Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to an eligible clinician (generally a physician or mid-level – see our previous blog post for details) except in certain circumstances. One of the circumstances in which an eligible clinician is excluded from MIPS is when the clinician participates in an advanced alternative payment model (APM) that meets certain operational, risk and patient/payment volume requirements. Notably, a participant in a qualifying advanced APM receives a 5 percent annual bonus payment from 2019-2024. A participant in an advanced APM who does not meet the patient/payment threshold requirements may still be exempt from MIPS adjustments (although such a partial qualifying advanced APM participant may choose to participate in MIPS) but will not receive the advanced APM bonus.

In order to qualify a participant for exclusion from MIPS, an advanced APM must:

(1) require participants to use Certified Electronic Health Record Technology;

(2) provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS and;

(3) either require that participating APM entities bear risk for monetary losses of a more than nominal amount under the APM, or be a Medical Home Model expanded under section 1115A(c) of the Act. To meet the financial risk requirement, an APM arrangement must involve: (i) marginal risk of at least 30 percent; (ii) minimum loss rate of at least 4 percent; and (iii) total potential risk of at least 4 percent.

CMS states that the following arrangements meet advanced APM requirements (subject to meeting risk and patient or payment volume thresholds):

  • Shared Savings Program Tracks 2 and 3;
  • Comprehensive End Stage Renal Disease (ESRD) Care Model (Large Dialysis Organization Arrangement);
  • Comprehensive Primary Care Plus (CPC+);
  • Oncology Care Model 2-sided risk arrangement;
  • Next Generation ACO Model; and
  • Full capitation arrangement (providing services to a Medicare Advantage plan on a fee for services basis is not a capitation arrangement).

In addition, beginning in 2021 a clinician may participate in an advanced other payer APM. Notably, in its final rule CMS states that it is considering additional arrangements for advanced APM status, including a Medicare ACO Track 1+, the Maryland All-Payer Model and the Comprehensive Care for Joint Replacement model.

The APM patient/payment volume thresholds are:

  • 2019-2020 = 25 percent Medicare payments from APM or 20 percent Medicare patients from APM
  • 2021-2022 = 50 percent Medicare payments from APM or 35 percent Medicare patients from APM
  • 2023-later = 75 percent Medicare payments from APM or 50 percent Medicare patients from APM

As mentioned above, if a clinician is in an APM but does meet the thresholds above, the clinician may nonetheless be a partial qualifying participant who will not receive the APM annual payment bonus but is excluded from MIPS adjustments.

Generally, in order to be an advanced APM, an entity will have sophisticated operations that likely include clinician outreach – so if you’re not sure if you’re in an advanced APM, you are probably not in one (although you need to consult with the APM to be sure). For clinicians looking to join an advanced APM, it is important to review data from the APM to make sure it is likely to meet the necessary requirements.

What is MACRA? See Managing MACRA – Part I.

Does MACRA apply to me? See Managing MACRA – Part II.