WELCOME TO THE 1Q2016 R4P MEETING February 16, 2016 AGENDA MCPIPA BUSINESS

1. WELCOME TO THE 1Q2016 R4P MEETING February 16, 2016 AGENDA • MCPIPA BUSINESS • VOTE MCPIPA BOARD OF DIRECTORS • COMMUNITY CALL TO ACTION – GUEST SPEAKER: JAY SEATON, THE DAILY SENTINEL • CLINICAL INTEGRATION 101 • 2016 MCPIPA INCENTIVE PROGRAM PRESENTATION AND VOTE

2. HOUSEKEEPING • Did you sign in? • Remember to VOTE and sign your ballots. • Remember to complete the three surveys. We appreciate your responses and will share the detail with various committees including the Incentive Design Team, PIE, QVOC, BHTF, and TBI.

3. Thank you Dr. David Terry for your many years of Service on the MCPIPA Executive Committee

4. WELCOME NEW MCPIPA MEMBERS M. Kurt Gordon, MD Radiology Diagnostic Radiology Jonathon Hathaway, MD Pediatrics Dinosaur Junction Pediatrics Ellen Volker, MD Pulmonology St. Mary’s Lung and Sleep Center

5. MCPIPA BOARD OF DIRECTORS Election

6. MCPIPA BOARD OF DIRECTORS ELECTION Candidates Mike Whistler, MD Pediatrics Pediatric Specialty Joshua Campbell, MD Family Medicine Primary Care Specialty Joel Dean, DO Neurology Non-surgical Specialty

7. BOARD ELECTIONS - 2016 • Board Positions to be Determined by Vote of the Membership in February 2016 • Pediatrics • Incumbent: Michael Whistler, MD • Primary Care • Incumbent: Josh Campbell, MD • Non-Procedural Specialty • Incumbent: Joel Dean, DO • Other nominations will be accepted. • Be involved – this is your organization • Vote Now (Green Ballot) • Return Ballot to the End of the Table

8. COMMUNITY CALL TO ACTION Guest Speaker: Jay Seaton Maybe we aren’t doing as well as we thought we were…..

9. JAY SEATON – THE DAILY SENTINEL Jay Seaton is the publisher of The Daily Sentinel in Grand Junction, Colorado. Jay also oversees several other local publications in western Colorado. Prior to his arrival at the Sentinel in August 2009, Jay was a corporate and commercial litigation partner at the law firm of Lewis Rice & Fingersh in Kansas City, Missouri.  Prior to his position at Lewis Rice & Fingersh, Jay worked in toxic tort litigation at the law firm of Shook Hardy & Bacon. Jay is former chair of the Grand Junction Economic Partnership and serves on the boards of the Riverside Education Center, the Saccomanno Higher Education Foundation, St. Mary’s Hospital Foundation and Rocky Mountain Health Plans. Jay also serves on the Colorado Economic Development Commission and is a member of The Colorado Forum.

10. QUESTIONS?COMMENTS?

11. WESTERN SLOPE PHYSICIAN LEADERSHIP PROGRAM Do not go where the path may lead, instead go where there is no path and leave a trail Acollaborative effort of Western Slope healthcare organizations to provide physicians with formal training and education in the area of physician leadership.

12. ARE LEADERS BORN OR MADE? Physician Leadership skills – 3 reasons doctors make poor leaders and what you can do about it. Dike Drummond, MD

13. CLINICAL INTEGRATION 101 What Is It And Why Do I Care?

14. WHAT IS A CLINICALLY INTEGRATED NETWORK (CIN)? Simply stated, a CIN is a network of providers (e.g., MCPIPA) that are sufficiently integrated at the clinical level to allow them to contract jointly with payers.

15. SAY IT LIKE THE FEDS -CLINICAL INTEGRATION IS: An active and ongoing program to: • Evaluate and modify practice patterns by the networks’ participants and • Create a high degree of interdependence and cooperation among the participants • To control costs and ensure quality

16. FTC SAYS CINS HAVE: • Joint utilization review and quality assurance programs to insure quality and control costs • Selectively choose physicians who may participate in the CI network panel; and • Significant investment, both human and monetary, in the network's infrastructure

17. QUESTIONS?

18. THE STANDARDS • To jointly contract, independent physicians must be clinically integrated or financially integrated Rule of Reason is applied – proceed with caution • Without Integration, agreement among separate providers concerning the prices they will charge is illegal because it is inherently likely to harm competition Per Se Illegal

19. RULE OF REASON BALANCING ACT

20. RULE OF REASON BALANCING ACT

21. RULE OF REASON BALANCING ACT

22. RULE OF REASON BALANCING ACT

23. WHAT CAN AN IPA DO TO SHOW CLINICAL INTEGRATION? • Develop mechanisms to provide cost-effective, quality care, including • standards and protocols to govern treatment and utilization of services, • information systems to measure and monitor both the individual performance of the hospital and physicians and aggregate network performance, and • procedures to modify hospital and physician behavior and assure adherence to network standards and protocols.

24. WHAT CAN AN IPA DO TO SHOW CLINICAL INTEGRATION?continued • The network is structured to achieve its efficiencies through a high degree of interdependence and cooperation among its participants. • The price agreementfor physician services, under these circumstances, is subordinate to and reasonably necessary to achieve these objectives. See FTC/DOJ Statement 9

25. QUESTIONS?

26. MCPIPA HISTORY WITH THE FTC • 1996 – FTC initiated investigation • 1997 – FTC Filed Action against MCPIPA: • Alleged Price Fixing • For contracting on behalf of members without integration • Alleged higher prices resulted • Allegation of Group Boycott • IPA caused its members to act as one unit • Physicians refused to deal with payors, causing payors to be excluded from the market, forcing payors to deal only with IPA

27. Currently in place Until May 4, 2019 Only Contract as Clinically Integrated or Sufficient Financial Risk IPA Liability Insurance saved the day MCPIPA FTC ACTION SETTLEMENT BY CONSENT DECREE FTC There now. It’s all on paper. Feel Better.

28. OTHER FTC ACTIONS CLOSE TO HOME Roaring Fork Valley Physicians I.P.A. • 2010, Garfield County, CO Boulder Valley Individual Practice Association • 2010, Boulder, CO, 365 physicians • Charged with • Price Fixing • Collective Refusal to Deal • Restrain Trade • Hinder Competition R.T. Welter & 8 OB/GYN practices • 2002 in Denver, CO • Collective contracts to increase prices  • FTC Action and Consent Order Aurora Associated Primary Care Physicians Physician Integrated Services of Denver • 2002 – Collective contracts without Integration resulting in FTC Actions

29. Questions?

30. ACA AMENDEDGOAL OF CLINICAL INTEGRATION Triple Aim • Better population health • Better experience of care for patients (andproviders?) • Lower per capita cost

31. HOW CI ACHIEVES TRIPLE AIM • Incentive payments to physicians that improve health outcomes for patients • Collaborative education and practice pathways • Disease clinics and registries that track outcomes Ex: QHN, ECHO, condition-based treatment • Transitions of Care between providers and facilities

32. CMS LINKS FEE FOR SERVICE (FFS) PAYMENTS TO QUALITY OR VALUE • Hospitals, % of FFS payment at risk (maximum downside) • 7% 2015-2016 • Based on readmission reduction, hospital value-based purchasing, inpatient quality reporting/MU, hospital-acquired conditions) • Physician, % of FFS payment at risk (maximum downside) • 2 - 9% performance period beginning 2015, paid FY17 • Based on Value Modifiers, MU, PQRS

33. MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015 (MACRA) • Medicare faces major demographic challenges. • Aging population of beneficiaries/potential beneficiaries. • By 2030, Hospital Insurance Trust Fund will be depleted, without either a payroll tax increase or 10% cut in spending (MedPac June 2015 Report to Congress, Ch. 2, p. 53). • SGR was also set to impose 21% cut to MPFS payments • MACRA intended to solve this dilemma

34. MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015 (MACRA) • MACRA accelerates the alignment of measures, program policies, and operations • Sunsetting the separate payment adjustments under the PQRS, VM, and EHR Incentive Program • Establishing Merit-Based Incentive Payment - MIPS • Provides incentives to accelerate participation in Alternative Payment Models - APMs

35. VALUE-BASED PAYMENT MODIFIER (VPM) • Created under PPACA. Went “live” in 2015. • Initially only applied to groups of 100+. Now applies to 10 or more EPs. 2017 Everyone. • Based on data reported under PQRS. • Runs on same 2-year “lookback” as PQRS. • Adjusts Medicare Physician Fee Schedule (PFS) payments to physicians based on quality and cost of care to Medicare across 6 quality and 2 cost domains. • Must report PQRS date for measurement year or automatic downward adjustment.

36. VPM EXAMPLE:

39. ENTER MERIT-BASED INCENTIVE PAYMENT (MIPS) AND ALTERNATIVE PAYMENT MODELS (APMS) • Shifts payment focus towards quality and value, rather than pure volume. • No government regulations yet – interpretation up in the air • Builds on PQRS, Meaningful Use, Value-based Payment Modifier (VPM) • Develops composite performance score (of 0-100) for each EP, based on 4 measure types: • Quality – 30% of score. • Resource Use – 10% of score in year 1, 15% in year 2, 30% in future years. • Clinical Practice Improvement – 15% of score. • Meaningful Use – 25% of score.

40. MERIT-BASED INCENTIVE PAYMENT • Compare score to nationally established performance threshold. • Every 3 years, HHS Secretary must decide on whether threshold is a median of composite scores, or a mean. • Sets a “moving target” for performance. • Guarantees that there will always be “winners” and “losers” to be budget neutral. • Upwards and downwards adjustments will be a percentage of Medicare payments. • 2019 = 4% 2020 = 5% 2021 = 7%

41. ALTERNATIVE PAYMENT MODELS • Provides Provider exemption from MIPS • Accountable Care Organizations • Patient Centered Medical Homes • Bundled Payment Models

43. ALTERNATIVE CI DEFINITION What Can Providers Do Better Together?

45. QUESTIONS?

46. MCPIPA 2016 INCENTIVE PROGRAM • Review Of The 2016 Measures • Opportunities For Questions And Comments • Vote To Approve Measures

47. MCPIPA 2016 INCENTIVE PROGRAM Administrative Measure • Technology • Value 10% • Quarterly Requirements: Questionnaires Completed by Office Manager • 1Q2016 Quality Reporting Questionnaire • 2Q2016 Secure Messaging Questionnaire • 3Q2016 Security Risk Analysis Questionnaire • 4Q2016 Attend Education Session

48. MCPIPA 2016 INCENTIVE PROGRAM Quality Measures • End of Life Decision Making or Grief Support For Children (As Appropriate For Your Specialty) • Value 45% • Quarterly Requirements: • 1Q2016 Physicians attend General Education Session • 2Q2016 Practices Produce Policy and Procedure • 3Q2016 Physicians Attend Book Club Discussions • 4Q2016 Physicians Attend Palliative Care or Grief Support Education

49. MCPIPA 2016 INCENTIVE PROGRAM Quality Measures • Choice of: Clinical Quality Improvement OR Clinical Pearl • Value 45% • Quarterly Requirements – Clinical Quality Improvement (CQI) • 1Q2016 Physicians Identify CQI and Produce Outline • 2Q2016 Physicians Write and Develop CQI Program • 3Q2016 Physicians Implement CQI Program • 4Q2016 Physicians Submit Summary or Progress Report

50. MCPIPA 2016 INCENTIVE PROGRAM Quality Measures • Choice of: Clinical Quality Improvement OR Clinical Pearl • Value 45% • Quarterly Requirements – Clinical Pearl • 1Q2016 Physicians Identify and Submit Detail on The Pearl • 2Q2016 Physicians Writes A Clinical Pearl o Be Posted on MCPIPA Website • 3Q2016 Physicians Implement and Educate on The Pearl • 4Q2016 Physicians Attest To Reading All Posted Pearls