Well, good morning, everyone. My name's Bob Flora. I'm currently Chief Academic Officer and Vice President of Academic Affairs at McLaren Healthcare in Michigan. And in my job, I actually oversee not just OBGYN, but actually all – I have 72 residency programs and faculty. So I see the whole spectrum of how this is going to affect. I'm going to focus my talk on obviously how it applies to us. But there's a general understanding that you have to have about Medicare to kind of see where this is all going. So I don't have any disclosures. And what I'm going to try to do in this 20 minutes is kind of develop what's called the mindset. And what's interesting is when you go on the web or in a book and look at the word mindset, what I found was medicine actually has its own definition. And I give this – I use this in my teaching surgery talk. But, you know, in medicine, developing a mindset is a fixed mental attitude or disposition that predetermines a person's response to an interpretation of the situation. And I think we all agree that the changes in healthcare and in CMS and the cost dollars, this is a situation that is ever evolving. So Sarah and I actually discussed this morning what Medicare does, everybody else follows. So, you know, if you understand this, then you'll understand when the other payers come and implement something either identical or similar. So my objectives, one, I'm going to – at the end of the session, you should be able to understand the Medicare payment program and its history. You should discuss the pre-macro CMS payment system because you have to understand what happened before you understand what's going to happen. And then the last thing, and in front of your – in front of you, I actually printed off the terminology from the CMS payment system. And then one from a book, and at the bottom of it, you'll see the reference. It's actually a text that I recommend because it's probably the simplest thing that you can use to teach yourself and teach others. For those on the webinar, these will be in the packet later on. So Medicare, believe it or not, when I talk to the residents, they actually don't even know what Medicare is. And then it's kind of scary, but there's actually people practicing that actually don't know what Medicare is. And so Medicare is a federal health insurance program where you qualify either if you're 65 years or older, certain younger people with disabilities, and people with end-stage renal disease. There are people that are called dual eligibles where they are both on Medicare and Medicaid. But we're focusing just on this group of people. And Medicare actually has been a concept back in Teddy Roosevelt's day. And at that point, they found that about 65 percent of people, Americans over 65, had no way to receive health care or to pay for it. And so it's actually been on the target politically, FDR. And it wasn't until Harry Truman in 1945 did they really start working on trying to fix the problem. John F. Kennedy, when he was running for president, this is one of the things that he used to try to attract voters. And it wasn't until Lyndon B. Johnson in 1965 did Medicare come about. And what you see here is that this is in July of 1965 where LBJ is signing Medicare into law. And what you also see is that Harry Truman is sitting there watching him sign since Harry was kind of the person that kind of really got the ball rolling. So when Medicare started in 1965, they only anticipated that about 19 million people would be on it and that their spend would be about 10 percent. And there's a couple things that I want to point out to you. There's no question you can see the growth in terms of spend. And when they talk about 18 percent gross domestic product for health care, this slide actually shows what percentage Medicare accounts for. So it's over 3 percent now of gross domestic product. It was going up almost linearly. And then in 1997, you see this little box called SGR. They knew it was not sustainable, and so they implemented something, which we'll talk about, to kind of halt it. And it worked for about three years. And then you see the line starting to go up exponentially. And at this current point, from 19 million, we now have 49 million people on Medicare and have gone from 10 billion to 595 billion. And there's certain things that are going to occur. And if you understand this, you start understanding why things are going to change in 2026 and something, because when I look at it from a business standpoint and an actuarial standpoint, a lot of the changes are actually going to come into effect as the population changes. And you can kind of see, this is the number of births per year, and so that big bump is obviously the baby boomers. And so right now, about 10,000 people a day turn 65. And so those people were born in 1952. You can actually see that up probably for the next seven years, six or seven years, that there's still going to be an increase. And then Gen X, there wasn't as many born, so you're actually going to see a decrease. The other problem that we're going to see, not a problem, obviously, we'd like to live longer. But the other thing that will affect how Medicare pays out is the actual life expectancy. And so currently, people born in 2015, because that always lags a couple years behind, the average life expectancy is 78.8 years, and there's big drama that it dropped by 0.1, 78.9 to 78.8. But males at 76.3 and females 81.2. And as you can see, the number of people, this is through 2060, that are 65 and older, are, again, dramatically increasing. So the problem we have is that we spend about $600 billion in Medicare, but we have this aging group that's increasing. We have this group that's living longer, and it's going to continue until the Gen X start moving into that 65. So it's really a way that the government is trying to contain costs. And just so we understand how much we're talking about, so we spend $3.2 trillion a year on health care, and Medicare accounts for 20 percent of that. So we're talking about $610 billion a year. And of that, we, being physicians and other clinical services, account for 20 percent of that spend. So what they're looking at in terms of Medicare Part B is about $12 billion that they're trying to control. So I mentioned earlier that they were trying to stop the growth, and in 1997, they came up with the Sustainable Growth Rate, or SGR. So that's one of the new terms you're going to kind of know. And so the whole point was, doctors, if you spend too much more, if you spend more than we budgeted for last year, you're going to take a cut in your payment that next year. And what happened was, is that they would vote in, okay, we're going to hold the SGR cut, we're going to hold the SGR cut. ACOG, you know, I was involved where we actually went to the Hill and said, you know, get rid of SGR. Because we were to the point where if they did not vote to not implement it, we would have taken a 21 percent cut in our payments. And so we are never going back to this. So MACRA, or a form of it, is going to stay, because nobody wants to go back to SGR. And there was a movement, though, that the government just didn't feel that they wanted to pay on volume anymore. Because the whole idea is, if you have a CT scanner, if you, you know, are making this many studies, if I buy a second CT scanner, I'm going to pay on volume. If I buy a third CT scanner, I'm going to make even more. And so it just, the cost would just keep increasing. So they started pushing more toward quality. And so in 2008, and part of the Affordable Care Act, there were programs that were starting to pay based on quality. And those, as Jill will mention, are being rolled into the current payment program. So MACRA was the end of the SGR, signed into law in April 2015, and it's called the Medicare Access and CHIP Reauthorization Act. And so this is where the new game begins. Just going back again, because I have to explain this to my residents, there's four parts to Medicare. Part A is inpatient, skilled nursing, hospice, and some health care. And what I was addressing was Medicare Part B, doctor services, outpatient care, medical supplies, and preventive services. And I'm not going to really go over this much, but if you're interested or if you want to explain it to your residents, Medicare Part C is called Medicare Advantage Plan, where private companies contract with Medicare to provide the first two parts, A and B. And then Part D, which you've seen, has to do with prescription drug coverage. Just as a reference, if you want more in-depth reading on this, this is off the Medicare Learning Network. It talks about the fee schedule. So when we get paid, we're paid based on what are called RVUs, and the payment is based on three parts. How much work it takes for us to do whatever we do, what the practice expense is, and what we spend to provide that service. And then there's a malpractice factor. So you have a higher adjustment if it costs more where you live. And then they multiply by a conversion factor, which is about, right now, almost $36 per RVU. And so one of the things that you're going to have to start looking at is that when you're billing, are you billing in non-facility versus facility fees? Because as a general rule, if you do these things in a non-facility, the practice expense tends, you get a higher reimbursement for the practice expense side since you're accepting that risk. The other thing that you need to look into is what affects your payment. These are called geographic practice cost indices. And you can see that there's different indices, for example, wages in your area, how much rent is in your area, et cetera, et cetera, that they'll also adjust. And again, this is a reference for if you want more information, they have a whole area on fee schedule and relative value files. So what's the whole purpose behind this MACRA law? It's a push from fee for service, or they like to call it fee for volume, to fee for value. And again, mentioned that the current quality mechanisms that they have will be rolled into the Quality Payment Program. So I'll say this another time, but MACRA is the law, Quality Payment Program, or QPP, is the payment program. But everybody just uses the term MACRA, but it's really not the proper terminology. And as Jill will talk to you about, as a clinician, if you qualify, you'll have to go one of two routes, MIPS, which is Merit-Based Incentive Payment System, or Advanced Alternative Payment Models. And this is the rationale behind why they're doing it. They're trying to convert to higher quality patient-centered care. They're going to offer you feedback the year after you submit your data to help you improve. You're supposed to take that, continuously improve, and increase the quality. And so it's really meant to not be a static thing, but to continue to improve our healthcare system. And these are the nine strategic goals. Again, it's there for your review later on. So when we talk about the QPP, or the Quality Payment Program, there's four things that they're going to look at. One of them is quality, second one is cost, which they're not going to look at this year. But over time, quality and cost will account for about 30%. Improvement activities, which I'll talk about a little bit later in another talk, accounts for 15%. And then how your EHR is utilized in providing care, it's called Advanced Caring Information, is 25%. So some of the terminology then that you'll need to be aware of is improvement activities. The funny thing is the law doesn't use that term, they use clinical practice improvement activities. So if somebody's saying CPIA and somebody else is saying IA, they're talking about the same thing. And then Advancing Care Information, or ACI, is how you integrate your certified EHR into your practice. So giving you the basics on that, and discussing the issue with how much the spend is going to be, I think you're going to have to get the mindset that this is basically what's called a zero-sum game. And what that means is that in a zero-sum game, you have this pot of dollars, and it's not going to change, but some people are going to get more of it, and some people are going to get less of it. So in a zero-sum game, you have winners and losers. And the rationale is that by making us play this game, it's going to theoretically move the needle in terms of us providing higher quality care. And so what happens is you're going to get your score, you're going to either be, you know, at the higher standard deviations, or you're going to be in the lower standard deviations. So what will happen is two things, is that that variation, and actually Tim was one of my residents, at SUMA in Akron, we had 75 attendings and 75 different ways to do everything, right? So what's going to happen is that the people, at least in the lower part, will get moved, and you're going to actually decrease the variation. But then on top of that, if you're in the lower part, you're going to want to move up, but if you're in the upper part, just understand, this is not static, they're going to keep increasing the bar, and so even people that are doing well are going to have to keep improving. So what's happening is they're shifting the curve of our practice patterns. You get by motivation or by one way either positive or one way negative. So penalties or taking risk. So what it ultimately is, is that we as providers now have skin in the game. And so I actually wanted to look up, and where did that term come from, and it was actually from Warren Buffett. So we do have skin in the game, we're going to have an upside, but we're also going to have a downside. So terminology and acronyms, and again, I think when you guys, whether you're sitting and talking to your practice partners, whether you're presenting in any kind of situation, I would recommend printing those and handing them out, because it's just like when we were starting OBGYN, you know, SROM, PPROM, SGA, LGA. I mean, when as a medical student, it's like, what is this new language? It's a new language. So this is the acronyms that I pulled off from the Federal Register, and these are the actual, I guess you would say the real terms by law, in terms of what they use it. But then the crazy thing is, when CMS starts putting out their PowerPoints and whatever, some of them they use are not exactly the same. And again, this is the acronyms from the book that I recommend. The key terms that I want you to understand today, MACRA stands for Medicare Access and CHIP Reauthorization Act 2015. The QPP, or Quality Payment Program, is the actual payment system that's being implemented. And one of those is what's called MIPS, which will be the Merit-Based Incentive Payment System, and the other one is called APM, or Alternative Payment Model. Now, when we were preparing for this before the law came into effect in October, you know, we gave a webinar in July, things have changed in terms of the terminology. So they talk about alternative payment models, but there's actually two that exist. If you're in an alternative payment model, you may not qualify for this payment model. In other words, you'll fall into what's called a MIPS, Alternative Payment Model, and the ones that qualify are called Advanced APMs. So people are starting to get a little bit hung up when they say APM. You're going to have to be a little bit more descriptive in terms of if you're talking about MIPS or if you're talking about an advance that qualifies in Medicare's eyes. To make it more confusing, there's the QPP, but then qualified APM participants are called QPs. So somebody may throw that term up. Then the other thing, believe it or not, people don't realize that they have an NPI number. So that's how they identify you as a provider. And then a tax ID number, or tax identification number, that's what you bill under to receive revenue. Other nuances that you're going to want to be aware of, especially through OGS. We were a registry, and now effectively, somebody tell me when we effectively become a qualified clinical data registry. Are we officially now? So we've gone from a registry to a qualified clinical data registry, and at my talk after the next one, I'll explain why that actually is beneficial to us. Again, CPIA or IAs are clinical practice improvement activities, the same as improvement activities. ACI, advancing care information, is really how well you've integrated and met certain criteria. I think there's about nine of them, of integrating your CEHRT or your certified EHR technology into providing care to your patients. And last slide is basically MACRA is not the same as QPP.

Medicare payment program

healthcare providers

MACRA

QPP

fee-for-service

fee-for-value