>> the presidential inauguration of donald trump will be friday, january 20th. c-span will have all the ceremonies. watch live on c-span and c-span.org and listen live on the free c-span radio app. >> now a look at the future of health care policy, medicare and health care payment plans hosted by the american bar association. this is just under an hour.

>> good afternoon. we'll go ahead and get started for our session since we're a little bit behind time. but welcome to going micro with macro and we're going to talk about the rule, the implementation and the realities. i'm sydney welch. i'm a partner and chair of health care innovation practice out of atlanta. it's my pleasure to be here today. i want to tell you about both. so jp has tremendous experience and relevance for today's topic having been intimately involved in the drafting on the apm side and he'll cover and kick it off for us in the piece of it. he has a joint jd and mph and macro lead. he joins cms in 2014 and leading the innovation center team

developing the macra actipm pol. and led legal and compliance monitoring activities for the pioneer aco model as well. before working at cms, he clarked at the henry ford health systems in the office of general council at university of michigan health system and he received his jd from the university of michigan law school and mda from university of michigan and a graduate with degree in psychology from harvard university and originally a native of texas which will be relevant to many of you in the audience. larry is the principal ot national leader of their center for health care regulatory insight and larry has particular substantive relevance in this area, not only having served as the former senior advisor to the

administrator of the center from medicare and medicaid services at hhs but larry also instrumental in working with the american medical association and the development of their macra implementation piece. before kmg having practiced law in dc and then also visiting fellow at economic studies in brookings institution and his accolades go on and on and on but welcome to both of them but hopefully our insights will help those who struggle through macro and how we get the ball rolling. j.p.? >> okay, thank you. and so what i'm going to do here is go through these slides, these will give us an overview of what macra payment program

and the apm side and set the foundation here and follow up on particular areas i think are of interest to all of you so with that, i'll hop into this overview. and so this is what we'll talk about. just what it is overall, and what to expect from it coming up. so very broad overview first. so the real impetus behind macra was the repeal of the sustainable growth rate. everybody could get behind that. that was a looming cuts to medicare payments which we regularly had a doc fix bill to make sure those weren't in place and no longer exist and have the cycle of correcting these potential cuts. instead, what macra does is replace it with the two new

programs. we have, on one hand, the merit based payment system or mips and we'll talk about more about that but it really changes part b payments in a way where we have payment adjustments associated with performance on cost and quality and improvement activities and ehr use, so we'll talk a little bit more about that. and on the other hand are these advanced alternative models. so advanced apms and that's kind of a new term that's come up in the past couple of years. apm. what that really does is support the participation in certain types of apms and collectively, they really focused on improving the quality of care and reducing the cost of care in a variety of ways, so we'll talk about that near the end of the slides here. so just kind of stepping back the goals when we're talking about macra and the quality payment program, what are the

perspectives that we're taking into this from cms angle and what are we trying to do with this tool? this is really a piece of legislation that allows us to fundamentally change the way we pay for care, medicare and set the stage for the country in general. so what we want to do is have this cycle where it's very evidence-based. we look at our stake holder communities and how each move we do affects them and we want to be very sensitive to that so we can all get behind the same goals that we are improving the care and the cost of care for our beneficiaries and there are a lot of ways to do that. so we want to make sure we bring everybody along as we go. and so these are some strategic goals that we've set out as well and i'll highlight a couple of them. i won't read through all of them. so one, i'll talk to near the end is the improvement in the advanced apm participation. so this law came out. it's really supporting with these additional incentives,

participation and certain types of apms and everybody says, i want to be in one of these and where are they all? show them to me and we have a few that were already made but we also want to show that we're actively working on developing more of these in the future to have more opportunities for people to get in these. and we'll talk about a few more of these in particular in our conversations later. so i'm actually going to skip over the rest of them because i think those are all good topics for us to touch on. so now we'll just get into a little bit of the content to do an overview, in case you're not too familiar with what the mips and the apms are. so this is mips and what you see first of all leading into mips is the sunsetting of current programs. you have the hr incentive program and the disparate programs, adjusted payments based on performance and quality

and cost performance and ehr use but they were independent of one another. so those will sunset. so this year, 2016, the last performance year for those programs, so those payment adjustments will go into effect in 2018. after that, so starting in 2017, payment adjustments in 2019, we have mips. so you see, those old programs have some legacy components that will still live on in mips, but in general, what mips is, is a consolidation into one program, all of these different measurement elements so there's one score, one payment adjustment instead of three separate ones. and these are the four performance categories that comprise mips. so you'll see the corollaries between the legacy programs and quality and cost and advancing care information as the ehr use piece. the new one here is improvement activities and so that's a novel

piece and that's focusing on actual clinical practice activities that we know are associated with better outcomes and there's a bit of reward there in the mips program for undertaking these kinds of activities and what you'll see is with improvement activities in particular that we want to tie all of these performance categories together, so they're not siloed. so if you perform in a certain way and improve in activities using your certified ehr technology, there should be synergies there and we want to represent that in the scoring. so we first, i think the way to look at this is that we are really taking a step back saying, what makes sense? we have this new opportunity to build this new system that affects part b payment across the board. has all of these different moving pieces but we want it to come together in one cohesive

piece at the end of the day and that's what we get with mips and the general goals behind it. all of these different performance activities, i want to get to the core pieces. what makes the practice of medicine better for our beneficiarie beneficiaries, how do we represent that in a final score that then will give more higher payment adjustment rate to those practices and physicians who perform highly on these measures and reduce those in a correlating manner in the future for those who did not perform as well. so those will balance out and we'll talk about the transition into those payment adjustments as well. this is the time frame. so don't need to read all the fine fingerpriprint there if yo want to but this is the general step by step approach you'll see from performance to payment under mips. so we're saying, the first performance period is in 2017 so

starting january 1, mips is live. performance, we can start measuring your performance under those measures starting then and what you do in 2017, you'll report on at the beginning of 2018 and so there's a reporting submission period at the beginning of 2018 and then those first payment adjustments associated with with that performance and payment will go into effect. so those will be plus or minus percentage adjustments on part b claims starting in 2019 and go for that year. and then that will be the cycle. so 2018 performance, 2019 submission, 2020 payment adjustments. so this is a key part of it. so who are we talking about when we're saying mips? who is affected by mips? and so, one, it's important to know it's a clinician program in part b focused on medical

enrolled practitioners. dhr program, for instance, continue as they otherwise have been and so this is really just with respect to part d clinicians and then you see at the bottom here, which is key. that only certain clinician types will be eligible for mips. so right off the bat, there are certain clinician types, say, registered dietitians are not on that list, otpt. so you'll notice that we start off with the starting in the third year of the program, we have the opportunity to expand the mips to cover everybody in medicare, so you can look out for that in the third year of the program to enlarge that group from the types of clinicians you see here to everybody that medicare has in their systems. the second one will actually move to this piece. this is a key part. there are certain exclusions

that were set in the statute for participation in mips. so certain types of clinicians, even if you are a physician, you could still be excluded from mips. and medicare. if it's your first year in medicare, you won't be subject to mips adjustments. the second one is really key. this is something i think we'll talk a little bit about. it's a change from the proposed to the final rule that we did based in this area in particular. low volume will exclude you from mips. if you only do a little bit of medicare business, you will not be participating in mips. the rationale behind that if you only have a little bit of medicare business, we don't need you to jump through the same reporting hoops to make sure you've been doing these same activities because there is a cost to that reporting. it's balancing the participation that we want everybody to participate, but we understand that it's not feasible for

people who don't do much medicare business. the last one is the tie-in to the apm part. this is where mips and apm overlap with one another. if you're in certain advanced apms, you're excluded from the mips reporting requirements and payment adjustments because they have their own rigorous requirements themselves, so the rational is we want you to focus on these specific advanced apm types of activities as opposed to what mips is asking to you do so they are not duplicative or conflicting reporting going on under cms. so this is something we highlighted a lot when the final rule came out. we called it pick your pace. and this is really about our strategy for transitioning into this new world of equality payment program. particularly with mips.

so there is a variety of options to how to participate in the quality payment programming. we want to highlight those and make sure we recognize every time we do a change, particularly with the final role coming out in the fall in the first performance year starting in the subsequent year, we want to make sure people are prepared and able to succeed instead of just having to quickly scramble to get their stuff together for the year. that's what this is about. there should be a transition from our legacy reporting programs into this new mips landscape and quality payment program. there are a variety of ways to dip your toe in mips and avoid a negative adjustment or go for higher payment adjustment. so we'll talk a little bit about the transition there. on the left hand you'll see that advanced apm part. instead of participating in

mips, you're raring and ready to go in advanced apms and take on those challenges and that's also an option. that's what i'll talking about here for a few minutes. then we'll get into discussion. the apm part is something new. there is no legacy aspect to this. this is looking at new payment models and providing additional incentives for participating in certain types of these payment arrangements. starting with the innovation center, but also looking at the shared savings program and other federal demonstrations, we have this body of things we call alternative payment models. they can touch payment in a variety of ways. they can look at clinical conditions, episodes of care, certain clinician types, total cost of care for beneficiary populations, they can partner with other nonmedicare enrolled entities to accomplish these

health goals of reducing costs and improving quality. that's really what ties apms together is they have this core goal of improving our health care system and testing a variety of options in doing that. that's what you've seen building out of the innovation center over the past six years is this portfolio of alternative payment models to look in a variety of directions and see what works. and the core tenet of the innovation center is to find those things that work and have the authority to expand. if something is proven to reduce costs and improve quality or reduce costs and keep quality neutral, one of those three categories, we can expand in duration and scope one of these tests we are doing. that's what we were trying to do. what the quality payment program does, it doesn't change those apms themselves, but it adds this additional layer of

incentives on top of them. for being in the most rigorous of the apms, you get this additional 5% lump sum bonus, just for participating, for being one of those early adopters in these models to figure out what works best for medicare and the health system in the future. when you see apms and advanced apms, they are slightly different things. advanced apms are the subset. that's that graphic there to help you conceptualize. we say apm, toss that word around, but when talking about these specific incentives in the quality payment program, talking about advanced apms. i'll talk about the criteria for them. these are the incentives. this is just a summary of what you get in the quality payment program. you get those advanced apm

specific rewards. the advanced apms, they don't change. the terms and conditions, the way we change care, the clinicians or the diseases we focus on, that doesn't change, but we add this 5% lump sum bonus on to it. so those clinicians participating in the advanced apms have the opportunity within the apm itself to earn rewards. like shared savings or quality performance bonuses. those exist plus you get this bonus on top of it. this just defines the advanced apm. this is what a large amount of the apm, part of the final rule delved into. there is a lot of meat on this i won't go into great detail. when we look at apm, that universe of payment models. so anything out of the innovation center, shared

savings program, other federal demos, we look at each of those and we ask these three questions. can we check these three boxes based on the terms and conditions of those payment models? if so, it's an advanced apm. then the participants can get those bonuses. so the goals for an apm to be an advanced apm is they must require their participants to use certified ehr technology, must tie payment to quality measures comparable to those in mips. payment tied to quality, the third one is the trickiest. this got the most attention we distinguishing between the world of apms and advanced apms. it's about financial risk. it's an either/or. the one i'll focus on is that number two. it's that participating entities must bear a more than nominal amount of financial risk for monetary losses.

what that means, we have many pages and lots of ink spilled on that, but we are looking at how much financial risk are these participants under when participating in these models? and what we distinguished the main distinction is there is a down side risk models or two-sided models and one-sided models or only up side models. so that's saying certain payment arrangements, you only get bonuses. if do you well, we'll give you more payment. others you have a risk involved. meaning you must repay cms if 2 you go over cost performance measures, or you can have withholds of payments or reductions in your payment rates, something like that. that's considered financial risk. that's what we are looking at, are these models based on some sort of financial risk? so that distinguishes between a lot of apms and advanced apms. what we do though, we provide

the answers. we have a lot of criteria there, technical details about how we assess which apms are advanced apms. we do those basic assessments for you and we post them on this new qpp.cms.gov website to see our comprehensive list of apms there. you can see all the apms that cms runs. which are advanced so where you can participate and get that 5% lump sum bonus. i'll also note because it's on the screen is that qpp.cms.gov website, if you have not been there, highly recommend it, there is a good overview of the quality payment program. but also an education and tools section where you can see an executive summary of the final rule. a bunch of our fact sheets we published, various determinations we made. that's a very useful tool.

it actually looks pretty slick. i recommend you take a look at that. something else that we focused on with the final rule and that i mentioned earlier on the goal to improve the opportunities for participating in advanced apms. so we want to express what we are working on right now for more opportunities for advanced apm participation starting in 2018. our portfolio is set for 2017. we have a lot of things in the works. so we just want to let everybody know some of the directions that we're going. this is not the only things we are working on, but these are a few that we've highlighted. so you have things like comprehensive care for joint replacement. that's already operating. we just made a proposed change to allow a track of it to be an advanced apm. you have a new voluntary bundles model like the current bundles we have going on that will end

this year. then you have a few new episode payment models. those are more options like the joint replacement model. so focusing on particular conditions and episodes of care. and then you have things like vermont aco model or track one plus. those are like our current acm models with different scopes. those are total cost of care models for beneficiary populations. that's kind of the gold standard for are you taking care of your entire beneficiary population that you touch and see? so that's kind of the variety of things that will be coming out as additional opportunities. the last thing i'll say before we get into our discussion is that there is additional hurdle that the law set forth. again, there's a lot of complicated methodology lining this up with the existing apms and how we calculate

denominators for this stuff. the main point you have to have a sufficient amount of participation in these advanced apms in order to receive those incentives. if you're in an advanced apm, this is mainly what you need to focus on. you don't need to worry about the criteria of what makes an apm an advanced apm we give that answer. then we need to mike sure that you are actually committed to that apm and you have enough of your medicare practice associated with that advanced apm for us to give you those bonuses. so we look at part b. like mips this is focused on part b. we look at both your payments through that advanced apm and your patients you see through that advanced apm. there are two parallel options. you can meet these thresholds of sufficient participation through either one of those options. we'll take the better one. that's how we'll evaluate it. are you seeing a high enough percentage of your patients or

having a high enough percentage of your payments through that advanced apm? if so, you get that 5% bonus, you're excluded from mips. so with that, i'll flash up some of our technical assistance opportunities we are focused on. also once again recommend going to qpp.cms.gov for details. then i want to jump into some of the juicy discussion we've got here. >> thanks, j.p. is the sound projecting in the back? okay, great. wanted to kick start by the conversation around the changes we saw between the proposed and final role. i think for a number of us in a consulting capacity or legal capacity advise physicians and other providers who house physicians and these other clinicians that are covered by macra when we originally read

the proposed rule which was, as you will remember, replacing sgr, many asked the question of, what mess have we gotten ourselves into? have we created a bigger problem? so in the 4,000 plus comments i believe that were received, there were a lot of them as j.p. probably knows all too well and intimately, there was those comments clearly were heard because the changes that appeared in the final role liberalized some of the fashions pointed out by j.p. in his presentation. things to make it easier on many providers, particularly physicians in participation. i think many of them were just struggling with, well, what does this mean operationally for me? how am i ever going to begin to get over this hump? so for those again working in the space, it's a huge educational curve.

larry will talk a little about those efforts that he's participated in. and that we assisted on. just trying to get over what does that mean for us? there is a sigh of relief when the final rule came out and we saw things that were going to make it a little bit easier on the small and solo practices. you may remember press headlines that said to the effect death knell for solo and small physician practices. it was very gloom and doom. i think the temptation perhaps we see on many physicians' part is to rest on their laurels. there is this tension that exists between now we have a smaller time here we can take the 90 consecutive days reporting period for the first year in 2017 rather than gathering our data over the full 2017 time period. maybe i'll wait until last quarter q4 of 2017 and see how it's looking for us. we don't have to report on cost, we don't have to worry about that for the first year. so we'll let the chips fall

where they may. particularly in the current political environment with repeal of aca and other things under way, all of that has implications, i think, for how providers globally are looking at some of these challenges. larry, you want to talk about that? >> yeah. i guess -- thank you for having me here, sidney. thanks, j.p. for being here, as well. you mentioned i worked with ama, on the implementation of macra, that's true. we also did work with the committee in terms of crafting the theory and the methodologies behind macra. really to take it a step back. one of the things that macra tries to do is to create a glide path to create a continuum that all providers could be on, which is to bring them from a volume-based world to a value-based world. if you frame it like that, it's easy to put this in perspective. one of the difficulties we had

as we looked at the way the legislation was drafted was it had a tendency to treat physicians the same. in other words, physicians are very different in terms of their sophistication, size and orientation. it was always a concern even with the drafting of the legislation we would leave the smaller physicians behind. indeed, when we came out, when you came out with the -- i was at cms so it's always the "we," the grand "we." i've been away from it for a while. when the proposed rule came out there was a cry from many small physicians that said, look what you've done. mips is where we start. we're not ready to get to advanced apms. we're in mips. mips is a budget-neutral program. for all of us that don't do well, some will do well, it will be taken from those who don't do well. people were starting to call it the "hunger games." all sorts of things.

there was this awful human cry we were leaving people behind and were going to kill small physicians. cms certainly did listen and should be commended for this first thing they did, you adjust the -- first of all, making it easier for small groups to get acclimated was one of the goals of the final rule. cms increased the fresh hold of physicians exempt from $30,000 in medicare billings or less than 100 part b patients -- they are all ors. not altogether. that means 32% of physicians in this first year won't have to do anything. building on what sidney said, they shouldn't view it that way. but they will not be affected in this first year. cms took steps to ease the burden on quality reporting. they did take legacy programs

and make them easier to participate in them, particularly for smaller physicians. they tried to make it easier in 2017 and 2018 as j.p. mentioned to qualify for advanced apms. creating more advanced apms in 2018. finally cms announced four alternative reporting options to minimize payment impacts and ease that physician transition into macra. the pick your own pace program. virtually, every physician can do minimal reporting and get at least a zero percent update. that means in effect every physician has an opportunity to not lose in this in 2017. kind of like where we were with the "hunger games," now in the final rule it's the "hunger games" meets "lake woebegone" where everybody is above average. nobody loses. that brings to mind something i wanted to ask you. we are going into 2017 and giving a lot of tools to physicians, teaching them that

this is not that complicated if they report, they will do well in 2017. as we move into 2018, as we always have in these programs, there will be the same group of people who in 2017 were complaining they weren't ready. we now enabled them to complain they are not ready in 2018. what is cms prepared to do in 2018 so we don't leave these folks behind? >> thanks, larry. that's a great question. that's something one we can answer part of that now. you can certainly see that we will have another rule-making cycle to figure out the rest of that glide path. we set that first stage to say, initial step we recognize people were not ready to jump into this new program right off the bat. next step is we see the end point. that's really what the statute hard coded in saying we need this to be a budget-neutral

program, assessing all these components on this scale and paid people accordingly. so there's going to start point now and end point there. i thing you can expect to see a little bit move towards that end point in 2018. maybe not all the way there. that's kind of what expect to see in that next rule-making cycle. i'd like to step back also about the small and rural practices and how we envision that because again, we really did listen to all these comments and appreciate them. they were actually very substantive. that helps cms move forward saying here is a suggestion we think can put us in the right place as an industry. there was this infamous table 64 in the proposed rule. it was among the few tables people know the number of. that's where it's showing that

predicted that small practices would be disproportionately getting negative payment adjustments as opposed to big practices. we did not want that outcome. we drilled down into why that was the case. it was based on participation rates. you can see one of our big strategic goals is to increase participation because once those small practices actually did the reporting, they were comparable in quality and the actual scoring with bigger practices. so that's what we wanted to look toward the future. how do we get those small practices incorporated because they are very important and doing just as well as the big practices. >> and related to that, obviously, gathering the quality information is going to be a big piece on the mips side of things as well as apm side. but that infrastructure of the gathering, the data and the indicators being so critical. many of the smaller physicians practices, less sophisticated ones or if you're in a large

health system, the huge costs associated with electronic health records or gatherer of that information which feeds into the quality measures. thoughts and comments on that, either one of you as to how all that sorts out over the next couple of years and how that problem gets solved or challenge? >> so i think one thing you've seen us introduce a little bit is on the ehr front. that's the main point to where we understand the smaller practices have an investment to make to meet these requirements. you have to buy this technology, certified ehr technology implements that. there is an expense to that. that is a barrier of entry to participating successfully in these programs. so something a little through

the regulation to make sure we transition into that, but i think outside of that space you'll see us really encouraging the vendor community, but also opening up with new tools. you may have seen announcements about our pursuit of api work to really make the transition or the movement of information through our systems a lot lower costs and more accessible for more players to come in and sync this up with smaller practices in a cost-effective manner. >> one of the real positive things you did in the final rule you made the focus on reporting and not on cost. in the mips program, you excluded cost, actually, from the calculation of the composite score, whatever we're calling it in the final rule. but that gives the -- them an opportunity not to be judged on the modifier that former program. however, you will be providing them with what their costs would

have been as attributed if you use that for scoring purposes. that's going to be really important, i think in this first year for physicians to see how they're doing costwise. how are you going to facilitate that reporting? that's going to be a tremendous undertaking going out to -- going out to all these different physician groups, particularly the smaller ones. >> yeah, so the cost piece in particular, so there is no reporting associated with the costs. so that's kind of the low burden option. but why we did not include it in the first year so we waited that category to zero in this fist transition here is because of that volume modifier in the past. we wanted to step back and take a little bit of fresh air and look at the cost assessment and make sure that we're getting it in the right place and looking at the right episodes and attributing the right beneficiaries to the right

doctors and accessing them in the right way. that's part of the part of the cost component. it is a low burden way to assess people. we want to make sure at the end of the day that it's meaningful. the higher cost people are on one end and the lower cost are on the other end instead of the value modifier and it's confusing to help you understand. we have these resource reports that would go out and they're really useful, but they're also very dense. that's the kind of space that we need to work on is how do we help practices translate this and understand what they need to do to be successful. that goes for the quality measures as well, pointing people to the right quality measures and say if you do this, then you're likely to end up on the positive side of the scale just so that it is very clear instead of a maze that the people have to navigate. >> we all tepid to focus on the amount of work that has to be done from the providers perspective.

certainly there is more work to be done from cms' perspective as well. i suspect that's one of the things that is great to hear. to tie back to the two components of the overall score on the quality and the cost standpoint, any thoughts or comments on the cost side of things when we have done the demonstration projects and other various projects that we have got the information on and the performance information on. it seems that quality is typically sweeping generalization and it's easy for folks to make adjustments and changes to it to provide for the providers standpoint. the cost is a little bit more of a challenge. did that enter into the delay factor or the pushing out on the cost standpoint? >> yeah, i think it did. there's a little bit of learning that we do from the apm and

apms and advanced apms aren't operating in isolation from the rest of the medicare program. a lot of what we do there is focusing on the cost assessment and performance there. what you will see is more of the learning from the apm experiences that we have will be translated into the whole medicare program. you don't have to necessarily have an expanded apm to use the things that have been successful in those programs. i think some of those elements particularly in the cost performance where we have some really useful measures there can be translated over to the minneapolis and the medicare program. >> i would suspect that the quality measures have a similar refinement as we have struggled to get over this transition on how we're defining quality and going back to the chart review and the level that we're starting and now we're looking

at affective quality measures and what they were. i know that some of the reactions around the quality measures are they're 90 of them and some commentary centered around were they hospital focused measures? what was the dynamic between the primary care and the special ty care? it's not a one size fits all, and then in the final rule we saw the measure will be published on an annual basis, which, you know, pluses and minuses, it may change the goal post for one perspective and the certainty of people knowing what the measures are. but it also may allow for input during that time period on an annual basis for providers to actually come to the table and comment to cms about things they're seeing and changes they would like to propose. >> well, we all have the quality of measures and i think we continue to find out that we have a lot of work to do in that area.

similarly, on cost, i think part of the theory is that you get people into the payment models and even mips alternative payment models where somewhere along that path to advanced alternative payment model they will start looking very naturally at their own cost and the cost calculus will become better as they become more mature. we still have a ways to go. macra set out broad goals and we really told physicians we would be rewarding them the most for being an alternative payment model. but the reality is we don't have any alternative payment models out there that are ready for primetime. cms has done a good job of putting some to the test and testing through cmi and so forth. there's still a lot in the pipeline and even the ones and some of ones that are up there

are eligible haven't been evaluated and expanded. we're catching up and trying to drive people to this better place, but the better place isn't fully formed yet. this is a work in process. >> yeah, absolutely. so the statute recognizes that in saying there is a process every year that we'll go through for the quality measures and it will be very public. it's just, you know, the to recognize and having that in a regular cycle of accessing the current quality measures and bringing in the new quality measures and there's, you know, it takes time to get the evidence based on the particular measures and making sure that it's reliable and valid and getting that and putting it through that ringer to make sure that it's assessing what we want it to assess and putting that in

the mix to add value to medicare and clinical practice and our beneficiaries. so, you know, it's on a measure by measure basis, but at least i think we set this platform up. that's what this is and we set the stage so that the process is there to make sure it becomes better and better in the future. >> i think when we talk about the impact here and one last question before we turn it over to questions for the group, but clearly this has a physician and ancillary provider focus piece to it. it has implications and all sort of different structural models. can you comment on the implications and the thought process and maybe the dialogue that has gone on about those providers that have feet in multiple camps, if you will, and how do you sort out which entity

is going to be the reporting entity for them, you know, if they are independent contractors or have a services agreement for a health system, but are employed by another on a part time basis and all those pieces to the puzzle. >> yeah, so that's exactly where we are right now and that's the implementation part. we set that policy and say how does this relate to actual practice on the ground? it's a lot complicated that any final rule can envision or what a statue can portray, and so yeah, you have one operating in multiple sites and one being in a hospital or an office and so it's the reality of the clinical practice where we need to make sure we think the rule is in place that the policy exists there too and encompass the different ways that people practice and how do we make sure that the tools are clear and

that people know what and how is it going to affect them if they are practicing in this way? that's a huge focus of ours now with our existing communications material and also things that we're work on through that qpp.cms.gov site is the front end for the portal where people actually go in and interact with the quality program there. so that will be a place where you can go for the truth of the medicare. what you will have to do and when and how. given your variety of ways that you practice. that will be a way that we address that. >> this just emphasizes how important and necessary and engagement of cms and other organizations like the ama and others that have built their own tools coordinating with cms to make sure that the messages are consistent, and the answers are consistent. there's going to be a lot of

questions. and having come from the perspective of someone at cms, you don't learn the questions until people ask them. you have not thought of all of the answers. that's something that cms will experience more and more. that's a natural part of the implementation process if you have clients, i'm sure that they want to listen to that and have the questions. through the trade associations and others, that's what we're going to be working on and continuing to work on. this is going to be a journey. and it's going to have some twists and turns along the way. we're going from one system that's better than the last one. the economy depends on it. >> this is just the tip of the iceberg, as we turn to the domino effect, and then the compensation and then leading to cross agency conversations about how that conversation measures up to fair market value. are we incenting the right

behaviors. with that, we can go on and on. we will take a pause and take any questions. there are two microphones that are set up, if you would use those, that's very helpful. >> thanks for a very lucid presentation on a subject that is informative. my question is unfair and maybe this is for you and can you maybe try to anticipate how this payment model is adapted by commercial health plans and how down the road this may start to set the stage, for not a new paradigm, but they're moving to similar models, but maybe elaborate on how you think it will impact how private insurers may approach reimbursement for doctor services? >> yeah, absolutely. i think that larry has thoughts on that as well. i would say that it's all intertwined and what is new is old, so a lot of this is what

we're seeing coming back around and so we're already seeing in the private payer world things that are being done that are very similar to this, so that's the short answer to the question. larry, do you have -- >> yeah, obviously private payers are moving ahead to the reforms. they were part of macra and will continue to. even cms is recognized in the out years, they will give credit to providers for participating in alternative payment models in the commercial sector. we have a lot of things that we have to work through on that and for example how does -- how do we deal with some of the abuse laws for example when you get a mix of commercials and cms payment models that don't recognize the same things. does quality become a whistle-blower problem in terms of quality reporting? there's a ton of things for lawyers to think about and how that works together.

this is all new grounds. we're going have new issues that come up. a lot of of legal issues. >> typically they feed hand and hand-off one another. >> so just to tag on to that and the other payer for apm's that's not going o to be kicking in to 2021 if i'm correct? i just want to get a confirmation on how that's working. >> yeah, that's a piece that we not dive into. as lair alluded to, there's this way to get those apm incentives through the other payer arrangements that's the advanced apm and performance year 2019 for the payment year 2021 is when that will start or later. >> and mips apms will be beginning -- these are weeds we didn't go into, but mips apms is something that is starting immediately or is that starting also delayed? >> yeah, that's starting

immediately and then that's a flavor of apm, not an advanced apm, but you can get special scoring under mips for that so it recognizes the cost and quality reporting done under those apms and can translate that over to mips. so the burden is reduced for those practitioners. that's starting right away. >> that's getting players to join apms. if there is no incentive, they may stay in mips. you want to give them a bridge to give them incentives to do so. >> thank you very much. >> you elaborate more on the pick your pace program as physicians consider their options under the program, what should they consider to ensure that they're making the best choice for their practice? >> maybe i'll let larry.

i think we can kind of describe it. it looks like from advice perspective, i will let larry. >> yeah, i think that the ama and other societies are encouraging physicians, look, you need to do something. if you do something, you will not get nothing. those that do nothing will be left in that bottom percentile of you will get a negative four percent adjustment if you do nothing. you can avoid a negative four percent and get to zero or a little bit better. you can do reporting but there's stages in this and if you report the data, it's like you're going to get zero. if you report two. >> if you move from one to two, you move into positive percentage, so it's really not that hard to accomplish. >> yeah, if they start with the mind set that you have to report something and if they fail, you're going to get a 0 percent

update plus maybe something in addition to that. >> we did not spend a lot of time on the deep dive of all of this because it would take three hours to cover all of that information. when you start looking at many of the measures, many of them are things that practices and physicians within the health systems are already doing. you really have to scroll through the measures and see what's the low hanging fruit and then prioritize that on a going forward basis. as we all have said, it really is a soft transition, if you will, because we are still building on the bottom of the fee for service. this is a layer on top of it that is helping ease what we presume is the ultimate transition into more risk bearing models. i think that we're at the end of the time. i want to say thank you to everybody. and we're on to next one, final session of the day. >> thank you.