Reprinted from HEALTH PLAN WEEK, the most reliable source of
objective business, financial and regulatory news of the health insurance
industry.
November 14, 2016 Volume 26 Issue 40
Now that HHS has issued a final rule (81 Fed. Reg. 77008)
implementing the Medicare Access and CHIP Reauthorization Act (MACRA) starting
on Jan. 1, 2017, the health insurance industry remains upset that CMS excluded
Medicare Advantage (MA) plans from possibly qualifying for the program’s
Quality Payment Program until 2021.
In the rule released on Oct. 14 (HPW 10/24/16, p. 8),
CMS said at first the new value-based bonus system would be based on
traditional Medicare, not MA. To qualify under the advanced Alternative Payment
Model (APM), MA plans will have to wait and be considered for inclusion under
the All-Payer Combination Option.
MACRA, which replaces the Sustainable Growth Rate formula, is
meant to modernize and streamline physician payments under a new quality-based
system. The rule spells out the two paths physicians can take to participate,
with the first involving performance measured by the Merit-based Incentive
Payment System (MIPS), and the second limited to physicians who participate in
advanced APMs and get a 5% bonus on Part B revenues.
2019 Looms as Key Year
Starting on Jan. 1, 2017, physicians’ and other providers’
performance will determine their future payment rate updates. Because of the
time required to gather and evaluate performance data, spending and other
performance measures reported for calendar year 2017 will provide the basis for
payments in 2019. For vendors active in the health insurance space, MACRA has
brought opportunities to offer carriers new tools to manage APMs (HPW
8/1/16, p. 1).
The insurance industry argues that MA plans, since they are
receiving capitated payments, should be part of the first-batch 2019 APMs
considering the risk they are taking. CMS, however, wants a different kind of
model to start, according to Anne Phelps, principal and U.S. health care
regulatory leader for Deloitte LLP.
“As for the MA classification, under MACRA in order to be what
they call an advanced APM the incentives have to be aligned to move
practitioners into these arrangements, and you have to do three things: bear
downside risk, not upside risk; second is to have to apply the new performance
measures (MIPS) to practitioners; and you also need certified electronic health
records,” she tells HPW. “That is why the list of advanced APMs is
limited since very few models have downside risk in them. But over time they
will expand.”
When the list of APMs grows after the first two years of the
program, then MA plans can apply for status under the All-Payer Combination
Option or another payment model. “If you can show that you are applying the
three principles to these other payers, like Medicaid or MA or the commercial
market, then you can draw down higher Medicare dollars,” Phelps says. “Some
plans and leading providers with a lot of MA business, they would like to see
CMS say, ‘well, you know MA right now is an advanced model because it is
capitated.’ But it is capitated at the plan level and CMS is hesitant. We will
have to see maybe what Congress says because MA does not meet the criteria of
MACRA since capitation cannot be just at the plan level but at the practitioner
level. They are sharing in the risk.”
She says it is important to note that MACRA is going to have
different iterations within the regulatory process and a number of annual
updates and changes that will occur as well. Another area of interest is that
there could be some similarities between MA stars quality performance program
measures and MIPS performance measures in MACRA. MIPS administers bonuses or
penalties based on how well physicians perform relative to other physicians on
a complicated set of quality and value measures.
As for the law’s survival under a Trump administration, Phelps
says the overwhelming bipartisan support MACRA received will likely keep it
protected, but there are always opportunities for tweaks by CMS and Congress,
including on the MA issue. “Many people feel MA is a coordinated care
risk-bearing arrangement, so I think it will be looked at more closely over the
next year or so….This is a dynamic process,” she adds.
Humana Promotes MA Model
Separate from the MACRA argument, but tied to the issue of MA and
value-based payment models, Humana Inc. on Nov. 2 said for the third straight
year it has seen better health status, improved quality of care and lower costs
from its efforts. “For the calendar year 2015 results, Humana compared quality
metrics and outcomes for approximately 1.2 million MA members who were
affiliated with providers in value-based reimbursement model agreements to
170,000 members who were affiliated with providers under standard MA settings,”
the insurer said.
The key findings from this comparison include that providers in
the value-based arrangements had 19% higher Healthcare Effectiveness Data and
Information Set (HEDIS) scores; the value-based members also saw 6% fewer
emergency department visits and Humana experienced 20% lower costs for these MA
members.
As of Sept. 30, Humana said around 63% of its individual MA
members are seeing providers who are in value-based payment arrangements.
Read the rule at http://tinyurl.com/zxuhpna.
https://aishealth.com/archive/nhpw111416-03?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=113700881
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