Andrew P. Miller, MD, FACC Drinking From the MACRA Fire Hose Thank You for Being Late: An Optimist’s Guide to Thriving in the Age of Accelerations” by Tom Friedman provides an insightful look at the 21st century. Friedman notes that since the development of the iPhone, we are in a transformative time with change that is outpacing our ability to adapt. I couldn’t help but think about this concept while attending the ACC’s 2017 Cardiovascular Summit which focused on thriving in a time of change and included numerous sessions on the Medicare Access and CHIP Reauthorization Act (MACRA), one of the biggest transformations for clinicians. The Cardiovascular Summit helped me move a little closer to the intersection of human adaptability and technology that Friedman calls “learning faster and governing smarter.” The education at the Cardiovascular Summit, which centered around finance, operations, quality and data, is vital to our future and it’s clear we can no longer bury our heads in the sand – change is upon us! The time for whining and pining for the past is over. First, we need to shore up our MACRA implementation team in our practices and hospitals now that the Quality Payment Program (QPP) is officially underway. In my practice, this team is led by a highly intelligent and computer savvy physician and an information technology director/clinical informatician, and includes representatives from our entire operation. Our answer to MACRA (and/or valuebased care) has to be embedded throughout our practices. In a smaller practice, the physician leader needs to own this response, get educated and get going. Anyone who is touched by the QPP should be a part of the team. This will pull people outside of their comfort zones, but it’s necessary in this new era of value-based care. Second, in 2017, most cardiovascular professionals will participate in the Merit-Based Incentive Payment System (MIPS) track of the QPP, as opposed to the Advanced Alternative Payment Model (APM) track. Reporting is at the center of MIPS. The 2017 transition year provides an opportunity to make sure you’re performing well on the Quality, Improvement Activities, Advancing Care Information and Cost categories before things really kick into gear in 2018. Cathleen Biga, MSN, RN, co-director of the Cardiovascular Summit, recommends aiming for 70 points for MIPS in 2017 to gain access to extra reimbursement. Otherwise, you are taking a cut or staying close to neutral. Here are some tips for success with MIPS: • Start by looking at how you are doing in the Physician Quality Reporting System, Electronic Health Record (EHR) Incentive Program (Meaningful Use) and the Value Modifier. • Ensure you know how your EHR is creating data points and how you are going to report (through the EHR or through a registry like the PINNACLE Registry). • Dashboard the 15 Quality metrics and benchmark them to national deciles with a plan to narrow these down to your best six (remember never to report poor performance). • Attempt to report for the full year as opposed to the other three “Pick Your Pace” options for 2017 – you get a bigger denominator and more power. • Understand the Cost category even though it does not count this year and make sure you are correctly categorized in the Provider Enrollment, Chain and Ownership System. • Review the Advancing Care Information base measures and performance measures, and plan to attest with proof that you really did them. • Look at the 94 options for the Improvement Activities category and get at least one provider in your group to do enough of these activities to accumulate 40 points (four medium, two high, or a combination). Third, it’s not too early to start looking at Advanced APMs. As the tide rises on the MIPS categories and we all get better at value-based care, we are going to be pushed to the next level. You might as well start thinking about how you are going to move into the Advanced APM bucket now. Finally, even though we all want to focus on seeing patients, this new era of Medicare payment requires us to continuously reduce variability in care, understand cost and episodes of care, coordinate care and better document care. This perspective is authored by Andrew P. Miller, MD, FACC, governor of ACC’s Alabama Chapter. Advocacy Action at ACC.17 Hear From MACRA Experts Get up-to-speed on how to successfully navigate the Quality Payment Program, initiated by MACRA: How to Redesign a Care Delivery Team in Preparation for MACRA and MIPS Session 619 Friday, March 17 12:15 - 1:45 p.m. Room 143 ABC Learn About MACRA at ACC Central Visit ACC Central (Booth 739) to get your MACRA questions answered. ACC staff will be on hand to help you understand the Quality Payment Program, prepare for program implementation and explore program resources. Visit the ACCPAC Lounge Stop by the ACCPAC Lounge in the Lounge & Learn Pavilion to learn about how the #1 cardiovascular political action committee is transforming cardiovascular care and meet ACCPAC staff and members. Sunny Jhamnani, MD ACC Emerging Advocate Episode Payment Models: A Primer For Cardiology It is undeniable that with the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) and introduction of cardiovascular episode payment models (EPMs), along with the numerous Center for Medicare and Medicaid Innovation demonstration projects, we are heading towards a value-based health care system. MACRA received immense bipartisan support, unlike the Affordable Care Act (ACA). Hence, while one may ponder the future of the ACA, MACRA and the move from traditional fee-for-service to value-based care is here to stay. This transition is occurring in all facets of our health care system, including Medicare, Medicaid, commercial third party health insurers and state insurance programs. While the early innovative payment models were primarily focused on primary care services and providers, the Centers for Medicare and Medicaid Services (CMS) recently turned its attention to the medical specialties by releasing three cardiovascular EPMs: Acute Myocardial Infarction (AMI), Coronary Artery Bypass Graft (CABG) and Cardiac Rehabilitation (CR), along with a surgical hip and femur fracture treatment model. “These EPMs offer an exciting opportunity for redesigning the care delivery of cardiac patients,” notes Cathleen Biga, MSN, RN, co-chair of the Cardiovascular Administrator Workgroup and a member of the Health Affairs Committee. “Caring for patients across the continuum, in a collaborative team environment, focused on quality and cost effectiveness will ensure our patients receive evidence based care in the best setting. While it’s difficult to transition from a fee-for-service world into a value-driven world, physician leadership will facilitate this transition.” The developed models aren’t perfect, as noted by the ACC and many other groups, but CMS had differing opinions. For example, one of the central themes was the need to have homogenous populations in the EPMs, thus limiting the AMI models to STEMI patients and not including those with cardiogenic shock (and sepsis). While acknowledging the concerns, CMS laid out the opportunities for care design in the different populations of STEMI and NSTEMI with differential analysis of past records. However, CMS did change rules in response to the comments. One notable example of this is that CMS made it optional to have downside risk by making it voluntary in Year 2, after hearing concerns from the ACC that participants should be held harmless during the initial phases of the program. Currently, these payment models are limited to 98 randomly pre-selected Metropolitan Statistical Areas (MSAs). While every ACC member will not be impacted, it will be vitally important for cardiovascular professionals to understand the payment models’ goals and structure. These types of bundled and EPMs are top of mind for many of the nation’s health insurers and could be developed by local health plans. Additionally, CMS and private payers tend to emulate other programs, especially if it is determined successful and results in cost savings. In this emerging value-based environment, it is important for cardiovascular professionals and their organizations to be cognizant of their outcomes and the relative “cost” of that outcome. They will need to monitor and track their data, analyze them and use a myriad of resources from statistical and econometrical to clinical and administrative to not only stay within their target prices but also achieve acceptable outcomes. “It will be vital going forward to have systems in place to know the true cost of care at the diagnosis and individual patient level, the impact pathways of care have on outcomes and cost, how adverse events affect both care and cost, and what we can do to effectively mitigate these events and use this data in the patient’s best interest,” says Keith Churchwell, MD, senior vice president, Heart and Vascular Center of Yale New Haven Hospital. These resources will require not an insignificant investment from organizations. CMS plans to provide spending and utilization data and waive certain Medicare requirements. However, this will likely not be enough. It will be more important for organizations to learn from each other and use all the help they can, including those from specialty societies like the ACC. “The mandated CMS episodes afford physicians a unique opportunity to lead their systems into this challenging process. While it is true the hospitals carry the financial risk in these bundles, physicians bring the clinical expertise to contain costs and improve outcomes,” says Biga. What You Need to Know About EPMs • Hospitals within the 98 pre-selected MSAs will be participating for a performance period of July 1, 2017 to Dec. 31, 2021. • The acute-care hospitals are financially responsible for episodes. • Cardiovascular physicians and professionals will be paid for services based on current Part B rates. • Hospitals that achieve both an acceptable or better quality composite score as well as spend below the quality adjusted target price will be eligible to receive a reconciliation payment. • AMI and CABG EPMs will allow clinicians to be able to qualify for Advanced Alternative Payment Models under MACRA. • Hospitals will receive an additional $25 for each CR or Intensive CR service for the first 11 services paid by Medicare, which will increase to $175 for each CR service thereafter.
Published by American College of Cardiology. View All Articles.
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