APMS 101 FOR THE 2019 PERFORMANCE YEAR OF THE QUALITY PAYMENT PROGRAM

Thursday, February 21, 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

• Overview of the Quality Payment Program

• Alternative Payment Models (APMs)

- Key terms to know

• Advanced Alternative Payment Models

• Advanced APMs - All-Payer Combination Option

- QP Determination and Performance Period

• MIPS APMs

• Available Resources

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The Quality Payment Program

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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:

ALTERNATIVE PAYMENT MODELS (APMS)

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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.

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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

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

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Advanced APMs are

a Subset of APMs

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ACO

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.

CMS APM Design Elements

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✓ APM Type

✓ Clinical Practice Transformation

✓ Rationale and Evidence

✓ Alignment

✓ Quality Improvement

✓ Scale and Scalability: Participants

✓ Participation: Operational Feasibility

Alternative Payment Model Design Toolkit

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*

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Alternative Payment Model Design Toolkit*Factors CMS would not expect stakeholders to focus on in designing APMs

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Illustrative Example 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

KEY TERMS TO KNOW RELATED TO APMS

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Relevant Terms

• National Provider Identifier (NPI) – 10-digit numeric identifier for individual clinicians.

• Tax Identification Number (TIN) – Number used by the Internal Revenue Service to identify an organization/entity, such as a group or medical practice.

• APM Name – The APM in which you participate as a part of your APM Entity.

• Subdivision Name (SD Name) – The specific APM in which a you participate, including track (if applicable).

• APM Entity Name (APME) – The name of the organization in which you participate.

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NPI APM Name Subdivision Name APME

1234567890 Comprehensive Primary Care Plus Model

CPC+ - Medical Home Sample Family Practice

Additional Terms

• 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 – 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.

• 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 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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Relevant Financial Terms

• Full capitation risk exists where the APM Entity receives a per capita or an otherwise predetermined fixed payment for all items and services delivered to a population of beneficiaries, with no settlements done to reconcile or share losses incurred or savings earned by the APM Entity.

• The APM Entity bears the full risk, both downside and upside; therefore, capitation risk arrangements always require the APM Entity to bear the risk of more than nominal financial losses.

• Cash flow adjustments to later reconcile or adjust predetermined amounts based on actual experience may not be full risk arrangements.

• Total Risk: The maximum amount of losses possible under an Advanced APM must be at least 4 percent of the APM spending target.

• Marginal Risk: The percent of spending above the APM benchmark (or target price for bundles) for which the Advanced APM Entity is responsible (i.e., sharing rate) must be at least 30 percent.

• Minimum Loss Rate: The amount by which a clinician’s spending can exceed the APM benchmark (or target price for bundles) before the Advanced APM Entity bears responsibility for financial losses cannot exceed 4 percent.

• Financial Risk Standard: APM Entities must bear risk for monetary losses.

• Nominal Amount Standard: The risk APM Entities bear must be of a certain magnitude.

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ADVANCED APMS

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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.

Advanced APMs: Why Participate?

Clinicians and practices can:

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

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Advanced APMs

Advanced APM-specific rewards

+

5% lump sum incentive

“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.

Rewards for Participating in APMs

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Not in APM In APM In Advanced APM

+If you are a

Qualifying APM

Participant (QP)

Potential financial rewards

+

5% lumpsum bonus

MIPS adjustments MIPS adjustments

In MIPS APM

+MIPS adjustments

APM-specific rewards

APM Scoring Standard

APM-specific rewards

APM-specific rewards

toward

Benefits of Participating in an Advanced APM as a Qualifying APM Participant (QP)

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QPs:

Are excluded from MIPS

Receive a 5% lump sum bonus

Receive a higher Physician Fee Schedule updatestarting in 2026

Performance Year Thresholds to Become a Qualifying APM Participant

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✓ 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 20212022 and

later

Percentage of Payments through an Advanced APM

Percentage of Patients through an Advanced APM

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.

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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 Does CMS Determine QP Status?

• During the QP Performance Period (January—August), an eligible clinician

must be on the APM Participation List on at least one of the three below QP

determination snapshot dates during the QP performance period.

MAR

31JUN

30AUG

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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 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)

The full list of 2019 APMs can be found on the QPP Resource library, and can be viewed in this fact sheet.

ADVANCED APMS –ALL-PAYER COMBINATION OPTION

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All-Payer Combination Option

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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.

All-Payer Combination Option

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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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Performance Year Thresholds for All-Payer Combination Option

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

All-Payer Combination Option

Payment 2017 2018 2019 2020 2021 2022 and Year later

QP Payment Amount N/A N/AThreshold

QP Patient N/A N/ACount Threshold

Med

icare

Total

Med

icare

Total

Med

icare

Total

Med

icare

Total

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All-Payer Combination Option: Determining QP Status

• An Eligible Clinician or APM Entity needs to participate in an Advanced APM with Medicare to a sufficient extent to qualify for the All-Payer Combination Option.

• For performance year 2019, based on the payment amount method, sufficient means:

<25% • Eligible Clinician or APM Entity does not qualify to participate in All-Payer Combination Option.

25% - 50%* • Eligible Clinician or APM Entity does qualify to participate in the All-Payer Combination Option.

≥50%•Eligible Clinician or APM Entity attains QP status based on

Medicare Option alone.

•Participation in the All-Payer Combination Option is not necessary.

*Eligible clinicians must have greater than or equal to 25% and less than 50% of payments through an Advanced APM(s).

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Is Medicare Threshold Score

> 50%

QP

Is Medicare Threshold Score

> 25%

Is Medicare Threshold Score

> 20%

Is All-Payer Threshold Score

> 50%

Is All-Payer Threshold Score

> 40% OR is

Medicare Threshold Score > 40%?

MIPS Eligible Clinician

YES

NOYES

YES

YES

YES

NO

NO

NO

NO

Partial QP

QP

MIPS Eligible Clinician

2019 Performance Year – Payment Amount Method

All-Payer Combination Option: Determining QP Status

MIPS APMS AND THE APM SCORING STANDARD

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What are MIPS APMs?

Goals

• Reduce eligible clinician reporting burden.

• Maintain focus on the goals and objectives of APMs.

How does it work?

• Streamlined MIPS reporting and scoring for eligible clinicians in certain APMs.

• Aggregates eligible clinician MIPS scores to the APM Entity level.

• All eligible clinicians in an APM Entity receive the same MIPS final score.

• Uses APM-related performance to the extent practicable.

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MIPS APMs are a Subset of APMs

What are the Requirements to be Considered a MIPS APM?

The APM scoring standard applies to APMs that meet these criteria:

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✓ APM Entities participate in the APM under an agreement with CMS;

✓ APM Entities include one or more MIPS eligible clinicians on a Participation List; and

✓ APM bases payment incentives on performance (either at the APM Entity or eligible clinician level) on cost/utilization and quality.

APM Scoring Standard Snapshot Dates

The APM scoring standard offers a special, minimally-burdensome way of participating in MIPS for eligible clinicians in APMs who do not meet the requirements to become QPs and are therefore subject to MIPS, or eligible clinicians who meet the requirements to become a Partial QP and therefore able to choose whether to participate in MIPS.

To be considered part of the APM Entity for the APM scoring standard, an eligible clinician must be on an APM Participation List on at least one of the below three snapshot dates of the performance period. Otherwise, an eligible clinician must report to MIPS under the standard MIPS methods.

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MAR

31JUN

30AUG

31Dec

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*New – FULL TIN ONLY*

*Note: The fourth snapshot date of December 31st is for full TIN APMs (Medicare Shared Savings Program).

MIPS APMs

• Bundled Payments for Care Improvement (BPCI) Advanced

• Comprehensive ESRD Care (CEC) Model (All Arrangements)

• Comprehensive Primary Care Plus (CPC+) Model

• Independence at Home Demonstration (IAH)

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

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

• Medicare Shared Savings Program Accountable Care Organizations Tracks 1, 2, & 3

• Next Generation ACO Model

• Oncology Care Model (OCM – All Arrangements)

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

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The full list of 2019 APMs can be found on the QPP Resource library, and can be viewed in this fact sheet.

WHERE CAN I GO TO LEARN MORE?

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Quality Payment Program Resource Library

New QPP Resource Library:

1. Navigate to qpp.cms.gov2. Select the APMs tab at the top of the screen

Technical Assistance

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CMS has free resources and organizations on the ground to provide help to eligible clinicians included in the Quality Payment Program:

To learn more, view the Technical Assistance Resource Guide: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Technical-

Assistance-Resource-Guide.pdf

Q&A

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Q&A Session

To ask a question, please dial:

1-866-452-7887

If prompted, use passcode: 4478537

Press *1 to be added to the question queue.

You may also submit questions via the chat box.

Speakers will answer as many questions as time allows.

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