Analysis from our publisher
By Naomi Levinthal and Ye Hoffman
The Advanced Alternative Payment Model (APM) track of MACRA's Quality Payment Program (QPP) benefits clinicians with experience taking on risk. Participants in the Advanced APM track not only earn a 5% incentive payment—they are also exempt from the Merit-based Incentive Payment System (MIPS) payment adjustment.
For 2017 and 2018, the only way to qualify for the Advanced APM track were through Medicare Alternative Payment Models. However, there will be an additional option from 2019 on—the All-Payer Combination Option.
What are the basics of the Advanced APM track?
Qualification into the Advanced APM track is no easy feat. First, clinicians must participate in "Advanced APMs that carry financial risks, tie payments to quality metrics, and require use of certified electronic health record technology.
Second, clinicians must satisfy a sufficient volume requirement of either patients or payments through the Advanced APM in order to become a qualifying APM participant (QP). Providers face a two-year lag between qualification and incentive payment: QP status in 2018 will result in a 5% bonus payment in 2020. The chart below shows the QP thresholds over time by payment year.
The threshold increases significantly in the third year of the program (i.e. the 2019 performance year tied to 2021 payment). This is also when clinicians who do not meet the QP threshold through the Medicare-only option will be able to supplement the required volume through other payer arrangements in the All-Payer Combination option.
How do clinicians participate in the All-Payer Combination option?
When the All-Payer Combination option launches in performance year 2019, clinicians will still have to have a sufficient volume of either patients or payments through Medicare Advanced APMs. However, they'll now have two options to meet the QP threshold: either through just Medicare Advanced APMs or in combination with volumes through other payer advanced APMs.
Here is an example of how this works for performance year 2019 (which affects payment in 2021):
2 ways to qualify for the Advanced APM track in 2019
What are the criteria for non-Medicare Advanced APMs?
CMS will apply criteria similar to Medicare-only models in order to determine whether "other payer" models are considered Advanced APMs. That means "other payer" Advanced APMs must also carry financial risks, tie payments to quality metrics, and require use of certified EHR technology.
When will CMS determine eligibility for 'other payer' Advanced APMs?
In order for providers to use an "other payer" model in the All Payer Combination option, CMS must determine that the payment model qualifies as an Advanced APM. This can happen through either a payer-initiated application process or a provider-initiated process, and the timelines are different for each.
Most providers will likely rely on their payers to submit applications to CMS to request Advanced APM determination for eligible payment models. For the 2019 performance period, the payer-initiated deadlines fall in the first half of 2018 (the exact date varies by type of payment model). For this first performance period of the All Payer Combination option, only certain types of other payer models can apply for Advanced APM eligibility through the payer-initiated process, including Medicaid, Medicare Advantage, and CMS multi-payer models. These are all arrangements in which the payer already has some sort of relationship with CMS.
For the 2019 performance period, the payer-initiated process is not available for commercial and other private payer arrangements, although it will be offered for future years. In order for such arrangements to be considered for Advanced APM eligibility for 2019, clinicians or their respective APM entities would have to directly submit requests to CMS sometime in late 2019.
How could CMS change the way providers qualify for the Advanced APM track in future years?
As it stands, Medicare Advantage (MA) is considered an "other payer" in the All Payer Combination option. That means that clinicians cannot qualify into the Advanced APM track using Medicare Advantage volumes alone. However, CMS has plans for a demonstration program for clinicians to qualify for the Advanced APM track solely through MA. This could benefit clinicians treating large populations of MA enrollees. We are still awaiting further details from CMS on the planned demonstration program.
*Editor's note: Naomi Levinthal is a practice manager with Advisory Board who specializes in quality reporting programs and Ye Hoffman is a consultant for Advisory Board who specializes in CMS' EHR Incentive Programs. The Advisory Board publishes American Health Line.