OVERVIEW May 9, 9, 2019 2019 Disclaimers This presentation was - PowerPoint PPT Presentation

ADVANCED APMS OVERVIEW May 9, 9, 2019 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. 2

Topics • Quality Payment Program Overview • Alternative Payment Models (APMs) Definition • Alternative Payment Models Design and Categories • Alternative Payment Models Overview • Advanced Alternative Payment Models - Criterion - Snapshot Dates • Qualifying APM Participant (QP) Status • Available Resources 3

QUALITY PAYMENT PROGRAM OVERVIEW 4

The Quality Payment Program 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. 5

ALTERNATIVE PAYMENT MODEL DEFINITION 6

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. ✓ CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award) As defined by ✓ MSSP (Medicare Shared Savings Program) MACRA, APMs s ✓ Demonstration under the Health Care Quality Demonstration inc inclu lude: Program ✓ Demonstration required by federal law 7

What is an APM? • A payment approach that provides Adv dvanced APM PMs ar are e added incentives to clinicians to a Su a Subset of of APM PMs 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 8

APM DESIGN AND CATEGORIES 9

CMS APM Design Elements ✓ APM Type ✓ Clinical Practice Transformation ✓ Rationale and Evidence ✓ Scale and Scalability: Participants ✓ Alignment ✓ Quality Improvement ✓ Participation: Operational Feasibility 10

CMS Model Design Factors FACT CTORS FR FROM ALTERNATIVE PAYMENT MODEL DE DESIGN TOOLKIT 1. Alignment with key CMS 6. Alignment with other 11. Economic impact* 16. Operational feasibility and HHS Goals payers and CMS Programs for CMS* 2. Extent of clinical 7. Potential for quality 12. Overlap with current 17. Effects on coverage and transformation in model improvement and anticipated models benefits design 3. Strength of evidence 8. Potential for cost savings 13. Evaluative feasibility 18. CMS’ waiver authority* base 4. Scale of the model 9. Size of investment 14. Stakeholder interest 19. Ability of other payers design required for CMS* and acceptance to test the model 5. Demographic, clinical, 10. Probability of model 15. Operational feasibility 20. Scalability* and geographic diversity success for participants *Factors CMS would not expect stakeholders to focus on in designing APMs 11

Reading the List 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 APM Medical Use of Quality Financial Advanced under the Home CEHRT Measures Risk APM APM Model Criterion Criterion Criterion Scoring Standard Comprehensive ESRD Care (CEC) Model (non-LDO YES No YES YES No No arrangement one-sided risk arrangement) Comprehensive Primary Care YES YES YES YES YES YES Plus (CPC+) Model Frontier Community Health Integration Project No No No No No No Demonstration (FCHIP) Home Health Value-based No No No YES No No Purchasing Model (HHVBP) *Update for 2019 is forthcoming 12

ALTERNATIVE PAYMENT MODELS (APM S ) OVERVIEW 13

Advanced APMs Terms to Know • APM En Entity tity - 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. • Adv dvanced APM – Advanced APMs must meet three specific criteria: Require CEHRT use, base payment on MIPS-comparable quality measures, and either be a Medicare Medical Home or require participants to bear a more than nominal amount of risk. • Affi filiated Pract ctiti tioner r - 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. • Affi filiated Pract ctiti tioner r 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. • Parti artici cipati tion List - The list of participants in an APM Entity that is participating in an Advanced APM, compiled from a CMS-maintained list. • Qu Qualify fying APM Parti artici cipant (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. 14

APM Structure Taxpayer Identification TIN Number NPI National Provider NPI Identifier APM Entity NPI TIN NPI (eligible clinicians) 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. 15

ADVANCED APM S Overview 16

Advanced APMs Benefits Clinicians and practices can: • Receive gr greater rewards for taking on some risk related to patient outcomes. + Advanced APMs Adv Advanced AP APM- spe pecif ific ic rewards “So what?” - It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extr xtra incentives for a sufficient degree of participation in Advanced APMs. 17

Advanced APMs Current List of 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) To learn more about these Advanced APMs, visit the Advanced APMs webpage on qpp.cms.gov 18

ADVANCED APMS Criteria 19

Advanced APMs: Basic Structure • Advanced APMs build on existing APMs • To be an Advanced APM, an APM must meet the following three requirements: Eith Either: (1) is a Med edical Provides payment for Hom ome Model covered professional exp xpanded under CMS Requires services based on Innovation Center participants to use qu qualit ity mea easures authority OR (2) cer ertifi ified EHR EHR comparable to those requires par parti ticipants technology; used in the MIPS to o be bear r a a mor ore tha than quality performance nom nominal am amount of of category; and financial ris risk. . 20

Advanced APM Criterion 1 Requires use of Certified EHR Technology 1. 1. Requir ires par articip ipants to use se ce certifie ied EHR technology • Requires that at t le leas ast 75 75% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other health care professionals. 21