>> J.P. Sharp: So, what are the criteria for Advanced
Alternative Payment Models?
I'm J.P. Sharp with CMMI and I will be leading you through
this discussion.
So, here we'll talk about what makes an APM an
advanced APM.
So, as we spoke about in an earlier module there are --
so, this broad definition of what APMs are.
So, those are innovations center models that -- shared
savings program and any other federal demonstrations.
So, from there, starting with those payment
arrangements, we ask in their terms and conditions
-- the requirements of those payment arrangements, do
they meet these three requirements to be an
advanced APM?
So, we look at those legal instruments that govern how
those payment arrangements work and we ask do we check
these three boxes here?
And so, first, does that APM require participants to use
certified EHR technology?
Second, does the APM provide payment for covered
professional services based on quality measures that are
comparable to those used in the MIPS quality
performance category?
And then the third one is an either, or.
So, there are two ways to check this box.
So, either that APM is a specific type of APM that we
call a medical home model and it's been expanded under
CMS innovation center authority, or the APM
requires its participants to bear more than nominal
amount of financial risk.
So, you check all three of these boxes and an APM is an
advanced APM.
So, that's what we'll go into detail in these next
few slides -- about what each of these means in
greater detail.
So, that first criterion for an APM to be an advanced APM
is about using certified EHR technology and so, when we
say certified EHR technology we mean the same technology
that is used in the advancing care information
performance category under MIPS so that they're not two
separate definitions for certified EHR technology.
So, when we look at an APM, the APM must have a
requirement of its participants that at least
50 percent of the clinicians in each APM entity use
certified EHR technology to document and communicate
clinical care.
And so, what that means is that an APM entity is that
participating entity or organization that signs an
agreement or is subject to a payment arrangement with CMS.
So, that can be an accountable care
organization, a hospital, a group practice depending on
the type of APM determines which -- an APM entity means.
So, you look at that APM entity and we look at all
the clinicians in that entity and the APM must
require that at least 50 percent of those clinicians
use that EHR technology in this prescribed way.
For the shared savings program, it's slightly
different and so, the shared savings program will
actually require its participating TINs in each
accountable care organization to report to
the advancing care information category under
MIPS and by doing that they'll meet this criterion.
So, that new requirement that those ACOs report to
the advancing care information performance
category under MIPS checks this box for the advanced
APM criterion.
So, this second criterion is about quality measures, and
the APM must base payment on quality measures, and those
quality measures must be considered comparable to
those used in the MIPS quality performance
category, and this is fairly flexible criterion.
So, what we determine comparable means is that the
APM uses quality measures that are evidence based,
reliable, and valid and those can come from a
variety of sources.
So, they can be actual MIPS measures, they can be
consensus based, entity endorsed, measures, they
could have been tested in another APM and proved to be
evidence based, reliable, and valid.
So long as they are evidence based, reliable, and valid
they are comparable to MIPS measures and then that
second bullet there is about outcome measures.
So, the APM must also tie payment to an
outcome measure.
There is a slight exception to that.
If the APM focuses on a specific specialty or
clinical condition for which there is not an outcome
measure available in the MIPS measure list, then that
requirement for an outcome measure does not need to be
there for the APM to be an advanced APM.
So, this is the third criterion and it's about
financial risk and this one's a little bit tricky so
we have a couple slides based on this.
So, first of all we'll look at that second part which is
the one where we'll look at most APMs through this
second part of the either or and that's -- does the APM
require its participants to bear more than nominal
amount of financial risk?
And, I'll note, that when we say participants we really
mean that APM entity.
So, it's the entity that has the agreement with CMS --
must bear risk.
We do not prescribe how those downstream risk
arrangements must be made with individual clinicians
or organizations within that APM entity.
So, we split this into two parts.
So, first on the left you see there's financial risk
and on the right, there is how much risk.
So, first on the left, this is what bearing financial
risk means under an APM and that's the APM may withhold
payment for services, may reduce payment rates, or
require direct payment.
So, any of those structures within the design of the APM
itself could be considered requiring its participants
to bear financial risk and then if that's present, then
we look on the right side to see how much risk are those
entities required to bear.
And we focus only on the total amount of risk and
that's the maximum amount that any APM entity could
lose under the terms of the APM and we do that in terms
of two different things.
So, there are two ways that an APM could meet this
amount of risk criterion and the first is looking in
relation to the Medicare revenue of its participants
and so, the total amount of risk that participants must,
potentially, lose is -- must be at least 8 percent of the
average estimated total Medicare parts A and B
revenues of its participating APM entities.
So, for those participating entities they must add up
their parts A and B revenues and ask, does this APM put
at least 8 percent of this at risk?
If so, that APM would meet this criterion.
The second way we look at this is in relation to the
benchmark or the expected expenditures for which an
APM entity is responsible under the APM.
So, that can be considered something like total cost of
care for beneficiaries for whom an accountable care
organization is responsible, for instance.
And this relates a little more closely to how our
current APMs usually operate, which is on that
total cost of care element and this just says that the
APM entities must be responsible for at least 3
percent of that benchmark amount of those
expected expenditures.
And, if so, that total amount that they could lose
is at least 3 percent then it meets this criterion.
So, then we have a slightly different take on this
criterion for medical home models.
Medical home models are a specific subset of APMs.
So, again, starting with that broad definition of
APMs, certain of them are considered medical home
models and we'll identify which APMs are considered
medical home models in our materials and on the QPP
website at qpp.cms.gov.
So, we look at certain medical home models in a
different light with respect to this financial
risk criterion.
So, first we look at whether they were expanded under CMS
innovation center authority.
However, none of them so far have met those expansion
criteria and have actually been expanded.
So, we won't discuss that in particular yet.
For all those medical home models that have not yet
been expanded, we still look at them a
little differently.
So, that's slightly easier for their structure and
design to meet this criterion overall.
So, this parallels what we just looked for that
generally applicable standard for financial risk
and nominal amount but you'll notice there are a
few differences in these two boxes.
So, what we can consider financial risk for a medical
home model is the same for those first three bullets.
So, that's withholding payment, reducing payment
rates, or requiring direct payments.
However, there's a fourth bullet there.
So, they can cause the APM to lose the right to all or
part of an otherwise guaranteed payment or
payments and what that really focuses on are
payments that are inherent to that medical home model
that are tied to risk or reward, under cost and
quality components.
So, that can be reduced in addition to any of those
other three bullets.
So, again, if you have a structure in that medical
home model that meets one of those four bullets in their
financial risk then we look at, how much is that
financial risk?
And this is lined up with that first bullet we saw in
the previous slide and we look at the total amount of
risk that these APM entities can be responsible for.
So, how much can they lose at the maximum and then here
it's related only to that parts A and B revenue.
So, there's no benchmark base standard here.
It's all associated with the revenue of the participants
and it increases over time.
So, it starts off, for medical home models, at the
beginning here in 2017, and only must hold those APM
entities for 2.5 percent of their Medicare
A and B revenue.
However, that will increase to 5 percent over time and
beyond that.
So, at the end of all this we don't require everybody
to do these determinations on their own or understand
all the math within the APMs and line those up against
those criteria.
Now, what we really do is make these determinations
and make them present on our qpp.cms.gov website so that
you can go on that site and see our comprehensive list
of APMs and understand which of those have met which of
the previous criterion -- criteria that we discussed
and then we will identify each year which APMs are
advanced APMs.
So, that by participating in these particular APMs here
will allow you to receive those rewards that we
discussed earlier in the program.
So, we'd also like to highlight some future
advanced APM opportunities that CMS is working on and
so we've identified that there's the comprehensive
care for a joint replacement model which has already been
undergoing and operating but there's been a change to
allow part of it to become an advanced APM.
We also are working on a new bundled payment model that
will be similar to bundled payments for care
improvement but will also be an advanced APM when
it is released.
Then we have advancing care coordination through episode
payment models and there are a series of these episode
payment models related to joint care and cardiac care
and there will be an option for those to be advanced APMs.
There's also the newly announced Vermont Medicare
ACO initiative that will be an advanced APM and then ACO
track one plus will be similar to the shared
savings program tracks but will have a significant
amount of financial risk relative to track one but
less financial risk than tracks two and three, so
that it would still meet the advanced APM criteria but
could be attractive to participants who would not
enter tracks two or three right away.
Thank you for viewing this presentation.
For more information, please visit the quality payment
program portal at qpp.cms.gov.