Alternative payment models (APMs) are growing in popularity among providers aligning with value-based care. More than a third of healthcare payments were tied to APMs in 2017 – an increase of 5% from just two years earlier. Yet for many clinicians, the thresholds required to become a Qualified Professional (QP) under MACRA’s Quality Payment Program (QPP) are unattainable. Fortunately, the Merit-Based Incentive Payment System (MIPS)-APM Scoring Standard allows providers to use programs like BPCI Advanced to realize the benefits of APMs under MIPS.
Challenges to MIPS
MIPS is a burdensome program with a fluctuating set of rules that often creates more work for providers, despite its aims to improve quality and care. Challenges include:
Mandatory Downside Risk
MIPS mandates upside and downside risk that grows each year from +/- 4%, to 5%, to 7%, and ultimately capping at 9% in 2022 onwards. While increased upside risk may look attractive, it comes with the corresponding increase in downside risk. The 9% cap remains in place indefinitely until new healthcare acts are passed from Congress.
Not Everyone is a Winner
Because MIPS is budget-neutral to Medicare on a year-by-year basis, there is a forced ranking mechanism whereby there will be always be winners and losers. In essence, all participants compete against each other, regardless of specialty. Providers must make sure they’re as well-positioned as they can be under MIPS, particularly as downside risk grows to 9%.
Unpredictable and Unstable Scoring
Under MIPS, providers are scored in metrics across four different domains: Quality, Improvement Activities, Promoting Interoperability, and Cost. Performance is aggregated into a single composite quality score, with those four elements weighted differently. Under the normal MIPS scoring methodology, the weights of those four domains change from year to year.
The Threshold Problem
A significant reason for APM popularity is the ability for providers to qualify out of MIPS. In order to qualify for the Advanced-APMs track and move out of MIPS, providers must meet certain volume thresholds. As of 2019, providers must have either 50% of their Medicare fee-for-service (FFS) reimbursement tied to an APM, or 35% of their Medicare FFS patient headcount tied to one to avoid being in MIPS.
Not all providers will meet these thresholds. MACRA established a way for providers to be Partial Qualifying APM Participants (QPs) by meeting slightly lower volume thresholds. Partial QPs are given the option to be scored under MIPS through the MIPS-APM Scoring Standard, or be exempt from MIPS altogether, in which they receive a 0% adjustment to their professional service rates and do not need to report on quality. Clinicians who do not meet the lowered Partial QP volume thresholds will be scored under the MIPS-APM Scoring Standard.
The MIPS-APM Scoring Standard aims to bridge the gap between APMs and MIPS by rewarding providers for their efforts toward value-base care, even if they fall short of the volume thresholds, by providing an intermediately favorable scoring system.
Benefits of the MIPS-APMS Scoring Standard:
MIPS-APMS: Under the MIPS-APM scoring standard, MIPS domain weights stay the same year to year which allows providers some consistency in a constantly evolving program. The domain weights under the MIPS APMs scoring standard are weighted differently relative to the general MIPS scoring standard – namely, under the MIPS APMs scoring standard, the Quality, Improvement Activities, and Promoting Interoperability domains are weighted higher at 50%, 20% and 30%, respectively, while the Cost domain is weighted 0%. Under the MIPS APMs scoring standard, the APM entity can submit additional improvement activities if it does not initially receive the maximum Improvement Activities score – an advantage for specialists who face a lack of specialty specific improvement activities. The recent overhaul of the Promoting Interoperability programs also makes its heavier weight in MIPS APMs Scoring more palatable. Additionally, providers benefit administratively by not needing to learn the complexities of the Cost measures.
We encourage providers who will be unable to meet the volume thresholds necessary for the Advanced-APMs threshold to utilize the stepping stone that is the MIPS APM Scoring Standard. If you’ve thought about participating in BPCI Advanced, keep this advantage in mind.
Want to learn how you can become a Partial QP through BPCI Advanced? Contact our value-based care team.