Medicare Advantage Groups Request Earlier APM Bonuses

Ken Terry

June 07, 2017

Ten diverse healthcare associations, including the American Medical Group Association (AMGA) and the American Medical Association (AMA), recently asked the Centers for Medicare & Medicaid Services (CMS) to allow eligible clinicians who contract with Medicare Advantage (MA) plans to use the revenue and numbers of patients from those contracts to help them qualify for the advanced alternative payment model (APM) track, starting in 2019.

Being classified as a participant in an advanced APM, such as a financial risk-bearing accountable care organization, exempts clinicians from CMS's Merit-Based Incentive Payment System (MIPS) and guarantees them 5% annual bonuses for 5 years.

Under CMS's current policy, clinicians must receive 25% of their Medicare Part B payments or see 20% of their Medicare patients through a CMS-approved APM to qualify for the advanced APM classification. For the Medicare payment adjustments scheduled in 2019 and 2020, only revenue from patients in Medicare's fee-for-service program can be counted in calculating whether a clinician meets this threshold. Beginning in 2021, risk-based MA contracts can be considered as well.

In a May 31 letter to CMS Administrator Seema Verma, AMGA and the other healthcare associations sought to have CMS incorporate the Medicare Advantage data in the initial 2 years of the program. This data would come from 2017 and 2018, the first 2 performance measurement years.

"We urge CMS to alter its regulations to allow clinicians' contracts with MA plans that meet the risk, quality and certified electronic health information technology requirements to be included under the beneficiary count test for the 5 percent Advanced APM bonus in 2019 and 2020," said the organizations' letter to CMS.

The signatories acknowledged that the Medicare Access and CHIP Reauthorization Act (MACRA), which established MIPS and advanced APMs, does not support the change that they request. However, they argued that CMS has the authority to make this change under a provision that allows the Secretary of Health and Human Services to create an alternative method of counting beneficiaries in APMs.

The letter warned of unintended consequences unless CMS expands its threshold definition carefully. If clinicians have Medicare Advantage contracts without advanced APM features, for example, it noted, adding MA beneficiary counts "will dilute the denominator with no commensurate addition to the numerator [of revenues and patients]." As a result, some clinicians who would otherwise qualify might fail the test.

Another unintended consequence might be to help clinicians in areas with high MA penetration, while harming those in areas with low penetration, the organizations cautioned. They suggested that CMS first test clinicians' ability to meet the advanced APM threshold from Medicare fee-for-service revenue and patients only. If they don't pass the test, CMS would then consider their MA population as well.

The letter also recommended that CMS accept clinicians' attestation of their revenue and patient panel from MA plans. Otherwise, it suggested, the process might be too burdensome for clinicians, especially if the MA plans had to verify their information.

CMS could implement this change in time for 2019 payment adjustments, the letter said, if it included the new policy in its upcoming Quality Payment Program proposed rule. If the provision were finalized by the fall, clinicians could attest to their MA participation in late fall, before CMS calculates which clinicians qualify for advanced APMs in January 2018, the letter said.

In a news release about the letter, Chester A. Speed, JD, AMGA's vice president of public policy, said, "Providers with risk-based Medicare Advantage contracts are meeting the requirements to qualify as advanced APMs, and they should be recognized for transitioning the health system to value sooner rather than later. We believe this proposal allows CMS to reward providers who are willing to take risk." 

Besides AMGA and AMA, the organizations that signed the letter include the Premier Healthcare Alliance, the American College of Surgeons, the American Osteopathic Association, America's Essential Hospitals, the Healthcare Leadership Council, the Healthcare Transformation Task Force, the Medical Group Management Association, and the National Association of ACOs.

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