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Renae Rossow
Renae Rossow
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Understanding MACRA and the Quality Payment Program Part 7

Understanding MACRA and the Quality Payment Program Part 7

Last week we walked you through the process of compiling your Composite Performance Score under the MIPS Payment Track of the Quality Payment Program (QPP). Now that we’ve taken you through MIPS step-by-step, it is time to begin going through the APMs payment track of the QPP. 

Let’s start with what APMs stands for. The acronym APMs stands for Alternative Payment Models. Under MACRA and the QPP, CMS defines APMs as new approaches to paying for medical care through Medicare that incentivizes quality and value. The CMS Innovation Center is where new payment and service delivery models are developed. Additionally, Congress has defined – both through the Affordable Care Act and other legislation – a number of demonstrations that CMS conducts under the Health Care Quality Demonstration Program.

At this point in time, as defined by MACRA, APMs include:

  1. CMS Innovation Center model
  2. The Medicare Shared Savings Program
  3. Demonstration under the Health Care Quality Demonstration Program
  4. Demonstration required by Federal Law.

The question we get asked most often is, “What is the benefit of participating in APMs?” The answer is three-fold. First, by becoming a qualified participant of an APM, you are excluded from the reporting requirements that the last six articles have walked you through with regards to MIPS. So all of those measures and objectives and activities that you have to report on basically go away. Secondly, all qualifying participants will receive a lump sum bonus of 5% in 2019 which is tremendous for most practices. Lastly, qualifying participants in APMs will receive a higher update to the Physician Fee Schedule beginning in 2026.  In short, being a qualified participant in an APM means less reporting and more money. 

Now let’s talk about “advanced” APMs.  Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to their patients’ outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM. For the year 2017, here are the models that are considered Advanced APMs:

  • Comprehensive ESRD Care (CEC) – Two-Sided Risk
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (OCM) – Two-Sided Risk
  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 – CEHRT)
  •  Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

The next question we most often receive is, “How do I Join an Advanced APM?”

On the CMS website, you will find a tremendous amount of information. The CMS Innovation Center supports the development and testing of innovative health care payment and service delivery models. It is their plan to grow the above list each year and they are currently testing more models with hopes to make it easier and easier for small practices to participate in advanced APMs also.  You can find a search engine that shows you advanced APMs available by state. 

Finally, let’s talk about how to become a Qualified Participant (QP). For the Performance Year 2017, in order to be considered a Qualified Participant in the APMs payment track in order to earn the benefits that come along with it such as being exempt from MIPS, you must meet at least one of these two criteria:

  1. You receive 25% of your Medicare Part B payments through an Advanced APM or
  2. See 20% of your Medicare patients through an Advanced APM

Each Advanced APM has its own website explaining how to send in that model’s required quality data. If you leave the Advanced APM during 2017, you should make sure you've seen enough patients or received enough payments through an Advanced APM to qualify for the 5% bonus. If you haven't met these thresholds, you may need to submit MIPS data to avoid a downward payment adjustment.

That is a high overview of APMs. In the next article, we’ll continue the Understanding MACRA series by discussing the difference between reporting as an individual or as a group.   



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