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Count Medicare Advantage Patients for Advanced APMs, Orgs Say

CMS can include Medicare Advantage plans in MACRA’s Advanced APM track by including MA patients in participation tests, ten groups argued.

AMGA and nine other groups called on CMS to include Medicare Advantage patients in Advanced APM participation tests

Source: Thinkstock

By Jacqueline LaPointe

- Eligible clinicians participating in appropriate alternative payment models under a Medicare Advantage plan should qualify for Advanced Alternative Payment Model (Advanced APM) incentive payments in 2019, the AMGA and nine other healthcare industry groups recently told CMS.

“Congress provided a framework with MACRA to move toward a system that is based on value,” stated Chester A. Speed, JD, LLM, AMGA’s Vice President of Public Policy. “This proposal builds on that effort and illustrates the opportunity that CMS has to increase APM participation by recognizing how participating in qualified Medicare Advantage plans can help providers meet the challenging advanced APM eligibility requirements.”

In 2019, eligible clinicians can earn an automatic 5 percent incentive payment by sufficiently participating in an Advanced APM. CMS plans to evaluate participation for the 2019 and 2020 payment periods based on Medicare fee-for-service revenue and patients.

Although the final MACRA implementation rule expanded the Advanced APM track to other payer alternative payment models, like those in Medicare Advantage plans. However, eligible clinicians partaking in other payer models cannot earn the incentive payment until the 2021 payment year.

The group of ten industry groups added their voices to an already growing coalition of organizations pushing CMS to include Medicare Advantage in the Advanced APM track sooner. Over 270 organizations wrote to CMS in March 2017 stating that Medicare Advantage alternative payment models should be incorporated because care quality is just as high and even better in some cases than Medicare fee-for-service.

READ MORE: Understanding the Quality Payment Program’s Advanced APM Track

AMGA and the nine other groups echoed their sentiments and advocated for Medicare Advantage inclusion based on the Advanced APM sufficient participation tests.

They proposed that CMS incorporate Medicare Advantage plans by allowing Medicare Advantage patients to count towards the patient threshold test for sufficient participation as long as the alternative payment model meets financial risk, care quality, and certified EHR requirements.

The final MACRA implementation rule specifically stated that CMS can only use Medicare fee-for-service revenue as part of the revenue threshold test for the 2019 and 2020 payment periods. However, the statutory language provides for flexibility with the patient count threshold, the organizations pointed out.

The regulation set forth the following rules for the patient count threshold test:

READ MORE: What We Know About Value-Based Care Under MACRA, MIPS, APMs

“The Secretary may base the determination of whether an eligible professional is a qualifying APM participant under this subsection and the determination of whether an eligible professional is a partial qualifying APM participant under section 1848(q)(1)(C)(iii) by using counts of patients in lieu of using payments and using the same or similar percentage criteria (as specified in this subsection and such section, respectively), as the Secretary determines appropriate.”

CMS can legally account for Medicare Advantage patients in Advanced APM designations because the statutory language refers to “counts of patients” in general terms, the groups argued.

“Had Congress intended to tie the agency's hands under the patient count methodology to restrict countable patients to FFS [fee-for-service] Medicare beneficiaries, it would have had to so specify,” they stated. “Since the statute does not include limiting language requiring CMS to only count FFS patients, then the agency has the latitude to interpret this provision to include MA enrollees in the patient count methodology beginning in 2019.”

The regulation also does not contain specific language pertaining to implementation years. Rather, the HHS Secretary may do as he deems “appropriate.” Therefore, CMS has the legal authority to restructure the patient count test for the 2019 payment year.

READ MORE: Key Ways to Succeed Under MACRA’s Quality Payment Program

However, the organizations warned CMS that simply including Medicare Advantage patients as part of the threshold may dilute the pool because not all clinicians participate in alternative payment models under the plans.

They recommended that the federal agency “augment its current staged test for determining passage of the threshold determinations to prevent the unintended consequence of helping those areas with high MA [Medicare Advantage] penetration, while harming those areas with low penetration.”

To do this, CMS should test Medicare fee-for-service revenue and patient thresholds first. If an eligible clinician fails the first test, then the federal agency should evaluate Medicare fee-for-service and Medicare Advantage together for the patient count test.

Additionally, the ten healthcare industry groups urged CMS to align financial risk standards for Medicare and Other Payer Advanced APMs.

The final MACRA implementation rule mandates that Other Payer Advanced APMs demonstrate greater marginal risk and minimum loss requirements than their Medicare counterparts.

But the organizations called on CMS to finalize the same financial risk requirements for all Advanced APMs regardless of payer to support multi-payer alternative payment model development. Finalizing separate financial risk requirements would increase administrative burdens, discouraging providers from participating in the alternative payment models.

Aligning the financial risk requirements would also encourage broader participation in alternative payment models outside of just Medicare fee-for-service and incentivize providers to improve care quality under Medicare Advantage plans.

“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,” AMGA’s Speed stated. “We believe this proposal allows CMS to reward providers who are willing to take risk.”


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