Advanced Alternative Payment Models (APMs) offer clinicians, quite literally, an alternative way in which to participate in the Quality Payment Program. Qualified Participants (QPs) can earn a 5 percent reimbursement incentive for seeing a certain number of patients or achieving a certain level of payments through Advanced APMs. QPs that meet the APM requirements are excluded from MIPS.
Advanced APMs offer clinicians a way to earn larger guaranteed reimbursement incentives than they might otherwise earn through MIPS. However, this typically comes with greater financial risk. Advanced APMs offer clinicians a 5% participation incentive. MIPS 2019 actually offers clinicians a maximum reimbursement bonus of 7% (MIPS 2018 offered 5%). However, MIPS bonuses aren’t guaranteed. Instead, clinicians/groups are individually scored, based on the data they submit. Ultimately, the average reimbursement bonus ranges from 0-2%.
Advanced APM participation is also generally a little more focused and structured. Large scale APM models, with specific guidelines, are in place. Some providers (like larger practices) may prefer the APM structure to that of MIPS.
Most clinicians that participate in Advanced APMs are MIPS-eligible, meaning they are required to participate in the Quality Payment Program in some manner. If these eligible clinicians opt to participate in Advanced APMs, they’re exempt from MIPS. To put it more bluntly, Advanced APMs give providers, who are already on the hook, the option to capitalize on the obligation by more fully committing to value-based care and earning more money.
To be considered a Qualified Participant (QP) and be eligible for Advanced APMs in 2019, clinicians must a) receive 50% percent of their Medicare Part B payments through an Advanced APM, OR b) see 35 percent of their Medicare patients through an Advanced APM. Additionally, 75 percent of practices, within an Advanced APM entity, must be using certified EHR Technology.
The Bundled Payments for Care Improvement (BPCI) initiative is comprised of 4 broadly defined models of care, which link payments for the multiple services beneficiaries receive during an episode of care.
The Comprehensive ESRD Care (CEC) Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD).
Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.
The Medicare ACO Track 1+ is a time-limited model for Track 1 Medicare Shared Savings Program (Shared Savings Program) ACOs. The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to provide coordinated, high-quality care to their Medicare patients. Track 1+ Model ACOs assume limited downside risk (less than Track 2 or Track 3).
Building upon experience from the Pioneer ACO Model and the Shared Savings Program, the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.
The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to provide coordinated, high-quality care to their Medicare patients. Track 2 and 3 ACOs may share in savings or repay Medicare losses depending on performance. Track 2 ACOs may share in a greater portion of savings than Track 1 ACOs. Track 3 ACOs take on the greatest amount of risk but may share in the greatest portion of savings if successful.
Under the Oncology Care Model (OCM), physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.
The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR).
The Vermont All-Payer Accountable Care Organization (ACO) Model is the Centers for Medicare & Medicaid Services’ (CMS) new test of an alternative payment model in which the most significant payers throughout the entire state – Medicare, Medicaid, and commercial health care payers – incentivize health care value and quality, with a focus on health outcomes, under the same payment structure for the majority of providers throughout the state’s care delivery system and transform health care for the entire state and its population.
The Comprehensive ESRD Care (CEC) Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD). Through the CEC Model, CMS partners with health care providers and suppliers to test the effectiveness of a new payment and service delivery model in providing beneficiaries with person-centered, high-quality care.
The Care Redesign Program (CRP) is a voluntary program within the Maryland All-Payer Model that advances efforts to redesign and better coordinate care in Maryland. The CRP provides hospitals participating in the Maryland All-Payer Model the opportunity to partner with and provide incentives and resources to certain providers. In exchange, suppliers offer activities and processes that aim to improve quality of care and reduce the growth in total cost of care for Maryland Medicare beneficiaries.
The Maryland Total Cost of Care Model builds on the success of the Maryland All-Payer Model by creating greater incentives for health care providers to coordinate with each other and provide patient-centered care, and by committing the State to a sustainable growth rate in per capita total cost of care spending for Medicare beneficiaries.
The Care Redesign Program (CRP) allows hospitals to make incentive payments to non-hospital health care providers who partner and collaborate with the hospital and perform care redesign activities aimed at improving quality of care. A participating hospital may only make incentive payments if it has attained certain savings under its fixed global budget and the total amount of incentive payment made cannot exceed such savings.