Specialists Hope to Avoid MIPS via APM Participation
CMS has announced that it will make the Merit-Based Incentive Payment System (MIPS) easier for practices to handle in its first reporting year, 2017, but the overall structure of MIPS doesn’t seem likely to change. That means each subsequent year will require more reporting and better outcomes, as practices nationwide essentially compete against one another to ensure positive payment updates – because MIPS is budget-neutral, there will be winners and losers.
But CMS does offer a way out of MIPS via the Alternative Payment Model (APM) – and some specialty practices in particular are hoping to ride out the storm using this option. First, let’s remember that CMS is actually dividing APMs into two categories: Advanced, and not advanced. The agency has also used the term “eligible” and “ineligible” to mean the same things, respectively.
Advanced or eligible APMs are the ones that offer an exit from MIPS. Participating fully in an advanced APM means your providers won’t be measured under MIPS, and will instead get a regular positive payment update of 5% to their Medicare fee schedule rates each year, with more future bonuses in future program years.
The list of ACOs currently recognized as advanced is fairly small, but it does include all CMS Innovation Center models, which means Accountable Care Organizations (ACOs) are potentially eligible for advanced status.
ACO practice hopes for APM recognition
The Sierra Regional Spine Institute is an orthopaedic group focusing on spine procedures in Reno, Nev. It has seven physicians and has been participating in an ACO for one full year, says Penny Forbes, practice administrator.
The group had little choice but to join their local ACO, run by their regional level 1 trauma center, Renown Regional Medical Center. Over the years, the Renown system acquired roughly 50% of the primary care practices in the northern Nevada area, which comprised the bulk of referring physicians who sent patients the Spine Institute, Forbes says. Suddenly her practice was on the outside looking in; the acquired primary care physicians had to refer to specialists within the ACO, because Renown didn’t want to be accountable for the cost of care provided by non-ACO physicians.
Eventually, Forbes’ practice signed a contract to participate in the ACO so they could get the referrals back. Now they are part of an APM that hasn’t yet received “advanced” status from CMS, but is hoping to get it.
The Renown ACO hasn’t yet produced any cost savings, but still has time to do so under CMS rules. Unfortunately, specialists like the surgeons at the Spine Institute aren’t eligible for the potential gainsharing, Forbes explains. The argument is that because the brunt of the data-gathering for the ACO data and quality measures is borne by primary care, specialists don’t do as much work. “They argue that spine care is highly episodic,” she says.
Thus the possibility of becoming an advanced APM is the upside benefit that her practice is looking for. “It would be nice just to be excluded from the potential MIPS penalties,” Forbes says. “Right now my doctors are worried that, because this is all budget-neutral, even if we met all the MIPS requirements, we could still be at the bottom quarter of participating providers and be penalized.”
CMS decides which APMs are ‘advanced’
Advanced or eligible APMs earn that status from CMS, which currently only has the following requirements for granting this status:
- APM requires participants to use certified EHR technology. Specifically, an advanced APM must require at least 50% of their providers to use certified EHR. This value goes up to 75% after the first MIPS program year.
- APM bases payment on quality measures comparable to those in the MIPS quality performance category. Fortunately, the advanced APM doesn’t have to report any minimum number of measures or domains. CMS is also open to accepting quality measures that it determines to be evidence-based, even if they haven’t appeared under existing quality reporting programs such as the Physician Quality Reporting System (PQRS) or been created by groups like the National Quality Forum (NQF).
- The APM either a.) requires its members to bear more than nominal financial risk for monetary losses, or b.) is a Medical Home Model expanded under CMMI (Centers for Medicare and Medicaid Innovation) authority. “Nominal” risk is being defined currently as a total risk of at least 4% of expected expenditures to provide care, and marginal risk of at least 30%, with a minimum loss ratio of no more than 4%. If any ACO has a participating provider cost more than projected (e.g. no savings), it must recoup those costs by charging the provider, reducing payment rates, or withholding payments.
These criteria are not final, and CMS is still in the process of recognizing existing APMs as advanced, but already many APMs are lobbying CMS for recognition. For example, practices participating in the Bundled Payments for Care Improvement (BPCI) model have asked CMS to certify their APM as being advanced. Many orthopaedic groups could thus avoid MIPS as more advanced APMs are certified by CMS, including ACOs that aren’t centered around any one specialty, such as in Forbes’ situation.
— Grant Huang, CPC, CPMA (email@example.com). The author is Director of Content at DoctorsManagement.