Exam 3: From Volume to Value-Based Payment Models

When measuring value in healthcare, quality is calculated based on (2)

outcomes, patient experience (surveys)

The ____________ performance category accounts for 45% of the weight for MIPS measures. 25% of the measures within this category are related to ____________

quality, medication management

Ways to integrate ambulatory care pharmacists into ACOs (just ideas, can be more than just these)

optimize medications encourage adherence monitor biometrics CMRs

Acceptable financial risk for APM entities: (3)

withhold payment for services to the APM entity, reduce payment rates to APM entity, require direct payment by APM entity to CMS

ACOs' top 4 priority quality metrics

-total cost of care -reduced hospital readmissions -patient satisfaction -reduced ER utilization

Providers in the MIPS program may also choose to adopt a(n) ____________, which would result in MIPS adjustments and (previous blank) specific rewards (or penalties)

APM

In 2016, the greatest national health expenditure category was a. prescription drugs b. physicians and clinics c. hospitals d. nursing care

c. (32%, high spending on acute care rather than preventive care)

Patients with (chronic/acute) conditions drive healthcare costed due to their increased utilization of healthcare services (more inpatient stays, ED visits, prescriptions, and outpatient visits)

chronic

Starting in 2019, providers can receive positive, negative, or neutral adjustments in their MIPS payments based on their ____________

composite performance score (positive and negative adjustments increase yearly e.g. +/- 4% in 2019, +/-5% in 2020, etc)

30% of overall UNC contracts are value based (say cool beans)

cool beans

Lots of payers are quickly moving to value-based contracting, including Aetna, BlueCross BlueShield, Humana, etc. (say cool beans)

cool beans

Volume-driven healthcare is high (quality/cost) and low (quality/cost); value-driven healthcare is the opposite

cost, quality

Who benefits from the bundled payment model? a. patients benefit from greater transparency and accountability on price and quality b. providers benefit by transitioning into larger scale payment reform systems c. Payers benefit as the model minimizes waste and over utilization of the healthcare system d. all of the above

d.

When measuring value in healthcare, cost is calculated based on (2)

direct costs, indirect costs

Pay for Performance (P4P) is a method of reimbursing providers based on the achievement of pre-determined measures of quality. P4P programs can involve the following incentives: a. bonus for achieving quality metrics b. withholds for missing quality or cost incentives (e.g. HRRP) c. Per member payment d. Payment for reports e. all of the above

e.

Ways to integrate community pharmacists into ACOs (just ideas, can be more than just these)

encourage adherence pill packs counseling access to EHR for medication monitoring and optimization

True or false: ACOs can get together in order to charge higher prices (price fixing)

false

True or false: you cannot charge fee-for-service in a MIPS program

false

True or false: we are spending more money on medications than we are on drug-related morbidity and mortality

false ($453 billion on medications, $528 billion on drug problems)

MACRA replaces the sustainable growth rate methodology to (increase/decrease) the number of providers participating in APMs

increase (bonus payments for participation in APMs)

Ways to integrate inpatient clinical pharmacists into ACOs (just ideas, can be more than just these)

monitor labs medication optimization work with community pharmacies for TOC/discharge

In Comprehensive Care for Joint Replacement (CJR) program, CMS allocates a single, pre-determined payment amount ("bundle") for hip and knee replacements for the inpatient hospital stay, and ____________, physician services, and other related services through 90 days post-discharge.

post-acute care (to prevent infection and re-hospitalization)

True or false: hospital readmission rates have been declining since implementing HRRP

true

True or false: the vast majority of eligible clinicians participating in MIPS will receive a positive payment adjustment in 2020.

true

System infrastructure dictates the ______(1)______ and ______(2)______. ______(1)______ supports ______(2)______ which enables ______(1)______. Reimbursement payments given for meeting quality metrics are used to improve system infrastructure and provide better care.

(1): delivery system (2): payment structure

Components of system infrastructure (4)

-population health (proactive and holistic clinical care management across the continuum for defined patient groups) -health IT (digital health tools that facilitate decision support, patient risk scores, and data analysis to improve quality and efficiency) -clinical integration (collection of providers who join together with a goal to improve quality and lower costs) -measurement (linking payment to quality of care and performance metrics)

15-25% of patients discharged from the hospital readmitted within ______ days 40% of these readmissions due to medication-related problems (MRPs) 14% of MRP readmissions are ____________ Pharmacy transition of care program meta-analysis showed 32% decrease in 30 day all-cause readmissions

30, preventable

Approximately ______% of all ACO contracts are in upside risk only; ______% are in downside risk (accepting greater risk for greater reward)

70, 30

There has been significant uptake of value-based programs, such as ____________, episode-based payment models (ex. bundled payments), and medical home models.

ACO models

Advanced APM Criterion: 1. Utilization of certified ____________ technology 2. Provides payment for covered services based on quality measures that are comparable to ____________ quality performance standards 3. Is either a ____________ or requires participants to bear more than nominal amount of financial risk

EHR, MIPS, Medical Home Model

All ____________ providers will either be reimbursed via an APM or MIPS

Medicare

Hospital Readmissions Reduction Program (HRRP) is an example of ____________; hospitals with poor performance in relation to other hospitals must accept up to a 3% reduction of their Medicare payments

P4P

____________ is a method of reimbursing providers based on achievement of pre-determined quality measures. Quality can be outcome-based (ex. A1c), or quality can be process-based (ex. adherence) and measured in terms of improvement

Pay-for-performance (P4P)

What three programs combine to form MIPS for Medicare providers?

Physician Quality Reporting System (PQRS), Value Based Payment Modifier (VBPM), Medicare EHR Incentive Program (aka Meaningful Use, MU)

An ACO is a group of providers whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population. How does an ACO define the population? a. through closed provider networks b. through patient attribution panels c. voluntary patient enrollment

b.

As we transition to value-based care, which of the following must occur? a. Increased access to acute care services b. providers must shift from single episodes to treatment across the care continuum c. frequent use of retrospective data

b.

The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) was passed to promote value based programs and encourages the adoption of ____________ or ____________

alternative payment models (APMs), merit-based incentive payment system (MIPS)

Benchmarks for MIPS change ____________ based on risk assessments

annually

____________: Medicare establishes a total budget for all services provided to a beneficiary throughout an episode of care. If the episode's spending on services is below budget, then providers share in savings; if providers' costs exceed the budget, then the providers incur losses.

bundled payments

Volume-based Payment: ____________ Incentives: ____________ Focus: ____________ Role of Provider: ____________ Information: ____________

fee-for-service, volume, acute episodes, single episodes, retrospective

(Coordinated/fragmented) care is contributing to a high volume of adverse drug events and patients on inappropriate medications

fragmented

Value-based Payment: ____________ Incentives: ____________ Focus: ____________ Role of Provider: ____________ (pharmacists fit in here) Information: ____________

outcome based, value, populations, care continuum, predictive

Value in healthcare is measured as ____________/____________

quality, cost

Advanced APMs (subset of APMs) require clinicians to take on extra ____________ in exchange for greater rewards

risk (potential to earn advanced APM specific rewards and 5% lump sum incentive, but also incur more costs and penalties if quality metrics are not met)

Many ____________ physicians and (larger/smaller) physician groups with (more/less) resources choose to participate in the MIPS program

rural, smaller, less