AMGA Advises CMS on Including MA Models as Advanced APMs by 2018

November 28, 2017 - CMS can boost participation in Medicare Advantage alternative payment models in 2018 by creating a submission form that allows providers in the models to apply to participate in MACRA’s Advanced Alternative Payment Model (Advanced APM) pathway, the American Medical Group Association (AMGA) recently suggested.

The most recent MACRA implementation rule detailed a CMS demonstration project that will test the effects of allowing eligible clinicians to earn credit under MACRA’s Advanced APM pathway. Credit would be rewarded for participating in certain Medicare Advantage alternative payments from 2018 to 2024 that meet Advanced APM criteria.

Previous MACRA implementation rules stated that CMS would not include Medicare Advantage plans in the Advanced APM pathway until the 2019 performance year.

CMS intends to uncover if offering eligible clinicians incentives for participation in Advanced APMs with Medicare Advantage alone will encourage more clinicians to move to the Advanced APM pathway. MACRA currently only provides incentives for eligible clinicians partaking in Medicare fee-for-service alternative payment models.

The demonstration’s announcement earned overwhelming support from industry groups. Notably, AMGA’s President and CEO Jerry Penso, MD, MBA, stated that the “best ways to increase APM participation is to include clinicians’ contracts with Medicare Advantage plans that meet the risk and quality requirements. More and more beneficiaries choose to enroll in Medicare Advantage and factoring these plans into the APM thresholds now would increase the number of providers in risk-based models and help move Medicare away from fee-for-service.”

In the new letter to CMS Administrator Seema Verma, the industry group added that the submission form would be “the most effective way to develop this demonstration in time to allow MA [Medicare Advantage] participation in the 2018 performance year.”

The submission form should include the elements required for Advanced APM inclusion. To qualify as an Advanced APM, the model must use comparable quality measures to those already used by approved models, require certified EHR use, and include nominal financial risk.

Medicare Advantage plans and eligible clinicians could use the form to demonstrate that the alternative payment models meet Advanced APM criteria. Then, CMS could easily review the submissions to determine which Medicare Advantage alternative payment models qualify as 2018 Advanced APMs.

“Developing the MA-Advanced APM demonstration by using existing and well-understood Advanced APM requirements will allow providers that already are meeting the MACRA goal of moving to value quickly and efficiently,” Penso wrote.

Developing the submission form for the demonstration should also accelerate care quality improvements and healthcare spending declines, AMGA added.

Medicare Advantage plans cover up to one-third of Medicare enrollees and, in some counties, the plans account for almost one-half of Medicare beneficiaries in that region, the industry group reported in a May 2017 letter urging HHS to include Medicare Advantage in MACRA.

AMGA, alongside nine other organizations, also provided evidence that Medicare Advantage alternative payment models deliver higher quality care at lower costs compared to models under Medicare fee-for-service.

Patients treated under Medicare Advantage alternative payment models with capitation had a 6 percent higher survival rate, the groups stated citing a recent American Journal of Managed Care study. Patients were also 11 percent less likely to visit the emergency department and 12 percent less likely to experience an inpatient admission.

The utilization shift resulted in over $2 million in savings per 1,000 enrollees in Medicare Advantage alternative payment models.

With a substantial number of beneficiaries covered by Medicare Advantage, offering additional incentives to transition to risk-based alternative payment models could speed up care quality and spending improvements, the AMGA argued.

“Including Medicare Advantage in the Advanced APM pathway as soon as possible is going to help more providers move away from fee-for-service and toward value-based care,” Penso stated. “AMGA is offering a framework that helps CMS meet its goals for this demonstration as quickly and efficiently as possible.”