Each of you is now familiar, or is hopefully growing more familiar, with the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA).
MACRA was enacted April 16, 2015, and repealed the Medicare sustainable growth rate. It also set in motion the creation and implementation of two payment pathways for physicians participating in the Medicare program. Last month I shared information and insights on the Merit-Based Incentive Payment System (MIPS). In this post, I am providing an overview of the MACRA Alternative Payment Model (APM).
The AAFP views the APM as the best opportunity for family physicians, primarily due to the fact that it promotes new delivery and payment models that migrate away from fee-for-service. Our primary goal for several years has been the establishment of payment policies that promote and finance comprehensive, continuous, and coordinated primary care. We believe that MACRA creates an environment whereby these models can be implemented, and we believe the APM pathway gives these models a place to grow and mature.
Starting in 2019, family physicians participating in a qualified alternative payment model who successfully meet the quality and performance criteria and exceed the established Medicare beneficiary thresholds will be eligible for a 5 percent bonus payment on their total allowed Medicare charges. Furthermore, qualifying physicians participating in a qualifying and eligible APM will be exempt from the MIPS program. APM qualifying physicians also will receive a higher Medicare physician fee schedule update (of 0.75 percent) starting in 2026.
There are three sets of criteria that must be met in order to secure the bonus payment in the APM pathway. Those three criteria are:
Qualifying Alternative Payment Model -- MACRA explicitly outlines which delivery and/or payment models will ultimately qualify as an APM. The law states that qualifying APMs must be established through one of four ways:
Eligible Alternative Payment Model -- Any APM that meets one of the four qualifying criteria listed above must also meet the performance and quality thresholds established by the law. There are three performance thresholds:
Qualifying Alternative Payment Model Physician -- The final criterion in determining if an individual physician or a group of physicians qualified for the 5 percent bonus payment is that a qualified physician must demonstrate that the required percentage of his or her payments is received through a qualified and eligible APM.
For 2019 and 2020, qualifying physicians must demonstrate that, at minimum, 25 percent of their total Medicare payments are aligned with a qualifying and eligible APM. Starting in 2021, the minimum threshold increases to 50 percent, but the law allows physicians to use a combination of Medicare and non-Medicare payments, such as those from Medicaid and commercial insurers, to meet that threshold.
A few observations on APMs:
The AAFP is committed to ensuring that you and your practice are ready to take advantage of new payment opportunities presented by MACRA. In the coming weeks we will be launching a comprehensive member education and communications effort designed to simplify the transition and provide the guidance you need to realize the benefits of value-based payment. Please watch for additional information at this blog or on aafp.org.
On March 8, CMS announced a proposed rule to test new models to improve how Medicare Part B pays for prescription drugs and the administration of those drugs by physicians. Although most prescription drugs are paid through Medicare Part D, there is a substantial number of drugs paid for under the Part B program. Primarily, Medicare Part B covers prescription drugs that are administered in a physician’s office or hospital outpatient department, such as cancer medications, injectables like antibiotics, or eye care treatments.
The proposal issued by CMS puts in place a value-based payment model for prescription drugs, but also alters the payment for the administration of such products in a manner that is favorable for family physicians. The proposed rule seeks to test six alternative approaches for Part B drugs. The AAFP issued a statement on the proposal and will be providing CMS with substantive comments on the proposal in the coming weeks. The full proposal is available on the Federal Register.
Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy. Read author bio »