CMS last week proposed a demonstration program that would waive certain MACRA requirements for eligible health care professionals participating in risk-based Medicare Advantage plans.

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MACRA details

Under MACRA's Quality Payment Program, which took effect in 2017, eligible professionals can choose from two payment tracks:

• The Advanced Alternative Payment Model (Advanced APM) track, for clinicians who take on a significant portfolio of Advanced APMs, which include risk-based accountable care organization models; or
• The Merit-based Incentive Payment System (MIPS) track, for clinicians who are reimbursed largely through fee-for-service.

How the Medicare ACO models stack up

Clinicians' pay in the MIPS track largely follows a traditional fee-for-service structure—but CMS adjusts eligible professionals' pay based on how they "score" in four categories of metrics: advancing care information, cost, improvement activities, and quality.

For 2018, CMS is requiring eligible professionals to report on a full year's worth of data on the metrics. Eligible providers who meet those requirements based on their 2018 data will receive penalties or bonuses of up to 5% beginning in 2020. That percentage will rise incrementally until it reaches 9% in payment year 2022.

Participants in the Advanced APM track are exempt from MIPS payment adjustment, and, instead, receive a 5% lump sum bonus on Medicare Part B payment for 2019 through 2024, as well as any potential incentives from their chosen Advanced APM programs. To qualify for the Advanced APM track in 2018, clinicians must have 20% of their Medicare patients or 25% of their Medicare payments billed through an Advanced APM, as determined by CMS.

CMS proposes demonstration that could waive MIPS requirements for some providers

CMS last week said it is looking to launch a five-year Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration, which, if implemented, would "waive [MIPS] requirements for clinicians who participate sufficiently in certain Medicare Advantage [MA] plans that involve taking on risk."

CMS said some MA insurers are creating payment arrangements that "resemble Advanced APMs" under MACRA. However, CMS said those arrangements currently do not qualify as Advanced APMs under the law, meaning clinicians participating in the arrangements still must meet MIPS requirements.

Learn how to expand into the Medicare Advantage market

CMS Administrator Seema Verma said, "The MAQI Demonstration aligns with the agency's goal of moving to a value-based health care system, and aims to put [MA] on a more equal playing field with fee-for-service Medicare." She continued, "CMS intends to test whether MIPS exemptions provided to clinicians under MAQI will increase participation in [MA] plans that are similar to Advanced APMs, and thereby accelerate the transition to a health care system that pays for value and outcomes."

CMS said the Trump administration currently is gathering public feedback "on the information collection burdens associated with the demonstration, which is under consideration for formal approval." According to Modern Healthcare, the White House Office of Management and Budget is responsible for approving or denying the demonstration. The administration is accepting public comments on the proposed demonstration through Sept. 3.

Physician groups react

A spokesperson for the American Medical Association—which in a joint letter with America's Essential Hospitals and the Medical Group Management Association sent last year urged CMS to consider such a demonstration—said MAQI could particularly benefit health care providers in communities with disproportionately high numbers of MA beneficiaries.

Donald Crane, president and CEO of America's Physician Groups, said the demonstration would offer "an important new path for groups wishing to move into value." He said, "With nearly 19 million beneficiaries enrolled in [MA], it is important to recognize the innovations that physician organizations are undertaking to provide high-quality accountable care to the patients and communities they serve. Advancing the MAQI demonstration is an important step in the right direction" (Snell, EHRIntelligence, 7/2; Dickson, Modern Healthcare, 6/29; Haefner, Becker's Hospital CFO Report, 7/2; Masterson, Healthcare Dive, 7/2; Slabodkin, Health Data Management, 7/2; CMS release, 6/29).

August 2 webconference: The 2018 MIPS Cost Category Decoded

Join the 30-minute webconference on Thursday, August 2 where we'll dive into the metrics included in the 2018 MIPS Cost category, how providers’ scores will be calculated, and strategies for improving performance.

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