Term
| A New Model of Health Care: Today |
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Definition
Treating Sickness
Fragmented Care
Specialty/Hospital Driven
Isolated Patient Files
Utilization Mgmt
Fee for Service
Payment for Volume/FFS
TFSIUFP |
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Term
| A New Model of Health Care: Future |
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Definition
Managing Population
Collaborative Care
Primary Care Driven
EHR/HIE
Evidence-Based Medicine
Shared Risk/Reward
Payment for Value
MCPEESP |
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Term
| Old Payment Methods: Fee-for-Service |
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Definition
- Provider selects CPT code, itemized charge associated with each code. When send claim to insurance company, CPT code and ICD-10 code on the bill
- Encourages volume – more you do, the more you are paid.
- Chargemaster Charges (Full Charges – Sticker Price) v Amount contracted with insurance companies – will talk in the next few weeks about charge master
Medicare/Medicaid set the amount of charge (what physician will be paid per CPT code) |
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Term
| Old Payment Methods: Capitation |
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Definition
| (per member – per month). Often primary care for HMO. Discourages over-utilization. Transfers risk to providers. Many believe this is end-goal of insurers. |
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Term
| Old Payment Methods: DRGs |
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Definition
| Medicare method to pay for hospitals admissions based on Diagnosis. (Fixed amount for each diagnosis) |
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Term
| New Payment Methods Value-based Approaches |
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Definition
- Transfer ‘risk’ to provider!
- Not pay for volume
- Payment based on:
+Quality measures
+Patient Satisfaction
+Cost as related to peer charges – if your charges are more than peers for similar diagnosis, you may face a penalty – CALLED MEDICARE Spend Metric – compares me the doctor to colleague doctor (across town or whatever) to see who pays more for tests and who has better outcomes
+Use of HIT to enhance patient engagement |
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Term
| Two ways to participate in MACRA |
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Definition
1. MIPS (Merit Based Incentive Payment System) – most physician practices
2. Advanced Alternative Payment Models (APM) – contracting for risk |
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Term
| Alternative Payment Models |
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Definition
- Patient-Centered Medical Homes (PCMH)
+ Often Medicaid, Some Commercial
- Accountable Care Organizations (ACOs)
+ Medicare ACOs, Commercial ACOs
- Bundled Payments
+ Orthopedics and Cardiology, to date |
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Term
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Definition
1. What it is : Payment Reform for Medicare Part B
2. Who it impacts: Eligible Clinicians subject to the Medicare physician fee schedule
3. IT is involved: continue Certified Electronic Health Record and Meaningful Use for physicians and other EC’s
4. IT involved : support reporting for Quality, Claims and Clinical Improvement
5. IT involved : one of three imperatives for success in Population Health and risk payment methodology |
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Term
| Financial Impact of New Methods - Merit-based Incentive Payment System (MIPS) |
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Definition
- Can impact Medicare reimbursement by as much as +/- 9% (by 2022)
+ The positive payment adjustments can go even higher, up to a factor of 3X
- Will feature a publically available Composite Performance Score (MIPS Score) |
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Term
| Financial Impact of New Methods - Advanced Alternative Payment Models (APMs) |
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Definition
- Providers engage in programs that have shared risk
+ E.g.,: ACOs, PCMH, others..
- Qualified participants avoid MIPS reporting and penalties
- Receive a fixed payment increase (5% through 2024) for each year that the provider or group qualifies (automatically receive this 5% for each year qualify)
- Medicare anticipates limited APM enrollment in 2017 (15% of providers or less – most will be in MIPS because APMs have not developed yet)
+ This may rise to 25% in 2018
- All clinicians may wish to consider reporting through MIPS to determine if they qualify for an advanced APM |
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Term
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Definition
- The medical home is an approach to primary care that is:
+ Patient-Centered Supports patients in managing decisions and care plans.
- Accessible: Care is delivered with short waiting times, 24/7 access and extended in-person hours.
- Comprehensive: Whole-person care provided by a team
- Coordinated: Care is organized across the ‘medical neighborhood’
- Committed to quality and safety: Maximizes use of health IT, decision support and other tools |
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Term
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Definition
- Navigators, Care coordinators – keep patients from falling in the cracks. Use HIT to coordinate.
- Value/ Outcome Measurement
+ Reporting of Quality, Utilization and Patient Satisfaction Measures
- Value-Based Purchasing
+ Reimbursement Tied to Performance on Value |
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Term
| Accountable Care Organization |
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Definition
| . . . A group of physician and other healthcare providers and suppliers of services (e.g., hospitals) that will work together and are willing to certify a willingness to become accountable for, and report to CMS, the quality and cost and overall care of Medicare Fee-For-Service beneficiaries assigned to the ACO. |
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Term
| Requirements for Medicare ACO |
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Definition
- Legal Organization – lawyers must get involved
- 3 Year Commitment
- Sufficient primary care providers for minimum 5000 Beneficiaries
- Accountable for Quality & Cost of Care
- Can collect and provide information, report quality measures
- Can provide administration and clinical care
Offers evidence based medicine and coordinated care
- Is patient centered |
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Term
| Shared Savings - two types of savings that ACOs can be a part of |
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Definition
- Track one “one sided” CMS will share savings with no risk
- Track two “two sided” ACO can achieve greater profit from sharing but must also share risk for loss
- Must be same track for 3 years |
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Term
| CMS’s Rule to Encourage Participation in ACOs |
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Definition
- Permit current ACOs taking one-sided risk to request a three-year extension before entering two-sided risk, provided that they did not have significant losses in the initial two years.
- ACOs that choose this extension option will receive a smaller bonus (there is currently the potential to achieve up to 50% of the savings).
- After the three-year extension period, all ACOs must enter the two-sided risk track if they wish to remain in the program. |
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Term
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Definition
- One payment to hospitals for encounter and for all related services for up to 90 days after discharge
- Hospitals, physician groups, post-acute providers bear financial risk for spending relative to target price based on historical ‘spend’ per episode less 2 -3 % discount. Assessed on annual basis.
- Some believe Bundled methodology is at odds with Accountable Care Approach(see articles) |
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Term
| MIPS will apply to following Clinicians: |
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Definition
| - Physicians, Mid-level practitioners, Chiropractors, CMS will add other professionals in 2021 |
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Term
| Clinicians Exempt from MIPS |
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Definition
- Low Medicare/Medicaid volume physicians (<100 patients or $30K)
- Physicians practicing at Critical Access Hospitals
- MIPS not applicable to RHCs and FQHCs (most of these PCMHs anyways)
- The intention is to exclude small practices; estimated about 50% of physicians will be excluded initially.
- HOWEVER… Medicare encouraging all insurance companies to move to similar methodology |
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Term
| MIPS – Four Determinants of Performance Score (2017) |
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Definition
1. Quality Reporting (60%)
2. Advancing Care Information (25%) – Replaces Meaningful Use
3. Clinical Practice Improvement Activities (15%)
4. Resource Utilization (0% - increases in coming years with decrease weight on quality)
*Remember - MIPS Is Budget-neutral for CMS |
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