Alternate Payment Model (APM) WHAT IS AN APM? Alternate Payment Model (APM) Medicare’s new approach to payments for medical care, incentivizing quality and value As defined by MACRA, includes: CMS Innovation Center Model Medicare Shared Savings Program (MSSP) Demonstration under Health Care Quality Demonstration Program Demonstration required by federal law

It creates extra incentives for APM participation. WHAT IS AN ADVANCED APM? As per MACRA, Advanced APMs must meet certain criteria: APM requires participants to use CEHRT APM bases payment on quality measures comparable to those in the MIPS quality performance category APM either: Requires APM Entities to bear more than nominal financial risk for monetary losses OR Is a Medical Home Model expanded under CMMI authority MACRA does not change how any particular APM functions or rewards value. It creates extra incentives for APM participation.

2017 ADVANCED APMs Based on the NPRM criteria, the following APMs will be Advanced APMs in 2017: Source: Quality Payment Program Homepage, CMS Fact Sheet, Quality Payment Program CMS: Where is Innovation Happening in Indiana?

QUALIFYING AAPM PARTICIPANT (QP) QPs must have a certain percentage of patients or payments through an Advanced APM QPs will: Be excluded from MIPS Receive a 5% lump sum bonus Applies for payment years 2019 – 2024 Higher Fee Schedule for QPs introduced in 2026

QUALIFYING AAPM PARTICIPANT (QP) Becoming a QP 4 Steps to becoming a QP QP determination done at the Advanced APM Entity level All participating eligible clinicians are assessed together “Threshold Score” given to each Advanced APM Entity CMS calculates the Threshold Score using payment amount and patient count, based on Medicare Part B professional services and beneficiaries attributed CMS will use the method (payment amount or patient count) that results in a more favorable QP determination Threshold Score for each method is compared to the corresponding QP Threshold All eligible clinicians in the Advanced APM Entity become QPs for the payment year

QUALIFYING AAPM PARTICIPANT (QP) Additional Information QP Selection Will occur each year following the QP performance period The first selection year for QPs will be 2018 QP Performance Period Aligns with the MIPS Performance Period Is the full calendar year that is 2 years prior to the payment year (e.g. 2017 performance year for 2019 payment year)

QUALIFYING AAPM PARTICIPANT (QP) AAPM Incentive Payments Lump sum 5% payment is based on the estimated aggregate payments for professional services furnished the year prior to the payment year (e.g. 2019 APM Incentive Payment will be based on 2018 services) NOTE: This is different than the QP Performance Period!! Source: Quality Payment Program Homepage, CMS QPP-MACRA/NPRM Slideshow

DON’T MEET QP REQUIREMENTS? Partial QPs Some eligible clinicians may be considered a “Partial Qualifying APM Participant” (Partial QP) Partial QPs meet a slightly reduced Threshold Score Partial QPs can: Opt out of MIPS AND receive no payment adjustment OR Participate in MIPS AND receive favorable weighting in MIPS

What if the QP practices outside the AAPM? QP status would apply to the individual eligible clinician’s NPI across all of the TINs to which he or she reassigned the right to receive Medicare payment This prevents situations in which an eligible clinician may be excluded from MIPS for part of his or her practice but still subject to MIPS with respect to another part of his or her practice.

PUTTING IT ALL TOGETHER… Source: Quality Payment Program Homepage, CMS QPP-MACRA/NPRM Slideshow

Source: Quality Payment Program Homepage, CMS QPP-MACRA/NPRM Slideshow

ACRONYMS & DEFINITIONS NPRM: Notice of Proposed Rule Making MACRA: The Medicare Access & CHIP Reauthorization Act of 2015 QPP: Quality Payment Program MIPS: Merit-Based Incentive Payment System APMs: Alternate Payment Model QP: Qualified Participant in an Advanced APM DEFINITIONS MIPS Eligible Clinicians: Providers that will be affected by and participate in MIPS Low Volume Threshold: Medicare billing charges ≤ $10,000 AND provides care for ≤ 100 Medicare patients in one year

CMS RESOURCES CMS Quality Payment Program (QPP) Homepage 04/27/2016 - MACRA NPRM (Text) Training Slideshow: Quality Payment Program Fact Sheet: Quality Payment Program Timeline: MACRA - MIPS - APM Training Slideshow: MIPS Training Slideshow: Advancing Care Information Fact Sheet: Advancing Care Information Training Slideshow: All Payer Combination Option Fact Sheet: Flexibilities & Support for Small Practices

Tara Hatfield RN, BSN, CHTS-CP Managing Advisor GLPTN Clinical Lead thatfie@purdue.edu pha.purdue.edu (812) 525-0023