[18] lack of meaningful provider level. Goal of







18 http://hcp-lan.org/workproducts/apm-framework-onepager.pdf


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16 http://hcp-lan.org/workproducts/apm-measurement-final.pdf

15 https://hcp-lan.org/groups/apm-refresh-white-paper/


13 https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2015.1468







6 https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0559

6 https://www.cbo.gov/publication/50692

5 https://www.healthaffairs.org/do/10.1377/hblog20170814.061537/full/



2 Medicare Access and CHIP Reauthorization Act of 2015, Public Law




I future of US health care system and practice of medicine MACRA can have
profound and lasting influence. However, there is need for substantial changes
in the law to realize the goal of establishing a Medicare payment system that
rewards the value and not the volume of health care services. The significant
objectives can be achieved using Medicare Advantage as the platform. 

The effects of MACRA on Medicare spending and how it would affect in
various settings was published in Health Affairs, April 2017 6. It is estimated that providers Medicare payments
will be significantly lower under MACRA present provisions than they would have
been if the cycle of SGR overrides had continued and MACRA had never been
passed. It is suggested that for MACRA to be successful well designed APMs
should be available for physicians. If not able to achieve this MACRA program
will fail to meet its value based payment objective and could have unintended
consequences for patients.



CMS should consider to significantly reduce the burden of reporting in
MIPS to a few, easily reportable measures that can be used to avoid negative
updates. In order to reduce the potential for large bonuses, and the erosion of
inflation based reimbursement over time can be done by reducing the number of
providers that receive penalties, and this would be strong incentive for
providers to seek an alternative to MIPS. In order to better align the goals of
the QPP and to ensure that MIPS does not become too comfortable, CMS should
repurpose the “exceptional performance” payments toward the APM bonuses.

MIPS as structured currently does nothing to further the QPP goals of
transitioning to a value based system. Presently as MIPS is structured will not
help to improve the value of care and when fully implemented, the penalties and
rewards that provider receive may not significantly help to improve the value of
care. By simply exempting a large number of providers does not address the
intrinsic difficulty of performance assessment at the individual provider level
or address the current lack of meaningful provider level. 

Goal of the QPP and
Alignment of MIPS

To facilitate transition in to a value based system, CMS should study
data provided by plans regarding provider participation and APM related data in
future years.

Develop a timeline
For Medicare Advantage Integration

The participation data will be sent to CMS by Medicare advantage plans
and based on revenue that flows through the specific model bonus would be made,
instead of on providers’ fee schedule payments, as suggested in the MedPAC June
report. The bonus payments would go to the plan, then they would be distributed
to providers according to their contracts. This will help to reduce burden on
physician practices and CMS. Reimbursement would be provided to plans for
additional administrative costs.

Medicare Advantage plans accepts risk and many providers within the Medicare
advantage are also involved in risk based contracts with the plan. Presently
CMS provides incentives only for participation in complex, risk-based advanced
APMs. CMS should consider Incremental incentives for participation at all
levels of the payment reform continuum by revising APM bonus model.  As defined by HCP-LAN using the payment model
taxonomy, providers would be eligible for differential bonus payments according
to the model category in which they participate. 18 This will serve as a ramp to value based payment
models that is currently missing in MACRA.

APM Participation Within
Medicare Advantage and Incremental Incentives

If CMS amends MACRA to consider Medicare Advantage contracts, then
providers will be able to count their Medicare advantage participation towards
meeting the revenue thresholds and would be eligible for APM bonus payments and
exemption from MIPS. Those providers who decide not to participate in an APM
within Medicare Advantage would not be eligible for the APM bonus but will be
able to use the star ratings of their contracts to avoid penalties in MIPS,
provided they meet MA participation thresholds and their Star rating is 4.0 or

Through their capitated payment contracts with CMS, Medicare
Advantage plans accept risk for a population of beneficiaries and therefore
offer an alternative to traditional fee-for-service Medicare, which is
well-advanced along the payment reform continuum. Medicare Advantage takes more
than nominal financial risk, use electronic health record technology and meet
quality through the Star rating system as advanced APMs.

Consider Medicare
Advantage Contracts as Advanced APMs

Several steps can be taken by policy makers to leverage the assets of
Medicare Advantage.

Integrating Medicare
Advantage Into MACRA

In order for MACRA to achieve its original goals, policy makers need to
incentivize participation in alternatives to fee-for-service at all levels. In
addition, the substantial burden in MIPS needs to be realigned with the goals
of the QPP, as access to APMs is expanded.



Beginning with the 2019 performance period Medicare Advantage payer
arrangements that meet the criteria will be considered among providers to determine
if the eligible physicians can earn the 5 percent incentive payment and are
exempt from MIPS. I order to allow payers to initiate the process on behalf of
providers to identify their arrangements as qualifying advanced APMs there is
option included in the rule.   This
is a withdrawal from the 2017 final rule, which largely ignored risk contracts
within Medicare Advantage. However, It will be hard to have a desired effect of
substantially expanding participation in alternatives to fee -for-service unless
the rules are planned to credit innovation along the entire payment reform

Consideration of APMS In
Medicare Advantage

Once MIPS is fully implemented, the average provider in the program will
see its inflation adjusted reimbursements fall substantially over the next
several years and there shall be substantial reporting burden as well. MIPS
will achieve the objective by making fee- for service uncomfortable, if not
untenable. Moreover, even with small variation in the score of an individual
provider will have large effect on the publicly reported performance scores,
affecting individual provider’s reputation and in turn hard on provider’s
employability, even though there is no significant impact on value of the care
provided. It has been reported by MedPAC to Congress on June 2017, that
presently structured MIPS program is unlikely to be successful in: (a) helping
patients choose physicians (b) helping Medicare program reward physician based
on value of care provided and (c) helping physician change practice patterns to
improve their care provided to patients.

2018 is a transition year for establishing QPP. Plan are in place to extend
QPP program flexibility and minimizing the MIPS reporting burden and exposure
to penalties. Estimated two-thirds of clinicians will be exempted from MIPS at
least for first 2 years. substantially limiting the impact of the program, at
least for the first two years. mainly through an expansion of the low-volume
thresholds (from $30,000 or 100 beneficiaries in 2017 to $90,000 or 200
beneficiaries in 2018). As a budget-neutral program, fewer penalties means
significantly smaller rewards for providers that participate and would
otherwise expect to benefit. Exclusion of large number of providers from MIPS
program raises questions among many providers regarding underlying purpose of
MIPS. Past experience suggest that MIPS will not achieve the goal of improving
the quality of care delivered in fee for service Medicare. Although MIPS is by
far the largest Pay-for -performance initiative taken to date, studies on pay-
for -performance over past several years have failed to demonstrate a
consistent association with improved health outcomes in any setting. 17

Delayed Effect Of MIPS

Current MACRA requirements only rewards providers who have capability to
participate in complex, risk bearing advanced APMs. Various payment models exist
in physician practices and Medicare advantage works with these practices
working on the different payment methods. This payment reform “glide
path” is not incentivized in the current MACRA requirements. By comparison, a
MACRA-mandated CMS study 14 reported to Congress that Medicare Advantage organizations and their
network providers have long been engaged in payment models that can be
classified under every category of the administration’s payment taxonomy
framework. 15 In addition, a recent
investigation by the Health Care Payment Learning and Action Network
(HCP-LAN) reported that in 2016, as much as 41 percent of Medicare
Advantage health care dollars were in a composite of more advanced categories
three and four payment models. 16 This is substantially higher than the corresponding portion for other
payers and suggests that Medicare Advantage could play a major role in
accelerating the transition to value in Medicare.

Flexibility to Innovate

The Medicare Payment advisory committee (MedPAC) and others have claimed
that the Medicare Advantage program is more expensive than fee-for-service
Medicare. 12 Yet there is evidence
that the methods used by Medicare Advantage plans are effective in changing
physicians’ care patterns to reduce the use of expensive services, which may
actually have a spending reduction “spillover” effect in fee-for-service Medicare.

Reducing Cost

Several studies suggest that the care provided through Medicare Advantage
may be of higher value than the care offered through traditional Medicare,
especially for patients with chronic medical conditions such as diabetes
mellitus and cardiovascular disease.10 Also there is evidence that the combination of full-risk capitation and
revenue gain sharing agreements in Medicare Advantage can promote clinical
practice transformations at the provider group level, which are associated with
increased outpatient care, decreased in patient services, and increased
survival for chronically ill, elderly patient population.11




As of 2017, one in three people with Medicare (33 percent or 19 million
beneficiaries) are enrolled in Medicare advantage plan. This enrollment is
projected to grow at least 41 percent over the next decade. 8 Beneficiaries choose to be in Medicare Advantage
plans because the efforts taken by MA to reduce cost results in plan rebates
that are passed on to the beneficiary as increased services or premium
reductions, incentivized patients to make high value health care decisions.
Enrollment in Medicare enrollment has grown 71 percent since 2010, In spite of
reduction in payments to plans authorized by affordable Care Act (figure1) 9.


To achieve goals of MACRA legislation, Medicare Advantage could serve as
a platform to reduce the burden on physician’s practices, fast track the
transition to a value based payment systemin Medicare and act as a ramp to
advanced payment models.

You do not have End-Stage Renal Disease (ESRD). 7

You live in the plan’s service area; and

You have Medicare Parts A and B;

You can join a Medicare Advantage Plan if:

Medicare Advantage Plans often charge a premium in addition to the
Medicare Part B premium. They also generally charge a fixed amount, called a
copayment, that you are responsible for whenever you receive a service. 
Some plans charge a percentage of the cost of the service, called a
coinsurance, for some or all services.

Health Maintenance Organizations
Preferred Provider Organizations
Private Fee-For-Service (PFFS)

The most common
types of Medicare Advantage Plan are:

While most people
with Medicare get their health coverage from Original Medicare, some people
(around one-third of beneficiaries) choose to get their benefits from a
Medicare Advantage Plan, sometimes called a Medicare private health plan.
Medicare Advantage Plans contract with the federal government and are paid a
fixed amount per person to provide Medicare benefits.

Medicare Advantage as a

Considerable steps have been taken to popularize MIPS among health care
providers. For example, the reporting system is made very flexible for better
adapbility of the new system. Choices can be made on the basis of practice size, specialty, location,
or patient population. Additionally, there are reduced financial penalities for
initial years of transition. However, many providers may realize that MIPS, in
its current form, increases their administrative burden. On top of that, a
recent report on effects of MACRA argues that enforcement of MIPS and
dissolution of SGR will reduce overall reimbursements of Medicare providers.
These and other issues will hamper the adaptability of MIPS and overall goals
of MACRA. As for APM, the path seems to be even more challenging. In its
current form, MACRA regulations makes APM limited to very few number of medical
programs. The guidelines are too complicated to adapt for those Medicare
providers who are willing to make the transition but lack the required tangible
as well as intangible assets. It is not surprising that
the early results of APM implementation are far from satisfactory, casting a
shadow of uncertainity on its sustainability 5. To make matters even worse, Congressional Budget
Office estimates that it may take upto seven years for scaling up APM from a
pilot program to a full-fledge successful healthcare policy 6. The combined effect of a
tedious APM and ineffective SGR may make the entire MACRA program a
counter-productive exercise.

As mentioned earlier, QPP was established for transition of providers from
traditional SGR Medicare payment system (largely based on fee-for-service notion)
to a comprehensive value-based payment system by using two-pronged approach;
make SGR increasingly unattractive and dysfunctional through MIPS and reward
participation in APMs.

iii) transition of providers to a comprehensive value-based payment

ii) stabilize payments for the given period of transition time

i) revoke the outdated Sustainable Growth Rate (SGR) Medicare payment

Overall, there were three main goals of MACRA for improving the payment
system in our health care setting:

Challenges for achieving
MACRA goals



There is diversity among clinician practices
in their experience with quality based payments. CMS is aware of this aspects and
expects Quality Payment Program to evolve in future years. Foundation has been
laid for expansion towards patient centered, innovation, health care which is
both cost effective and patient appreciated focused outcome. The Quality Payment
Program (a) focuses on better outcomes for patients and preserving the
independent clinical practice, (b) promotes low-cost, incentives for high
quality care across healthcare stakeholders and (3) promotes existing delivery
system reform efforts, including ensuring a smooth transition to a health care
system that promotes high value, efficient care through unification of CMS
programs. 4

These both meaningful goals can be attained
using Medicare Advantage as the platform. In
this paper I will be giving overview on how Medicare Advantage can help achieve
the goals of MACRA.

CMS should consider revising MIPS to better
align the two arms of the QPP. At the same time needs to recognize the full range
of innovation in the Medicare Advantage program and incentivize APMs

The broad purpose of above-mentioned programs
is to support not only health care providers but also patients for making
pragmatic decisions about health care using state of the art technology,
insights from quantitative measures and quality measures that can with stand
ever-changing face of healthcare norms. This is accompanied by emphasis on reducing
burden on providers so that maximum resources are devoted towards better
healthcare services. Even though QPP aims to bring huge set of amendments to current
policies, it is structured to be flexible and transparent. Another important
feature of QPP design is it’s inherent capacity to improve over time with input
from clinicians, patients, and other stakeholders.

In general, the QPP is aimed to take a
comprehensive quality-oriented approach. In order to have a measurable matrix
for the quality of service, clinicians developed a set of evidenced-based
measures. The development of self-evaluating measures was thought to improve
clinical practice with suitable support from technological advancements,
community surveys, demographic data and peer evaluation.

2. Merit-based
Incentive Payment System (MIPS): Participation in MIPS can provide an opportunity to earn performance-based payment adjustment 3.

1. Advanced Alternative Payment Models (Advanced
APMs): Participation in an
Advanced APM can provide an opportunity to earn “incentive payment for
participating in an innovative payment model” 3.

In order to have a comprehensive approach for
rewarding and re-imbursement, the Medicare Access and CHIP Reauthorization Act
of 2015 (MACRA) 2 amended Title XVIII of the Social Security Act to repeal the SGR
formula and to strengthen Medicare access by improving health care provider
payments. The MACRA was intended to provide clinicians with a futuristic and
well-coordinated platform for their transition from SGR formula to its
replacement called Quality Payment Program (QPP) 3. The
main purposes of creating QPP were to revoke SGR formula and introduce a better
payment system that rewards quality over quantity. The QPP has two main tracks:

In today’s health care system, doctors and
other clinicians are often paid on the basis of the number of services they
perform rather than patient health outcomes. This classic fee-for-service
clause has been the integral part of Medicare Sustainable Growth Rate (SGR) formula,
which is the prime guideline of our payment to health care providers 1. However, it
should be noted that in addition to conducting tests or writing prescriptions,
doctors also take time to i) have a conversation with a patient about test
results, ii) be available to a patient through telehealth or expanded hours,
iii) coordinate medicine and treatments in order to avoid confusion or errors
and, iv) develop health care plans. Therefore, it is beyond doubt that the
re-imbursement system should have a broader scope than the outdated SGR formula
for true reflection of the services provided by health care personnel.



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