Alternative Payment Models in the Quality Payment Program

Alternative Payment Models in the Quality Payment Program
Pamela Ballou-Nelson, RN, MSPH, PhD Senior Consultant MGMA Health Care Consulting Group cell , ext office Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

TCPi Collaborative Learning Session
June Denver Marriott West Golden, Colorado Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Objectives Review CMS QPP APM option
Understand the difference between APM and Advanced APM Define participation in A-APM for incentive options Differentiate between A-APM and MIPS APM How to develop or participate in an APM Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

MGMA Polls Show CareCloud 2017 practice performance index states High Performing practices are defined as those that saw improvements in at least three of the following five performance dimensions over the last three years: CareCloud has been tracking the financial and operational performance of physician practices since 2013 through partnerships with leading organizations in the field. In 2017 the PPI has been carried out with the support of UBM Medica, one of the largest healthcare media and publishing companies in the United States. 2,020 physicians and practice administrators participated in the 2017 edition of the PPI survey during March and April of Participants provided their insights via an interactive online survey. Conversely, practices that were grouped in our Falling Behind segment saw declines in at least three of the five performance dimensions stated above. High Performing practices represent 24% of survey respondents, and Falling Behind 15%. • Practice Collections • Number of Practice Locations • Number of Providers • Total Patient Volume • Provider Satisfaction Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Move all to APM to meet APM goal Sounds simple right?
CareCloud 2017 practice performance index states High Performing practices are defined as those that saw improvements in at least three of the following five performance dimensions over the last three years: CareCloud has been tracking the financial and operational performance of physician practices since 2013 through partnerships with leading organizations in the field. In 2017 the PPI has been carried out with the support of UBM Medica, one of the largest healthcare media and publishing companies in the United States. 2,020 physicians and practice administrators participated in the 2017 edition of the PPI survey during March and April of Participants provided their insights via an interactive online survey. Conversely, practices that were grouped in our Falling Behind segment saw declines in at least three of the five performance dimensions stated above. High Performing practices represent 24% of survey respondents, and Falling Behind 15%. • Practice Collections • Number of Practice Locations • Number of Providers • Total Patient Volume • Provider Satisfaction Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Challenges to APM Models
Alternative payment models (APM) seek to deliver better care at lower cost. Providers, payers, and others in the healthcare system must make fundamental changes in their day-to-day operations that improve quality and reduce the cost of healthcare. Making operational changes will be viable and attractive only if new alternative payment models and payment reforms are broadly adopted by a critical mass of payers. When providers encounter new payment strategies for one payer but not others, the incentives to change are weak. When payers align their efforts, the incentives to change are stronger and the obstacles to change are reduced. Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Advanced APM An APM is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to their patients' outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM. Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Advanced APM Participate in the Advanced APM path:
If you receive 25% of Medicare payments or see 20% of your Medicare patients through an Advanced APM in 2017, then you earn a 5% incentive payment in 2019. See QPP website for current list of APM and AAPM comprehensive list If you leave the Advanced APM during 2017, you should make sure you've seen enough patients or received enough payments through an Advanced APM to qualify for the 5% bonus. If you haven't met these thresholds, you may need to submit MIPS data to avoid a downward payment adjustment. Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

What happens if I am in an Advanced APM?
Once you're in an Advanced APM, you'll earn the 5% incentive payment in 2019 for Advanced APM participation in 2017 if: You receive 25% of your Medicare Part B payments through an Advanced APM, or See 20% of your Medicare patients through an Advanced APM. You'll need to send in the quality data required by your Advanced APM. Your model's website will tell you how to send in your Advanced APM's quality data. Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

MIPS APMs in the 2017 Performance Period
Alternative Payment Models (APMs) can include MIPS eligible clinicians as participants and hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. This type of APM is called a “MIPS APM,” and participants in MIPS APMs receive special MIPS scoring under the APM scoring standard. CMS will assign scores to MIPS eligible clinicians in the improvement activity performance category for participating in MIPS APMs. Certain Alternative Payment Models (APMs) include MIPS eligible clinicians as participants and hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. This type of APM is called a “MIPS APM,” and participants in MIPS APMs receive special MIPS scoring under the “APM scoring standard.” As finalized in the Quality Payment Program rule, under the Merit-Based Incentive Payment System (MIPS), CMS will assign scores to MIPS eligible clinicians in the improvement activity performance category for participating in MIPS APMs. Most Advanced APMs are also MIPS APMs so that if an eligible clinician participating in the Advanced APM does not meet the threshold of having sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), the eligible clinician will be scored under MIPS according to the APM scoring standard. Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Most Advanced APMs are also MIPS APMs so that if an eligible clinician participating in the Advanced APM does not meet the threshold of having sufficient payments, or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), the eligible clinician will be scored under MIPS according to the APM scoring standard. CMS determined that the Comprehensive Primary Care Plus (CPC+) Model meets the criteria to be a Medical Home Model; therefore, its participants will receive full credit under the improvement activities performance category without the need for CMS to assess its required improvement activities. The weights applied to the improvement activities performance category under the APM scoring standard in the 2017 performance year are as follows:  The Shared Savings Program and the Next Generation ACO Model improvement activities performance category weight is 20 percent.  MIPS APMs other than the Shared Savings Program and the Next Generation ACO Model (which includes the CPC+ Model, the CEC Model, and the OCM) improvement activities performance category weight is 25 percent. Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Quality Payment Program
MIPS APM Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

CMS determined that the Comprehensive Primary Care Plus (CPC+) Model meets the criteria to be a Medical Home Model. Therefore, its participants will receive full credit under the improvement activities performance category without the need for CMS to assess its required improvement activities. The weights applied to the improvement activities performance category under the APM scoring standard in the 2017 performance year are as follows: The Shared Savings Program and the Next Generation ACO Model improvement activities performance category weight is 20 percent. MIPS APMs other than the Shared Savings Program and the Next Generation ACO Model (which includes the CPC+ Model, the CEC Model, and the OCM) improvement activities performance category weight is 25 percent. Standard weighting for IA is XXX Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Quality Payment Program
Advanced APM Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Qualifying APM Participant

How to develop or participate in an APM
Quality Payment Program Seven elements to consider How to develop or participate in an APM Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Develop a value proposition

What type(s) of Alternative Payment Model(s) would your design be?
Element 1 What type(s) of Alternative Payment Model(s) would your design be? Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Look at existing models on QPP website
Can call it something else as long as it meets criteria Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Element 2 Define how clinical care is delivered.
Tests difference in payment: the effect on paying for value over volume. The model will test the impact of the interventions on total healthcare costs, and healthcare utilization, inpatient and outpatient, as well as impact on health and quality of care. Describes amount of any new payments proposed. Different Medicare payment methodology. Provides enhanced services to Medicare beneficiaries such as care coordination, navigation, and national treatment guidelines for care. Modifies the way primary care practices deliver care, centered on the following key functions: (1) Access and Continuity; (2) Care Management; (3) Comprehensiveness and Coordination; (4) Patient and Caregiver Engagement; and (5) Planned Care and Population Health. address a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. Payment Per beneficiary per month (PBPM) Management Fee Track 1 $15 (average) PBPM Track 2 $28 (average) PBPM $100 (complex) PBPM A $160 per-beneficiary Monthly Enhanced Oncology Services (MEOS) payment assists participating practices in effectively managing and coordinating care for oncology patients during episodes of care, while a potential performance-based payment incentivizes practices to lower the total cost of care and improve care for beneficiaries during episodes. CMS will make awards through cooperative agreements to successful applicants to implement the model. Applicants will partner with state Medicaid agencies, clinical delivery sites, and community service providers and are responsible for coordinating community efforts to improve linkage between clinical care and community services. Methodology payment Care Management Fee: Risk-adjusted per-beneficiary MEOS payment for the duration of the episode and the potential for a performance-based payment for episodes CMS funds for this model cannot pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, and transportation) received by community-dwelling beneficiaries as a result of their participation in any of the three intervention tracks. Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

What is the rationale for your Alternative Payment Model?
Element 3 What is the rationale for your Alternative Payment Model? Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Element 2 Rationale for Payment Design

Comprehensive Care for Joint Replacement (CJR) Model:
Despite the high volume of hip and knee replacement surgeries, quality and costs of care for these surgeries vary significantly among providers. For instance, the rate of complications like infections or implant failures after surgery can be more than three times higher at some facilities than others, increasing the chances that the patient may be readmitted to the hospital. And, the average Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas. More information available at: Pioneer Accountable Care Organization (ACO) Model: The payment models tested in the first two years of the Pioneer ACO Model were a shared savings payment policy with generally higher levels of shared savings and risk for Pioneer ACOs than levels in the Medicare Shared Savings Program. In year three of the program, participating ACOs that showed a specified level of savings over the first two years were eligible to move a substantial portion of their payments to a population-based model. These models of payments are flexible to accommodate the specific organizational and market conditions in which Pioneer ACOs work. More information available at: Bundled Payments for Care Improvement (BPCI) Initiative: The BPCI initiative bundles payment for services that patients receive across a single episode of care to encourage efficient, coordinated care among different providers. Traditional Medicare payments do not hold providers accountable for related care a patient receives in other settings. Recognizing the diversity of providers’ needs, the BPCI initiative offers four different models for types of care provided to Medicare beneficiaries who have been hospitalized. More information available at: Examples from existing APM Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Element 6 How is improved clinical quality or better patient experience of care measured under your Alternative Payment Model? Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Ease of Participants Implement Payment Model
Example from existing APMs: Pioneer Accountable Care Organization (ACO) Model: The Pioneer ACO Model is designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Savings Program. And it is designed to work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients. This APM fits in to the workflow because of the experience coordinating care and the existing operational processes were in place, however, the Pioneer ACOs required data and information from CMS. More information available at: Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Helpful Links Physician-Focused Payment Model Technical Advisory Committee (PTAC): Center for Medicare and Medicaid Innovation (Innovation Center): Comprehensive List of APMs: Quality Payment Program: Model Design Factors: MACRA Speaker Engagement Requests: Copyright Medical Group Management Association® (MGMA®) . All rights reserved.

Alternative Payment Models in the Quality Payment Program

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