Monday, 09 May 2016 05:37

MACRA Proposed Rule Features Update on Advanced Alternative Payment Models (APMs)

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r tallerThe recently released proposed rule regarding the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 includes a lengthy section detailing what advanced alternative payment models (APMs) are, how to qualify, and which APMs are being considered for the first performance year. Clinicians participating to a certain degree in advanced APMs will qualify for incentive payments. 

From 2019-2024, a clinician meeting the standards for advanced APM participation is excluded from the Merit-Based Incentive Payment System (MIPS) adjustments and would receive a 5-percent Medicare (Part B) incentive payment. Beginning in 2026 and beyond, clinicians who continue to meet the standards for advanced APM participation are excluded from MIPS adjustments and would receive a higher fee schedule update than those not in an advanced APM. 

Advanced APMs are APMs in which clinicians are providing coordinated, high-quality care while accepting a certain risk criteria. In the proposed rule, three criteria are given for meeting the standards for an advanced APM. The first criteria relates to financial risk, as participants are required to bear risk representing at least 4 percent of the APM spending target, marginal risk for which the advanced APM entity is responsible for of at least 30 percent, and a minimum loss rate of no greater than 4 percent. 

The proposed rule includes more granularity for each of these concepts. The second set of criteria relates to basing payments on quality measures comparable to those in the MIPS quality performance category. In discussing this concept, CMS noted that quality measures must be evidence-based, reliable, and valid – and, where available, one of the measures must be an outcome measure (if an appropriate measure for the advanced APM is on the MIPS measure list). 

The third criteria relates to the requirement that an advanced APM mandate that at least 50 percent of clinicians use a certified electronic health record (EHR) technology  in the first performance year, and this increases to 75 percent in the second performance year. The proposed rule also details rules for medical home models that would be expanded under the Center for Medicare & Medicaid Innovation (CMMI) authority enabling them to qualify as an advanced APM. 

For performance year one, the models that are proposed to qualify as advanced APMS include Comprehensive Primary Care Plus, Medicare Shared Savings – Tracks 2&3, Next-Generation ACOs, Comprehensive End Stage Renal Disease Care Models (large dialysis organization arrangement), and Oncology Care Model Two-Sided Risk (available in 2018). 

CMS is seeking comment on other models that could qualify as advanced APMs and intends to update the list on an annual basis. To qualify for incentive payments requires significant participation, and clinicians would qualify based on either payments received or patients seen in an advanced APM. For 2019 and 2020, participation requirements are Medicare-only (payments or patients). Beginning in 2021 (performance year 2019), the participation requirements expand to include non-Medicare patients or payors, and thresholds increase as well. The proposed rule also has an extensive section defining other payor advanced APMs. MACRA legislation established the Physician-Focused Payment Technical Advisory Committee (PTAC), whose purpose is to review/assess physician-focused payment models submitted to the Committee and make recommendations on them to the Secretary of the U.S. Department of Health and Human Services. Additional details on the role of PTAC and physician-focused payment models is also included in the proposed rule. PTAC has held two meetings and recently released a draft document on the process for reviewing physician-focused payment models, with public comment due by mid-May. For additional information on PTAC, go online to https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee.

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of the WEDI ICD-10 Transition Workgroup.

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Rhonda Taller has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs and strategic consulting.  Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use and health reform.  Rhonda have held volunteer positions with HIMSS and WEDI including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing HIMSS ICD-10 Task Force (2013-2014) and co-chair of WEDI ICD-10 Transition Workgroup.