PBM Best Practices Series: What to expect from your PBM account team
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This article was updated on January 20, 2017.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) represents a tectonic shift in how providers are reimbursed for the services they provide to Medicare fee-for-service (FFS) beneficiaries. While on the surface this may seem like it has little to do with health plans in the commercial, Medicare Advantage, or Medicaid space, in reality MACRA has broad and wide-ranging implications for other payers. Furthermore, with MACRA implementation starting on January 1, 2017, payers need to understand how this soon-to-be implemented law will impact the market.
MACRA will have a major impact on the way most providers will be reimbursed for the care provided under Medicare Part B.
|MIPS||Partial qualifying participant||Qualifying Participant|
The MIPS adjustment will vary by year, starting with a transition year in 2019 (allowing providers to choose between various levels of participation), full implementation for the 2020 payment year, and increasing to a reimbursement adjustment of -9% to +9% in 2022 onward (actual positive MIPS adjustment will vary to target budget neutrality). While the adjustment is designed to be cost-neutral (and some providers will benefit from the MIPS adjustment) certainly the prospect of a downward adjustment to fees makes the certainty of QP status and the associated bonus all the more attractive. Providers who are not yet in a position to take on the two-sided risk that is a precursor to QP status will want to achieve a positive outcome by focusing on increasing their MIPS adjustment.
It will be quite difficult to achieve the QP status. To be classified as a QP, two conditions must be met:
1) The eligible clinician must be associated with an Advanced Alternative Payment Model (APM). For now, this is limited to a small list of Centers for Medicare and Medicaid Services (CMS) programs that involve two-sided financial risk (among other requirements).
2) The Advanced APM must have a certain percentage of reimbursement or patient counts associated with the attributed members of the Advanced APM. For example, for a Medicare accountable care organization (ACO), the numerator of this ratio might be the Part B reimbursement for attributed members, while the denominator is the Part B reimbursement for all attribution-eligible members.
For 2019, the claim dollar threshold for QP status is 25%, while the patient count threshold is 20%. However, these thresholds increase precipitously in later years. Both because there are relatively few Advanced APMs and the additional criteria for QP status are challenging, we expect that there will be relatively few QPs, especially in the early years of MACRA implementation. Furthermore, because Advanced APMs will be trying to meet the twin objectives of achieving shared savings and maintaining QP status, we expect these entities will carefully prune their networks to include providers whose practice patterns promote both organizational goals. Therefore, we expect that providers will be invited to join an Advanced APM rather than being able to elect to be included.
QP status (and the associated 5% bonus3) may be seen as highly desirable. However, in 2023 and beyond, it may prove to be difficult for Advanced APMs to meet the required thresholds through Medicare FFS reimbursement alone.
In 2021 and beyond, QP status can also be obtained through an “All-Payer” option:
Hospitals and provider organizations will actively seek out risk-sharing arrangements with commercial, MA, and Medicaid plans. Many health plans are already building these arrangements with providers, and MACRA will provide further leverage for the health plan and incentive for the providers to participate.
Providers will not see a fee schedule increase for Part B services from 2020 to 2025. The cumulative effect over this period will be substantial and may put a strain on providers’ budgets. In addition to the lack of fee schedule increase, roughly half of providers subject to MIPS will have a negative adjustment.
The next effect is that there may be pressure to shift costs to other payers. This may make contract negotiations for health plans more challenging and may result in increased unit-cost trends. This will be especially true for payers with less negotiating leverage in the marketplace. On the other hand, payers who can continue to index their reimbursement to Medicare may well benefit from the lack of a fee schedule update.
MACRA: Key considerations for health plans
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) may seem like it has little to do with health plans in the commercial, Medicare Advantage, or Medicaid space, but in reality, MACRA has broad and wide-ranging implications for other payers.