Alternative Payment Models (APMs)
APMs offer an opportunity for providers to begin sharing the risk and reward for providing high quality patient care and managing patient populations. APMs can apply to a specific clinical condition, a care episode, or a specific patient population. APMs utilize reimbursement methods that are different from traditional fee-for-service payments, but an APM may also retain elements of fee-for-service payments as part of its reimbursement structure.
What are Advanced APMs?
When CMS implemented MACRA, it established a subset of APMS, designated as Advanced APMS to qualify for MACRA's second payment track. An Advanced APM offers a 5 percent incentive for achieving threshold levels of payments or patients through payment models that move away from the fee-for-service payment system.
Advanced APMs meet three criteria:
- Requires participants to use certified EHR technology (CEHRT);
- At least 50 percent of eligible clinicians in each participating APM entity group to use CEHRT to document and communicate clinical care information.
- 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 significant financial risk.
- A payment arrangement meets the financial risk if actual expenditures exceed expected aggregate expenditures or be in a Medicaid Medical Home Model that meets criteria comparable to Medical Home Models. If a clinician achieves these thresholds, they are excluded from the MIPS reporting requirements and payment adjustment.
Starting in 2019, the Advanced APM path provides 2 ways for eligible clinicians to become QPs:
- The Medicare Option, which takes into account the clinician's participation solely in Medicare Advanced APMs, and;
- The All-Payer Option, which takes into account the clinician's participation in Advanced APMs both with Medicare and other payers.
APM Performance Pathway (APP)
The Centers for Medicare & Medicaid Services (CMS) has finalized a new reporting and scoring pathway for Merit-based Incentive Payment System (MIPS) eligible clinicians who participate in MIPS Alternative Payment Models (APMs): the APM Performance Pathway (APP). Learn more here.
Becoming an Advanced APM Qualifying Participant
If you are interested in becoming an Advanced APM clinician, CMS suggests you:
- Learn about specific APMs through CMS communications.
- Subscribe to receive email updates.
- Visit the CMS Innovation Center webpage.
- Visit the Shared Savings Program webpage.
- Verify the APM is accepting applications.
- Apply to an APM that fits your practice.
To learn more, please go to: Advanced Alternative Payment Models
The Physician-Focused Payment Model Technical Advisory Committee (PTAC)
Section 101 (e)(1) of MACRA created the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to make comments and recommendations to the Secretary of the Department of Health and Human Services (the Secretary, HHS) on proposals for physician-focused payment models (PFPMs) submitted by individuals and stakeholder entities.
- The Secretary is required by MACRA to establish criteria for PFPMs.
- PTAC will evaluate stakeholder-submitted PFPMs against the criteria established by the Secretary.
- The HHS Secretary will respond to the recommendations of PTAC.
More information can be found here: Physician-Focused Payment Model Technical Advisory Committee (PTAC)