In lesson three we will look at a
high-level overview of participation in
an Advanced Alternative Payment Model, or
Advanced APM, for Year 2 of the Quality
Payment Program. First, let's understand
that in general, an APM is a payment
approach, developed in partnership with
the clinician community, that provides
added incentives to clinicians to
provide high quality and cost efficient
care. APMs can apply to a specific
clinical condition, a care episode, or a
population. APMs may offer significant
opportunities to eligible clinicians who
are not immediately able or prepared to
take on the additional risk and
requirements of Advanced APMs. Advanced
Alternative Payment Models or Advanced
APMs are a subset of APMs and enable
clinicians and practices to earn greater
rewards for taking on some risk related
to their patient outcomes. By
participating in this path of the
Quality Payment Program, an opportunity
for extra incentives is created.
There is a 5% lump sum incentive for a
sufficient degree of participation in
advanced APMs. As mentioned in lesson
one, three criteria must be met in order
to be an Advanced Alternative Payment
Model. First, participants must be
required to use certified electronic
health record technology, or CEHRT. This
means that at least 50% of the
clinicians in each APM use CEHRT to
document and communicate clinical care
information with patients and other
health care professionals. Second, the APM
must base payments on quality measures
that are comparable to those used in the
MIPS Quality performance category.
Payments must be tied to quality
measures that are evidence-based,
reliable, and valid and at least one of
these measures must be an outcome
measure if an appropriate outcome
measure is available on the MIPS measure
list. The third requirement is that the
APM is either a Medical Home Model
expanded under CMS Innovation Center
authority or it
requires participants to bear a more
than nominal amount of financial risk. In
order to achieve status as a Qualifying
APM participant, or QP, and qualify for
the 5% APM incentive payment for Year
2, eligible clinicians must receive a
certain percentage of payments for
covered professional services or see a
certain percentage of patients through
an advanced APM during the 2018
performance period. For payment years
2019 through 2024, clinicians who meet
the QP requirements are excluded from
MIPS adjustments and receive a 5% lump
sum incentive payment for their Part B
professional services furnished during
the calendar year immediately prior to
the payment year. Qualifying APM
participants will also receive a higher
Physician Fee Schedule update starting
in 2026. Let's look at some of the 2018
Advanced APMs. The Comprehensive
End Stage Renal Disease Care Model, the
Comprehensive Primary Care Plus (CPC+)
Model, Tracks 2 & 3 of the Medicare Shared
Savings Program, the Next Generation
Accountable Care Organization (ACO) Model,
and the Oncology Care Model with
two-sided risk arrangement were all
Advanced APMs for transition year 2017.
Note that the Medicare Shared Savings
Program Track 1 Model is not currently
considered an advanced APM and, therefore,
is not eligible for the 5% bonus.
However, the newly introduced MSSP Track
1+ Model is considered an Advanced
APM for 2018.
Clinicians are encouraged to check back
with CMS periodically on the Quality
Payment Program website to stay up to
date on the most accurate list of
Advanced APMs for 2018.
Next let's look at a few variables that
apply to advanced APMs for Year 2 of
2018.
For the 2017 transition year, there were
two ways that APMs can meet the nominal
amount standard, which governed whether
an APM imposes at least a nominal amount
of financial risk on clinicians. APMs
can meet the standard if the total
potential risk under the APM was at
least eight percent of the average
estimated Parts A and B revenue of
providers and suppliers in participating
APM entities. The same is true for Year
2 in 2018 and will extend to
performance periods of 2019 and 2020 as
well. Another way to meet the nominal
amount standard is if the total
potential risk under the APM is equal to
or at least either 3 percent of the
expected expenditures an APM entity is
responsible for under the terms of the
APM. This expected expenditure standard
or benchmark based standard is
applicable to all performance years. In
addition to the general nominal risk
standard, CMS also finalized a separate
definition of a Medical Home Model that
only applies to the Quality Payment
Program along with the special financial
risk criterion. Per this definition,
Medical Home Models that are APMs start
with a pair arrangement where the
participants are focused on primary care.
Participants may also be multi
speciality practices that include
primary care physicians and
practitioners and other primary care
services. They empanel patients to
primary clinicians and require a patient/
clinician link. There are also seven
model design options that the model can
incorporate, of which at least four must
be met.
They include planned coordination of
chronic and preventive care, patient
access and continuity of care, risk
stratified care management, coordination
of care across the medical neighborhood,
patient and caregiver engagement, shared
decision-making, and payment arrangements
in addition to our substituting for
fee-for-service payments. Medical
Home Models are subject to different and
more flexible standards in order to meet
the financial risk criterion to become
an Advanced APM. Previous rulemaking
stated that beginning in performance
year 2018 and thereafter, the Medical
Home financial risk standard would only
apply to the APM entities and advanced
APMs with fewer than 50 clinicians in
their parent organization. The same
standard applies for Year 2 of the
Quality Payment Program with a limited
exception. Specifically, 2017 participants
in round one of the Comprehensive
Primary Care Plus Model or CPC+ are
exempted from the requirement that the
Medical Home Model financial risk
standard applies only to APM entities
with fewer than 50 clinicians in their
parent organization. However, all future
participants in CPC plus, including 2018
starters will be subject to the 50
clinician cap policy. There is also one
change to the Medical Home Model nominal
amount standard for Year 2 of the
Quality Payment Program. In the 2017 rule,
CMS finalized that the total potential
risk for an APM entity must be equal to
or at least 3 percent in 2018, and then
gradually increased to 5 percent in 2020
and thereafter. The nominal amounts are
changed so that the minimum required
amount of total risk increases more
gradually. Therefore, the standard of 2.5
percent will apply in 2018, and then
increase to 5 percent in 2021 and
thereafter. CMS believes this approach
may allow for greater flexibility and
encourage more participation in Medical
Home Models.