Most ACOs Worried About Rising Advanced APM Thresholds Next Year

A new survey confirms a growing concern among accountable care organizations (ACOs) – most ACOs are unlikely to meet rising participation thresholds for MACRA’s Advanced Alternative Payment Models (APMs) in 2021.

The survey from the National Association of ACOs (NAACOS) recently found that more than 90 percent of ACOs participating in an Advanced APM, including the Medicare Shared Savings Program and the Next Generation ACO Model, are concerned they will not meet the new threshold to secure the 5 percent incentive payment under MACRA.

And that concern is validated by survey data, NAACOS highlighted.

About 96 percent of the 216 ACO respondents would not meet the 2021 thresholds based on their performance in 2020 and would therefore not receive the incentive payment during the corresponding payment period.

“These bonuses are critical to Medicare’s value movement,” said Clif Gaus, ScD, NAACOS president and CEO. “The current thresholds are a challenge for many ACOs. To increase them again in 2021 would put the incentive out of reach for nearly everybody.”

Advanced APM thresholds were set by Congress in 2015 through the Medicare Access and CHIP Reauthorization Act of 2015, otherwise known as MACRA. The thresholds are scheduled to increase every two years until MACRA’s Quality Payment Program and its two tracks – the Merit-Based Incentive Payment System (MIPS) and Advanced APMs – are fully implemented.

In 2021, the threshold for becoming a Qualifying APM participant (QP) under the Advanced APM track is slated to increase to 75 percent of a clinician’s Medicare Part B payments.

This threshold, however, is unrealistic, according to NAACOS.

The average payment threshold score was just 44 percent for ACOs in the Medicare Shared Savings Program and 49 percent for those in the Next Generation Model in 2018, the most recent year for which CMS has complete participation data.

The average payment threshold scores were enough for most ACOs to earn the 5 percent incentive payment that year, but the clinicians will need to significantly expand their ACO footprint to get the lump-sum bonus next year, NAACOS stated.

To achieve the level of participation needed for the incentive payment will be very difficult, ACOs said in the survey. ACOs that have attempted to do so already said they tried by increasing engagement with beneficiaries through outreach and encouraging patients to come in for their annual wellness visits.

ACOs have also tried to remove certain providers from the ACO to increase QP scores, a move that NAACOS said is concerning “because dropping providers means less engagement in a value-based model and fewer benefits for patients.”

The Advanced APM incentive payment is very important to ACOs, the survey found.

No respondent said the payment was not important to the ACO when asked about the bonus’ impact on the ACO. In fact, the majority of respondents (84 percent) said the bonus was “extremely important.”

The Advanced APM incentive payment has supported ACO efforts to advance value-based care. Over half of ACO respondents said they have used the payment to invest in ACO initiatives such as care coordination or data analytics (58 percent) and on supporting the ACO’s move to a risk-based model (51 percent).

About 41 percent of respondents also said they have used the payment to recruit new providers, while 39 percent said they used it to pay physician bonuses.

“Congress intended to shift Medicare payment to a value-based approach, and we are seeing the benefits of that transformation through improved patient care and reduced costs. We need Congress to correct these thresholds to prevent the value movement from stalling,” Gaus stated.

NAACOS urged Congress to limit the increase to 50 percent of Medicare Part B payments or less in 2021. Additionally, the HHS Secretary should be allowed to raise the thresholds by no more than 5 percent per year to “minimize provider burden,” the group added.

Additionally, for performance periods impacted by the recent COVID-19 pandemic, the group asked Congress to permit the Secretary to disregard the QP thresholds and award the incentive payment to providers participating in qualifying alternative payment models.

A group of policymakers is already considering altering QP thresholds in 2021.

The coalition of Representatives led by Suzan K. DelBene (D-WA),  Roger Marshall, MD (R-KS), Peter Welch (D-VT), and Darin LaHood (R-IL) recently called on House leaders to address what they are calling the “QP cliff.”

“We encourage the House to take action to ensure that value-based care organizations continue to provide these vital services by modifying the Qualifying APM Participant (QP) thresholds included in the Medicare Access and CHIP Reauthorization Act (MACRA),” they wrote in a letter obtained by RevCycleIntelligence.

“The impending QP threshold jump in 2021 will derail the shift to value-based care right when seniors need it the most,” they added.

Bipartisan legislation introduced by Representatives DelBene, Welch, LaHood earlier this year would alter QP thresholds to encourage more clinicians to participate in Advanced APMs. It would also extend the 5 percent incentive payment for another six years.

NAACOS, along with the American Hospital Association, American Medical Association, and ten other industry groups, recently supported the bill.