Advanced Alternative Payment Model Thresholds

Washington D.C. (Dec, 2020) – Next Generation ACO Coalition participants joined 501 practices across the country today calling on Congressional leaders to act to ensure access to strong financial incentives for clinicians participating in two-sided risk models that deliver high quality, coordinated, cost-effective care.

Congress enacted legislation, the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA), establishing an incentive payment for providers who participate in Advanced Alternative Payment Models (APMs). The law included a 5% Medicare bonus intended to accelerate the transformation away from fee-for-service, volume-based reimbursement. This funding helps clinicians continue to build on the success of these models, driving further innovation that benefits patients. To qualify for the bonus, Advanced APMs must achieve certain revenue or patient count thresholds to demonstrate sufficient shifts to risk-bearing models.

In 2021, both the revenue and patient participation thresholds for the advanced APM bonus are scheduled to significantly increase. Currently, to qualify for the 5 percent bonus clinicians must have 50 percent of payments or 35 percent of patients in an advanced APM. In 2021, the thresholds jump to 75 percent of payments or 50 percent of patients. These dramatic increases will cause many clinicians, including those participating in the highest levels of financial risk available in the Medicare program, to lose the opportunity to qualify for a bonus payment.

“If providers cannot count on receiving these bonus payments, due to unrealistic thresholds, fewer providers will be willing to participate in APMs in the future, exactly the opposite of what MACRA’s authors intended when they drafted the threshold tests” the letter states.

Today, 501 practices, including Next Generation accountable care organizations (ACOs), are calling on Leadership in the House and Senate to freeze the MACRA APM thresholds at the 2020 levels for the next two performance years. “This freeze will give us the flexibility and financial security we need to continue to innovate and improve population health for our patients, as well as to continue to drive forward models that create a fiscally health future for the Medicare program” the letter concludes.

The increased threshold is set to take effect January 1, 2021.

The full letter is available here.