MACRA proposed rule: What it means for Medicare Advantage

Medicare's newly proposed physician payment overhaul includes clues that federal health officials want to credit participation in Medicare Advantage plans toward alternative payment models.

The Department of Health and Human Services on Wednesday unveiled the long-awaited proposed rule, which begins implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). It establishes a Quality Payment Program for doctors that offers two distinct paths--the Merit-based Incentive Payment System and Advanced Alternative Payment Models (APMs).

As it currently stands, though, the Quality Payment Program is based on payments for Medicare Part B, not Medicare Advantage.

"The Quality Payment Program has the potential to influence a wide range of payment arrangements, such as those under Medicare Advantage, but there is a clear distinction between Medicare Part B and all other payers in how calculations are performed for QP determinations and the APM Incentive Payment," the proposed rule states.

Under the All-Payer Combination Option, eligible clinicians and "Advanced APM entities" can meet the Quality Payment Program threshold based in part on payment amounts or patient counts associated with Medicare Advantage plans and other payers, according to the proposal. Medicare may base pay on those calculations beginning in 2021, Centers for Medicare & Medicaid Services Principal Deputy Administrator Patrick Conway, M.D., tells Inside Health Policy.

However, those arrangements must meet the criteria to be considered "Other Payer Advanced ATMs," the proposal says. CMS notes that not all Medicare Advantage arrangements count as alternative payment models, as MA plans do not disclose how they pay providers.

Thus, the agency has asked MA plans to report the proportion of provider payments that are categorized as various payment models--a move some lawmakers see as an acknowledgement that some MA arrangements could count as APMs, the Inside Health Policy article adds.

To learn more:
- here's the proposed rule (.pdf)
- read the Inside Health Policy article (registration required)

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