1. Advanced Alternative Payment Models: A Deeper Dive
Maximizing MACRA Funding through APM Participation
Trudi Matthews, Senior Policy Advisor, UKHC and
Managing Director, Kentucky Regional Extension Center, UK

2. Volume to Value Based Shift
Recent legislative, regulatory and marketplace developments suggest that the transition from volume to value-based payment is accelerating from a “testing” phase to a “scaling” phase
Pioneer ACO Program Launched
April 2013
Bundled Payments for Care Improvement (BPCI)
Medicare Access and CHIP Reauthorization Act (MACRA) Enacted
April 2015
July 2016
Cardiac & CJR Episode Payment NPRM Released
January 2012
October 2012
Hospital Value Based Purchasing Program
April 2016
MACRA NPRM,
Medicaid Managed Care Final Rule Released
CMS Announces Value-Based Payment Goals; Value Modifier Program Begins
January 2015
March 2010
October 2016
Affordable Care Act Enacted
MACRA Final Rule Released
Notes:
1According to a Leavitt Partners analysis
2CMS aims to tie 30% of payments to quality or value through advanced payment models by the end of 2016
3On March 3, 2016, the President announced that as of January 2016, more than 30% of Medicare Part A and B
payments are tied to alternative payment models.
Testing Phase
Scaling Phase

3. October 2016 MACRA Final Rule: New Medicare Part B Payment Program
APM
MIPS
Merit-based Incentive Payment System
Alternative Payment Models
MIPS
APMs
Advanced APMs

4. MACRA Has Bipartisan Support
MACRA was passed on April 14, 2015 by both houses of a Republican-controlled Congress, had substantial Democratic support and was signed by a Democratic president. It is highly unlikely it will be repealed under the new administration.
MACRA Vote in Congress
Senate Vote: House Vote:

5. New Care Delivery Models
Medical Home /
Advanced Primary Care
Accountable Care Organization
Episode-Based Care
Emphasis on primary care
Does not include hospitals or specialists
Lower risk model
Attribution - often assigned based on most recent visit
Emphasis on primary care
May or may not include hospitals, specialists
Risk-based payment
Attribution – patients assigned on plurality of care
Emphasis on acute and post-acute care teams working together
Usually includes hospitals
Can be prospective or retrospective
Trudi:
DIFFERENTIATE – STRUCTURE OF DELIVERY AND STRUCTURE OF PAYMENT
ACO – shared savings, providers accountable for total per capita costs – No required lock in, no provider risk, incentive based on value not volume
PCMH – supports primary care efforts, no accountability for total per capita cost, no specialists, hospital, no incentive to decrease volume, patients are assigned for PMPM provider payment

6. New Payment Models Payment Adjustments Shared Savings Capitation
Bundled or Episode-Based Payments
(prospective or retrospective)
Capitation
Global Capitation (full-risk)
Partial Capitation (partial-risk)
Trudi
Lower Risk Higher Risk

7. What’s the big deal about APMs?
Stated intention of CMS that more and more of its $ will be spent in APMs over time
5% Annual Participation Bonus for Advanced APM participants from
Favorable scoring under MIPS for all APM participants
Annual update after 2025 is 0.75% for APM entities versus 0.25% for MIPS entities

9. Catch: Not Every APM Participant Will Qualify for the 5% APM Bonus
Most physicians and practitioners who participate in APMs will be subject to MIPS and will receive favorable scoring under MIPS.
All APM
Participants
Advanced APM Participants
Clinicians in Advanced APMs will be deemed Qualifying APM Participants (“QPs”) if they:
Report APM quality measures comparable to MIPS
Use of Certified EHR
Meet Advanced APM criteria (risk-bearing or medical home model)
Must meet APM thresholds for payment and patient volumes
QPs
What kind of APMs will qualify for a Bonus?
Have to be a qualifying physician in an eligible APM to get 5% bonus.
Eligible APMs are the most advanced APMs that meet the following criteria according to the MACRA law:
Base payment on quality measures comparable to those in MIPS
Require use of certified EHR technology
Either (1) bear more than nominal financial risk for monetary losses OR (2) be a medical home model expanded under CMMI authority
Have to meet thresholds to qualify:
More than 25% of Medicare payments in APM in 2019, 2020
More than 50% of Medicare payments in APM in 2021, 2022
More than 75% of Medicare payments in APM in 2023
Option for combined all payer APM thresholds: Beginning in 2021, this threshold % may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid.
Only QPs receive the 5% bonus
from Medicare.

10.  50% 0% 20% 30% What about non-QPs?
MIPS APM Scoring for MSSP & NextGen ACOs
Eligible clinicians participating in an APM who are not QPs will be scored using the MIPS APM scoring standard. 
Improvement activities
No separate reporting, full points in 2017
Advancing Care Information
Different reporting than general MIPS*
MIPS
Final Score
0-100
Quality
No separate reporting
Cost
50% 0%
20%
30%
*For ACI, see specific program requirements for reporting.

11.  0% 0% 25% 75% What about non-QPs?
MIPS APM Scoring for CPC+ & Other APMs
Eligible clinicians participating in an APM who are not QPs will be scored using the MIPS APM scoring standard. 
Improvement activities
No separate reporting, full points in 2017
Advancing Care Information
Different reporting than general MIPS*
MIPS
Final Score
0-100
Quality
Cost 0% 0%
25%
75%
*For ACI, see specific program requirements for reporting.

12. Participate in an Advanced APM
Step 1:
Participate in an Advanced APM

13. Advanced Alternative Payment Models
Advanced APM participants are eligible for 5% bonus payment.
But, only some APMs are risk-bearing Medicare payment models that qualify for this bonus payment.
Next Generation ACO Model
Medicare Shared Savings Program – Tracks 2 & 3
Comprehensive Primary Care Plus (CPC+)
Comprehensive ESRD Care -Two-Sided Risk
Oncology Care Model -Two-Sided Risk (in 2018)
CJR Episode Payment Model (new rule, added for 2017)
In new MACRA
Final Rule, Advanced APMs include:
MACRA does not change how any particular APM rewards value.
APM participants who are not “Qualifying Providers” (QPs) will receive favorable scoring under MIPS.

14. Report Quality Measures: Medical Home Model or Risk-Bearing APM:
Advanced APM Requirements
Use of CEHRT:
For 2017, at least 50% of the ECs in each APM Entity must use CEHRT to document and communicate clinical care.
Each TIN in an ACO reports separately; results aggregated for the whole ACO
Report Quality Measures:
Must report quality measures comparable to MIPS.
No minimum # of measures except APMs must report at least one outcome measure.
Medical Home Model or Risk-Bearing APM:
Total Risk cannot be more than:
8% of the average estimated total Medicare Parts A and B revenues of participating APM Entities; OR
3% of the expected expenditures for which APM Entity is responsible.

15. Advanced APM Opportunities Ahead
New CPC+ Opportunity
CMS will reopen solicitations for payers and practices (PDF) for a January 1, 2018 start in the model. Interested payers will be able to submit their proposals to partner in CPC+ beginning in mid-February 2017 via an online portal.
Next Generation ACO
On December 15, 2016, CMS announced a new opportunity to apply for the Next Generation ACO Model. The Letter of Intent (LOI) is non-binding and are due by Friday, May 4, The Next Generation ACO Model’s application portal opens March 2017; and applications will be due in May 2017.
Cardiac & CJR Episode Based Payment Model
New mandatory EPM will be eligible as an Advanced APM in 2018, Starts in July 2017.
Also keep an eye out for: ACO Track 1+, Voluntary Bundled Payment

16. Meet requirements to be a “Qualifying Provider (QP)”
Step 2:
Meet requirements to be a “Qualifying Provider (QP)”

17. Have to Meet Payment & Patient Thresholds
Once you're in an Advanced APM, you'll earn the 5% incentive payment in 2019 for Advanced APM participation in 2017 & 2018 if:
25% of Medicare Part B payments through an Advanced APM; or
20% of Medicare patients through an Advanced APM
Special category: Partial QPs may be choose to do MIPS OR exemption

18. Advanced APM Thresholds Get Higher
Regular QP Thresholds:
*Starting in 2021, thresholds may include other payer APMs
Partial QP
Thresholds:

19. QP Snapshots CMS takes 3 snapshots in a performance year.
QP Performance Period is January 1 –August 31st two years prior to the payment year.
Any QP designation is good for whole period. (But new ECs added after snapshot are not grandfathered in)
QPs notified within 4 months after snapshot.

20. APM QP Incentive Timeline
2017
QP Performance Period
2018
Program Reporting
3X QP Snapshots
Incentive Payment Base Period
Performance Feedback
2019
Payment Year
+5% lump sum

21. How to Prepare
Getting ready for APMs

22. Next Steps
Team
Assessment
Action Plan

23. ACO/Medical Home Checklist
Medical home recognition critical first step
Review Model requirements
Engage leadership & relevant clinicians in planning
Compare enterprise quality vs national benchmarks
Review of utilization data and payer feedback
Develop specific targets for improvement & action plan
Assess compensation models

24. EPM/Bundle Checklist Review Model requirements
Engage leadership, relevant clinicians & care teams
Compare enterprise quality vs national benchmarks
Review available payer data
Re-examine post-acute care strategy in light of episode-specific data
Set aims for quality, cost and Advanced APM bonus targets
Develop action plan with focus on reducing clinical & administrative variation (differences in quality, device costs, etc.)