Issue link: https://beckershealthcare.uberflip.com/i/674245
49 FINANCE higher payments. In particular for physicians who currently don't do well in PQRS, MU or other existing payment adjustments, MIPS may not be the breath of fresh air they expect. 3. How are payments determined for APM? "From a strategic perspective, everyone has to do some form of MIPS," says Mr. Belokrinitsky. "APM is more of a leap forward than an incremental step." APM builds off of existing value-based alternative payment programs like accountable care organizations, patient-centered medical homes and bundled payment programs. Under this track there are "APMs" and "eligible APMs." e key difference here is "eligible APMs" are more ad- vanced, meet several criteria under MACRA and have a certain percent- age of patients who are treated as part of the ACO, PCMH or alternative program of choice. ose eligible APMs, also called qualifying APM participants, do not receive MIPS adjustments and instead receive a lump-sum bonus for years 2019 to 2024. is lump sum will be 5 percent of the estimated aggregate expenditures under the fee schedule for the prior year. e lump sum will transition into a higher fee schedule update starting in 2026 and beyond. In 2025, eligible APMs do not receive a lump payment or higher fee schedule, according to CMS. APMs continue using their own method of rewarding value, making this the more lucrative track compared to MIPS. "Risk-based models have performance incentives baked into them. APM doesn't need to double those incentives, so the lump sum is meant to be a reward for qualifying as an APM," says Ms. Friedman, who describes the lump sum as a "bump for being at risk." at said, CMS says most physicians will be considered less-advanced APMs. ose participants will still receive their APM-specific rewards and will also be subject to MIPS payment adjustments. ey receive fa- vorable scoring for the clinical practice improvement category, of the four categories in the MIPS composite score, according to CMS. "APM encourages providers to take on more risk. And it's no small un- dertaking — the average provider is still trying to figure out how to suc- ceed under risk-based models," says Ms. Friedman. 4. Which track should my practice pick? is is a trick question. "An important thing to know — and a source of misconception among many providers — is you can't pick between the two models," says Ms. Friedman. "You have to qualify based on your book of business." Details are yet to come on what will categorize a provider as an APM or an advanced APM, but once those come out, organizations will be as- sessed to determine if they fall into one of those two categories. e rest of providers will fall into MIPS, according to Ms. Friedman. "Providers do still need to get educated about what each of the tracks entail and which they are qualified for because the payment schemes are meaning- fully different," she says. 5. How does it affect meaningful use? Many providers were excited when Mr. Slavitt announced the end of MU in January. "We are now in the process of ending meaningful use and moving to a new regime culminating with the MACRA implemen- tation," he said at the J.P. Morgan Annual Health Care Conference. "e meaningful use program as it has existed, will now be effectively over and replaced with something better." is statement was tempered a few days later in a CMS blog post Mr. Slavitt authored jointly with Karen DeSalvo, MD, acting assistant sec- retary of HHS. ey wrote that MACRA is an opportunity to adjust EHR-related payment incentives, but it does not eliminate EHR-related payment systems, nor will it eliminate meaningful use woes overnight. While MACRA details are hammered out, meaningful use Stage 3 is still in effect. Mr. Slavitt and Dr. DeSalvo also underlined the fact that any chang- es to meaningful use under MACRA apply only to physicians and clinicians, not hospitals, as MACRA applies only to Medicare physi- cian payments. EHR incentive programs for Medicaid and Medicare hospitals will not change as a result of this program, though CMS is working to improve them. 6. What are some other unforeseen impacts of MACRA? Some physicians may be bewildered at the thought of adding MACRA to the mix of payment frameworks they already deal with, including those from commercial payers, according to Mr. Belokrinitsky. "ey will be saying, 'I wish these guys would all figure it out. Everyone has their own metrics and I wish it was a little bit simpler.'" Luckily for those providers, Mr. Belokrintisky sees MACRA as a future standard framework for payers to hang their metrics on. "I think [com- mercial payers] are happy it's happening. MACRA is putting more pres- sure on providers to use alternative payment instruments," he says. "e next step is how they can bring commercial reimbursement closer in line with what's being proposed here." He says CMS' newest initiative — the Comprehensive Primary Care Plus model — requires commercial payers to partner with CMS and Medicaid agencies, indicating more collaboration between private payers and CMS could be on the horizon However, Ms. Friedman disagrees. When asked if MACRA would in- spire changes among commercial payers, she says, "Five years ago I might have said yes. We really expected private payers to follow Medi- care's move to risk, and we have seen that to some extent…but generally speaking we have not seen a move to risk-based contracting on the pri- vate side to the extent we have seen it in Medicare." She says it's possible, but unlikely based on past behavior. 7. What does MACRA mean for smaller providers? Smaller providers may face more difficulty complying with MACRA metrics, in particular the EHR and technology-based requirements or some of the qualifying APMs that require greater capital or a pa- tient population. Mr. Belokrinitsky says MACRA does not necessarily exclude smaller practices, though it could create an impetus for more provider affiliations. "What we've seen in our research is the larger organizations have not created the savings that everyone is hoping for," he says, also referring to research that shows physician-based ACOs tend to achieve more savings than those led by hospitals. "We do anticipate more consolidation, but more along the lines of loose affiliations," Mr. Belokrinitsky adds, noting that consolidation purely for the purpose of getting bigger will likely not be the answer. Future provider affiliations will be characterized by tight partnerships through which the entities can share capabilities, but not necessarily exchange capital, he says. Ms. Friedman agrees that MACRA does not necessarily pose challenges for smaller providers. Instead, smaller, independent practices may ac- tually have more agility as the sole authority in craing their MACRA