December 2, 2020
By Brittany Cassar & Travis Broome
When CMS released its proposed MACRA rule in April, Aledade immediately dove in to understand how it would influence important issues ranging from health care market competition to the advancement of health IT. Overall, we believe the rule is a step in the right direction toward creating greater value in health care and encouraging the move of eligible clinicians out of fee-for-service and into advanced alternative payment models (AAPMs).
However, we believe there are some changes that CMS could make to help create a path for independent practices to thrive, deliver high quality care, and reduce costs. We highlighted these changes in a formal comment letter to CMS during the recently closed public comment period.
One of the primary changes we called for focuses on the “more than nominal risk” taken on by practices participating in AAPMs. Specifically, we believe that the level of financial risk needs to be more than nominal as it relates to the organization.
With nearly 50 percent of eligible clinicians still in small practices, health care organizations of all sizes must consider AAPMs a viable option. The proposal to base the determination of “more than nominal” on the benchmark of the APM will not succeed in moving more providers to financial risk. If left unchanged, the rule will create vastly different amounts of risk depending on the type/size of the organization and depending on the APM model.
Instead, as we said in our formal comment to CMS, we explained that we believe financial risk would be best measured as a percentage of revenue so that the risk is based on the size of each organization. We proposed:
“CMS should base the level of risk on how much revenue the organization and/or its members received from Medicare. This approach was appropriate for Medical Home Models and will also make sense for all APM entities at a higher threshold. We propose 15% of the APM Entity’s participant aggregate Medicare Parts A and B revenue.”
We told CMS this is the single most important policy change it could make for the implementation of MACRA and is absolutely crucial to encouraging eligible clinicians to embrace AAPMs.
We are happy to see that many of our peers agree with our assessment.
On the risk provision, the American Academy of Family Physicians (AAFP) said: “Entities of all sizes will be able to assume varying levels of risk. It is critical that CMS ensures the success of these entities by allowing for risk structures that will support this success.”
The American College of Physicians said a revenue-based risk level “would reflect significant nominal risk to the practices within the entity, but not place them in unreasonable financial jeopardy.”
Others voiced support for a revenue-based level of risk, including:
- American Medical Association
- Federation of American Hospitals
- Health Care Transformation Task Force
- Medical Group Management Association
- National Association of ACOs
- National Committee for Quality Assurance
- Premier
Aledade hopes that when CMS reviews all of the comments and finalizes the rule, it considers making these small but important changes that will benefit patients, doctors, and the health care system overall.