The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: MACRA (page 1 of 2)

Going National with The Michigan Model of Collaborative Quality Initiatives

Scott Regenbogen

Dr. Regenbogen is the MVC Co-Director

Over the last 10-plus years, the Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships have grown to include, among other programs, 17 Collaborative Quality Initiatives (CQI). The clinical focus of the CQIs ranges from cardiology to spine surgery to radiation and many others. This “Michigan Model” of collaboration, pay-for-participation, and statewide, population-based quality improvement has yielded wide-ranging improvements, as reported several years ago.

Still, the regional collaboratives model has not spread widely beyond Michigan. Last month, at the inaugural summit of the Center of Excellence for Collaborative Quality Improvement, discussion focused on the challenges of securing financial support for regional collaboratives. Several other states—including Tennessee, South Carolina, Illinois, and Pennsylvania—have multi-hospital improvement initiatives around surgical care, but on a smaller scale than in Michigan. Like Michigan’s, all of these CQIs are supported by a regional Blue Cross Blue Shield insurer. In a commentary in this week’s JAMA Surgery, the leaders of the Michigan Surgical Quality Collaborative argue that an all-payer strategy, including investment from the Centers for Medicare and Medicaid Services (CMS), is needed in order to replicate the Michigan approach to care improvement.

To date, BCBSM has been the sole third-party funding source for the CQIs. Yet, the efforts of each collaborative have been payer-naïve—the benefits accrue to all patients regardless of their insurance coverage. In the Michigan Value Collaborative, we analyze payment data for individuals insured by both BSBSM and Medicare, and will soon expand to include Medicaid beneficiaries as well. And even in states like Michigan, where BCBSM handles quite a large portion of the commercial insurance market, CMS still remains the truly dominant payer, once we consider Medicare and Medicaid in all of their various forms.

This week’s JAMA Surgery Viewpoint considers how CMS could partner with private payers in support of regional collaboratives. Such a partnership could allow Michigan to become a model for the rest of the country. Under the new requirements for MACRA, physicians may satisfy reporting requirements through Qualified Clinical Data Registries. But what if active participation in a proactive CQI became a central part of all medical care in this country, and was supported by CMS? If this degree of dissemination could be achieved, CMS could catalyze innovative care delivery improvement on a far greater scale.

Unpacking Medicare’s MACRA Resource Use measure

Paige VonAchen

Paige is a MVC Research Intern and MD/PhD candidate at the University of Michigan Medical School

The Medicare Access and CHIP Reauthorization ACT (MACRA) Merit-based Incentive Payment System (MIPS) will begin payment adjustments beginning 2019, resulting in approximately $199 million in payment adjustments and $500 million in additional bonuses across physicians nationally each year. The program scores physicians based on their performance in four areas: quality, improvement activities, advancing care information and resource use. While the Resource Use category comprises 0% of the overall weighting in 2019 (based on performance year 2017), the weighting will rise to 10% in 2020 (based on performance year 2018), and then to 30% beginning 2021. Therefore, understanding how the new measure is determined and adapting accordingly will be critical to providers’ success under the new payment system.

So, what does Resource Use really mean? And how is it calculated?

First, let’s establish who is not being scored…clinicians participating in the Advanced Alternative Payment Models (AAPM) and clinicians that are non-patient-facing (e.g., pathologists and radiologists) will also not be scored (instead, the weights of the other categories will increase).

For those that are being scored, it’s important to know the three measures that comprise the Resource Use category:

  • Total per capita costs: this measure represents the total yearly costs (for Parts A and B) for all patients assigned to a physician, divided by the total number of patients assigned to that physician. Patients are attributed to the physician or physician group that delivers the plurality of “primary care services” (under Part B) to the beneficiary as compared to any other practice, and includes admissions due to COPD, CHF, CAD, and Diabetes Mellitus.
  • Medicare Spend per Beneficiary (MSPB): this is a measure of combined Part A and B spend incurred around a hospitalization beginning 3 days prior to admission through 30 days post-discharge. MSPB is attributed to the provider submitting the majority of Part B claims during the index hospitalization. The total cost of care for such an episode is attributed to the physician or physician group that spends the most time with the patient during the initial admission.
  • Condition- and Episode-Based Measures: this measure looks at episodes of care triggered by a specific diagnosis of procedure. Many episodes are surgical (e.g., hip or knee replacement); however, there are medical as well (e.g., CHF, and COPD exacerbation). Any physician that provides over 30% of inpatient E&M codes during the index event (inpatient stay) will have the Part A & B costs of that episode attributed to them. This is currently reported in today’s Quality and Resource Use Report (QRUR); however, now it impacts reimbursement. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016-QRUR.html

Needless to say, the Resource Use category of MACRA is complex and the implications for individual physicians depend on their type of practice and compilation of patients. Understanding and monitoring the payment and utilization of your own services will help you identify the most efficient services and allow you to adapt to MACRA’s new payment system.

Read more about MACRA at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Resource-Use-Performance-Category-slide-deck.pdf

 

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