Medical groups struggle to find clinically relevant alternative payment models

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7/19/2023

Advanced Alternative Payment Models (APMs) were created under the Quality Payment Program (QPP) as part the Medicare Access & CHIP Reauthorization Act (MACRA) of 2015 to transition practices from fee-for-service to value-based care. While MGMA has long supported the ability of medical groups to voluntarily move from fee-for-service to value-based care, the QPP has been beset with issues stifling this goal.

A July 18, 2023, MGMA Stat poll asked the question, “Does Medicare offer an Advanced APM that is clinically relevant to your practice?” Nearly eight in 10 (79%) respondents answered “no.” The poll had 208 applicable responses.

Member responses

An MGMA Stat poll from January 2023 found that 93% of medical group leaders report Medicare has not done enough to incentivize adopting value-based care.
In MGMA’s 2022 Annual Regulatory Burden Report, 61% of surveyed medical group practices stated they would be interested in participating in an APM. However, 78% indicated that there is not a clinically relevant APM currently available for practices to participate in.
An MGMA Stat poll from January 2020 found that only 19% of medical group practices participated in APMs.
An MGMA Stat poll from March 2018 found almost 3 out of 4 (72%) of medical group leaders were opposed to mandatory participation in Medicare APMs.

#MGMAAdvocacy

The lack of clinically relevant APMs available is a significant barrier for medical groups, and there are flaws in the model development process compounding this problem. The Centers for Medicare & Medicaid Innovation Center (CMMI) and private sector entities through the Physician-Focused Payment Model Technical Advisory Committee (PTAC) can develop APMs. PTAC can submit models to CMMI for testing, while CMMI has the sole responsibility to test and implement APMs. To date, CMMI has yet to test any of the models PTAC has recommended.

MGMA Government Affairs recently submitted testimony to the House Committee on Energy and Commerce Subcommittee on Oversight and Investigations offering recommendations on how to improve APM development in response to the Subcommittee’s hearing on MACRA. The Government Affairs team continues to advocate for QPP reform in other forums as well, and our APM advocacy priorities center around:

Providing support for participants through upfront investments, resources and tools.
Reinstating the 5% payment bonus for APM participation beyond the 2025 payment year, for a period of at least six years. The APM 5% incentive payment was set to expire at the end of 2022, but the Consolidated Appropriations Act of 2023 extended the bonus at 3.5% for the 2023 performance year. While we are happy MGMA advocacy helped avert the expiration of this important bonus, we continue to work to extend it at 5%.
Designing and implementing APMs that provide sufficient supports for group practice participants and appropriate financial incentives and regulatory flexibilities.
Supporting the development of new, voluntary physician-led APMs that meet the needs of practices of vary types, sizes and specialties to inherently drive more widespread participation.
Ensuring CMS has the flexibility to adjust the Qualifying APM Participant (QP) payment threshold to ensure the criteria to achieve QP status is not set arbitrarily high.

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