Introduction to Advanced Alternative Payment Models (APMs)


>>J. P. Sharp: Introduction to advanced alternative payment models. I’m J. P. Sharp with CMMI, and I will be leading you through this discussion. So here we start with the
definition of an alternative payment model, and this is
a very broad definition, and this was set by
the FCRA statute. So when we say the word APM,
it means this huge universe of payment models that we
use, and they’re all tied together by the fact that
they’re new approaches to paying for care under
Medicare, and they can change the way that we
reward quality and value, and the CMS innovation
Center produces a bunch of these new payment
models every year. So when we say APM, it
means any of these four categories. So that’s CMS innovation
Center models, other than the healthcare
innovation awards. The shared savings program:
any of those tracks under the shared savings program,
or those last two are any other federal demonstrations
required by law. So, collectively, those
are the world of APM. So when we say APM, that’s
that starting place and, then from there, we’ll
narrow things down for certain types of APMs. So this is the definition
of an advanced alternative payment model. So these are where the
incentives are in the quality payment program. So you start with that APM
definition, and then you have these subsets of those
APMs or advanced APMs. And they tend to have
greater rewards, both in the design of those types
of APMs themselves. They’re greater risk,
greater reward types of payment arrangements. But then what the quality
payment program does is add an additional bonus on top
of all those APM-specific rewards that you have, in
order for taking on that additional risk for
being in an advanced APM. And there at the bottom of
the slide it’s important to note that what the quality
payment program does is add these extra incentives:
the 5 percent lump-sum incentive. It does not change the
actual terms of the advanced APM itself. So all of those terms and
conditions that are inherent to the APM, those
remain the same. The quality payment program
does not change any of those elements for how the new
payment arrangements change the way that Medicare
pays for care. Rather, it rewards just
adoption of that new payment arrangement. And so this is a more
explicit layout of the rewards on the advanced APM
track of the quality payment program. So for participating in
an advanced APM, we will identify those participating
clinicians as qualifying APM participants, or
sometimes you’ll see QP. And so these QPs receive
these specific rewards for being in advanced APMs,
in addition, as we said earlier, to what the
APM itself offers. So, first, qualifying APM
participants are excluded from MIPS, so they won’t
have to do any of the reporting requirements or
receive any of those payment adjustments
associated with MIPS. Instead, they’ll receive a 5
percent lump-sum bonus, and that lump-sum bonus is based
on their Part B professional service payments. And that is limited in
time, so the first lump-sum payment will go out in 2019,
and the last one will go out in 2024. So after that, the long-term
incentive for being in an advanced APM is in
the fee schedule. So these QPs will receive a
higher fee schedule update, starting in 2026, and so
from there that compounds upon itself so that QPs will
get a higher and higher fee schedule rate, relative
to non-QPs overtime. So those two lines will
diverge from one another. So every year that someone
participates in an advanced APM, they’ll have an
opportunity to receive this higher fee schedule update. And so this is a summary
of the incentives that we talked about. So, side-by-side, starting
from the left, if you’re not in an APM and you meet the
criteria to be part of MIPS, then you’ll receive
those MIPS adjustments. But you won’t receive
anything in addition to that. If you are in an APM that is
not an advanced APM, you’re still subject to the MIPS
reporting requirements and payment adjustments, but
you also get whatever is inherent to those APMs. So, as we said earlier,
those APMs have their own risk and reward structure. So those do not change under
the quality payment program. And as we’ll talk a little
bit later, there are specific ways that we score
APM participants under MIPS, so there’re some certain
favorable scoring elements under MIPS as well. On the far right side in an
advanced APM you have the opportunity to be excluded
from MIPS: so no reporting requirements, no MIPS
payment adjustments, but you get those
APM-specific rewards. And for advanced APMs, those
tend to be a little bit larger than those for
non-advanced APMs. And then, finally, those
advanced APM participants receive that 5 percent
lump-sum bonus. So that’s an automatic
payment that they will receive. Thank you for viewing
this presentation. For more information please
visit the quality payment program portal
at qbp.cms.gov.

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