AMGA Risk Survey: Providers Moving Away From Fee-for-Service, but Obstacles Remain

Many multispecialty medical groups and integrated delivery systems increased their use of risk-based revenue sources in federal and commercial settings from 2015 to 2018, with Medicare Advantage (MA) being the most dominant payment model (30 percent) last year, according to the AMGA’s Fourth Annual Risk Survey.

For the 2018 survey, there were a total of 75 respondents from AMGA (American Medical Group Association) membership, 70 percent of whom were multispecialty medical groups or integrated delivery systems. In its research, the Alexandria, Va.-based AMGA also found that significant impediments existed in the move to value and respondents felt these obstacles need to be addressed by policymakers to ensure the transition away from fee-for-service (FFS) payments continues.

According to 2018 survey respondents, 56 percent of member revenues were risk-based in the federal setting, and 28 percent of revenues were risk-based in the commercial setting. Federal fee-for-service payments declined by 20 percent during the four years between AMGA’s first survey in 2015 and the 2018 survey. During the same time span, commercial FFS payments declined by 8 percent.

In 2018, 74 percent of respondents answered that they would be ready to participate in downside-risk payment models within two years. This is a marked change from 2015, when 42 percent indicated they would be ready to accept downside-risk payments within two years.

Interestingly, 47 percent of AMGA respondents reported that commercial payers are offering either no or limited access to risk products in their markets. However, this is an improvement from 2015, when 70 percent of respondents indicated they had no or limited access to commercial risk products. The data indicated that accountable care organizations (ACOs) account for most of the increase in commercial value-based arrangements.

Similar to the past three years’ surveys, AMGA members noted ongoing obstacles in moving to value. External impediments largely involve a lack of access to administrative claims data from payers, lack of a uniform data submission and reporting standard, multiple quality measurement programs, and problematic financial-benchmarking and risk-adjustment methodologies, particularly in the federal ACO program. Meanwhile, internal impediments involve building and financing the infrastructure necessary to take risk, change management challenges, and physician compensation issues.

More specific results from value-based payment programs include:

• The 2018 results found that Medicare Advantage plans accounted for 30 percent of revenues, up from 22 percent in 2016. Fully capitated MA payments increased from 10 percent of MA revenues in 2016 to 24 percent in 2018. MA revenues are double the revenues from any other federal risk-based payment model, the data revealed.
• Respondents reported that 15 percent of federal revenues came from ACO arrangements—downside risk 7 percent and upside-only risk 8 percent. AMGA members conveyed that 16 percent of commercial revenues originated from commercial ACOs. Since 2016, federal ACO revenues have remained flat, accounting for 14 percent to 15 percent of total revenues.
• By 2020, respondents predicted that MA revenues will outpace Medicare FFS revenues by 6 percent and revenue from downside-risk ACOs will generate twice as much revenue as upside-only ACOs.
• Survey respondents indicated little traction with bundled payment models. In 2018, AMGA members reported revenues from bundled payments amounted to only 1 percent of federal or commercial revenues.
• In 2018, survey respondents indicated that twice as many members participated in the Merit-based Incentive Payment System (MIPS) program than participated in Advanced Alternative Payment Models (AAPMs) or MIPS-APMs (upside-risk only ACOs) under the Medicare Access and CHIP Reauthorization Act (MACRA). In 2019, more respondents expect to qualify as AAPMs than expect to remain in MIPS. Notably, the number of respondents unsure of which MACRA path they would choose in 2019 doubled in this survey.

“This year’s survey shows AMGA members are making the costly financial investments necessary to address impediments within their control,” Chet Speed, AMGA chief policy officer and primary white paper author, said in a statement. “However, the survey responses also indicate that AMGA members are frustrated over the lack of attention external impediments are receiving from stakeholders and policymakers. These barriers must also be addressed to ensure momentum towards value-based care is not halted.”

Jerry Penso, M.D., AMGA president and CEO, added, “When comparing survey responses from the 2015 and 2018 surveys, it is clear that AMGA members are moving to value. AMGA members believe value-based models support their team-based, coordinated, data-driven model of care, which results in better patient outcomes.”