Another limitation to eligible clinicians pursuing participation in an Advanced APM is the threshold limitations for reaching the status of Qualifying APM Participant. To become a Qualifying APM Participant, a clinician must meet a specific Medicare payment or patient count threshold, which may not be easily attainable depending on a practice’s mix of services. For example, gastroenterologists may be interested in participating in CMS’ new Bundled Payments for Care Improvement Advanced model, which is an Advanced APM, but because all the gastroenterology-related bundles are inpatient bundles, gastroenterologists are unlikely to meet either the required revenue or patient count thresholds. Only Advanced APM participants that meet the thresholds qualify for the APM bonus payment and a guaranteed exemption from MIPS.
To encourage development and participation in Advanced APMs, ASGE supports and encourages Congress to act on the proposal in the President’s Fiscal Year 2019 Budget that would allow clinicians to receive a five percent bonus on physician fee schedule revenue received through the APMs in which they participate regardless of whether they meet or exceed the payment or patient thresholds. As explained in budget documents, this change would reward clinicians along a continuum for their participation in Advanced APMs without imposing arbitrary participation thresholds. Removing the thresholds would also simplify the QPP.
ASGE also suggests that clinicians who participate in Other Payer Advanced APMs should also be allowed to claim an exemption from MIPS until more Medicare Advanced APMs become available for physician specialists.
Lastly, Congress can facilitate the movement of clinicians to APMs by waiving the Stark and Anti-kickback laws for physician practices that are developing or operating an APM. ASGE supports the Medicare Care Coordination Improvement Act of 2017 (H.R. 4206) as introduced by Reps. Bucshon, Ruiz, Marchant and Kind, which would remove the “value or volume” prohibitions in the Stark law. These Stark law prohibitions pose barriers to the participation of physician group practices in APMs.
Even the mere threat of violating Stark impedes innovative payment arrangements.
By granting physician practices the same waivers that were provided to Accountable Care Organizations in the Affordable Care Act, there will be more flexibility to move money around in the APM to create incentive structures designed to improve quality and encourage appropriate resource use.
The ASGE appreciates the Subcommittee’s engagement and oversight of MACRA throughout its implementation. The ASGE asks the Subcommittee to support physicians as they transition to new value-based payment models by fostering early opportunities for success and eliminating barriers that impede advancement toward new payment and delivery designs. Congress can support physicians during this transition by: