As you may have heard, the October Final Rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA) gives physicians and certain other clinicians two tracks to choose from when participating in the Medicare Part B program in 2017 and beyond. CMS refers to these tracks as 

  • Merit-Based Incentive Programs (MIPS)
  • Advanced Alternative Payment Models (APMs) 

In Part 2 of this series on MACRA, we told you about critical dates, baseline requirements, and consequences for payment adjustments based on your participation level in the Merit-Based Incentive Programs (MIPS) track. (Click here if you missed the post on MIPS.)

In this, Part Three of the MACRA series, you’ll learn about Advanced Alternative Payment Models (APMs) and the requirements for participating in this track, along with how doing so will affect your Medicare payments for 2017 and beyond. 

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What is an Alternative Payment Model?

First, a little background on Alternative Pay Models in general. An APM offers financial incentives for providing high-quality and cost-efficient patient care. Reimbursement for services may be based on quality and outcomes rather than on the traditional fee-for-service model.

APMs can apply to a specific clinical condition, a care episode, or a particular patient population. For example, the Medicare Shared Savings Program is a type of APM, as is the Bundled Payment for Care Improvement initiative. Both were launched through CMS’ Innovation Center. Commercial payers may have their own APMs for physicians and patient populations in the regions they serve.

What Constitutes an Advanced APM?

An “Advanced APM” is distinguished as a subset of all Alternative Payment Models. The distinction is important to note, as only Advanced APMs qualify as a payment pathway under MACRA. To be considered an Advanced APM, the participating entities must take on a “more than nominal amount” of financial risk in caring for a patient population. Notably, this means that Track 1 Medicare Shared Savings Program participants don’t qualify as Advanced APM participants, since Track 1 MSSPs don’t take on downside risk. In addition, to qualify as “Advanced,” an APM must require all participants to use a Certified Electronic Health Record Technology and must establish quality measures comparable to those found in the MIPS track.  

CMS expects the following models to qualify as Advanced APMs in 2017:

  • Comprehensive ESRD Care (Two-Sided Risk) is “designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD).” (Source: CMS) 
  • Comprehensive Primary Care Plus (CPC+) aims to “strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation. CPC+ will include two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States.” (Source: CMS)
  • Next Generation ACO Model presents “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.” (Source: CMS)
  • Medicare Shared Savings Program Track 2 or Track 3, established by section 3022 of the Affordable Care Act “to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO).” (Source: CMS)
  • The Oncology Care Model (Two-Sided Risk) seeks to “provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare.” (Source: CMS)

According to CMS, this list may change before the end of the year. A final list will be published before January 1, 2017. Advanced APMS for 2018 will likely include a new MSSP “Track 1+” model and the Comprehensive Care for Joint Replacement model, among others.

Incentives for Advanced APM participants

Those clinicians seeing a minimum threshold of patients in an Advanced APM will receive a 5% incentive payment under MACRA. Those meeting the threshold are exempt from MIPS reporting, but are required to submit quality data as dictated by the Advanced APM. The takeaway? Participating in an Advanced APM now or in the near future is worth considering!

Click here to connect with us and learn how you can position your practice for success under MACRA in 2017 and beyond.