ADVANCED APMS OVERVIEW

May 9, 2019

Disclaimers

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

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Topics

• Quality Payment Program Overview

• Alternative Payment Models (APMs) Definition

• Alternative Payment Models Design and Categories

• Alternative Payment Models Overview

• Advanced Alternative Payment Models

- Criterion

- Snapshot Dates

• Qualifying APM Participant (QP) Status

• Available Resources

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QUALITY PAYMENT PROGRAM OVERVIEW

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The Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program.

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ALTERNATIVE PAYMENT MODEL DEFINITION

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What is an APM?

APMs are new approaches to paying for medical care through Medicare that incentivize quality and value. The CMS Innovation Center develops new payment and service delivery models. Additionally, Congress has defined—both through the Affordable Care Act and other legislation—a number of demonstrations that CMS conducts.

As defined by MACRA,

APMs include:

✓ CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)

✓MSSP (Medicare Shared Savings Program)

✓ Demonstration under the Health Care Quality Demonstration Program

✓ Demonstration required by federal law

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What is an APM?

• A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care

• Can apply to a specific condition, care episode, or population

• May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs

Advanced APMs are

a Subset of APMs

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APM DESIGN AND CATEGORIES

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CMS APM Design Elements

✓ APM Type

✓ Clinical Practice Transformation

✓ Rationale and Evidence

✓ Scale and Scalability: Participants

✓ Alignment

✓ Quality Improvement

✓ Participation: Operational Feasibility

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CMS Model Design Factors

FACTORS FROM ALTERNATIVE PAYMENT MODEL DESIGN TOOLKIT

1. Alignment with key CMS and HHS Goals

6. Alignment with other payers and CMS Programs

11. Economic impact* 16. Operational feasibility for CMS*

2. Extent of clinical transformation in model design

7. Potential for quality improvement

12. Overlap with current and anticipated models

17. Effects on coverage and benefits

3. Strength of evidence base

8. Potential for cost savings 13. Evaluative feasibility 18. CMS’ waiver authority*

4. Scale of the model design

9. Size of investment required for CMS*

14. Stakeholder interest and acceptance

19. Ability of other payers to test the model

5. Demographic, clinical, and geographic diversity

10. Probability of model success

15. Operational feasibility for participants

20. Scalability*

*Factors CMS would not expect stakeholders to focus on in designing APMs11

Reading the List of APMs

• Comprehensive list of APMs*

• Includes the APM name, MIPS APM status, Advanced APM status, and

criteria for being considered an Advanced APM.

APM MIPS APMunder the

APM Scoring

Standard

MedicalHome Model

Use of CEHRT

Criterion

QualityMeasures Criterion

Financial Risk

Criterion

Advanced APM

Comprehensive ESRD Care (CEC) Model (non-LDO arrangement one-sided risk arrangement)

YES No YES YES No No

Comprehensive Primary Care Plus (CPC+) Model

YES YES YES YES YES YES

Frontier Community Health Integration Project Demonstration (FCHIP)

No No No No No No

Home Health Value-based Purchasing Model (HHVBP)

No No No YES No No

*Update for 2019 is forthcoming 12

ALTERNATIVE PAYMENT MODELS (APMS) OVERVIEW

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Advanced APMs

Terms to Know

• APM Entity - An entity that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation.

• Advanced APM – Advanced APMs must meet three specific criteria: Require CEHRT use, base payment on MIPS-comparable quality measures, and either be a Medicare Medical Home or require participants to bear a more than nominal amount of risk.

• Affiliated Practitioner - An eligible clinician identified by a unique APM participant identifier on a CMS-maintained list who has a contractual relationship with the Advanced APM Entity for the purposes of supporting the Advanced APM Entity's quality or cost goals under the Advanced APM.

• Affiliated Practitioner List - The list of Affiliated Practitioners of an APM Entity that is compiled from a CMS-maintained list.

• MIPS APM – Most Advanced APMs are also MIPS APMs so that if an eligible clinician participating in the Advanced APM does not meet the threshold for sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard. The APM scoring standard is designed to account for activities already required by the APM.

• Participation List - The list of participants in an APM Entity that is participating in an Advanced APM, compiled from a CMS-maintained list.

• Qualifying APM Participant (QP) - An eligible clinician determined by CMS to have met or exceeded the relevant QP payment amount or QP patient count threshold for a year based on participation in an Advanced APM Entity.

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APM Structure

TIN Taxpayer Identification Number

NPI National Provider Identifier

APM EntityTIN

(eligible clinicians)

NPI

NPI

NPI

APM Entity - An entity that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation.

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ADVANCED APMS

Overview

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Advanced APMs

Benefits

Clinicians and practices can:

• Receive greater rewards for taking on some risk related to patient outcomes.

Advanced APMs

Advanced APM-specific rewards

+

“So what?” - It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

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Advanced APMs

Current List of Advanced APMs for 2019

• Bundled Payments for Care Improvement (BPCI) Advanced Model

• Comprehensive Care for Joint Replacement Model

• Comprehensive ESRD Care Model (LDO Arrangement)

• Comprehensive ESRD Care Model (non-LDO Two-sided Risk Arrangement)

• Comprehensive Primary Care Plus (CPC+) Model

• Medicare Accountable Care Organization (ACO) Track 1+ Model

• Maryland Total Cost of Care Model (Care Redesign Program)

• Maryland Total Cost of Care Model (Maryland Primary Care Program)

• Next Generation ACO Model

• Shared Savings Program – Track 2

• Shared Savings Program – Track 3

• Oncology Care Model (OCM) – Two-Sided Risk Arrangement

• Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

To learn more about these Advanced APMs, visit the Advanced APMs webpage on qpp.cms.gov18

ADVANCED APMSCriteria

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Advanced APMs: Basic Structure

• Advanced APMs build on existing APMs

• To be an Advanced APM, an APM must meet the following three requirements:

Requires participants to use certified EHR technology;

Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and

Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk.

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Advanced APM Criterion 1Requires use of Certified EHR Technology

1. Requires participants to use certified EHR technology

• Requires that at least 75% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other health care professionals.

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Advanced APMsRequires use of Certified EHR Technology

New In 2019

• Beginning in 2019, CMS introduced a specific threshold of CEHRT use as an eligibility requirement for participation in the Shared Savings Program and removed the ACO quality measure that assessed the Use of Certified EHR Technology (ACO-11). Participants in the Shared Savings Program that meet the financial risk standard to be an Advanced APM must now certify annually that at least 50 percent of eligible clinicians in the ACO use CEHRT.

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Advanced APM Criterion 2Requires MIPS-Comparable Quality Measures

2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category.

• Ties payment to quality measures that are evidence-based, reliable, and valid.

• At least one of these measures must be an outcome measure if an appropriate outcome measure is available on the MIPS measure list.

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Advanced APM Criterion 2Requires MIPS-Comparable Quality Measures

NEW IN 2019

MIPS Comparable Measures:

• Beginning in 2020, streamline the quality measure criteria to state that at least one of the quality measures upon which an Advanced APM bases payment must be:

1. On the MIPS final list;

2. Endorsed by a consensus-based entity; or

3. Otherwise be determined to be evidence-based, reliable, and valid by CMS

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Advanced APM Criterion 2Requires MIPS-Comparable Quality Measures

NEW IN 2019

Outcome Measures:

• Beginning in 2020, amend the Advanced APM quality criterion to require that the outcome measure used must be evidenced-based, reliable, and valid by meeting one of the following criteria:

1. On the MIPS final list;

2. Endorsed by a consensus-based entity; or

3. Otherwise determined to be evidence-based, reliable, and valid by CMS

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Advanced APM Criterion 3Medical Home Model

3. Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority, OR (2) requires participants to bear a more than nominal amount of financial risk.

NEW IN 2019

• All participants in the Comprehensive Primary Care Plus Model (CPC+) are subject to the 50 clinician cap.

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Advanced APM Criterion 3Medical Home Model

A Medical Home Model is an APM that has the following features:

Participants include primary care practices or multispecialty practices that include primary

care physicians and practitioners and offer primary

care services.

Empanelment of each patient to a primary

clinician; and

At least four of the following additional elements:

Planned coordination of chronic and preventive care.

Patient access and continuity of care. Risk-stratified care management. Coordination of care across the medical

neighborhood. Patient and caregiver engagement. Shared decision-making. Payment arrangements in addition to, or

substituting for, fee-for-service payments.

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Advanced APM Criterion 3Medical Home Model – Risk Standards

Medical Home Model Financial Risk StandardBearing financial risk means that the Medical Home Model may do one or more of the following if actual expenditures exceed expected expenditures: • Withhold payment for services to the

APM Entity or the APM Entity’s eligible clinicians

• Reduce payment rates to the APM Entity or the APM Entity’s eligible clinicians

• Require direct payments by the APM Entity to CMS, or

• Cause the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments.

Medical Home Model Nominal Risk StandardTotal potential risk that an APM Entity potentially owes CMS or foregoes must be equal to at least:

• 3% of the average estimated total Part A and B revenues of all providers and supplies in participating APM Entities for Performance Year 2019.

• 4% … for Performance Year 2020.

• 5% … for Performance Year 2021 and after.

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Advanced APM Criterion 3Bear a More than Nominal Amount of Financial Risk

Financial RiskBearing financial risk means that the Advanced APM may do one or more of the following if actual expenditures exceed expected expenditures:

• Withhold payment for services to the APM Entity and/or the APM Entity’s eligible clinicians

• Reduce payment rates to the APM Entity and/or the APM Entity’s eligible clinicians

• Require direct payments by the APM Entity to CMS

Total Amount of RiskThe 8% revenue-based standard is extended for two additional years, through performance year 2020. Total potential risk under the APM must be equal to at least either:

• 8% of the average estimated Parts A and B revenue of providers and supplies in participating APM Entities for QP Performance Periods 2017, 2018, 2019, and 2020,

OR

• 3% of the expected expenditures for which an APM Entity is responsible under the APM for all performance years.

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BECOMING A QUALIFYING APM PARTICIPANT (QP)

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Qualifying APM Participant (QP)Becoming a QP

• APMs allow eligible clinicians to become a Qualifying APM Participant (QP). If you’re eligible for QP status, you receive 5% APM incentive payment and you are excluded from MIPS.

• There are 3 criteria to becoming a QP:

1. You must receive at least 50% of your Medicare Part B payments OR see at least 35% of Medicare patients through an Advanced APM entity at one of your determination periods (snapshots).

2. In addition, 75% of practices need to be using certified EHR technology (CEHRT) within the Advanced APM entity.

3. Eligible Clinicians may else become a QP through the All-Payer and Other Payer Option, which is a combination of Medicare and non-Medicare payer arrangements such as private payers and Medicaid.

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Qualifying APM Participant (QP)Determination of QP Status

• During the QP Performance Period (January—August), CMS will take three “snapshots” (March 31, June 30, August 31) to determine which eligible clinicians are participating in an Advanced APM and whether they meet the thresholds to become Qualifying APM Participants.

• Eligible clinicians must meet either:

- Patient Count

OR

- Payment Thresholds

• At any one of the below three dates

MAR

31JUN

30AUG

3132

How do Eligible Clinicians become Qualifying APM Participants?Identification of Eligible Clinicians in Advanced APMs

✓ CMS will identify eligible clinicians participating in Advanced APMs using:

1. An APM Entity’s Participation list

AND/OR

2. An Affiliated Practitioner List

Exception:

• Some entities, such as those participating in certain episode-based payment models, may use either a Participation List or an Affiliated Practitioner. In this case, CMS will identify eligible clinicians using the APM Entity’s Participation list, when available.

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How do Eligible Clinicians become Qualifying APM Participants?Identification of Beneficiaries – Attribution Eligibility

✓ CMS will identify beneficiaries as attribution-eligible to an Advanced APM Entity if during the QP determination period the beneficiary:

1. Is not enrolled in Medicare Advantage or a Medicare cost plan;2. Does not have Medicare as a secondary payer; 3. Is enrolled in both Medicare Parts A and B for the entire QP

determination period; 4. Is at least 18 years of age on January 1 of the QP Performance Period; 5. Is a United States resident; 6. Has a minimum of one claim for evaluation and management services

furnished by an eligible clinician or group of eligible clinicians within an APM Entity during the QP determination period. Healthcare Common Procedure Coding System codes 99201–99499, G0402, G0438, G04395 and G04636 indicate evaluation and management services.

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How do Eligible Clinicians become Qualifying APM Participants?Identification of Beneficiaries – Alternative Attribution Eligibility

✓ To ensure the attribution eligibility definition appropriate for each APM’s attribution methodology, CMS may apply exceptions to the evaluation and management requirement for attribution-eligible beneficiaries and develop an alternative attribution-eligible definition for specific APMs.

The Models with Alternative Attribution-Eligible Criteria are:• Comprehensive ESRD Care Model • Bundled Payments for Care Improvement Advanced Model• Comprehensive Care for Joint Replacement Model • Maryland Total Cost of Care Model: Care Redesign Program

✓ Note: The standard definition of an attribution-eligible beneficiary would exclude certain attributed beneficiaries who do not necessarily receive any evaluation and management services from eligible clinicians who are participants in any certain Alternative Payment Model. Because attributed beneficiaries are not a subset of the standard definition of the attribution-eligible beneficiary population, an alternative definition of an attribution-eligible beneficiary for purposes of the Quality Payment Program is appropriate.

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How do Eligible Clinicians become Qualifying APM Participants?Calculation

✓ CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods (payment amount and patient count).

✓ Methods are based on Medicare Part B professional services and beneficiaries attributed to Advanced APM.

✓ CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity.

These definitions are used for

calculating Threshold Scores

under both methods.

Attributed (beneficiaries for whose cost and quality of care the APM Entity is responsible)

Attribution-eligible (all beneficiaries who could potentially be attributed)

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How do Eligible Clinicians become Qualifying APM Participants?Calculation

✓ The two methods for calculation are Payment Amount Method and Patient Count Method.

Payment Amount Method

$$$ for Part B professional services to attributed beneficiaries

$$$ for Part B professional services to attribution-eligible beneficiaries

=Threshold Score %

Patient Count Method

# of attributed beneficiaries given Part B professional services

# of attribution-eligible beneficiaries given Part B professional services

= Threshold Score %

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How do Eligible Clinicians become Qualifying APM Participants?Requirements

✓ The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result.

Requirements for Incentive Paymentsfor Significant Participation in Advanced APMs

(Clinicians must meet payment or patient requirements)

Performance Year 2017 2018 2019 2020 2021 2022 and later

Percentage of Payments through an Advanced APM

Percentage of Patients through an Advanced APM

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How do Eligible Clinicians become Qualifying APM Participants?

✓ All the eligible clinicians in the Advanced APM Entity become QPs for the payment year.

Advanced APM

Advanced APM Entities

Eligible Clinicians

Threshold Scores below the QP threshold = no QPs

Threshold Scores above the QP

threshold = QP status

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What is the Performance Period for QPs?

• The QP Performance Period is the period during which CMS will assess eligible clinicians’ participation in Advanced APMs to determine if they will be QPs for the payment year.

• The QP Performance Period for each payment year will be from January 1—August 31st of the calendar year that is two years prior to the payment year.

Performance Period: QP status based on Advanced APM

participation

Incentive Determination:Add up payments for Part B

professional services furnished by QP

Payment:+5% lump sum payment made

(excluded from MIPS adjustment)

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How are QPs determined during the Performance Period?

• For each of the three QP determinations, CMS will use claims data from period “A” for the APM Entity participants captured in the snapshot at point “B.” CMS then allows for claims run-out during period “C” and finalizes QP determinations at point “D.”

• If an APM Entity meets the QP threshold, subsequent eligible clinician additions to the Participation List do not automatically confer QP status to those eligible clinicians. If the group meets the QP threshold for a subsequent QP determination, then the new additions become QPs.

Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019

B C D

DCB

B C D

#1

#2

#3

A

A

A

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When Will Clinicians Learn their QP Status?

• Reaching the QP threshold at any one of the three QP determinations will result in QP status for the eligible clinicians in the Advanced APM Entity

• Eligible clinicians will be notified of their QP status after each QP determination is complete (point D)

Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019

B C D

DCB

B C D

#1

#2

#3

A

A

A

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What if Clinicians do not meet the QP Payment or Patient Thresholds?

• Clinicians who participate in Advanced APMs, but do not meet the QP threshold, may become “Partial” Qualifying APM Participants (Partial QPs).

• Partial QPs choose whether to participate in MIPS.

Medicare-Only Partial QP Thresholds in Advanced APMs

Payment Year

2019 2020 2021 2022 2023 2024 and later

Percentage of

Payments

Percentage of Patients

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Where Can I Check My QP Status?

• You have the opportunity to review your QP status using the QPP Participation Look-up Tool on the Quality Payment Program website – qpp.cms.gov

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ADVANCED APMS

IN 2019Overview of All-Payer Combination Option & Other Payer Advanced APMs

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All-Payer Combination Option

OverviewThe MACRA statute created two pathways to allow eligible clinicians to become QPs.

Medicare Option

• Available for all performance years.

• Eligible clinicians achieve QP status exclusively based on participation in Advanced APMs within Medicare fee-for-service.

All-Payer Combination Option

• Available starting in Performance Year 2019.

• Eligible clinicians achieve QP status based on a combination of participation in Advanced APMs within Medicare fee-for-service, AND Other Payer Advanced APMs offered by other payers.

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All-Payer Combination Option

Overview

• The All-Payer Combination Option is, along with the Medicare Option, one of two pathways through which eligible clinicians can become a QP for a year.

• QP Determinations under the All-Payer Combination Option will be based on an eligible clinicians’ participation in a combination of both Advanced (Medicare) APMs and Other Payer Advanced APMs.

• QP Determinations are conducted sequentially so that the Medicare Option is applied before the All-Payer Combination Option.

• Only clinicians who do not meet the minimum patient count or payment amount threshold to become QPs under the Medicare Option (but still meet a lower threshold to participate in the All-Payer Combination Option) are able to request a QP determination under the All-Payer Combination Option.

• The All-Payer Combination Option is available beginning in the 2019 QP Performance Period.

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All-Payer Combination Option

Other Payer Advanced APMs

• Other Payer Advanced APMs are non-Medicare payment arrangements that meet criteria that are similar to Advanced APMs.

• Payer types that may have payment arrangements that qualify as Other Payer Advanced APMs include:

✓ Title XIX (Medicaid)

✓ Medicare Health Plans (including Medicare Advantage)

✓ CMS Multi-Payer Models

✓ Other commercial and private payers

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WHERE CAN I GO TO LEARN MORE?

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Quality Payment Program Website

QPP Resource Website – APM Web Pages:

1. Navigate to qpp.cms.gov2. Select the APMs tab at the top of the screen3. Scroll down to the desired APM web pages

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Quality Payment Program Resource Library

QPP Resource Library:

1. Navigate to qpp.cms.gov2. Go to the “About” tab at the top of the screen3. Scroll down to “Resource Library”

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Technical Assistance

CMS has no cost resources and organizations on the ground to provide help to eligible clinicians included in the Quality Payment Program:

To learn more, visit:https://qpp.cms.gov/about/help-and-support#technical-assistance 52

Q&A

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Q&A Session

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Press *1 to be added to the question queue.

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Speakers will answer as many questions as time allows.

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