Healthcare Orgs Urge Congress to Improve Value-Based Care Participation

Revising Thresholds

Some of the main concerns from the groups centered around the various thresholds included in the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

MACRA’s current qualification thresholds are measured based on the individual providers in the APM. This approach has several limitations that make it difficult for some ACOs to qualify. The current qualifying participant (QP) thresholds can also make it challenging for some ACOs to include specialists.

To qualify as an advanced APM, APMs must be experts in MIPS reporting and APM regulations, NAACOS wrote. Congress should consider eliminating QP thresholds or varying them based on purpose, such as removing them for payment updates but maintaining them for qualifying for bonuses.

Freezing the qualifying thresholds would prevent the steep increases expected under the current law.

Additionally, ACR urged Congress to remove the performance threshold requirement in the QPP and allow CMS to set appropriate score thresholds. The current performance threshold was maintained during the COVID-19 pandemic because MACRA required it and was not influenced by any feedback from CMS or stakeholders. Incorporating ideas from providers may help boost participation in the payment program, ACR said.

The group also recommended that leaders lower the payment and patient count thresholds for physician-focused APMs. This would allow more small practices and providers with disease-specific models to reach qualifying participant status, thus, encouraging small practices to pursue physician-focused APMs.

AMGA brought attention to the inconsistent thresholds of Advanced APMs as well. According to the organization, its members often struggle to meet the thresholds because they have little control over what providers patients see, among other issues.

AMGA also urged Congress to eliminate the low-volume threshold in MIPS.

“For the MIPS 2023 performance period, physicians who bill $90,000 or less in Part B-covered professional services, see 200 or fewer Part B patients, and provide 200 or fewer covered professional services to Part B patients will be excluded from the program,” the AMGA letter stated. “Due to these criteria, CMS estimates that 840,224 physicians and qualified healthcare professionals will not be MIPS eligible in the 2023 performance period.”

Expand Incentive Payments

Another central request from the healthcare groups was for Congress to extend the 5 percent APM incentive payment. MACRA created the incentive payments to encourage participation in Advanced APMs. Advanced APMs also use the bonus to further value-based care by investing in wellness programs, social determinants of health services, and patient navigators.

Without congressional action, the incentive payments will expire at the end of 2022.

“The 5 percent advanced APM incentive payments help drive growth in risk-based models, which save Medicare money and provide additional services for patients,” NAACOS wrote. “If the incentives expire this year, and qualifying thresholds increase to unattainable levels, there will be a significant reduction in the move to value.”

NAACOS also encouraged Congress to revise MACRA’s two-pathway approach and create three-tier participation tracks consisting of fee-for-service, APMs, and Advanced APMs. The new tracks should simplify the incentive structure and account for providers serving vulnerable populations.

Pass Legislation

The healthcare groups urged Congress to pass various legislation to help improve value-based care participation.

ACR called on leaders to advance the Meaningful Access to Federal Health Plan Claims Data Act, which will provide clinician-led clinical data registries with timely, broad, and continuous access to claims data for research purposes.

AMGA asked Congress to consider the Value in Health Care Act to improve APM participant incentives, modify risk adjustment factors, and extend the Advanced APM bonus for an additional six years.

AMGA also recommended leaders pass the Social Determinants Accelerator Act to increase investment in social determinants of health (SDOH).

“AMGA strongly believes that SDOH plays a vital role in achieving health equity, which is essential for providing high-quality care. However, if these concerns are not accurately discovered, measured, recorded, and reported, they cannot be addressed,” the organization wrote. “It is imperative for Congress to address the total cost of treatment to meet these social demands, lessen health inequities frequently caused by certain aspects of poor SDOH, and in turn, move our healthcare system toward a value-based culture.”

Extend Waivers

NAACOS asked Congress to direct CMS to establish a common set of waivers for APMs, allowing all APMs to access waivers instead of limiting them to certain models, like the ACO Realizing Equity, Access, and Community Health (REACH) model.

Additionally, there should be a standard set of waivers for risk-bearing APMs to encourage the shift from fee-for-service to value-based models.

AMGA also stressed the importance of permanently extending Medicare telehealth waivers and allowing providers to care for patients without geographic limits.

Editor's note: This article has been updated to correct an abbreviation. A previous version of the article used 'MGMA' instead of 'AMGA' when referencing the American Medical Group Association.