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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.

Current Participants

The table below displays the Advanced Alternative Payment Models that CMS currently operates or has announced, as of November 2018. If you are an eligible clinician currently participating in an Advanced APM, please contact your APM entity for participation specifics.

Advanced APM List
Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)
Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1-CHERT)
Comprehensive ESRD Care (CEC) Model (LDO Arrangement)
Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement)
Comprehensive Primary Care Plus (CPC+) Model
Medicare Accountable Care Organization (ACO) Track 1+ Model
Maryland All-Payer Model (Care Redesign Program)
Maryland Total Cost of Care Model (Maryland Primary Care Program)
Maryland Total Cost of Care Model (Care Redesign Program)
Medicare Shared Savings Program Accountable Care Organizations – Track 2
Medicare Shared Savings Program Accountable Care Organizations – Track 3
Next Generation ACO Model
Oncology Care Model (OCM) (Two-sided Risk Arrangement)
Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

Becoming an Advanced APM Qualifying Participant

If you are interested in becoming an Advanced APM clinician, CMS suggests you:

  1. Learn about specific APMs through CMS communications.
    1. Subscribe to receive email updates.
    2. Visit the CMS Innovation Center webpage.
    3. Visit the Shared Savings Program webpage.
  2. Verify the APM is accepting applications.
  3. 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)