Disclosure. Learning Objectives 8/31/17. Navigating Value-Based Healthcare Models: MACRA, MIPs and APMs. September 8, 2017

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1 Navigating Value-Based Healthcare Models: MACRA, MIPs and APMs September 8, 2017 Brian J. Isetts, RPh, PhD, BCPS, FAPhA University of Minnesota College of Pharmacy Disclosure Brian Isetts has no relevant financial relationships or conflicts of interest to report. It is disclosed that I formally and informally consult with Centers for Medicare & Medicaid Services (CMS) contractors & CMS colleagues on medication management safety and effectiveness initiatives. Organizations in which I receive compensation for service as either a technical advisor or consultant include: Iowa Healthcare Collaborative (Des Moines, IA) Tabula Rasa Health Care (Morrisville, NJ) Community Care of North Carolina (Raleigh, NC) Learning Objectives Upon successful completion of this activity, pharmacists should be able to: 1) List the four Quality Payment Program (QPP) performance benchmark categories, and provide specific examples of effective and safe medication use measures. 2) Describe pharmacists roles and responsibilities in highperforming health systems and community-based organizations that are most likely to succeed in MACRA risksharing payment arrangements. 1

2 Learning Objectives Upon successful completion of this activity, pharmacy technicians should be able to: 1) Describe the roles and responsibilities of medication management technicians supporting practices seeking to improve the effective and safe use of medications. 2) List the four Quality Payment Program (QPP) performance benchmark categories. Program Agenda Ø Evolution from volume-based to value-based healthcare delivery and financing Ø Policy and reimbursement reforms Ø Role of redesigned care models Ø Engineering an accountable medication use system Ø Measuring progress toward national aims through the Quality Payment Program Key Questions to Run On Ø How can we use the opportunity of value-based financing to build a medication use system in which patients routinely achieve their drug therapy treatment goals with zero tolerance for preventable medication harms? Ø How can we help patients and families become confident medication users so they know the intended use, goals of therapy, and safety concerns related to the use of all their drug therapies? 2

3 Think-Pair-Share Team-based Active Learning Moment-1 Ø What are some of Pharmacy s most exciting patient care initiatives you ve heard about, or are doing yourself? Ø What are some of the challenges you re encountering with pharmacist integration in healthcare teams? Powerful Meeting Cycle - 2 minutes per person Ø Please pair up with your colleague next to you, and then share their responses to these queries 3

4 Overview of Redesigning Health Care Delivery & Financing Ø Payment reform was in motion well before the Affordable Care Act Ø Stakeholder engagement blue print through the National Quality Strategy Ø CMS Payment Taxonomy aims: Over 50% of payments in pay-for-value categories Framework for Progression of Payment to Clinicians and Organiza8ons in Payment Reform Descrip8on Examples Category 1: Fee for Service No Link to Quality Payments are based on volume of services and not linked to quality or efficiency Category 2: Category 3: Fee for Service Alterna8ve Payment Link to Models on Fee-for Quality Service Architecture At least a por8on of payments vary based on the quality or efficiency of health care delivery Some payment is linked to the effec8ve management of a popula8on or an episode of care Payments s8ll triggered by delivery of services, but, opportuni8es for shared savings or 2-sided risk Category 4: Popula8on-Based Payment Payment is not directly triggered by service delivery so volume is not linked to payment Clinicians and organiza8ons are paid and responsible for the care of a beneficiary for a long period (eg, >1 yr) Medicare Limited in Medicare feefor-service Majority of Medicare payments now are linked to quality Hospital valuebased purchasing Physician Value- Based Modifier Readmissions/ Hospital Acquired Condi8on Reduc8on Program Accountable Care Organiza8ons Medical Homes Bundled Payments Eligible Pioneer accountable care organiza8ons in years 3 5 Some Medicare Advantage plan payments to clinicians and organiza8ons Some Medicare-Medicaid (duals) plan payments to clinicians and organiza8ons Medicaid Varies by state Primary Care Case Management Some managed care models Integrated care models under fee for service Managed fee-for-service models for Medicare-Medicaid beneficiaries Medicaid Health Homes Medicaid shared savings models Some Medicaid managed care plan payments to clinicians and organiza8ons Some Medicare-Medicaid (duals) plan payments to clinicians and organiza8ons Rajkumar R, Conway PH, Tavenner M. The CMS Engaging Mul8ple Payers in Risk-Sharing Models. JAMA. Doi: /jama A Three-Part Aim BeXer Health for the Popula8ons BeXer Care for Individuals Lower Cost Through Improvement 4

5 Engines for Redesigning Health Care Delivery & Financing Ø Department of Health & Human Services collaboration (CMS, AHRQ, NIH, CDC, FDA, VA, IHS, HRSA, etc.) Ø Nat l Priorities Partnership convened by the National Quality Forum (NQF) Ø Contracts, program agreements, grants Ø Payment policies CMS Investments in MACRA Ø CMS Innovation Center (CMMI) alternative payment models Ø Transforming Clinic Practice Innovation (TCPi) Practice Transformation Network contracts Ø State Innovation Models (SIMs) Ø Enhanced MTM initiative (Region 25) Ø Patient and Family Engagement (PFE) component of care transformation contracts The Volume-based Spiral Ø ~75% of Americans were insured in 1960 (through employer-based health insurance) Ø Growing need to insure elderly (65 y.o.+) who were no longer employed Ø 1964 Congress majority mustered support for the Medicare-Social Security Act Ø Physician fees based on usual, customary, & reasonable billing Ø Disincentive to keep patients well 5

6 The Rise of Quality Measures Ø Purchaser and Employer demand for accountability in the Value Equation Ø Quality indicators so consumers can see true outcome differences Ø HEDIS measures (1991-present) Ø PQRS ( ) Ø Comparing providers and plans Ø State scorecards MN Community Measures Physician Payment Reform (MACRA) Ø Congress 18 th time was the charm Ø Medicare Access & CHIP Reauthorization Act Ø Repeals the Sustainable Growth Rate (SGR) Ø a 0.5% SGR increase through 2019 Ø 2 paths: MIPS or APMs Ø Merit-based Incentive Payment System (opt out for small clinics = <$30K AND 100 patients) Ø Alternative Payment Models Quality Payment Program in MACRA MIPS Score Performance Categories (w/2017-%) Ø Quality (60%) replaces PQRS; choose 6 quality measures (from 200+ measures) Ø Advancing Care Information (Meaningful Use) (15%) H.I.E., patient access, registries Ø Clinical Practice Improvement (25%) 90+ activity options in care coordination, beneficiary engagement, patient safety Ø Cost (0 à10%) replaces value-based modifier 6

7 Advanced - Alternative Payment Models Ø CMMI Models (ACO, MSSP, Oncology, CPC+, etc.) Ø Physician-focused Payment Model Technical Advisory Committee (PTAC) for vetting new models Ø Financial risk sharing requirements Ø Payments based on quality measures Ø Evidence-based, valid and reliable measure criteria (e.g. ACO core measures, others) Ø One outcome measure in MIPs list Ø Certified EHR use Ø Beneficiary engagement Impact of Medication Management on Performance Measures Ø ACO measures (17 of 33 measures directly related to effective or safe use of medications) Ø HEDIS measures (diabetes D-5 example) Ø Quality Payment Program examples Ø % of patients with diabetes having uncontrolled A1c level > 9% Ø Hypertension, Depression, Cholesterol measures Ø Patient & Family Engagement measures Relationship of Medicare STAR Ratings to MACRA Measures Ø Medicare Advantage with Rx coverage (MA- PD) = 44 quality measures Ø MA-only (no Rx) = 32 measures Ø Stand-alone PDP=15 measures with 5 in drug use (adherence, high risk meds and CMR completion rate) Ø PDPs not always aligned with MACRA 7

8 Minnesota Quality Incentive Payment System (QIPS) Ø Health Reform Law of 2008 Ø Pay-for-performance system for clinics Ø Diabetes Care, Vascular Care, and Depression Remission at 6 months Ø $900K paid to 228 clinics in 2016 Ø Hospital measures removed as they participate in federal value initiatives This is Reality in Homes across America Framing the Value Proposition for Pharmacist Integration Drug-related Morbidity & Mortality Ø Spend $300 billion annually to fix the ineffective & unfortunate consequences of medication use Ø (2 nd )Largest category of hospital acquired conditions Ø Most common cause for hospital readmissions Ø 4 categories of drugs related to 2/3 rd of harms Ø Approximately 10 people die every HOUR from preventable medication harms So why has it taken so long to get serious about systematic medication effectiveness & safety? 8

9 Characteristics of Medication Use Ø Bad things happen to patients routinely Ø Are considered a normal cost of doing business Ø Patients don t always know the intended medical use for each of their medications Ø Don t know the goals of therapy for their medications Ø And we haven t built systems around the way patients take medications at home Dysfunctional Medication Use Drivers Ø Fee-for-Service (f-f-s) inadvertently rewards providers/organizations when drug therapies don t work or harm patients Ø No one has stepped back and designed medication use systems from the patient perspective Ø No one has been responsible or accountable for what happens when patients take medications that is, UNTIL NOW! The Medication Use System We Can Have Key Characteristics Ø Every drug in use in America is assessed to ensure: it has an intended medical use, is effective and safe, and can be taken by the patient as intended Ø Patients, family members, and care givers contribute to establishing realistic, achievable goals of therapy Ø Clear care plan responsibilities for achieving goals Patients are demanding health systems help them: Ø 1) Describe the intended medical use of each medication Ø 2) Set realistic, patient-specific goals of therapy Ø 3) Understand safety for their co-morbidities & medications 9

10 Medication Management Outcomes Ø Transition care model standard of practice Ø Clinical outcomes: % of goals of therapy achieved, improved care (A1c, BP, LDL) Ø Humanistic outcomes: Quality of life, patient experience, reduced sick days Ø Economic outcomes: Cost-benefit, fewer hospital visits; R.O.I. = consistently $4:1 Comprehensive Team-based Medication Management All team members help set patient-specific drug therapy goals for each medical condition: Ø Assessment of intended use, effectiveness, safety, and adherence embedded across the care continuum Ø When patient is not achieving goals of therapy there is more efficient and effective use of pharmacists Ø Coordination of care as pharmacists transfer their assessments across settings and transitions Ø Patients, families, care-givers & community health workers build a support system to manage therapies Responsibilities of Medication Management Technicians Ø Patient recruitment compelling MTM sales pitch Ø Appointment scheduling based on patient complexity Ø Pre-visit medical records, insurance information, and administration of screening tools (if applicable) Ø Care coordination among other community practitioners and social service resources Ø Patient reception and rooming (telephonic MTM) Ø Post-visit documentation, insurance billing, and follow-up appointment scheduling 10

11 The Business Case for Pharmacists in Value-based Financing Ø Aligning contributions toward better care and lower costs in redesigned care delivery and financing systems transitioning to payment for outcomes Ø Convincing administrators, payers, colleagues & patients that you can t afford not to have a medication management specialist on your care team Pharmacists in the Future of MACRA Ø Practical data mining and analysis of meaningful patient outcomes Ø Aggressive pay-for-value bridging using TCM, CCM, CoCM, incident-to and direct patient billing Ø Financial management training aligned with total cost of care analysis Ø Consistent use of MTM CPT Codes Patient & Family Engagement (PFE) in Medication Management Ø Campaign for Meds Management CMS QIO (Quality Improvement Organization) contract Ø PFE Medication Management Change Package of best practices in TCPi Ø Patient self-management pillar in all care transition models 11

12 Lessons Learned on Our Journey Ø We are (finally) making measurable progress so that patients/families can confidently manage medications Ø Value-based financing is good news for individuals who take medications Ø We have a second chance to design a medication use system we deserve Ø Can t be an ACO if not accountable for medications Ø Patient demand for Medication Management is accelerating progress toward a medication use system our country deserves Assessment Question 1 What are the four Quality Payment Program performance categories? a.) Cost, Practice Improvement, Advancing Care Information, and Quality b.) Quality, Practice Improvement, Care Information, Provider Engagement c.) Quality, Practice Transformation, Provider Engagement, and Cost d.) None of the above are correct Assessment Question 2 Which CMS payment category is best for pharmacist compensation in the future? a.) Category 1 no links to quality b.) Category 2 voluntary links to quality c.) Category 3 fee-for-value d.) None of the above are correct as there is little hope for pharmacist payment 12

13 Open Forum Active Learning Moment - 2 Ø What have we done well in Minnesota to advance the value proposition of pharmacist integration in new care delivery and financing systems? Ø What challenges do you think we can realistically overcome to advance pharmacist integration in new care delivery and financing systems? Discussion Brian J. Isetts, RPh, PhD, BCPS, FAPhA isetts@umn.edu 13