EVOLVING and EMERGING Health Care Trends—Where does PT Fit in?

1. EVOLVING and EMERGING Health Care Trends—Where does PT Fit in? Jody Swearingen, PT, DPT, OCS, STC, COMT Alan Meade, PT, DScPT, MPH Justin Meade , PT, DPT

2. EVOLVING and EMERGING Health Care Trends—Where does PT Fit in? MIPS for 2019……and beyond 2018 TPTA Fall Meeting Memphis, TN

3. Objectives • Introduction to MIPS timeline • Understand who is eligible to report MIPS • Understand Key Terms of the MIPS program and how it relates to PT • Introduction to scoring

4. What is MIPS? • The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created a new quality payment program (QPP) for Medicare part B. The QPP established 2 ways for providers to participate in quality improvement programs under MACRA: • Merit-Based Incentive Payment System (MIPS) • Advanced Alternative Payment Models (APMs)

5. MIPS • On July 12, 2018 - CMS released the proposed rule for updating payment policies, payment rates, and quality provisions for services furnished under the Medicare physician fee schedule for calendar year 2019. • Took 3 CMS programs and consolidated into MIPS categories: • PQRS • Value-based Payment Modifier • Medicare Electronic Health Records Incentive Program (aka – Meaningful use) • A fourth program was created and added to promote the ongoing improvement and innovation to clinical activities • Based on these programs, the 4 categories are: • Quality • Improvement Activities • Promoting Interoperability • Cost

6. Who is eligible?? • Clinicians that are currently (2018) included are: physicians, physician assistants, nurse practitioners, and clinical nurse specialists • 2017 / 2018 – PT/OT were not included as eligible clinicians • CMS is proposing to add PT/OT in Private Practice as eligible clinicians to participate in MIPS for 2019 – bill on HCFA 1500 forms • Non-Private practice are not eligible to participate in MIPS. These include: rehab agencies, SNF’s, Hospital therapy departments, CORF’s, Home Health Agencies – bill on UB-04 forms

7. Key Terms • Performance Year / Period – January 1st – December 31st 2019 (calendar year) • Payment Period – Occurs 2 years after the performance period • E.g. Performance period is 2019 and the payment period and payment adjustments will occur in 2021

8. Key Terms • Small Practice – practice consisting of 15 or fewer eligible clinicians • Group – a single TIN with two or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their individual NPI who has reassigned their billing rights to the group TIN. • Virtual Group – A combination of two or more TIN’s assigned to one or more solo practitioners or to one or more groups consisting of 10 or fewer eligible clinicians, or both, that elect to form a virtual group for a performance period for a year.

9. Key Terms • Determination Period – two 12-month assessment periods CMS will use to determine who is an eligible clinician: • Period # 1: September 1st 2017 – August 31st 2018 • Period # 2: September 1st 2018 – August 31st 2019 • It is proposed for CMS to change these periods to: • Period # 1: October 1st 2017 – September 30th 2018 • Period # 2: October 1st 2018 – September 30th 2019 • If accepted, this will be published in the final rule (late Oct. / early Nov)

10. Key Terms • Submission Type – mechanism by which data is provided to CMS • Direct Submission – allows users to transmit data through a computer to computer interaction • Login and upload Submission – allows users to upload and submit data in the forma and manner specified by CMS with a set of authenticated credentials • Login and attest submission – allows users to manually attest that certain measures and activities were performed in the form and manner specified by CMS with a set of authenticated credentials

11. Submission to CMS • Electronic Clinical Quality Measures (eCQM’s) • MIPS Clinical Quality Measures (MIPS CQM’s) • Qualified Clinical Data Registry (QCDR’s) Measure • Medicare Part B Claims Measures • CMS web Interface Measures • Consumer Assessment of healthcare providers and systems (CAHPS) for MIPS Survey • Administrative Claims Measures

12. MIPS and Point Scoring • 4 categories: • Quality (replaces PQRS) • Promoting interoperability (replaces EHR) • Cost (Replaces the value-based modifier) • Improvement Activities (new category) • The points from each category are added together to give you a MIPS final score (Max = 100 points) • Payment adjustment – score is compared to the performance threshold to determine if you receive a positive, neutral, or negative payment adjustment

13. MIPS and Point Scoring 4 categories and proposed weighing of categories for 2019 scoring • Quality (85 % or 70 %) • Promoting interoperability (0%) • Cost (0%) • Improvement Activities (15% or 30 %)

14. Quality (up to 60 points) • Report up to 6 quality measures, including one outcome measure, for the 12 month calendar year performance year (60 % completion rate) • Unfortunately, there are only 5 measure to report for PT/OT (if only submitting through claims) • Falls Measure • BMI • Medications • Pain • Functional Outcome • If an outcome measure is not available, choose another high priority measure to report • If fewer than 6 measures apply to the MIPS eligible clinician / group, report on each measure that is applicable • Using a Registry (like FOTO) will allow you to get more than the 5 options

15. Improvement Activities (up to 40 points) • Attest that you completed up to 4 improvement activities for a minimum of 90 days • Groups of fewer than 15 participants attest that you completed up to 2 activities for a minimum of 90 days • To earn full credit for this category: • Report at least 2 High-weighted activities • Report at least 1 High-weighted activities and 2 medium-weighted activities • Report at least 4 medium-weighted activities • A list of activities can be found in the CMS proposed rule.

16. 2019 Proposed Scoring

17. MIPS Timeline and Bonus Structure + 5 % + 7 % + 4 % + 9 % - 9 % - 4 % - 7 % - 5 %

18. Mandatory Participation

19. Low Volume Threshold • You are excluded if: • ≤ $90,000, ≤ 200 unique patients, and / or ≤ 200 covered professional services • If you are newly enrolled in the Medicare program for the first time during the performance year • Significantly performing in an Advanced Alternative Payment System (AAPM) • If you are below these thresholds in the 1st 12-month analysis period, you will continue to be excluded regardless of findings of 2nd 12-month analysis period

20. Low Volume Threshold – Opt In • If an eligible clinician meets or exceeds at least one, but not all of the low volume threshold determinations, they may choose to opt-in for MIPS. • To Opt-in, the eligible clinician will need to make an election via the Quality Payment Program portal. They may choose to: • Opt-in for payment adjustments • Report voluntary but remain excluded and not receive payment adjustments • Be careful – if you choose to Opt-in, it is irrevocable and cannot be changed for the specific performance year

21. Low Volume Threshold

22. A Reason to Opt-in? • Medicare Physician Fee Schedule conversion factor update in 2019 = 0.5 % • Medicare Physician Fee Schedule conversion factor update in 2020 - 2025 = 0.0 % • This means that for years 2020 – 2025, participating in MIPS and scoring well will be your only opportunity for additional monies from Medicare

23. How can you prepare for MIPS … • Familiarize yourself with the Medicare Quality Payment Program website • Profile your practice to see whether or not you will be required to participate • Begin thinking about the best data submission method for your practice • Leverage EMR and patient engagement tools to simplify the MIPS reporting process

24. Resources • APTA: http://apta.org • Gawenda Seminars: https://gawendaseminars.com/ • CMS Proposed Rule for MIPS 2019: https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions • Quality Payment Program: https://qpp.cms.gov/

30. MIPS IMPROVEMENT ACTIVITIES CATEGORY • The existing subcategories are: • Expanded practice access, such as same-day appointments for urgent needs and after-hours access to clinician advice. • Population management, such as monitoring health conditions of individuals to provide timely health care interventions, or participating in a QCDR. • Care coordination, such as timely communication of test results, timely exchange of clinical information to patients or other clinicians, and use of remote monitoring or telehealth. • Beneficiary engagement, such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training, and using shared decision making mechanisms. • Patient safety and practice assessment, such as through clinical or surgical checklists and practice assessments related to maintaining certification. • Participation in an APM. • Health equity, such as for providing high-quality services for underserved populations, including persons with behavioral health conditions, racial and ethnic minorities, sexual and gender minorities, people with disabilities, people living in rural areas, and people in geographic HPSAs. • Emergency preparedness and response, such as participating in the Medical Reserve Corps, registering in the Emergency System for Advance Registration of Volunteer Health Professionals, measuring relevant activities within the reserve and active-duty uniformed services, and measuring volunteer participation in domestic or international humanitarian medical relief work. • Integrated behavioral and mental health, such as measuring or evaluating such practices as colocation of behavioral health and primary care services, shared and integrated behavioral health and primary care records, cross-training; and integrating behavioral health with primary care to address substance use disorders or other behavioral health conditions, as well as integrating mental health with primary care.

31. Questions???

32. EVOLVING and EMERGING Health Care Trends—Where does PT Fit in? NEW RULE 2019 MEDICARE PHYSICIAN FEE SCHEDULE MIPS and MACRA Alan Meade, PT, DScPT, MPH

33. VALUE-BASED CARE Themes in the Affordable Care Act • Health Insurance Marketplaces • Medicaid Expansion • Essential health benefits • Non‐discrimination Expansion of Coverage • Accountable Care Organizations • Medical Homes Collaborative Models of Care ‐ Innovation in Programs • Cuts in payment rates • Refinements to payment systems • Patient assessment instruments Payment Changes and Linking Payment to Quality • Provider Enrollment • Funding Increases for Enforcement

34. VALUE-BASED CARE What are Valued Based Arrangements? • Shared Savings – Potential for upside payment and downside risk • Bundled Payment – Episodic Case Rates • Sub-capitation • MSK Direct Access • Outcome driven payment

35. VALUE-BASED CARE Payment Methodologies $$$ Cash $$$ You can offer patients a cash discount however the same discount must be made available to all payers. Your actual “per visit” rate should be consistent with your normal fee schedule. You are simply offering a discount for payment at the time of service. You cannot offer a cash pay option to Medicare patients if the service you are providing is covered and considered medically necessary

36. VALUE-BASED CARE Payment Methodologies • Fee for Service – Providers negotiate rates based upon the RBRVS/CPT codes. Billing is done a ‘per code’ basis, most commonly in 15 minute increments. Most payers have a fee schedule. • Per Diem – Providers are paid on a per visit basis. Continue to bill using the CPT Codes but the amount paid is capped at a daily amount. Sometimes there are issues when billing multiple services on the same day. Usually a flat rate for an evaluation and a separate rate

37. VALUE-BASED CARE Payment Methodologies • Case/Episodic Rate – Providers are paid a single flat rate for the patient’s entire episode of care that is specific to a single injury. The rate does not specify the number of visits but requires a favorable outcome. A new episode of care will initiate a new case rate. Possibly separate rates for post surgical and non-surgical patients. • Capitation – Providers are paid on a per member per month (pmpm) basis. A specified number of enrollees are assigned to the provider and all care is directed to that provider. As an example 5,000 enrollees are assigned at a pmpm of $.56 or 5,000 x $.56= $2,800. The provider is paid $2,800 per month regardless of utilization.

38. VALUE-BASED CARE RISK (Lowest to Highest) Cash Fee for service Per diem/Per visit Case/Episodic Rate Capitation/Bundled

39. VALUE-BASED CARE CMS Direct Contracting Model (Proposed) • CMS would directly contract with provider practices and pay a fixed per-beneficiary per-month payment to cover various services, such as office visits, certain office-based procedures, and time spent managing care for a patient. • Practices could be eligible for incentive payments if they hit savings and quality goals

40. VALUE-BASED CARE Preparing for Value Based Care Value… In value based pricing you are telling the customer (patient, payer, employer), that you are good at what you do and can demonstrate that via your predictive pricing and outcome tracking. Your pricing is based upon your ability to know your outcomes, predict costs and therefore demonstrate your true value.

41. VALUE-BASED CARE Perspectives… Clinician vs. Payer

42. VALUE-BASED CARE Clinician Perspective: • Most Clinicians look at value based care from the patient perspective 1. Did the patient meet their goals? 2. Did the patient return to work, sport, or other activity at previous functional ability? 3. Did the patient realize “measurable” gains (ROM, Strength, Endurance)? 4. Patient Satisfaction – is the patient happy with their care? 5. COST - How much did the care cost??? • Only if the patient cost is ever brought to clinician’s attention...copayment/coinsurance or deductible

43. VALUE-BASED CARE Payer Perspective: • Most VBC Programs will rely heavily on 2 main areas & possibly a 3rd 1. Total Cost of Care 2. Patient Satisfaction 3. Subjective Report of Some “Objective” Functional Outcome

44. VALUE-BASED CARE Ultimately…. Value Based Care is simply payers looking to quantify and link patient clinical outcomes with the cost of care. Bang for the Healthcare Buck

45. Practice Management Practice Management Systems In today’s private practice we are all using (or should be using) some type of EMR – Practice Management System. • The vast majority of these systems will have modules including: • Patient Intake & Registration • Scheduling • Documentation of Conditions, Treatments, Outcomes • Billing, Collections, Follow-up • Patient Satisfaction • Financial Management • The combination of these modules and the data in these modules is capable of producing just about any data point you will need in your quest to be ready for VBC

46. Practice Management So…which one, which metric, what data? • Volume – How many new patients do you see (new evaluations vs. follow up visits) • Duration – How long do you see new patients – (visits/evaluation) • Utilization – How many CPT or Billable Units are generated each visit and each episode – (UPV) • Revenue – How much income is produced with your volume & utilization – (Income/Visit, Income/Unit) • Cost – How much does it cost you to deliver a Unit and / or Visit of care – (Cost/Visit, Cost/Unit) • Payor Mix – What is the make up of your practice (% of each payor) • Productivity - Visits/Provider/Day **Break these down by payer / contract type

47. Practice Management Ok – So I Know My Data…. Who is going to ask??? • Private Payor – maybe • Collaborator (Health System, ACO, Physician Group, etc.) – maybe • Federal or Government Payor – maybe • Potential Employee – maybe • Potential Acquisition Partner – maybe • Potential Referral Source – maybe It doesn’t really matter who asks you – what matters is that you can easily and accurately answer the questions and use the data to make educated decisions on which contracts make sense for your practice AND profession.

48. MIPS & MACRA January 1st, 2019 • MIPS: Merit Based Incentive Payment System • MACRA: Medicare Access and CHIP Reauthorization

49. MIPS & MACRA • PTs are part of the Rule beginning in 01/01/19 • Can report as an individuals in a practice or by group or by Tax Identification Number • 2017 data applies to 2019; 2018 data applies to 2020. • Performance is measured through the data clinicians report in four areas: Quality, Improvement Activities, Promoting Interoperability or known as Advancing Care Information, and Cost

50. MIPS & MACRA • MIPS is replacing PQRS Jan. 1st, 2019 • Effects PTs in Private Practice, Hospitals, CORFs, and Out-patient • Looking at whether you hit the threshold • If you do nothing, you may undergo a 7% penalty. However, could gain up to a 7% incentive. • DO NOT TRY TO REPORT BY CLAIMS, drive to report electronically. • Between 2020-2025, NO more changes to the Fee Schedule