models mean for interventional cardiology. “MACRA repealed the Sustainable Growth Rate and left something more confusing in its place,” noted Joynt. “Now is the time for cardiology to get involved.” During the James T. Dove Lecture, Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, offered a closer look at the transition from volume to value and the role physicians and other health care providers can play going forward. "Physicians must play the lead role in creating a higher-value health care system, because only physicians can redesign the way services are delivered to reduce spending without harming quality or access for patients,” said Miller. Another session titled “Piecing Together the MACRA Puzzle” featured speakers from the Centers for Medicare and Medicaid Services and the American Hospital Association who discussed opportunities under the new payment system and how hospitals are preparing for MACRA. While MACRA legislation is written with broad directions that will be implemented through more specific regulation by the federal agencies over the next few years, physicians are already beginning to be paid differently than in the past. In March, the U.S. Department of Health and Human Services nnounced that it had achieved its goal of linking 30 percent of all Medicare payments to quality through alternative payment models (APMs) nearly a year ahead of its original prediction. APMs, one of the payment pathways under MACRA, are designed to encourage providers to take on financial risk for the health outcomes of an entire patient population. This approach demonstrates accountability not only for individual patients, but for an entire group of people. Furthermore, APMs tie financial risk to quality metrics that enhance information sharing, facilitate transitions of care and ultimately improve care coordination between all entities involved. MACRA also created the Merit-Based Incentive Payment System (MIPS). Eligible professionals who participate in MIPS will receive annual payment increases or decreases based on their performance. Furthermore, the three existing quality reporting programs – the Physician Quality Reporting System, Meaningful Use and the Value-Based Payment Modifier – are streamlined into one system under MACRA along with a new Clinical Practice Improvement category. There’s no question that practice quality improvement efforts, quality reporting and value-based reimbursement are here to stay, and will undoubtedly be a critical part of provider payment models regardless of how the details unfold. “The ACC is already at the table working to minimize challenges and take advantage of opportunities under the new system to support policies that facilitate evidence-based, cost-effective and high quality care,” said Immediate Past President Kim Allan Williams Sr., MD, MACC, during ACC.16. Stay up-to-date on MACRA developments and resources at ACC.org/MACRA. CMS Proposes Structure For MACRA Implementation The Centers for Medicare and Medicaid Services (CMS) released proposed regulations on April 27 to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These regulations will establish rules for clinician participation in both the Merit- Based Incentive Payment System and qualifying for incentive payments based on participation in Advanced Alternative Payment Models beginning with the 2019 payment year. The proposed regulations are open for public comment for 60 days. Additional information will be forthcoming as ACC's committees, councils and Advocacy staff review and analyze the proposals. Get up-to-speed on the background of the law and continue to watch for new updates on ACC’s MACRA Information Hub. Read more about CMS’ proposed implementation on ACC.org/MACRA. All Inclusive: Tips For Involving More Women in Clinical Trials With substantial disparities continuing to exist in the prevention, treatment and clinical outcomes of cardiovascular disease in women, a recent guest editor’s page in the Journal of the American College of Cardiology stresses the need for clinical scientists to have additional sex-specific strategies and methods at their disposal to study sex-specific cardiovascular health and disease in women. “Under-representation of women in cardiovascular clinical trials and data registries, coupled with lack of sex-specific data analysis, has constrained the evidence base for clinical decision-making,” write Nanette K. Wenger, MD, FACC, Pamela Ouyang, MBBS, Virginia Miller, PhD, and C. Noel Bairey Merz, MD, FACC. They note that clinical investigations addressing cardiovascular disease often fail to consider factors like reproductive history and psychosocial variables that disproportionately affect women. Their advice to investigators: • Improve trial design, enrollment and retention of women subjects • Improve results analysis and reporting • Provide better incentives to perform research in women • Mandate changes in the drug and device development and approval processes • Incorporate specific recommendations for women into guidelines when data are sufficient • Apply proven sex-based differences in risk stratification, diagnostic testing and drug usage and dosing They also suggest that population researchers consider including additional relevant clinical information such as hormonal phenotype, hormonal level status, pregnancy-related disorders, depression, abuse, domestic violence and post-traumatic stress disorders, as part of demographic information collected from study participants. “Including this information in appropriate databases will expand the scientific understanding of sex differences in clinical cardiovascular disease and provide additional evidence of specific sex-related variables influencing cardioascular disease in women,” they write. Good News For NIH Funding For the first time in roughly 12 years, Congress increased the budget for the National Institutes of Health (NIH) by 5. 9 percent for fiscal year (FY) 2016. This increase provides a much-needed boost in research capacity for the agency, which has suffered over the last more than a decade as a result of federal budget cuts, sequestration and inflationary costs. According to the NIH, between FY 2003 and FY 2015 the agency saw a 22 percent drop in its capacity to fund research, resulting in fewer research grants, fewer new discoveries and a decline in the number of scientists choosing to either remain in or join the research field. Even with this year’s increase, however, NIH’s capacity to fund research is still lower than it was prior to FY 2013. The ACC, working with its Health Affairs Committee and the Academic Cardiology Section, is committed to fostering research and innovation in cardiovascular care. Advocating for funding and policies that facilitate clinical research is critical to this effort. The Academic Cardiology Section is focused on advocating for support for research and graduate medical education (GME), collaborating with other like-minded academic and medical specialty organizations, and educating colleagues, legislators, and the general public about the specific issues facing academic medicine. Learn more about the Academic Cardiology Section at ACC.org/Academic. New Quality Measure Core Sets Provide Continuity For Measuring Quality Improvement The Core Quality Measures Collaborative, convened by the Centers for Medicare and Medicaid Services and America’s Health Insurance Plans, has announced six core quality measure sets, including one for cardiology, that are intended to make “quality measurement more useful and meaningful for consumers, employers, clinicians and public and private payers.” The ACC has been involved in the Collaborative since 2014 and played an instrumental role in shaping the final cardiology core measure set. However, both the ACC and the American Heart Association (AHA), while applauding the work of the Collaborative, are expressing concern about the inclusion of two conflicting measures addressing blood pressure control for patients with hypertension given their potential to confuse patients and providers. “Though we recognize that the inclusion of these two measures was a compromise agreed to by the members of the Collaborative in order to achieve a consensus, AHA and the ACC have concerns with the inclusion of the HEDIS 2016 measure in these core measure sets because of its potential to result in an increased population of patients with higher blood pressure,” write Richard A. Chazal, MD, FACC, president of the ACC, and Mark A. Creager, MD, FACC, president of AHA, in an editorial published in the Journal of the American College of Cardiology. Learn more about the measures on ACC.org. ACC Past President Takes Part in Capitol Hill Forum on Health Equity As part of National Minority Health Month, ACC Immediate Past President Kim Allan Williams Sr., MD, MACC, joined colleagues and lawmakers in Washington, DC, on April 29 at the U.S. Capitol Visitor Center for the Democratic Forum on Achieving Health Equity: The Path Forward. Williams was invited by the House Energy and Commerce Committee Democrats in partnership with the Congressional Black Caucus, Congressional Hispanic Caucus and Congressional Asian Pacific American Caucus to speak on a panel titled, “Examining Disparities Across the Continuum of Care through the Lens of Heart Disease.” Read more on the ACC in Touch Blog. Rehabilitating the Heart of the Nation Pending legislation before the U.S. Congress represents a opportunity to expand access to cardiac rehabilitation (rehab) for patients in areas of need and to transform secondary prevention of cardiovascular disease across the country. This legislation would allow advanced practice clinicians (nurse practitioners, physician assistants and clinical nurse specialists) to meet the "direct supervision" requirement under Medicare. Currently, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires a physician to supervise cardiac rehab programs – a requirement that is inappropriately and unnecessarily more stringent than other outpatient services and limits patient access to cardiac rehab services while adding unnecessary costs for high-quality programs. According to Linda L. Hart, DNP, RN, ACNP-BC, AACC, a member of ACC’s Health Affairs Committee, and chair of ACC’s Cardiovascular Team Section Advocacy Work Group, “this legislation represents an opportunity for U.S. health care to move away from costly and unnecessary requirements, and provides a model for cardiovascular practices to embrace team-based care in a way that positively impacts our patients and expands access to important programs that prevent repeat cardiovascular events.” ACC Advocacy worked with other medical specialty societies, including the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation, to get H.R. 3355 introduced in the House after the Senate version was introduced in mid-2015. The ACC, along with AHA, is currently urging the Senate Finance Committee to include S.488 in its upcoming chronic care package. Read an ACC in Touch Blog by Richard A. Josephson, MS, MD, FACC and Derin Tugal, MD, members of ACC's Prevention of Cardiovascular Disease Section, about cardiac rehab. Learn more about the Section at ACC.org/PreventionSection. Visit the Prevention Clinical Topic Collection on ACC.org for the latest clinical news, patient case quizzes and more.
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