Recognizing Medicare Advantage as Advanced APM supported by members of Congress

24 members of the U.S. House of Representatives have written CMS asking the agency to include risk-based Medicare Advantage (MA) arrangements to count towards requirements for Advanced Alternative Payment Models (APMs) under the Quality Payment Program (QPP).

To qualify as an Advanced APM, introduced as part of the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), clinicians have to meet minimum revenue thresholds from certain models or serve a minimum number of beneficiaries in APMs. The final MACRA rule restricts the 2019 and 2020 payment periods to Medicare fee-for-service (FFS) revenue and patients. Those in “other payer” APMs—such as MA plans—won’t be able to earn the incentive payment until the 2021 payment year.

The congressmen, led by Reps. Tom Reed, R-New York, Tony Cardenas, D-California, Larry Bucshon, R-Indiana, and Earl Blumenauer, D-Oregon, argued given the risk contracts which already exist in MA and how much of the Medicare beneficiary population is now covered by these plans, they should be included in the beneficiary count needed to qualify for the 5 percent Advanced APM bonus.

“Preventing physicians who participate in Medicare Advantage networks from incentives under MACRA is not only a disincentive to their participation in those networks, it could limit patient options, and place further reporting burdens on physicians,” the representatives wrote to CMS Administrator Seema Verma, MPH. “To solve this issue, a physician that attest to having a certain percentage of their payments or patients in a qualifying risk-bearing relationship should meet the requirements to participate in the advanced APM track.”

The letter asks for this recognition to be included in the 2018 QPP rule. An earlier appeal from ten healthcare groups had asked for a less aggressive timeline, with recognition beginning in the 2019 plan year, and the American Medical Group Association said in an interview with HealthExec that MA plans shouldn’t be excluded.

The push from members of Congress to include MA risk-based contracts in Advanced APMs was praised by Don Crane, president and CEO of CAPG.

"Recognizing the value of alternative payment model contracting in Medicare Advantage is absolutely essential to the success of the value movement," Crane said in a statement. "We simply cannot succeed in transforming the delivery system if we continue to ignore Medicare Advantage, the option that provides high value care to a third of the senior population. We thank these members of Congress for their support for seniors and physicians participating in MA today and in the future."