3. 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

4. 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.

5. 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?

6. 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

7. 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

8. 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 performance year for 2019 payment year)

9. 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 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

10. 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

11. 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.

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

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

14. 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

15. CMS RESOURCES CMS Quality Payment Program (QPP) Homepage
04/27/ 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

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