MACRA Forces Providers Seeking APM Track to Move Quickly

In the recent proposed rules for MACRA, CMS offered some clarity for providers who are trying to decide whether to participate under the Merit-Based Incentive Payment System (MIPS) or the Alternative Payment Model (APM) track.  In short, it really is not a decision that the provider makes, but rather a determination made by CMS based on the provider’s level of participation – if any – in qualifying APMs (also known as advanced APMs).

To qualify for the APM track in 2019, providers must get at least 25% of their Medicare Part B business (based on either charges or patients) through advanced APMs.  In the proposed rules, which are subject to change, the APMs that meet MACRA’s criteria include:

  • Comprehensive ESRD Care (LDO Arrangement)
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Program: Track 2
  • Medicare Shared Savings Program: Track 3
  • Next Generation ACO Model
  • Oncology Care Model Two-Sided Risk Arrangement

Providers who meet the criteria for payment under the APM track are specifically excluded from the definition of a “MIPS-eligible clinician” and therefore cannot participate in the MIPS track.  In other words, providers do not tell CMS which track they prefer – that determination will be made for them by CMS.  The “decision” really comes down to how aggressively providers choose to pursue advanced APMs, and also how successful they are in that pursuit.

But here’s the rub:  while MIPS and APMs go into effect in 2019, both programs are based on 2017 performance data.  For the APM track, that means providers’ participation levels are also based on 2017 results.  This is because CMS needs to determine, in 2018, which providers are eligible for which payment track so that payment adjustments can be made beginning in 2019.  That gives providers very little reaction time to qualify for the APM track, if that is their intention.

What’s more, the threshold level of participation ramps up rapidly, to 50% in 2021 and 75% in 2023,1 which would be based on data from 2019 and 2021, respectively.  As a result, providers who are not already participating in advanced APMs at a meaningful level may find themselves unable to catch up to the moving participation targets, and could be shut out of this option entirely.

It is perhaps because the bar for participation is set so high that CMS itself is projecting that relatively few providers will be in the APM track in 2019.  In the executive summary to CMS’s proposes rules, the agency indicates that in 2019 roughly 30,000 to 90,000 clinicians will qualify for the APM track, as compared to 687,000 to 746,000 clinicians in the MIPS track.

Organizations that are already moving forward with advanced APMs may determine that they need to go full steam ahead with these initiatives in order to meet the participation requirements.  Those that have not yet begun should urge CMS to give providers as much time as the law permits to ramp up their advanced APM programs. MACRA does seem to allow some flexibility in this, but time is of the essence – CMS must finalize its rules by November, and the commentary period ends June 27.

  1. Providers can qualify for the APM track at lower levels of Medicare participation if they meet alternative, all-payor advanced APM threshold criteria.
This entry was posted in Accountable Care Organization, Healthcare Reform, Healthcare Reimbursement, Legislative & Regulatory Issues, PCMH, Physician Compensation and tagged , , , , , , , , by Dave Wofford. Bookmark the permalink.

About Dave Wofford

For almost 20 years, Dave has focused on improving performance and achieving alignment between hospitals, physicians, and other entities. Dave’s clients appreciate his knowledge of the issues related to hospital/physician relationships and affiliations, as well as his understanding of the perspective and value that each party brings. This, in turn, allows him to help parties reach sustainable arrangements. As providers seek opportunities for clinical affiliation and collaboration in an era of shrinking revenue sources and increased competition, Dave works closely with hospitals and medical groups on matters such as physician compensation plan redesign, strategic planning, and the negotiation and development of professional services arrangements. He consults to hospitals and physicians on issues concerning operations, business planning, strategic alignment, and in particular, professional revenue cycle performance turnaround. Recently Dave worked with Children’s Hospital Los Angeles Medical Group, an organization consisting of approximately 500 professionals. He led an effort to improve the group’s revenue cycle performance, which resulted in significant reductions in accounts receivable and IT vendor fees, positioning the organization for enhanced ongoing collections. Prior to joining ECG, Dave served as an officer in the U.S. Army for 8 years, and today his clients value the leadership qualities honed during important international assignments.

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