Alternative Payment Models
APMs include Accountable Care Organizations, Bundled Payments and Medical Homes. Participating in a MACRA "advanced" APM can exempt you from MIPS, and can lead to more favorable financial incentives, including a potential 5% lump sum bonus payment. APMs give new ways to pay health care providers for the care they give Medicare beneficiaries. For example:
APMs are systems of care and models for payment specifically designed to deliver value-based care by rewarding high-quality, low-cost care. APMs include, among other models, accountable care organizations (ACOs), patient-centered medical homes, and bundled payment models for specific conditions and procedures.
The Affordable Care Act (ACA) has played a key role. The ACA created the Medicare Shared Savings Program (MSSP), a program designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO).
The ACA also established the Center for Medicare and Medicaid Innovation, or CMMI, to encourage and evaluate new models of care for Medicare, Medicaid, and even private payers.
For Medicare, the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, encourages physicians to participate in new models of care. The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule implementing MACRA, and a final rule is due out in November. The Society has delivered comments to CMS in response to the proposed rule.
Many details of this program are very technical and subject to revision in the final rule and in coming years. But here is what is known so far.
Not at the moment. The Society is working closely to develop Advanced APMs for MACRA. However, there are other primary care based programs, such as the Comprehensive Primary Care Plus and Next Generation ACOs that do qualify as Advanced APMs.
Yes. The Bundled Payment for Care Initiative (BCPI) is an alternative payment model that does not currently qualify as an Advanced APM but does provide an alternative to the fee-for-service model.
The Center for Medicare & Medicaid Innovation (CMMI) is also running an Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents but it is currently not an Advanced APM under MACRA.
What is the Society doing to help post-acute and long-term care practitioners participate in new models of care?
The Society is partnering with a number of other stakeholder organizations to develop a framework for Advanced APM development. The Society participates in the Emerging Issues Workgroup of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) in discussions on APMs.
The Society is also a member of the Healthcare Payment Learning and Action Network (HCLAN) that disseminates educational materials and helps to develop APMs. HCLAN has developed a white paper on APMs with various other resources.