September has been a very busy month in the Advanced Alternative Payment Model world. Just 10 days ago I had the privilege of joining about 90 other ESCO participants at the 2-day 2018 Cross-Model ACO face-to-face meeting in our nation’s capitol. What better time to unpack some of the AAPM updates in the proposed rule we’ve been discussion in the Acumen blog? Let’s start there, and then finish with an update from the meeting in DC.
Before we dive in, let me clear the air about a question I have been fielding lately. At last year’s face-to-face ESCO meeting, then CMMI director Dr. Patrick Conway thrilled the audience by announcing that based on historical performance, all of the 2-sided risk ESCOs achieved the QP status. Recall doing so means every provider on the ESCO participant list is excluded from MIPS and will receive the 5% AAPM bonus on their entire Part B book of business. While we have not seen a general announcement this year, I can tell you the first wave of QP determinations are complete, and the news is good. If you are in an ESCO, you can determine your 2018 QP status by entering your NPI number on this CMS website.
I have to say, when compared with what we heard in the DC meeting, the recently released proposed rule contains little ground-breaking news for the ESCO program (probably a good thing). Highlighted below are the few items of note. As you may recall, CMMI uses 3 criteria to define an Advanced APM:
- Requires participants to use CEHRT
- Awards payment based on quality measures comparable to those in MIPS
- Requires participants to bear more than nominal financial risk
Curious what models meet the 3 Advanced APM criteria? CMS does a great job of displaying the models for 2018 and 2019 here.
With respect to number 1, the NPRM proposes a requirement that at least 75% of the eligible clinicians within the APM use CEHRT. This is an increase from the prevailing threshold of 50%. While this is a large increase, in my experience most nephrologists are using CEHRT today, so this should not impact the existing ESCOs I am familiar with.
While little has changed here, there was big news about quality at the face-to-face meeting this month (a teaser to keep you reading through the end of this post). The only thing of substance in the NPRM with respect to quality is the addition of specificity regarding the requirement that at least one of the AAPM quality measures is an outcomes measure. The ESCO program is in great shape with this change.
The proposed rule contains welcome news for nephrology with respect to the financial risk we are required to take. Within this NPRM, they are proposing to fix what’s called the “revenue-based nominal amount standard” for Advanced APMs at 8% through performance year 2024. The big news here is that in previous rule-making years, they always left the door open to raising this figure. Raising it is bad news for those of you in one of these models, as it increases your potential downside risk. By fixing it at 8% through 2024, they appear to be acknowledging that this degree of downside risk is enough to make a difference.
Other payer Advanced APMs
Within this NPRM, CMS also devotes quite a bit of attention to what are called “other payer AAPMs.” This is the concept they shared in earlier rules whereby they extend the chance to become a QP by combining your participation in a Medicare program (like the ESCO) with the experience you may have with other payors offering Advanced APMs. For the most part, this simply ensures this path is aligned with the Medicare-only program. Frankly, I have been underwhelmed with the appetite other payers have shown to joining the fun. If that occurs, I think nephrology will pay more attention, but today, we have bigger fish to fry.
The big news for nephrology-facing AAPMs came at the combined ESCO/NextGen ACO face-to-face meeting in DC earlier this month. The organizers reported an attendance of around 240 folks, including 90 from the ESCO programs. As you may recall, there are 7 dialysis organizations participating in the ESCO program today. Just north of 60,000 Medicare ESRD beneficiaries are now aligned with one of the 37 ESCOs in operation today. The CEC-Model staff remain substantially committed to the program. One of the important announcements they shared with us is a sizeable reduction in number of quality measures in the coming year. In the name of administrative simplification, they are reducing the total number of quality measures within the ESCO program to 5 for the 2019 performance year. The devil in the details will be forthcoming, but I must say this dramatic reduction in the number of quality measures we will face in the ESCO next year is welcome news.
The highlight of the meeting for me, however, was the keynote address by the new director of CMMI, Adam Boehler. Adam joined CMMI earlier this year following 5 years as the CEO of healthcare startup Landmark Health, which he founded in 2013. As the keynote speaker, he participated in a Q&A session with former CMS Administrator Mark McClellan. During the one hour “fireside chat” in DC, Adam spoke candidly about his vision for value-based care and his interests in solving the many problems our patients with renal disease face today. It was very clear to me that he has every intention of advancing the value-based payment framework, and under his leadership, the renal space is going to receive a lot of attention. I was among the many folks who left the meeting energized by Adam’s enthusiasm.
In a nutshell, that’s the Advanced APM update. Not much to share from the NPRM, but a pretty exciting 2 days in DC with our ESCO colleagues. What are your thoughts about Advanced APMs and the future of value-based care? Drop us a note and join the conversation.
Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.
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