Policy Watch

The projected APM participation decline could stem from a combination of tightening qualifications for clinicians seeking the APM bonus and a lack of new models, said one provider advocate.

July 19—Provider organizations next week will continue their analysis of the recently issued massive Medicare physician payment proposed rule, including the surprise projection that alternative payment model (APM) participation may decline.

Organizations, such as America’s Physician Groups, plan member briefings on the new Medicare physician payment proposed rule, which continues the implementation of revisions to physician payment under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA divides physicians paid by Medicare between those in the Merit-based Incentive Payment System (MIPS), advanced APMs, or an exempted class.

The vast majority of physicians continue in the exempted category, and MIPS participation is expected to inch up. But provider advocates were surprised to see that Medicare expects clinician participation in APMs to stagnate or decline in FY19.

Specifically, the Centers for Medicare & Medicaid Services (CMS) estimated that between 160,000 and 215,000 clinicians will earn APM bonuses of 5 percent of their Part B payments in FY19. That range was a decline from FY18 projections of 185,000 to 250,000, which CMS estimated in the previous physician payment rule.

“We are disappointed in the stagnation of the number of providers projected to be in Advanced APMs in 2019 compared to previous years,” said Allison Brennan, vice president of policy for the National Association of Accountable Care Organizations (NAACOS). “Given the importance of MACRA implementation and the limited number of years to earn advanced APM bonuses, we would expect to see those numbers steadily increase, not level off this early.”

“That projection going down certainly seems to be in conflict with what should be the goal of MACRA: to get more people into advanced APMs,” said Jennifer McLaughlin, JD, senior associate director of government affairs for the Medical Group Management Association (MGMA). Her organization plans to ask the agency to reverse the declining enrollment by creating more APM options for clinicians.

Why the Decline?

CMS officials did not address in the recently proposed rule why they expected APM enrollment to stagnate or decline in FY19. That fall-off would come after a big increase from about 100,000 clinicians who were in APMs in FY17.

The FY18 bump could have stemmed from the start of the newest qualifying APM, Track 1+, and an expansion of the Next Generation ACO model, Brennan said in an interview.

The projected decline for FY19 could arise from a combination of tightening qualifications for clinicians seeking the APM bonus and a lack of new models in which they can participate, McLaughlin said in an interview.

For FY17 and FY18, physicians could qualify for the APM bonus if 25 percent of their Medicare payments or 20 percent of their patients flowed through the APM. That threshold was proposed to increase in FY19 to 50 percent of payments or 35 percent of patients.

“It’s essentially saying you have to be more invested in getting your payments or your patients through the advanced APM,” McLaughlin said.

Physicians can qualify for the APM bonus if they meet participation requirements for the following models in FY19:

  • Next Generation ACO model
  • Comprehensive Primary Care Plus (CPC+) model
  • Comprehensive ESRD Care model (two-sided risk arrangement)
  • Vermont All-Payer ACO model
  • Comprehensive Care for Joint Replacement Payment model (CEHRT track)
  • Oncology Care Model (two-sided risk arrangement)
  • Medicare ACO Track 1+
  • Bundled Payments for Care Improvement Advanced
  • Maryland Total Cost of Care model (Maryland Care Redesign Program; Maryland Primary Care Program)
  • Medicare Shared Savings Program Tracks 2 and 3

One change proposed by CMS would waive MIPS requirements for physicians participating in the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration, which will test MA value-based arrangements that are similar to APMs. However, that pilot may not increase the number of physicians in the APM category because it’s not clear that they would qualify for the APM bonus, only that they would not face the possibility of MIPS cuts. Potentially a large number of physicians could qualify to participate in the MAQI model, and MGMA plans to ask CMS to clarify whether they could garner the APM bonus.

Another potential obstacle to APM participation may come from a lack of new or returning accountable care organizations (ACOs). Advocates are worried that CMS has failed to issue guidance for starting the application process for ACOs to renew or launch in 2019. It’s a process that typically starts in May, with the delay possibly owing to the pending the release of a promised overhaul of ACO rules.

“While CMS has discussed its commitment to continuing on the path to value-based care, it’s important that the agency follow through and continue to strengthen APMs, including ACOs,” Brennan said.

Another potential route for increasing physicians’ APM participation could come from the 2019 launch of the all-payer model.

Physician Models

Physician advocates are increasingly concerned that another obstacle to physicians’ APM participation is the lack of new physician-led models. MACRA established the Physician-focused Alternative Payment Model Technical Advisory Committee (PTAC) to review and assess proposals from physicians and recommend models to the secretary of the U.S. Department of Health and Human Services (HHS).

PTAC was expected to vastly increase the number of APMs and allow many more physicians to qualify for APM bonuses. However, no such models have been accepted or implemented by HHS, and that has increasingly worried physician advocates.

“We’ve had an exchange of communication, and [CMS officials] have indicated they are not going to move forward with the testing with those,” Richard Deem, senior vice president for the American Medical Association, said at a recent media briefing.

The lack of progress to-date on physician-focused models comes as the window in which the APM bonus is available continues to close, Deem said. The APM bonus is available for six years—for clinician performance through 2022.

“We’re hitting year three; we’ve got a few models that many specialties don’t seem to fit, and before you know it that pumpkin is no longer going to be there and you’ll have missed another opportunity for a way to encourage people to consider them,” Deem said.

Monday, July 23

Launch of the Health Resources and Services Administration’s “Using Technology to Prevent Childhood Obesity Challenge.” Learn more.

Association of Credit and Collection Professionals (ACA International) Conference & Expo 2018 in Nashville (through July 25). Learn more.

Tuesday, July 24

Webinar by CMS titled “ CY 2018 eCQM Self-Directed Tools and Resources for the Hospital IQR and Promoting Interoperability Programs.” Learn more.

Meeting by the U.S. Department of Health and Human Services titled “Partnerships to Advance Tribal Health (PATH): A National Town Hall on Combating Opioids and Substance Abuse”; livestreamed online. Learn more.

Webinar by CMS titled “ Public Reporting on Physician Compare.” Learn more.

Hearing by the House Energy and Commerce Committee’s Oversight and Investigation Subcommittee titled “Examining Advertising and Marketing Practices within the Substance Use Treatment Industry.” Learn more.

Hearing by the House Ways and Means Committee’s Human Resources Subcommittee titled “The Opioid Crisis: Implementation of the Family First Prevention Services Act (FFPSA).” Learn more.

Webinar by America’s Health Insurance Plans titled “Stressbusters: The Latest Research on Managing Workplace Stress.” Learn more.

Webinar by America’s Physician Groups titled “A Deep Dive on the MACRA Proposed Changes to the Physician Fee Schedule and QPP Program Rate Notice and Call Letter.” Learn more.

Submission deadline for abstracts to the AcademyHealth Conference on the Science of Dissemination and Implementation in Health. Learn more.

Wednesday, July 25

Votes by the Senate Health, Education, Labor, and Pensions Committee on four healthcare bills, including one on transparency in drug prices. Learn more.

Hearing by the House Energy and Commerce Committee’s Health Subcommittee titled “21st Century Cures Implementation: Updates from FDA and NIH.” Learn more.

Special Open Door Forum by CMS titled “The IMPACT Act and Standardized Patient Assessment Data Elements.” Learn more.

Webinar by CMS titled “Overview of the FY 2019 HAC Reduction Program and HRRP.” Learn more.

Webinar by the College of Healthcare Information Management Executives titled “A Journey to Opioid Prescribing Reduction.” Learn more.

Thursday, July 26

Webinar by CMS titled “Public Reporting on Physician Compare.” Learn more.

2018 American Hospital Association Leadership Summit (through July 28). Learn more.

Webinar by Health Catalyst titled “The Patient's Power in Improving Health and Care.” Learn more.

Webinar by athenahealth titled “Giving Physicians the Right Resources: a Conversation with Privia’s Jim Sams, MD.” Learn more.


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

Publication Date: Friday, July 20, 2018