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Level the Playing Field for Medicare Advantage in MACRA, Orgs Urge

CMS should reconsider the 25 percent Medicare revenue threshold for Advanced APMs to allow risk-based Medicare Advantage plans to qualify under MACRA, the groups advised.

Medicare Advantage and MACRA

Source: Thinkstock

By Jacqueline LaPointe

- Eleven industry groups are urging CMS to include Medicare Advantage (MA) in MACRA as soon as possible to provide the same incentives to eligible clinicians in risk-based MA models as those offered to clinicians in Medicare Advanced alternative payment models (APMs).

Risk-based contracts with payers other than traditional fee-for-service Medicare can qualify as Advanced APMs under MACRA.

In the 2019 Quality Payment Program performance year, eligible clinicians can qualify for the automatic five percent bonus under the Advanced APM track by participating in either a qualifying Medicare APM or both a Medicare APM and an other payer model, like risk-based MA plans. This option is known as the All-Payer Advanced APM option.

However, eligible clinicians in the All-Payer Model pathway must still meet the 25 percent traditional Medicare revenue threshold to qualify for the bonus, the Medical Group Management Association, America’s Physician Groups, Premier, America’s Health Insurance Plans, and several other associations recently pointed out.

“For many physicians in areas of the country with heavy MA penetration, this is not achievable,” they wrote to CMS Administrator Seema Verma and HHS Secretary Alex Azar. “Risk contracts should and must be treated equally across traditional Medicare and MA to truly advance the value movement.”

MA plans cover nearly one in three Medicare beneficiaries, with some regions facing a concentration of MA plan enrollees. In such areas, eligible clinicians may not have enough revenue under traditional fee-for-service Medicare because the market has shifted to MA plans.

Despite participating in risk-based MA models that qualify as Advanced APMs, these eligible clinicians will not be able to earn the bonus under MACRA because of their market’s characteristics.

CMS aims to address this issue by developing a demonstration that will test the effects of expanding incentives for eligible clinicians in risk-based MA arrangements that could qualify as Advanced APMs. The demonstration would count participation in such models in 2018 through 2024.

But the industry groups are calling on CMS to implement the demonstration as quickly as possible.

“Even though one in three Medicare beneficiaries is now enrolled in an MA plan, the innovative providers who are engaged in MA risk contracts will not get credit in the eyes of CMS for three more years,” they wrote. “We strongly encourage you to afford credit to these providers by announcing a new MA Advanced APM in time to impact payments for 2019 (based on 2017 performance).”

The demonstration project has received widespread praise from industry groups since CMS proposed the project in November 2017.

AMGA’s President and CEO Jerry Penso, MD, MBA, stated that the “best way 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.”

He added that that the most effective method for developing the demonstration would be to allow MA participation in MACRA by the 2018 performance year.

MGMA, America’s Physician Group, AMGA, and other stakeholders continue to fight for MA’s inclusion in MACRA because risk-based plans under the untraditional Medicare track have demonstrated care quality improvements and healthcare cost reductions.

Patients treated under an MA arrangement with capitation payments had a six percent higher survival rate compared to their peers in other plans, an American Journal of Managed Care study showed. Patients were also 11 percent less likely to visit the emergency department and 12 percent less like to face an inpatient admission.

A recent Health Affairs analysis also revealed that patients receiving care through a value-based MA model were three times more likely to receive preventative care visits, and 1.2 percent less like to use the emergency department.

“MA plays a significant role in properly aligning provider incentives to move away from fee-for-service toward value-based reimbursements. If we are truly serious about modernizing our nation’s healthcare delivery system and improving access to quality healthcare services for America’s seniors, providers in MA must have access to the same incentives as their colleagues practicing in traditional Medicare,” the eleven industry groups advised.


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