Advanced APMs

Physicians who participate in Advanced Alternative Payment Models (APMs) are exempt from MIPS reporting requirements. 

Currently, there are several existing models that meet the definitions of Advanced APMs for performance year 2017:

  • Comprehensive Primary Care Plus
  • Medicare Shared Savings Program – Track 2 and Track 3
  • Next Generation ACO Model
  • Oncology Care Model with 2-sided Risk
  • Comprehensive End Stage Renal Disease (ESRD) Care Model with 2-sided risk

To qualify for bonus payments, you’ll need to receive a minimum amount of payments or see enough patients through the Advanced APM.  In payment years 2019 and 2020, the participation requirements for Advanced APMs are only for Medicare payments or patients. Starting in 2021, the participation requirements for Advanced APMs may include non-Medicare payers and patients, including those with Medicare Advantage plans.

Participation Requirements for Medicare Advanced APMs

 

 

 

 

 

 

  

Physicians practicing in an Advanced APM who meet certain other criteria will receive a 5% bonus between 2019 and 2024.  For 2026 and beyond, clinicians in an Advanced APM will receive a 0.75% increase in the Physician Fee Schedule.

You can choose to participate in several different APMs, including Accountable Care Organizations and demonstrations under the Medicare Health Care Quality Demonstration Program. 

Advanced APMs must meet a number of requirements:

  1. Participants must accept financial risk for providing coordinated, high-quality care.  In order to be considered an Advanced APM, the model must either withhold payments, reduce rates, or require the APM Entity to pay CMS back if the APM Entity’s actual expenditures exceed expected expenditures.  The amount of risk that an APM Entity potentially owes to CMS must be at least equal to:
    • For performance periods 2017 and 2018, 8 percent of the estimated average total Medicare Part A and B revenues of participating APM Entities, or
    • 3 percent of the expected expenditures for which an APM Entity is responsible under the APM.

  2. Payments must be based on quality measures that are evidence-based, reliable, and valid and must include an outcome measure, if applicable.

  3. At least 50% of the Advanced APM participants must be required to use certified EHR technology (CEHRT) in the first performance year. This requirement increases to 75 percent in the second performance year.

  4. Medical home models developed under the Center for Medicare and Medicaid Innovation (CMMI)authority can also qualify as Advanced APMs.  The medical home model financial risk criteria differ somewhat from the criteria applied to other Advanced APMs.  While ob-gyns may be able to participate in medical home models in Medicare and Medicaid in the future, at present there are no CMMI medical home models that include ob-gyns.

 

Physicians practicing within a qualifying APM will receive a 5% bonus between 2019 and 2024.  For 2026 and beyond, clinicians will receive a 0.75% increase in the Physician Fee Schedule.

You can choose to participate in several different APMs, including Accountable Care Organizations and demonstrations under the Medicare Health Care Quality Demonstration Program.   Advanced APMs must meet a number of additional requirements:

  1. Physicians accept financial risk for providing coordinated, high-quality care.  CMS may withhold payments, reduce rates, or require the APM to pay CMS back if the APM’s actual expenditures exceed expected expenditures.  The amount of risk must meet these requirements:

    • The maximum amount of losses possible under the Advanced APM must be at least 4 percent of the APM spending target

    • Marginal risk -- the percent of spending above the APM benchmark (or target price for bundles) for which the Advanced APM is responsible -- must be at least 30 percent.        

    • Minimum loss rate – the amount by which spending can exceed the APM benchmark (or bundle target price) before the Advanced APM Entity has responsibility for losses -- must be no greater than 4 percent.

  2. Payments must be based on quality measures that are evidence-based, reliable, and valid; and must include an outcome measure on the MIPS list, if applicable.

  3. At least 50% of the Advanced APM participants must use certified EHR technology (CEHRT) to document and communicate clinical care information in the first performance year. This requirement increases to 75 percent in the second performance year.

  4. Medical home models developed under the Center for Medicare and Medicaid Innovation (CMMI)authority can also qualify as Advanced APMs.  The medical home model financial risk criteria differ somewhat from the criteria applied to other Advanced APMs.  While ob-gyns may be able to participate in medical home models in Medicare and Medicaid in the future, at present there are no CMMI medical home models that include ob-gyns.

Email your questions about the MACRA Quality Payment Program to practicemanagement
@acog.org

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