Some doubt APMs will attract large numbers of physicians without expanding to include the wider variety of approaches used by commercial payers.

Dec. 20—Medicare plans to reopen two alternative payment models (APMs) to physicians, but whether that will be enough drive many more clinicians into APMs is unclear.

Beginning in January, more physicians can enroll—effective in 2018—in either the Comprehensive Primary Care Plus (CPC+) model or the Next Generation Accountable Care Organization (ACO) model, the Centers for Medicare & Medicaid Services (CMS) recently announced.

Expanded participation in advanced APMs such as those will allow more physicians to qualify for 5 percent annual Medicare pay bonuses while avoiding onerous quality-reporting requirements under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). However, reopening APM enrollment will not initially provide shelter from MACRA’s reporting requirements when those take effect in 2017.

The move drew some positive early reactions from physicians and their advocates despite the uncertain effects.

Reopening two of the existing models “is a good step in the right direction,” Anders Gilberg, senior vice president for the Medical Group Management Association (MGMA), said in an interview.

But Gilberg warned that CPC+, a five-year multi-payer model that launches in January, remains untested. Potential shortcomings include restrictions on the model’s availability to only certain regions of the country and to primary care providers. That limitation will expose practices that include even a small number of specialists to complex quality-reporting requirements under MACRA. Medicare will pay physicians who do not qualify for APMs under the Merit-based Incentive Payment System (MIPS), which eventually cuts payments by up to 9 percent for physicians who do not successfully report combined Medicare quality measures. 

MGMA also has pushed back on the limitation of CPC+ eligibility to practices with 50 or fewer employees.

“Larger groups with care coordination teams, health coaches, and others can do a fine job at this, too,” Gilberg said.

Among other challenges practices face in joining CPC+ is the complexity of contracting independently with the commercial health plans involved in the multi-payer model.

Meet Expectations?

Others saw the potential for positive impacts from CMS’s decision to reopen APM enrollment.

“This is a good opportunity for physicians who are thinking about how to participate in MACRA in the advanced APM path,” said Mara McDermott, vice president of federal affairs for CAPG, which advocates for physicians in value-based payment models.

CAPG had urged reopening the models and expects such a step to increase the number of physicians enrolled in the programs—but not necessarily to the extent expected by CMS.

CMS expects reopening the models to have a big impact, according to a release. The agency estimated that the move will increase the share of physicians who enroll in advanced APMs by 2018 to 25 percent of all those subject to the new Medicare physician payment system, which launches when MACRA regulations take effect in January. Those projections represent a big jump from 2017, in which CMS expects only about 10 percent of physicians to qualify for advanced APMs.

McDermott was skeptical the APM enrollment will reach 25 percent because most of the approved APMs come from CMS’s Center for Medicare and Medicaid Innovation, which faces an uncertain future given previous calls by congressional Republicans for its elimination.

The physician enrollment projections also stem from the start of four new APM options in 2018: the Medicare ACO Track 1+ model, a new voluntary bundled payment model, a new track (the certified electronic health record technology track) in the Comprehensive Care for Joint Replacement Payment model, and Track 1 of the Advancing Care Coordination Through Episode Payment initiative.

But two of the above are mandatory models, which in general have drawn sharp criticism from Rep. Tom Price (R-Ga.), whom President-elect Donald Trump nominated as secretary of the U.S. Department of Health and Human Services.

“The future of the mandatory bundled payment programs is uncertain at this point,” McDermott said in an interview.

More APMs

Alternatively, physician enrollment in advanced APMs could surge well over 25 percent if the incoming administration moves beyond the “top-down approach” favored by the Obama administration and allows a wider range of payment models, such as those used by Medicare Advantage plans, said physician payment policy watchers.

“CMS has a really high bar in terms of what they consider an advanced APM,” said John O'Shea, MD, a senior fellow at The Heritage Foundation. “There doesn’t seem to be a good glide path to get providers from where most of them are right now in fee for service to way over where these advanced APMs are.”

Barriers for many providers include excessive regulations and excessive risk requirements, O’Shea said in an interview.

Many physician advocates have been urging CMS to offer more APMs that can better fit different types of physicians in different types of practices.

Advocates said physicians appear much more excited about some of the future APMs than they are about the ones CMS is reopening. For instance, the Medicare Shared Savings Program Track 1+ model proposed in October and the voluntary bundling models have drawn more interest.

“I don’t see a lot of groups going into Next Generation ACOs—it’s a much higher bar,” Gilberg said.

Allowing commercial options to qualify as advanced APMs may require legislation amending MACRA, O’Shea said.

The new Congress may have an incentive to expand APMs to include private-sector approaches because the CMS models have provided little financial benefit for the federal government thus far. For instance, Medicare’s ACOs generated a $216 million net loss for the government after its bonus payments to providers were calculated, according to an analysisby a Harvard researcher.  

“Medicare Advantage organizations are engaging physician practices and they are incorporating models that span the entire spectrum of APMs, so that is something that should probably be looked at,” O’Shea said.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Wednesday, December 21, 2016