MACRA for Busy Docs: 12 Things to Know

Leigh Page


September 07, 2016

In This Article

Care Delivery Method Is Not a Payment Mechanism

5. PCPs Will Have a Special Pathway to Advanced APMs

The MACRA law directed that physicians in patient-centered medical homes should qualify for the APM track, but this presents implementation problems, says Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, which studies APMs.

"The medical home is a care delivery method, not a payment mechanism," he says. "That means practices with medical homes have to be treated as alternative payment entities that accept financial risk."

Thus, the practice with a medical home becomes a "payment entity," like an ACO. But practices are not set up for this work, so CMS is proposing that qualifying practices with medical homes be allowed a lower risk standard than other advanced APMs.

In the first year of MACRA, Miller says, these practices would be protected from Medicare losses greater than 2.5% of each practice's own revenue for that patient, and that limit would rise to 5% in 2020. In comparison, "everyone else in an advanced APM would be responsible for up to 4% of all Medicare spending on that patient," he adds. That's a big difference.

In the proposed rule, CMS outlined its reasoning for this special pathway. "Medical homes tend to be smaller in size and have lower Medicare revenues relative to total Medicare spending than other APM entities, which affects their ability to bear substantial risk," the agency stated. Furthermore, they have never been required to bear financial risk, so "the assumption of any financial risk presents a new challenge."

Miller says the rule for medical homes may well change in the final rule. Rather than tightening the financial standard for medical homes, the AAFP wants to drop it completely. "The AAFP strongly recommends that CMS remove the Medical Home Model financial standard in its entirety from the proposed rule," the AAFP stated in its formal response[3] to the proposed rule.

Another question is how practices with medical homes would enter the advanced track. In the proposed rule, CMS seems to leave open the possibility that it might approve individual practices for this status—but Miller says CMS has never approved practices with medical homes or any type of entity for individual APM status, and in any case, it would be very time-consuming.

Instead, CMS confers APM recognition on model programs that maintain a certain structure, such as the Medicare ACO programs. There is one such program that could accept practices with medical homes: the new CPC+ program, which starts in January. However, CPC+ is only available to primary care physicians (PCPs) in practices with 50 or fewer clinicians, and it has a limit of 5000 practices in only 20 regions of the country.

Specialists in particular will be thwarted if they wish to join advanced APMs. Whereas at least some PCPs will be getting special access to APMs, there is currently little access for most specialists—a problem that might persist for many years to come, according to Mark Edney, MD, a Maryland urologist who is on executive committee of American Association of Clinical Urologists.

"It's very difficult for specialists to move on, because few of the advanced APM models involve specialists," Dr Edney says. Nephrologists can join the Comprehensive End-Stage Renal Disease Care program, and oncologists can join the new Oncology Care Model. The latter program started in July but will not qualify as an advanced APM until 2018, when it begins to accept two-sided financial risk.

Dr Edney has been working on an APM model for urology, but even if it is ultimately accepted by CMS' Center for Medicare & Medicaid Innovation, he says that the approval process will be very lengthy. "The hope is that eventually there will be some advanced APMs for every major specialty, but it will probably take years," he says.


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