Some proposed measures of the Medicare Access and Children's Health Insurance Program Reauthorization Act are more advantageous to physician groups than they appear.
Physician groups are reacting with understandable apprehension to the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA).
But not all the preliminary information about the aggressive timeline and multiple unknowns of the program is necessarily bad news for physician groups, according to the American Medical Group Association (AMGA).
AMGA, in a May 24 webinar about the Centers' for Medicare & Medicaid Services' proposed rule, identified the following nuances that may fall in medical groups' favor:
1. Advantages to Track 1 ACOs
While it may come as an initial disappointment to groups participating in Track 1 ACOs to not qualify for advanced alternative payment model (APM) bonuses under MACRA, the groups will not necessarily be in a bad position, explains David Introcaso, PhD, AMGA's senior director of regulatory and public policy.
Related: 56% of ACOs Would Quit MSSP if Ineligible for MACRA's APM Bonus
ACOs should actually have an advantage over other groups reporting under the Merit-Based Incentive System (MIPS).
"Presumably, if you're a Track 1 ACO, you should perform well on all the component scores, which would mean that you're more likely to get a positive MIPS adjustment," Introcaso says.
"And keep in mind that theoretically you have no downside risk, so being a successful ACO could mean a positive MIPS score as well as shared savings."
2.Bearing Risk Just Got Better
For the minority of groups expected to qualify as advanced APMs in year one, however, CMS's 5% bonus applies regardless of performance, offering a welcome cushion to groups bearing substantial risk.
"Say you're a Track 3 or Next Generation ACO and lose money and have to repay some of that money to CMS. But you meet the threshold [to qualify as an advanced APM]. The 5% you gain is offset by whatever amount of money you lost because you blew your benchmark," Introcaso says.
"In some ways, that's how CMS and Congress thought through this logically, because they thought some number of advanced APMs in their own model might lose money."
3.Top Scores Get Calculated
Groups and individuals participating in MIPS, on the other hand, are allowed to select their own quality measures to report. While six measures (including one outcomes and one cross-cutting measure) is the minimum, there is no limit.
So a group could choose 10 measures, for example; and CMS would only count the six highest scores.
Moreover, CMS is aware of a potential gaming of its top-score policy should participants select measures for which they do not meet the minimum reporting standard.
"And if that's the case, CMS throws out the measure, and you can still score a maximum number of 90 points on the five [remaining] measures," Introcaso say.
It remains to be seen whether this loophole gets closed in CMS's final rule.
Debra Shute is the Senior Physicians Editor for HealthLeaders Media.