The share qualifying for the bonus payment surprised some industry experts but still was a small percentage of all physicians.

June 8—Ninety-nine percent of the 100,000 physicians who applied for the advanced alternative payment model (APM) bonus in the first available year qualified for it, according to a Medicare executive.

Gregory Woods, acting deputy director for the Center for Medicare and Medicaid Innovation (CMMI), told attendees at the National ACO, Bundled Payment, and MACRA Summit on June 8 about the overwhelming success of physicians who sought the 5 percent bonus for successfully participating in an APM under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The preliminary results for 2017—the first assessment year under MACRA—likely reflected the “relatively low thresholds” the law required for physicians to garner the bonus, Woods said. He expected smaller shares of applying clinicians to qualify for the bonus in subsequent years as requirements tighten.

Among the scheduled changes are increases in the qualifying threshold from 25 percent of payment or 20 percent of patients in such models for 2017 to 50 percent of payment or 35 percent of patients in 2019.

“We’re certainly hopeful that the majority, probably the strong majority, of clinicians in advanced APMs will still” qualify for the bonus in future years, Woods said.

About half of the qualifying physicians were working in Track 2 or Track 3 accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP). About 40 percent were in Next Generation ACOs, and the remaining 10 percent were participating in either Comprehensive Primary Care Plus (CPC+), the Comprehensive ESRD model, or the Comprehensive Care for Joint Replacement model.

“The number of clinicians who failed to meet the threshold was vanishingly small in year one,” Woods said.

The 100,000 seeking APM bonus payments represented a “smaller share” of clinicians who participated in any APM because most clinicians were not in models that qualified as advanced APMs under MACRA. Woods said those non-qualifying clinicians were mostly in MSSP Track 1 ACOs, which comprise 82 percent of all Medicare ACOs, according to CMS data. Such physicians will default to the second MACRA track—the Merit-based Incentive Payment System (MIPS), which includes bonuses and penalties that eventually will be as high as 9 percent of a practice’s Medicare payment.

“It’s not ultimately where I think the drafters of the law expected … that we’re going to get with APM penetration and probably not ultimately where we want to be in terms of the percentage of providers at risk,” Woods said, referring to the share in bonus-qualifying APMs.

The early APM bonus results reflected some industry expectations.

“We could see that the MIPS program was burdensome; that people would flock to APMs just as much as they possibly could, and we’re seeing that,” Don Crane, president and CEO of America’s Physician Groups, said in an interview.

The high share qualifying for APM bonus payments was “a little surprising,” Crane said, and likely reflected how “easy it is to get a large slice of your Medicare population into an ACO. It’s good. We need to push people into APMs. We’ve got to aggregate physicians to get done what we want to get done.”

Michael Chernew, PhD, a professor at Harvard Medical School who studies ACOs, was expecting a large share to qualify for APM payments.

“They are voluntary, so the ones who go in are motivated and think they will do well, so it’s not surprising,” Chernew said in an interview.

Gail Wilensky, a former Medicare leader, said the high share qualifying for bonuses was “a pretty big deal” but questioned whether the total number of qualifying clinicians met expectations. CMS had predicted that 70,000 to 120,000 would apply for the bonus in 2017. That number was projected to increase in 2018 to between 180,000 and 250,000.

The challenge now is figuring out long-term strategies for clinicians who won’t “and shouldn’t” go into APM-qualifying risk-bearing models, Wilensky said in an interview.

2018 Changes

The number of APMs in which participants are eligible for MACRA bonuses increased in 2018 with the addition of ACO Track 1+, which accounted for the “lion’s share” of clinicians who are expected to be first-time qualifiers for the bonus this year, Woods said.

Additionally, the Bundled Payments for Care Improvement Advanced (BPCIA) model launches in the fall of 2018, but that timing means participating clinicians will not be able to qualify for the APM bonus this year, he said.

However, CMMI has changed its reporting rules to allow clinicians in MSSP Track 2 or 3 to qualify for the bonus in 2018 even if they join those models after August.

Among major MACRA changes in 2019 will be the launch of the all-payer combination option, which allows clinicians to be eligible for the 5 percent APM bonus if they see patients in both Medicare and qualifying payment models offered by Medicaid managed care plans or Medicare Advantage plans. In subsequent years, that option will be extended to clinicians in qualifying models offered by commercial health plans. CMS expects to announce which plans and models qualify later this summer, Woods said.

“What the all-payer option does is that it creates another path for clinicians to qualify for bonuses,” Woods said. It does not replace any earlier APM-qualifying options.

Under Consideration

The Centers for Medicare and Medicaid Services (CMS) is considering major payment model changes that include adding prospective-payment options.

“We think there are some places where prospective payment does make some sense,” said Christina Ritter, PhD, director of the patient care models group at CMMI. “One of the challenges we’ve had with prospective payment, generally, is figuring out how to send the money across multiple different folks in a way that makes sense to all the different players in the system and in a way that doesn’t violate fraud and abuse laws.”

CMMI has identified areas where prospective payment “makes sense,” she said.

The addition would be a major change from the approach to date of CMS models, which overwhelmingly use retrospective payment.

The decision on where to try the prospective approach also awaits input from the new director of CMMI, Adam Boehler, whom Ritter described as “dedicated to bundles and transformation.”

Boehler, appointed in April, formerly was CEO of Landmark Health, a home-based medical care company. 

CMS also is considering the addition of total knee arthroplasty (TKA) to the 32 clinical episodes included in BPCIA. Ritter said that addition is not likely to happen until 2020.

Effective Jan 1, 2018, TKA was removed from Medicare’s inpatient-only list and assigned an ambulatory payment classification. That change allowed TKA to be paid as an outpatient procedure, but it still must be performed in a hospital.


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

Publication Date: Friday, June 08, 2018