MACRA 101: What you need to know about Advanced APMs
Editor’s note: MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015, and is Medicare payment reform that goes into effect Jan. 1, 2017. The associated Quality Payment Program (QPP) is the regulation that will shift the reimbursement model from volume-based payments to a more comprehensive value-based framework. In this MACRA 101 blog series, Jim Brulé dives into the details of the two tracks within the QPP, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).
Participants that choose the optional APM track are agreeing to higher risk but also have the potential for higher potential reward than their counterparts in the default MIPS track.
The APM track relies on a category of risk-based payment models with shared characteristics. These models require Certified Electronic Health Record Technology (CEHRT), use quality measures similar to MIPS and involve financial risk.
What counts as an advanced APM
Only advanced APMs are eligible for MACRA, which currently includes Medicare Shared Savings Program (MSSP) Track 2 and Track 3, Next Generation Accountable Care Organizations (ACO), Comprehensive Primary Care Plus (CPC+), Comprehensive ESRD care Model (LDO and non-LDO, two-sided risk arrangement) and the two-sided risk arrangement of the Oncology Care Model. CMS has made it clear that this list will grow over time.
In 2018, physicians will have the option to create a model, called the Physician-Focused Payment Model (PFPM). These offer incentives for higher-value care, but they will require time to satisfy the steps required in the CMS approval process. Realistically, these models will not likely begin to be approved for a couple of years. For now, participants should monitor their clinical and financial performance with an eye to how they might be willing to take risk in the future.
Being in an advanced APM is not enough to be considered successful in the larger QPP, however; each EC must be a Qualified Participant (AP) in that advanced APM by meeting a minimum threshold either in a percentage of Part B billings (25% for performance year 2017), or percentage of patients (20% for performance year 2017). These thresholds increase every other year.
The impact of participating in the advanced APM track
The advantages of participating in the APM track are several: eligible clinicians do not have to complete MIPS requirements; they will receive current financial incentives, plus a bonus; and for payment years 2019 through 2024, these participants will receive a 5% increase in Medicare Part B incentive payments.
These models require less investment up front, for the promise of greater rewards upon meeting certain milestones. They also require providers to bear more than a nominal financial risk. To be successful, providers may need to create new organizational systems for clinical and financial management to manage quality.
Editor’s Note: Though the Trump administration will ultimately put forward policies related to health IT, all conversations to date indicate no plan to change the path outlined for the QPP. Regulatory deadlines remain in effect and healthcare organizations should stay the course. Jim Brulé shares some of the finer points of MACRA’s QPP in additional blog posts, including: