Lawmakers seek to ease increase in threshold for quality bonus payments due to COVID-19

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Lawmakers are pressing House leadership to include a provision in the next COVID-19 relief package that eases the qualifying thresholds to get advance payment model bonus payments. (Getty Images/Bill Chizek)

A group of nearly 30 bipartisan House lawmakers wants to ease qualification requirements for advance alternative payment models for next year, fearing that more stringent requirements set to kick in could cause providers to flee the program.

The collection of 29 lawmakers sent a letter Monday to House leadership seeking changes in the next COVID-19 relief package. They worry that lingering issues with COVID-19 could make it harder for participants in advance payment models (APMs) such as accountable care organizations (ACOs).

Currently, to get a bonus for participation in an advance APM, 50% of a provider’s revenue must come through the APM and the rest via fee-for-service. But that threshold is set to go up to 75% under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

“It has become clear that COVID-19 will make it more challenging for many of these providers to meet the law’s current thresholds due to shifts in care,” according to the letter led by Rep. Suzan Delbene, D-Washington.

It pointed to new data from the Centers for Medicare & Medicaid Services that found it was hard for providers to even meet the 50% threshold, let alone a 75% threshold.

A recent survey of 116 ACOs from the National Association of ACOs found that 90% were concerned about qualifying thresholds for 2021. Another 96% reported they would not meet the 2021 targets based on their performance this year.

Without a change, providers could decide to drop out of their payment model because the goal is unattainable, the lawmakers said.

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Other signers on the letter are Reps. Roger Marshall, R-Kansas; Peter Welch, D-Vermont; and Darin LaHood, R-Illinois.

Lawmakers call for House leadership to include a fix for the qualification cliff in the next COVID-19 relief package.

“Providers participating in APMs are conducting care coordination strategies that are needed now more than ever,” the letter said. “Many seniors and vulnerable patients have been isolating themselves for months while they wait for a vaccine. ACOs and other APM providers are making sure their beneficiaries are accessing food and medications while they isolate.”

But it remains unclear when Congress will agree on another COVID-19 package. The House passed its own $3 trillion package a few months ago, but it was rejected as too partisan by the GOP-controlled Senate.

Senate Republicans released their own slimmed down bill that also failed to get approved and the both sides have been in a stalemate.