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Provider groups pressure Congress to freeze incentive payment thresholds for advanced APMs

The letter warns that the new thresholds are too high and will force many clinicians to exit from APMs and revert back to fee-for-service.

Mallory Hackett, Associate Editor

A group of 19 healthcare organizations co-signed a letter sent Thursday calling on Congressional leaders to support legislation freezing the current thresholds for incentive payments to advanced alternative payment model (APM) practices.  

The organizations asked lawmakers to freeze the thresholds at the current rate for the 2021 and 2022 performance year to make sure that providers participating in risk-bearing APMs get their bonuses and to encourage new participation.

Under the Medicare Access and CHIP Reauthorization Act of 2015, clinicians can receive a 5% bonus on Part B payments if they meet certain thresholds of payment or patients through an advanced APM.

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With the current thresholds, clinicians qualify if  50% of payments or 35% of patients are in the advanced APM. In 2021, the threshold will rise to 75% of payments or 50% of patients.

The letter warns that the new thresholds are too high and will force many clinicians to exit from APMs and revert back to fee-for-service.

The organizations that sent the letter include: Aledade; American Academy of Family Physicians; American College of Physicians; American Hospital Association; American Medical Association; American Medical Group Association; American Society for Radiation Oncology; America's Essential Hospitals; America's Physician Groups; Association of American Medical Colleges; Caravan Health; Evolent Health; Federation of American Hospitals; Health Care Transformation Task Force; Medical Group Management Association; National Association of ACOs; Next Gen ACO Coalition; Premier healthcare alliance; and Renal Physicians Association.


If the thresholds do increase as they are planned to, a majority of clinicians will not qualify for the bonus, according to a survey from the National Association of ACOs. Of the 116 ACOs that participated in the survey, 96% of them would not meet the 75% payment amount threshold for 2021 based on their payment amounts from the first quarter of 2020.

Further, nearly 80% of the ACOs surveyed said it would be difficult or extremely difficult to qualify for their bonus under the 2021 thresholds.

The average payment threshold score for APMs in the Medicare Shared Savings Program in 2018 was 44% – a figure that would not qualify under current standards or in 2021, according to the 2018 Quality Payment Program Experience Report. 


These types of value-based care programs are proven to create savings for Medicare.

In fact, for the past three years, the Medicare Shared Savings Program has generated net program savings and in 2019 it had its largest savings yet -- $1.19 billion, according to the Centers for Medicare and Medicaid Services Administrator Seema Verma.

Earlier this summer, a group of national provider organizations voiced their support for the Value in Health Care Act of 2020, a bipartisan effort that proposed to make changes to MARCA. The bill would extend the 5% advanced alternative payment model bonus for an additional six years, modify the threshold to achieve the bonus and authorize a study of the overlap of various Medicare APMs.

The push for more value-based care has been ongoing for its ability to keep costs low while improving the standard of care. In September, CMS issued guidance to state Medicaid directors designed to advance the adoption of value-based care strategies across their healthcare systems and to align provider incentives across payers.


"Advanced APMs have proven to generate savings to Medicare and in the absence of these bonuses, we believe many clinicians will exit from APMs and revert to fee-for-service," the letter said. "This would be a significant detriment to moving our nation's health care system to one that pays based on quality and value."

Twitter: @HackettMallory
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