Becker's ASC Review

Executive Briefing: 20 Executive Briefing: CJR's Orthopedic Bundled Payments Value-Based Payments Are Coming for Orthopedics: Are You Ready? By Laura Dyrda and Megan Wood T here is no doubt that the government is accelerating its shift to value-based payments, where physicians are rewarded — to an increasing extent — for quality, rather than quantity of care. And it's likely that private payers will fol- low suit. So, how have orthopedists been affected? How will they be affected in the future? What should they be doing now to prepare for success? The government initially developed programs such as Mean- ingful Use with primary care providers in mind, marginalizing specialists. "Orthopaedists, and other specialists were accommo- dated as an afterthought and many managed to meet mean- ingful use by claiming multiple exclusions," says Lynn Scheps, Vice President, Government Affairs and Consulting Services for Montvale, N.J.-basedSRSsoft, an EHR and HIT solutions provider. Clinical quality measure reporting for meaningful use, and even PQRS (if providers report electronically, which the government encourages), requires that orthopaedists report extraneous mea- sures. They must report on nine quality measures, but only four, or possibly five, are directly relevant to their specialty. But now the government is shifting focus to value-based pay- ments. Having implemented the Value-Based Payment Modi- fier over the last few years, this shift is now taking the form of bundled payments, accountable care organizations and the Comprehensive Care for Joint Replacement programs. The CCJR began on April 1 and impacts 67 geographic areas. "Medicare is trying to shift the risk for cost and quality to the providers and away from Medicare," says Ms. Scheps. CMS recently stated that it is meeting its goal of 30 percent of 2016 payments being value-based; by 2018 the agency intends to increase that number to 85 percent. Effective in 2017, the Medicare Access & CHIP Reauthorization Act of 2015 will replace the current MU, PQRS, and V-BPM and reward physicians based on their ability to improve quality and lower costs. Medicare payment adjustments associated with MACRA will begin in 2019. Under MACRA, physicians will either participate in the Merit- Based Incentive Payment System or the Alternative Payment Models. Medicare claims the new program will prove more meaningful for specialists and offer more flexibility. Initially, most physicians will operate under MIPS, which is a com- bined weighted score of quality, resource use, meaningful use and practice improvement scores. The exemptions from MIPS include physicians who are in their first year of Medicare billing, providers whose volume of Medicare payments or patients fall below a still undefined threshold and providers qualifying for payments under APMs with associated MIPS-exempt bonuses. APM participants must reach a volume threshold of Medicare payments or beneficiaries paid through the APM. This model involves ACO participation and the Medicare Shared Savings Program. Nearly 40 percent of primary care physicians and 31 percent of specialists are involved in ACOs, with 6 percent of primary care physicians and 5 percent of specialists planning to join ACOs this year, according to Medscape's "Physician Compensation Report 2016." Between 2019 and 2024, APM participants will receive 5 percent lump-sum bonuses and transition into more risk-based payments. "Because of the volume requirements, I don't think many orthopaedists will initially be evaluated under the APM option; most will have to participate on the MIPS side for the first few years," says Ms. Scheps. "But physicians are trying to position themselves for success in the future by dipping their toes into the APM/ACO world where opportunities exist." (Update: In the proposed MACRA rule, released on 4/27/16 subsequent to the writing of this article, CMS specifically excludes CCJR and other bundled payment programs from the list of qualified APM options, with obvious implications for how orthopaedists will participate in MACRA.) Managing the data The new payment models rely on quality and cost data to inform value. No one in the healthcare industry is crystal clear on what data analytics implies — from the data needed, to what to do with the gathered data. "It's still early, but physicians are, thinking, planning and critically observing what other practices are doing," says Ms. Scheps. "Ultimately, they want to position themselves to be valuable participants in ACOs and other risk-sharing arrangements in the future." Orthopedists are first focusing on understanding how their patients are doing right now. Current quality measures tracks only the rate at which patient outcomes surveys are completed, but physicians want the tools to analyze the actual outcome itself. By analyzing their current performance and outcomes, orthopedists can strategize how to improve outcomes and control costs. "Knowing what you need to capture is the first step and that's where we have a deviation from the current regulation," says Lester Parada, Senior Implementation Manager at SRS. "What the practice wants to capture and analyze is different than what they are currently required to capture and analyze." Once a practice decides which data to gather, the next step involves obtaining the proper electronic health record system to successfully collect the data. "Practices want the best system for each need, instead of one system that does it all poorly," says Mr. Parada. Actionable data allows orthopedists to intertwine the data from different systems to enhance how they practice medicine. Sponsored by:

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