Can you believe Thanksgiving is now in the rearview mirror and Christmas is less than a month away? Where has 2018 gone? It has been several weeks since my last post, and I am feeling a bit rusty. That post struck a nerve and generated an overwhelming amount of feedback! And while perhaps less exciting, today I thought we would drop back under the radar and follow up Diana Strubler’s fabulous introduction to the 2019 QPP final rule by exploring the impact we will see in the Advanced Alternative Payment Model (AAPM) space next year.
Before we dive into the specifics, the Cyber Monday shopper might ask, who cares? A fair question. The answer is a large number of nephrologists care. The ESCO is one of several Advanced APMs available to docs today, and it is by far the most popular among nephrologists. There are 37 ESCOs in operation this year. And while year 2 results are not available, in its first year, every participating ESCO generated savings for Medicare. That year, 12 of the 13 original participants elected to take downside risk, and all 12 received a share of the savings generated. Perhaps more importantly to Acumen blog readers is this fact: last year 34 of the 37 ESCOs took downside risk and thus were considered Advanced APMs. Even more importantly, each of those 34 ESCOs cleared the prevailing Qualifying Participant (QP) threshold. Why is that important? Every nephrologist and advanced practitioner in one of those ESCOs became a Qualifying APM Participant in 2017 and were excluded from MIPS last year. And let’s not forget, in 2019 those providers will receive a lump sum payment equivalent to 5% of their 2018 Medicare Part B book of business. The QP threshold for 2018 is identical to the threshold in 2017 which makes this blogger believe the same thing has happened this year.
Now that I have your undivided attention, let’s review what it takes to be considered an Advanced APM, and potentially qualify for the Advanced APM benefits noted above. As a quick reminder, Advanced APMs are a special type of alternative payment model characterized by 3 features. To be designated an AAPM, the APM entity must:
- Require participants to use certified electronic health record technology (CEHRT);
- Provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of the MIPS; and
- Either (1) be a Medical Home Model expanded under CMS Innovation Center authority or (2) require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses
What, if anything, changed for the ESCOs in the 2019 final rule? The truth is not much, which is a good thing in my humble opinion.
Regarding criterion number 1 above, in 2019 and beyond, Advanced APMs must require that at least 75% of the eligible clinicians (ECs) in the ESCO use a Certified EHR. Granted, this is an increase from the 50% of ECs using CEHRT today. But the reality is that CEHRT utilization is almost universal today. Per ONC, this hurdle was generally cleared in 2015. Importantly, as with MIPS, the CEHRT hurdle specifically requires the use of 2015 Edition CEHRT. While moving from 50% to 75% looks like a big step, this change would not keep me up at night.
Nothing new for 2019 regarding criterion number 2 above. However, things could change in 2020, the last year of the current version of the ESCO. For 2020 and beyond “at least one of the quality measures upon which an Advanced APM bases payment must either be finalized on the MIPS final list of measures; endorsed by a consensus-based entity; or determined by CMS to be evidenced-based, reliable, and valid.”
The fine folks running the Comprehensive ESRD Care Model (secret code for the ESCO program) make annual updates to the ESCO quality measures and recently released next year’s measures and weights as noted below.
Last, but certainly not least, is the criterion that in my opinion separates Advanced APMs from all other APMs—the requirement to bear financial risk for monetary losses. The good news here is nothing changes. The 2017 and 2018 final rules left the door open to raise what’s referred to as the “revenue-based nominal amount standard” from 8% (where it has been the last 2 years) to as high as 15%. If that had happened, Advanced APMs could be required to almost double their downside exposure. Thankfully, wiser heads prevailed and in this final rule—the 8% figure will be maintained through performance year 2024.
Less is more
That about sums up the 2019 QPP final rule’s impact on the ESCO program. The basic framework used to define an Advanced APM will not change in a significant manner for 2019. The QP threshold does rise next year. But that’s a topic for a future post. In contrast to those delicious Thanksgiving leftovers, with respect to the final rule’s impact on the ESCO program, less is more.
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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