org/workproducts/apm-framework-onepager.pdf17http://annals.org/aim/fullarticle/2596395/effects-pay-performance-programs-health-health-care-use-processes-care16 http://hcp-lan.org/workproducts/apm-measurement-final.pdf15 https://hcp-lan.org/groups/apm-refresh-white-paper/ 14https://www.cms.gov/Medicare/Medicare-Advantage/Plan-Payment/Downloads/Report-to-Congress-APMs-and-Medicare-Advantage.
2016.05596 https://www.cbo.gov/publication/506925 https://www.healthaffairs.org/do/10.1377/hblog20170814.
061537/full/4https://www.federalregister.gov/documents/2017/11/16/2017-24067/medicare-program-cy-2018-updates-to-the-quality-payment-program-and-quality-payment-program-extreme3https://www.federalregister.gov/documents/2017/06/30/2017-13010/medicare-program-cy-2018-updates-to-the-quality-payment-program2 Medicare Access and CHIP Reauthorization Act of 2015, Public Law114–10.
1https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/index.html?redirect=/SustainableGRatesConFact/References I future of US health care system and practice of medicine MACRA can haveprofound and lasting influence.
However, there is need for substantial changesin the law to realize the goal of establishing a Medicare payment system thatrewards the value and not the volume of health care services. The significantobjectives can be achieved using Medicare Advantage as the platform. The effects of MACRA on Medicare spending and how it would affect invarious settings was published in Health Affairs, April 2017 6. It is estimated that providers Medicare paymentswill be significantly lower under MACRA present provisions than they would havebeen if the cycle of SGR overrides had continued and MACRA had never beenpassed. It is suggested that for MACRA to be successful well designed APMsshould be available for physicians. If not able to achieve this MACRA programwill fail to meet its value based payment objective and could have unintendedconsequences for patients. Conclusion CMS should consider to significantly reduce the burden of reporting inMIPS to a few, easily reportable measures that can be used to avoid negativeupdates. In order to reduce the potential for large bonuses, and the erosion ofinflation based reimbursement over time can be done by reducing the number ofproviders that receive penalties, and this would be strong incentive forproviders to seek an alternative to MIPS.
In order to better align the goals ofthe QPP and to ensure that MIPS does not become too comfortable, CMS shouldrepurpose the “exceptional performance” payments toward the APM bonuses.MIPS as structured currently does nothing to further the QPP goals oftransitioning to a value based system. Presently as MIPS is structured will nothelp to improve the value of care and when fully implemented, the penalties andrewards that provider receive may not significantly help to improve the value ofcare. By simply exempting a large number of providers does not address theintrinsic difficulty of performance assessment at the individual provider levelor address the current lack of meaningful provider level. Goal of the QPP andAlignment of MIPSTo facilitate transition in to a value based system, CMS should studydata provided by plans regarding provider participation and APM related data infuture years. Develop a timelineFor Medicare Advantage IntegrationThe participation data will be sent to CMS by Medicare advantage plansand based on revenue that flows through the specific model bonus would be made,instead of on providers’ fee schedule payments, as suggested in the MedPAC Junereport. The bonus payments would go to the plan, then they would be distributedto providers according to their contracts.
This will help to reduce burden onphysician practices and CMS. Reimbursement would be provided to plans foradditional administrative costs.Medicare Advantage plans accepts risk and many providers within the Medicareadvantage are also involved in risk based contracts with the plan. PresentlyCMS provides incentives only for participation in complex, risk-based advancedAPMs. CMS should consider Incremental incentives for participation at alllevels of the payment reform continuum by revising APM bonus model.
As defined by HCP-LAN using the payment modeltaxonomy, providers would be eligible for differential bonus payments accordingto the model category in which they participate. 18 This will serve as a ramp to value based paymentmodels that is currently missing in MACRA. APM Participation WithinMedicare Advantage and Incremental IncentivesIf CMS amends MACRA to consider Medicare Advantage contracts, thenproviders will be able to count their Medicare advantage participation towardsmeeting the revenue thresholds and would be eligible for APM bonus payments andexemption from MIPS. Those providers who decide not to participate in an APMwithin Medicare Advantage would not be eligible for the APM bonus but will beable to use the star ratings of their contracts to avoid penalties in MIPS,provided they meet MA participation thresholds and their Star rating is 4.0 orbetter.Through their capitated payment contracts with CMS, MedicareAdvantage plans accept risk for a population of beneficiaries and thereforeoffer an alternative to traditional fee-for-service Medicare, which iswell-advanced along the payment reform continuum.
Medicare Advantage takes morethan nominal financial risk, use electronic health record technology and meetquality through the Star rating system as advanced APMs.Consider MedicareAdvantage Contracts as Advanced APMsSeveral steps can be taken by policy makers to leverage the assets ofMedicare Advantage.Integrating MedicareAdvantage Into MACRAIn order for MACRA to achieve its original goals, policy makers need toincentivize participation in alternatives to fee-for-service at all levels.
Inaddition, the substantial burden in MIPS needs to be realigned with the goalsof the QPP, as access to APMs is expanded.Recommendations: Beginning with the 2019 performance period Medicare Advantage payerarrangements that meet the criteria will be considered among providers to determineif the eligible physicians can earn the 5 percent incentive payment and areexempt from MIPS. I order to allow payers to initiate the process on behalf ofproviders to identify their arrangements as qualifying advanced APMs there isoption included in the rule. Thisis a withdrawal from the 2017 final rule, which largely ignored risk contractswithin Medicare Advantage. However, It will be hard to have a desired effect ofsubstantially expanding participation in alternatives to fee -for-service unlessthe rules are planned to credit innovation along the entire payment reformcontinuum.Consideration of APMS InMedicare AdvantageOnce MIPS is fully implemented, the average provider in the program willsee its inflation adjusted reimbursements fall substantially over the nextseveral years and there shall be substantial reporting burden as well.
MIPSwill achieve the objective by making fee- for service uncomfortable, if notuntenable. Moreover, even with small variation in the score of an individualprovider will have large effect on the publicly reported performance scores,affecting individual provider’s reputation and in turn hard on provider’semployability, even though there is no significant impact on value of the careprovided. It has been reported by MedPAC to Congress on June 2017, thatpresently structured MIPS program is unlikely to be successful in: (a) helpingpatients choose physicians (b) helping Medicare program reward physician basedon value of care provided and (c) helping physician change practice patterns toimprove their care provided to patients.
2018 is a transition year for establishing QPP. Plan are in place to extendQPP program flexibility and minimizing the MIPS reporting burden and exposureto penalties. Estimated two-thirds of clinicians will be exempted from MIPS atleast for first 2 years. substantially limiting the impact of the program, atleast for the first two years.
mainly through an expansion of the low-volumethresholds (from $30,000 or 100 beneficiaries in 2017 to $90,000 or 200beneficiaries in 2018). As a budget-neutral program, fewer penalties meanssignificantly smaller rewards for providers that participate and wouldotherwise expect to benefit. Exclusion of large number of providers from MIPSprogram raises questions among many providers regarding underlying purpose ofMIPS. Past experience suggest that MIPS will not achieve the goal of improvingthe quality of care delivered in fee for service Medicare. Although MIPS is byfar the largest Pay-for -performance initiative taken to date, studies on pay-for -performance over past several years have failed to demonstrate aconsistent association with improved health outcomes in any setting. 17Delayed Effect Of MIPSCurrent MACRA requirements only rewards providers who have capability toparticipate in complex, risk bearing advanced APMs.
Various payment models existin physician practices and Medicare advantage works with these practicesworking on the different payment methods. This payment reform “glidepath” is not incentivized in the current MACRA requirements. By comparison, aMACRA-mandated CMS study 14 reported to Congress that Medicare Advantage organizations and theirnetwork providers have long been engaged in payment models that can beclassified under every category of the administration’s payment taxonomyframework.
15 In addition, a recentinvestigation by the Health Care Payment Learning and Action Network(HCP-LAN) reported that in 2016, as much as 41 percent of MedicareAdvantage health care dollars were in a composite of more advanced categoriesthree and four payment models. 16 This is substantially higher than the corresponding portion for otherpayers and suggests that Medicare Advantage could play a major role inaccelerating the transition to value in Medicare.Flexibility to InnovateThe Medicare Payment advisory committee (MedPAC) and others have claimedthat the Medicare Advantage program is more expensive than fee-for-serviceMedicare. 12 Yet there is evidencethat the methods used by Medicare Advantage plans are effective in changingphysicians’ care patterns to reduce the use of expensive services, which mayactually have a spending reduction “spillover” effect in fee-for-service Medicare.
13Reducing CostSeveral studies suggest that the care provided through Medicare Advantagemay be of higher value than the care offered through traditional Medicare,especially for patients with chronic medical conditions such as diabetesmellitus and cardiovascular disease.10 Also there is evidence that the combination of full-risk capitation andrevenue gain sharing agreements in Medicare Advantage can promote clinicalpractice transformations at the provider group level, which are associated withincreased outpatient care, decreased in patient services, and increasedsurvival for chronically ill, elderly patient population.11Value As of 2017, one in three people with Medicare (33 percent or 19 millionbeneficiaries) are enrolled in Medicare advantage plan. This enrollment isprojected to grow at least 41 percent over the next decade.
8 Beneficiaries choose to be in Medicare Advantageplans because the efforts taken by MA to reduce cost results in plan rebatesthat are passed on to the beneficiary as increased services or premiumreductions, incentivized patients to make high value health care decisions.Enrollment in Medicare enrollment has grown 71 percent since 2010, In spite ofreduction in payments to plans authorized by affordable Care Act (figure1) 9.ChoiceTo achieve goals of MACRA legislation, Medicare Advantage could serve asa platform to reduce the burden on physician’s practices, fast track thetransition to a value based payment systemin Medicare and act as a ramp toadvanced payment models.You do not have End-Stage Renal Disease (ESRD). 7You live in the plan’s service area; andYou have Medicare Parts A and B;You can join a Medicare Advantage Plan if:Medicare Advantage Plans often charge a premium in addition to theMedicare Part B premium. They also generally charge a fixed amount, called acopayment, that you are responsible for whenever you receive a service. Some plans charge a percentage of the cost of the service, called acoinsurance, for some or all services. Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Private Fee-For-Service (PFFS)The most commontypes of Medicare Advantage Plan are:While most peoplewith Medicare get their health coverage from Original Medicare, some people(around one-third of beneficiaries) choose to get their benefits from aMedicare Advantage Plan, sometimes called a Medicare private health plan.
Medicare Advantage Plans contract with the federal government and are paid afixed amount per person to provide Medicare benefits.Medicare Advantage as asolution:Considerable steps have been taken to popularize MIPS among health careproviders. For example, the reporting system is made very flexible for betteradapbility of the new system. Choices can be made on the basis of practice size, specialty, location,or patient population. Additionally, there are reduced financial penalities forinitial years of transition. However, many providers may realize that MIPS, inits current form, increases their administrative burden. On top of that, arecent report on effects of MACRA argues that enforcement of MIPS anddissolution of SGR will reduce overall reimbursements of Medicare providers.These and other issues will hamper the adaptability of MIPS and overall goalsof MACRA.
As for APM, the path seems to be even more challenging. In itscurrent form, MACRA regulations makes APM limited to very few number of medicalprograms. The guidelines are too complicated to adapt for those Medicareproviders who are willing to make the transition but lack the required tangibleas well as intangible assets. It is not surprising thatthe early results of APM implementation are far from satisfactory, casting ashadow of uncertainity on its sustainability 5. To make matters even worse, Congressional BudgetOffice estimates that it may take upto seven years for scaling up APM from apilot program to a full-fledge successful healthcare policy 6. The combined effect of atedious APM and ineffective SGR may make the entire MACRA program acounter-productive exercise.As mentioned earlier, QPP was established for transition of providers fromtraditional SGR Medicare payment system (largely based on fee-for-service notion)to a comprehensive value-based payment system by using two-pronged approach;make SGR increasingly unattractive and dysfunctional through MIPS and rewardparticipation in APMs.
iii) transition of providers to a comprehensive value-based paymentsystem ii) stabilize payments for the given period of transition timei) revoke the outdated Sustainable Growth Rate (SGR) Medicare paymentsystemOverall, there were three main goals of MACRA for improving the paymentsystem in our health care setting:Challenges for achievingMACRA goals There is diversity among clinician practicesin their experience with quality based payments. CMS is aware of this aspects andexpects Quality Payment Program to evolve in future years. Foundation has beenlaid for expansion towards patient centered, innovation, health care which isboth cost effective and patient appreciated focused outcome. The Quality PaymentProgram (a) focuses on better outcomes for patients and preserving theindependent clinical practice, (b) promotes low-cost, incentives for highquality care across healthcare stakeholders and (3) promotes existing deliverysystem reform efforts, including ensuring a smooth transition to a health caresystem that promotes high value, efficient care through unification of CMSprograms. 4These both meaningful goals can be attainedusing Medicare Advantage as the platform. Inthis paper I will be giving overview on how Medicare Advantage can help achievethe goals of MACRA.CMS should consider revising MIPS to betteralign the two arms of the QPP.
At the same time needs to recognize the full rangeof innovation in the Medicare Advantage program and incentivize APMsParticipation. The broad purpose of above-mentioned programsis to support not only health care providers but also patients for makingpragmatic decisions about health care using state of the art technology,insights from quantitative measures and quality measures that can with standever-changing face of healthcare norms. This is accompanied by emphasis on reducingburden on providers so that maximum resources are devoted towards betterhealthcare services. Even though QPP aims to bring huge set of amendments to currentpolicies, it is structured to be flexible and transparent. Another importantfeature of QPP design is it’s inherent capacity to improve over time with inputfrom clinicians, patients, and other stakeholders.In general, the QPP is aimed to take acomprehensive quality-oriented approach.
In order to have a measurable matrixfor the quality of service, clinicians developed a set of evidenced-basedmeasures. The development of self-evaluating measures was thought to improveclinical practice with suitable support from technological advancements,community surveys, demographic data and peer evaluation. 2. Merit-basedIncentive Payment System (MIPS): Participation in MIPS can provide an opportunity to earn performance-based payment adjustment 3.1. Advanced Alternative Payment Models (AdvancedAPMs): Participation in anAdvanced APM can provide an opportunity to earn “incentive payment forparticipating in an innovative payment model” 3.In order to have a comprehensive approach forrewarding and re-imbursement, the Medicare Access and CHIP Reauthorization Actof 2015 (MACRA) 2 amended Title XVIII of the Social Security Act to repeal the SGRformula and to strengthen Medicare access by improving health care providerpayments. The MACRA was intended to provide clinicians with a futuristic andwell-coordinated platform for their transition from SGR formula to itsreplacement called Quality Payment Program (QPP) 3.
Themain purposes of creating QPP were to revoke SGR formula and introduce a betterpayment system that rewards quality over quantity. The QPP has two main tracks:In today’s health care system, doctors andother clinicians are often paid on the basis of the number of services theyperform rather than patient health outcomes. This classic fee-for-serviceclause has been the integral part of Medicare Sustainable Growth Rate (SGR) formula,which is the prime guideline of our payment to health care providers 1. However, itshould be noted that in addition to conducting tests or writing prescriptions,doctors also take time to i) have a conversation with a patient about testresults, ii) be available to a patient through telehealth or expanded hours,iii) coordinate medicine and treatments in order to avoid confusion or errorsand, iv) develop health care plans.
Therefore, it is beyond doubt that there-imbursement system should have a broader scope than the outdated SGR formulafor true reflection of the services provided by health care personnel. Background:MACRA