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Are you in an Alternative Payment Model? Why it matters
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From international law firm Arnold & Porter LLP comes a timely column that provides views on current regulatory and legislative topics that weigh on the minds of today’s physicians and health care executives.
The recently enacted Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the long-criticized Sustainable Growth Rate but added new elements to Medicare’s methods for determining physician payments (see our previous post on new payment options). Starting in 2019, a physician participating in certain “Alternative Payment Models,” or APMs, may receive a 5% bonus (2019-2024) or a preferential update (2026 and later years). Eligible Professionals also include any non-physician practitioners who can bill Medicare directly, such as nurse practitioners and physician assistants, physical and occupational therapists, and qualified speech-language pathologists and audiologists.
Thomas A. Gustafson
What is an APM?
An APM is one of a set of CMS projects operating under specified legislative authorities. Most prominent are Medicare’s Accountable Care Organizations (ACOs) — the Medicare Shared Savings Program, Pioneer ACOs and Next Generation ACOs. Also included are many of the projects mounted by CMS’ Center for Medicare & Medicaid Innovation. These are projects, either current or new ones set up later, that rely on the Affordable Care Act’s demonstration authority, such as the Oncology Care Model. Health Care Quality Demonstrations are also included, but Health Care Innovation Grants are not. Finally, any other demonstration required by federal law is included. To date, CMS has not issued a complete list of current APMs, and new forms of APMs may be launched prior to 2019 when they can affect physician payments.
Will any participation in a Medicare APM count?
No. To receive higher payments, a physician must be participating in an “Eligible Alternative Payment Entity” that is part of an APM that requires participants to use electronic health records and provides payment for professional services based on quality measures. The entity itself must bear downside financial risk or be one of certain “medical home” models.
Does every participant get a boost?
No. To qualify for an increase, an Eligible Professional must receive a minimum percentage of Medicare payments through an Eligible Alternative Payment Entity. In 2019-2020, the minimum will be 25%, which will rise incrementally to 75% in 2023 and later years. Starting in 2021, an Eligible Professional who has a smaller share (but no less than 25%) of Medicare payments attributable to an Eligible Alternative Payment Entity but also participates in an alternative payment entity for beneficiaries of other payers with characteristics similar to an Eligible Alternative Payment Entity can qualify by meeting the threshold for total, not just Medicare, payments.
Amanda Cassidy, MPP, health policy advisor, can be reached at Amanda.Cassidy@aporter.com.
Thomas A. Gustafson, PhD, senior policy advisor, can be reached at Tom.Gustafson@aporter.com.