MACRA May I? CMS Identifies Qualifying APMs


When it released its final rule to implement MACRA last week, CMS estimated that 25% of all eligible clinicians (ECs) will choose to participate in an advanced alternative payment model (APM). This week, it released a list of MACRA-approved APMs that could qualify ECs for a 5% bonus for the 2017 performance year (payable in 2019).

The appeal of participating in an APM could be quite strong for some physician practices—especially those who were disappointed with their 2015 Annual Quality and Resource Use Reports (QRURs) released September 26. Despite the agency’s attempt to broaden participation opportunities, however, radiologists may be considerably underrepresented in 2017.

For the 2017 performance year, CMS anticipates including the following Advanced APM models:

The final list of eligible Advanced APMs will be published prior to January 1, 2017.

Clearly, the models selected for participation reflect CMS interest in enlisting primary care and targeting high-value opportunities to manage chronic conditions and diseases such as cancer and renal insufficiency. To participate in such ACOs and successfully qualify for the 5% incentive, ECs would have to receive 25% of their Medicare payments through the model in 2017 and 2018.

In subsequent years, ECs will have the opportunity to meet an alternative standard for Advanced APMs that will include non-Medicare payments. For the 2018 performance year, the agency expects to approve ACO Track 1+, a new voluntary bundled payment model, Comprehensive Care for Joint Replacement Model, and Advancing Care Coordination through Episode Payment Models Track 1.

In other CMS news this week, the agency also approved the Vermont All-Payer Accountable Care Organization (ACO), which was modeled on Maryland’s All-Payer ACO. CMS will provide $9.5 million in start-up funding to test the alternative payment model.

The agency and the state of Vermont believe the model will provide “an opportunity for all providers, including small physician practices, to succeed as health care moves from fee-for-service to value-based payment systems.” Vermont expects that 36% of all healthcare payments in 2017 will be through the all-payor ACO, with a goal of 70% in six years, accord to a report from AP.

Radiology is likely to find further opportunities in so-called Physician-focused Payment Models (PFPMs), described in the rule-making for MACRA: “A physician-focused payment model is an Alternative Payment Model wherein Medicare is a payer, which includes physician group practices or individual physicians as APM Entities and targets the quality and costs of physician services.”

PFPMs must meet criteria designed to promote higher value care; improve coordination, encourage patient engagement, and protect patient safety; and encourage the use of information technology to inform care.  Each model must be approved by the Physician-Focused Payment Model Technical Advisory Committee.

CMS intends that PFPMs will be a part of the 2018 performance year.