Under MACRA's new Merit-based Incentive Payment System, physicians must report on quality, resource use, clinical practice improvement activities and meaningful use of electronic health records. Medicare consolidates those results and then adjusts payments accordingly. In 2019, physicians can receive penalties or bonuses of up to 4%, a percentage that will rise incrementally to 9% in 2022.
But providers can free themselves of those requirements and qualify for bonuses if they have a substantial amount of business in eligible alternative models, which include the risk-based ACO models. This avenue promises bonus payments of 5% for five years starting in 2019.
Most providers aren't there yet. The CMS has estimated that in 2017 only about 10% of physicians will qualify as participating in advanced APMs.
Three Medicare ACO models currently qualify. But most of the participants in the government's ACO experiments are in the one model that doesn't.
In 2017, only 42 of 480 ACOs in the Medicare Shared Savings Program are in tracks that qualify as advanced APMs. Twenty-eight new ACOs joined the Next Generation model, bringing that program to 45. The CMS also has rolled out an accountable care model intended to improve quality and efficiency in the treatment of end-stage renal disease. This year there are 37 participants in the Comprehensive ESRD Care program, which also qualifies as an advanced APM.
Beginning in 2018 the CMS will offer a Track 1+, a two-sided model with less downside risk that's meant as a bridge to the more robust options while also allowing providers to choose the APM avenue under MACRA.
“More and more (ACOs) are assuming more risk,” said Steven Shortell, a professor of health policy and management at the University of California at Berkeley. “My prediction is that the pace of that change is going to accelerate.” But, he said, “I don't think it's going to happen overnight.”
Some ACOs are confident about taking on downside risk. They share certain hallmarks, namely that they are often physician-led and have accumulated years of experience through other Medicare ACO programs.
Both the Accountable Care Coalition of Southeast Texas and the Accountable Care Coalition of Chesapeake were created as Next Generation ACOs, Spight said. But they were not entirely new to the world of accountable care when they joined NextGen, which Southeast Texas did in 2016 and Chesapeake in 2017. The Chesapeake ACO, for instance, combined four ACOs in Maryland and Virginia that had operated in Track 2 of the Shared Savings Program in 2016.
Several elements of the NextGen program were appealing, Spight said. It offers waivers, such as exemptions to the rule that Medicare beneficiaries must spend three nights in a hospital before Medicare will pay for a skilled-nursing facility. Overall, it expanded physicians' ability to control patient care beyond the typical clinical realm.
“Our physicians can now focus on how the delivery system should look outside the clinic walls. It's putting them in charge of which specialists, which post-acute care facilities, which home-care setups do we really want to home in on,” Spight said. “NextGen gives us an economic way to do that, a legal way to do that, and it gives us volume to do that.”