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A Pathway to Alternative Payment Models (APMs)

A Pathway to Alternative Payment Models (APMs)

Earlier this month, Debra Harris, senior product manager specializing in Health IT standards, presented on all things APM, or Alternative Payment Models. This pathway is one of two tracks available as part of MACRA, which, as of 2017, replaces the medley of incentive and penalty payment programs of today to drive the value-based healthcare of tomorrow. The goal for the future is the delivery of patient-centered services that lead to better care, and the new MACRA mandate seeks to create programs that are meaningful, understandable and flexible. Powerful incentives will drive these reform principles and participation in APMs.

Why Alternative?

“Alternative” in the acronym “APM” is a choice word—the expectation is that the majority of eligible clinicians in 2017 will report via MIPS track I, or the merit-based incentive payment system. The clinicians using MIPS include MDs, DOs, PAs, Nurse Practitioners, Clinical Nurse Specialists, and CRNAs.

An APM, alternatively, addresses a specific population, promoting items and services coordinated under Medicare Part A and Part B, encouraging investments in higher Quality Care Services and their delivery, explains Harris. An APM can also be a demonstration project under the Health Care Quality Demonstration Program, or a group of physicians participating through a commercial payer other than Medicare (CMS).

Unclear on whom this would cover? APMs include ACOs, medical homes, patient-centered medical homes, or federal payment arrangements. To make things even more complicated, not all APMs are created equal.

The Risk-Takers

The advanced APM track is a classic payment model that shares assumed risk, provides financial benefit for achieving quality, and requires information sharing across providers and locations. These physicians are risk-takers: there’s a higher potential for both loss and reward. To be recognized as advanced, the APM must have more than half of its participants using a certified EHR technology to document and communicate clinical care. After 2017, this will increase to 75 percent. Working smarter and more efficiently is certainly the push.

Advanced APMs must also base payment on quality measures comparable to those under MIPS. These must be evidence-based, reliable, and valid quality measures that are endorsed by a consensus-based entity, or measures submitted in response to MIPS through their call for quality measures, or any other quality measure that CMS determines to have an evidence-based focus to be reliable and valid.

Thirdly—back to those risk-takers—the APM must bear more than a nominal amount of financial risk for monetary losses. Basically, providers or clinicians and organizations must share in potential losses. Harris summarizes the risk components and provides examples.

Choices, choices…

The advanced APMs for next year include the Shared Savings Program tracks II and III and next generation ACO models. There’s the CEC, the large dialysis organization arrangement, and CPC+. Harris explains the two types of qualifying participants: the fully qualified participant (QP), who meets a higher threshold for qualification and is entitled to the 5% lump sum payment or bonus, also excluded from the MIPS adjustment; and the partially qualified participant who meets lower thresholds for qualification and isn’t entitled to any of the bonus. Harris notes the percentages of payments/patients that would need to be met for each type of participant. Becoming a qualified APM participant involves numerous steps by CMS and the participant, which she reviews, noting that she highly recommends all clinicians or providers billing Medicare Part B seek to meet MIPS requirements just in case they are refused QP status.

In case you’re not having fun just yet, Harris explains the scenario if you’re not qualified as a CMS advanced APM, but can be considered a MIPS APM. There will be more webinars on this, she assures us, but provides a summary of the scoring with an informative chart including examples.

The webinar addresses one more payment model called the Physician Focused Payment Model, an APM where Medicare is a payer and includes physician group practices or individual physicians as APM entities with the target on the quality of cost of physician services.

The webinar concludes with the sobering reminder: 2017 is fast approaching. Review your business practices, pick your payment model, consider improvements to your benchmarks. Get ready! Because ready or not….


Topic: MACRA/MIPS, Medical Billing | Content Type: Blog Articles

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