Advanced Alternative Payment Model Participation Rose in 2018

January 06, 2020 - Over 84,200 more eligible clinicians sufficiently participated in one of the Quality Payment Program’s Advanced Alternative Payment Models (APMs) in 2018 compared to the previous year, according to a new official blog post from CMS.

New data points released earlier today showed that 183,306 eligible clinicians earned Qualifying APM Participant (QP) status under the Advanced APM path in 2018, up from 99,076 eligible clinicians the previous year. CMS also reported that 47 eligible clinicians received partial QP status during 2018, down from 52 the previous year.

The increase in Advanced APM participation is a step in the right direction for value-based care and reimbursement, CMS Administrator Seema Verma stated in the blog post.

“The increase in Advanced APM participation in 2018 reflects an increase in clinicians who provide high quality and cost-efficient care while moving towards value-based payments through Advanced APM participation,” she wrote.

Gradually transitioning clinicians from the Quality Payment Program’s first path – the Merit-Based Incentive Payment System (MIPS) – to an Advanced APM is the goal of the relatively new value-based reimbursement program for Medicare.

Unlike MIPS, Advanced APMs require eligible clinicians to use certified EHR technology, provide payment for covered professional services based on quality measures, and either be a medical home model expanded under the authority of the CMS Innovation Center or require clinicians to assume a significant financial risk. By meeting these criteria, CMS believes the healthcare industry will be able to truly deliver value-based care.

But progress with the adoption of Advanced APMs and similar models has been lagging. Less than 15 percent of healthcare payments in 2018 were reimbursed through an alternative payment model with two-sided financial risk, according to the latest measurement effort from the Health Care Payment & Learning Action Network.

Providers are encountering a growing list of challenges with assuming two-sided alternative payment models like the ones in the Advanced APM path, including a lack of adequate reimbursement, timely data, reporting standards, health IT infrastructure, and data sharing.

To encourage greater participation in two-sided risk models, CMS offers qualifying eligible clinicians a five percent incentive payment on top of their Medicare Part B reimbursements for achieving payment or patient thresholds through an Advanced APM during a performance year. The incentive payments are notably greater than those given through the Quality Payment Program’s other path, which is budget neutral.

However, MIPS continues to be a popular option for clinicians paid under Medicare Part B. In the blog post, CMS reported that MIPS participation also rose in 2018, growing to 872,148 MIPS eligible clinicians in 2018.

Most of the MIPS eligible clinicians in 2018 (98 percent) will receive a positive payment adjustment in the 2020 payment year, representing a five-point increase compared to data points from 2017. The remaining 2 percent will face a financial penalty in 2020, CMS revealed

However, the federal agency noted that the financial rewards for meeting MIPS criteria will be modest in 2020. Since MIPS is budget neutral, the funds available for positive MIPS payment adjustments hinges on the estimated decrease in payments from negative payment adjustments. Additionally, CMS has decreased MIPS participation thresholds, including the point threshold for positive payment adjustments, which led to more MIPS eligible clinicians avoiding penalties in 2018.

Stakeholders have criticized CMS’ MIPS implementation strategy, arguing that lower participation thresholds fail to reward providers for starting the transition to two-sided risk alternative payment models.

For example, CMS reported last year that MIPS eligible clinicians earning a positive adjustment based on 2017 performance earned a maximum adjustment of 1.88 percent compared to the maximum 4 percent adjustment promised in the original MACRA statute.

This level of reward is not enough to encourage clinicians to start the journey to risk-based care, critics have contended.

In the latest blog post, CMS projected positive payment adjustments to increase. The agency plans to increase performance thresholds as clinicians become more comfortable with the program, which will result in fewer MIPS eligible clinicians qualifying for positive payment adjustment. Agency leaders also finalized an overhaul of MIPS reporting processes, which will take effect in 2020.