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Advocates Want CMS to Increase APM Options for Clinicians

The recently released “massive” Medicare physician proposed payment rule included a “surprise” projection that alternative payment model (APM) participation may decline. Provider organizations are planning member briefings on the rule. (“Providers Examining Why APMs Are Expected to Stall,” HFMA Weekly News, July 23, 2018)


The proposed rule continues the implementation of revisions to physician payment including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Under MACRA, physicians are paid by Medicare either through the Merit-based Incentive Payment System (MIPS), advanced APMs or an exempted class.


The vast majority of physicians continue in the exempted category, and MIPS participation is expected to slowly increase. “But provider advocates were surprised to see that Medicare expects clinician participation in APMs to stagnate or decline in FY19.” (“Providers Examining Why APMs Are Expected to Stall,” HFMA Weekly News, July 23, 2018)


CMS estimated that between 160,000 and 215,000 clinicians will earn APM bonuses of 5 percent of their Part B payments in FY19. That range was a decline from FY18 projections of 185,000 to 250,000, which CMS estimated in the previous physician payment rule.


“We are disappointed in the stagnation of the number of providers projected to be in Advanced APMs in 2019 compared to previous years,” said an executive for the National Association of Accountable Care Organizations


An executive from the Medical Group Management Association (MGMA) agreed and noted that MGMA will ask CMS to reverse the declining enrollment by creating more APM options for clinicians.


Although CMS officials didn’t address why they expected APM enrollment to stagnate or decline in FY19, some analysts offered possible explanations:


  • A combination of tightening qualifications for clinicians seeking the APM bonus and a lack of new models in which they can participate
  • A lack of new or returning accountable care organizations (ACOs); advocates have expressed concern that CMS has not issued guidance for starting the application process for ACOs to renew or launch in 2019—this typically happens in May
  • A lack of agency follow through on strengthening APMs, including ACOs
  • A lack of new physician-led models— the Physician-focused Alternative Payment Model Technical Advisory Committee was expected to review, assess and propose physician-proposed models to vastly increase the number of APMs and allow many more physicians to qualify for APM bonuses; however, no such models have been accepted or implemented by HHS


List of Current Models


Currently, physicians can qualify for the APM bonus if they meet participation requirements for the following models in FY19:


  • Next Generation ACO model
  • Comprehensive Primary Care Plus (CPC+) model
  • Comprehensive ESRD Care model (two-sided risk arrangement)
  • Vermont All-Payer ACO model
  • Comprehensive Care for Joint Replacement Payment model (CEHRT track)
  • Oncology Care Model (two-sided risk arrangement)
  • Medicare ACO Track 1+
  • Bundled Payments for Care Improvement Advanced
  • Maryland Total Cost of Care model (Maryland Care Redesign Program; Maryland Primary Care Program)
  • Medicare Shared Savings Program Tracks 2 and



Read rule here:


(Source: “Providers Examining Why APMs Are Expected to Stall,” HFMA Weekly News, July 23, 2018)


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