Transcript Advanced Alternative Payment Models (APMs)

Legislative Update from Washington DC
Association of Community Cancer Centers
POHMS 22nd Annual Fall Conference
Leah Ralph
Director of Health Policy
Association of Community Cancer Centers
[email protected]
accc-cancer.org
LEGISLATIVE OUTLOOK
 Contentious election
 Lame duck session
 Funding for NIH/Cancer
Moonshot
 Focus on drug pricing and
transparency will be
unavoidable
 Increasing premiums and
fewer insurers on health
insurance exchanges
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Source: www.ACAsignups.org
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UNDER PRESSURE
 Unsustainable health care spending growth
 Increasing reliance on public programs to fund the cost of treating cancer
 Drug costs under a microscope
 Growing discussion of value in cancer care
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SHIFT TO VALUE-BASED CARE
 Shifting health care delivery paradigm: transitioning to alternative
payment models (APMs) based on premise of risk-sharing and shared
savings.
 Forcing health care organizations to consider the likely pattern in their
markets and make the structural and operational changes needed to
succeed in today’s “new normal.”
 APMs aim to rein in rising health care costs and restructure financial
incentives, all while maintaining or improving quality of care.
 Private payers implementing similar reforms at much faster pace.
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ADVOCACY PRIORITIES
It’s a busy time in oncology policy…
-
Part B Drug Payment Model
Site Neutral Payment Efforts
340B
MACRA Implementation
Value frameworks
Oncology APMs
Reimbursement for supportive care
services
- Safe handling
- Cancer Moonshot
- Oral parity
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NEW QUALITY PAYMENT PROGRAM
 Starting in 2019, MACRA essentially requires doctors to choose one of two
quality-based payment tracks:
1. Merit-Based Incentive Payment
System (MIPS) – eligible clinicians get a
% adjustment to Medicare payment
based on four-part score designed to
measure quality, cost, and value of
care.
2. Advanced Alternative Payment
Models (APMs) – eligible
clinicians who successfully participate
in one of these are exempt from MIPS
and get a payment bonus.
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MIPS PERFORMANCE CATEGORIES
Source: CMS. Webinar slides. Quality Payment Program NPRM.
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MIPS PAYMENT ADJUSTMENTS
Source: CMS. Webinar slides. Quality Payment Program NPRM.
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Alternative Payment Model (APM)
Route
 Participation in a qualifying alternative payment model (APM) is an alternative to
the MIPS adjustment, but still geared toward quality-based payment
 APM has to qualify as an “Advanced APM:” either APM is a CMS “medical home”
(under CMMI authority) or APM participants bear more than a nominal risk for
losses
 Comprehensive ESRD Care (CEC) – two-sided risk
 Comprehensive Primary Care Plus (CPC+)
 Next Generation ACO Model
 Shared Savings Program – Track 2
 Shared Savings Program – Track 3
 Extra incentives for APM participation, but doesn’t change the underlying rules of
qualifying APMs
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2017: PICK YOUR PACE
 Test the Quality Payment Program
 Participate for part of the calendar year
 Participate for the full calendar year
 Participate in an Advanced APM in 2017
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WHAT SHOULD YOU BE DOING TO
PREPARE?
1) Obtain your Quality and Resource Use Reports (QRUR), the
basis for the value-based modifier (VBM)
2) Focus on performance improvement in your practice
3) Ensure data accuracy
4) Review your contracts for the impact of value-based
reimbursement
5) Evaluate your EHR
6) Begin discussions with commercial payers about valuebased reimbursement and APMs
7) Prepare your practice staff for value-based practice
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CMMI ONCOLOGY CARE MODEL
 CMMI announced the OCM in February 2015
 Voluntary, five-year program from July 1, 2016 – June 30, 2021
 Encourages participating practices to improve care and lower costs
through six month episodes of chemotherapy treatment
 Three payments (FFS, MEOS, performance based payment)
 Requirements to make structural and operational changes (practice
“redesign” changes) and meet quality measures
Status quo FFS
payments
(including
ASP+6%)
ocmcollaborative.org
$160 PBPM
payment for
enhanced care
coordination
Performance
payment
Source: Avalere. “Providers Across the US Express Interest in Moving to New Cancer Payment Model to Control Medicare Costs.” June 29, 2016.
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OCM PRACTICE REDESIGN
REQUIREMENTS
Patient Navigation: providing the core functions of patient navigation
**Care Plan: documenting a care plan that contains the 13 components in IOM
report
Clinical Guidelines: treating patients with therapies consistent with nationally
recognized clinical guidelines
Access to Clinician: providing patient access 24 hours/day, 7 days/week to
appropriate clinician
EMR Use: effective use of electronic medical records (EMR)
Data: using data to drive continuous quality improvement
ocmcollaborative.org
PROPOSED PART B DEMO
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IMPACT BY PROVIDER
Source: Avalere Health. “Proposed Medicare Part B Rule Would Reduce Payments to Hospitals and Some Specialists, While Increasing
Payments to Primary Care Providers” April 7, 2016.
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IMPACT BY DRUG COST
Source: Avalere Health. “Proposed Medicare Part B Rule Would Reduce Payments to Hospitals and Some Specialists, While Increasing
Payments to Primary Care Providers” April 7, 2016.
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PART B FINANCIAL MODELING
 Of the top 25 oncology drugs, 15
are already underwater – that
number will increase to 19 under
the proposed demo.
 Mean annualized margin for non340B hospitals would fall from 3.3% to -5.7% under the
proposal.
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0
-1
Margin (%)
 Change in margin for oncology
drugs will be as great as -113.2%
for non-340B hospitals. (19% for
non-oncology drugs)
Non-340B Hospital Margins
-2
-3
-3.3
-4
-5
-6
-5.7
PART B DEMO: WHERE ARE WE NOW?
 Final rule by the end of the year – after the election?
 ACCC comments:
 Too narrowly focused on drugs
 Based on a flawed rationale
 Cancer care providers already providing care at reduced rates under
sequestration
 Need far more input from providers and stakeholders
 What we may see:




Flexibility for small or rural practices
Exemption of the OCM practices
Adjustment to implementation timeframe
Dialing up or down percent add-on or flat fee amount
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PAYMENT FOR OFF-CAMPUS FACILITIES
New Restrictions for Relocation, Expansion and Change of Ownership
LOOKING TO THE FUTURE…
 Policymakers will continue to look for ways to rein in Medicare
spending and lower drug costs
 MACRA solidifies movement towards Alternative Payment Models
(APMs)
 CMMI uses authority to expand demonstration programs, for better
or worse
 Providers must prepare for new risk-based world
Changes are underway that will impact oncology care delivery
and reimbursement for years to come. Get the facts you need
to understand how to stay ahead of these changes.
Represent your cancer program—and your patients—during
Capitol Hill Day. Advocate for improved funding and access to
quality oncology care.
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CONNECT WITH US
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bit.ly/accc-cancer
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