Alternative Payment Models under the Quality Payment Program

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One way that clinicians can participate in the Medicare Quality Payment Program is through an Advanced Alternative Payment Model, or APM. (The other option is the Merit-Based Incentive Program, or MIPS.)

Only Qualifying Participants (QPs) in Advanced APMs will be eligible for the 5% Medicare incentive payment offered under this track. If you are determined to be a QP in an Advanced APM, you are not only eligible for this higher incentive payment, but CMS also will refrain from scoring your performance under MIPS.

For performance in 2017 and 2018, CMS defines Advanced APMs and QPs as follows:

CMS has identified the following as Advanced APMs for 2017:

These are identified as Advanced APMs for 2018 or later:

Importantly, MACRA also provides the opportunity for physicians to develop their own APMs for potential implementation by CMS after preliminary review and approval by the Physician-Focused Payment Model Technical Advisory Committee. STS collaborated with the American College of Surgeons on its recent proposal.

Included as an appendix to that proposal was the STS APM whitepaper. This whitepaper may be the foundation for the Society’s own APM proposal in the future. Although implementation of an STS-designed Advanced APM may take a number of years, it remains one of the Society’s principal goals.

What Is a MIPS APM clinician?

Clinicians who participate in certain APMs, but do not satisfy the criteria for being a QP in an Advanced APM, are considered “MIPS APM clinicians.” These clinicians are not eligible for the 5% APM bonus and are still required to participate in MIPS. However, they will receive special scoring accommodations (e.g., for 2017, MIPS APM participants will automatically receive the maximum score for the MIPS Improvement Activities category with no extra data submission requirement). This policy ensures that clinicians who are part of an APM will still get credit under MIPS for their efforts if, in the end, they are not determined to be a QP in an Advanced APM.

An APM may be considered a MIPS APM if it has an agreement with CMS and bases payment incentives on cost/utilization performance and quality measures. Also, at least one participating clinician must be eligible for MIPS. CMS has a comprehensive list of common APMs and whether they qualify as MIPS and/or Advanced APMs.

Last updated: 8/29/2017