What urologists need to know about APMs


In this installment in a series on MACRA, I will review the definition of APMs, how participating providers would be reimbursed under MACRA (as proposed), and the relevance to specialists, including urologists.


Dr. DowlingAs discussed in previous articles, the Centers for Medicare & Medicaid Services (CMS) in April released its proposed rule for implementing health reimbursement reform under the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). While most urologists will be reimbursed under a “pay-for-value” modification of fee for service in the first years of the program (Merit-Based Incentive Payment System or MIPS), policy makers and other stakeholders assume that with time, the legislation will incentivize participation in alternative payment models (APMs).

In this installment in a series on MACRA, I will review the definition of APMs, how participating providers would be reimbursed under MACRA (as proposed), and the relevance to specialists, including urologists. 

What is an alternative payment model?

Let’s start with some important definitions. An alternative payment model is generally recognized to be a system other than traditional fee for service that provides value by improving quality and reducing cost. APMs have a narrower definition within MACRA: They must be either a Center for Medicare & Medicaid Innovation model under section 1115A of the Social Security Act, a Shared Savings Program, a Health Care Quality Demonstration Program under section 1866C, or a demonstration required by federal law.

As proposed, the list of APMs thus defined is very short: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Medicare Shared Savings program (all tracks), Next Generation Accountable Care Organization, and the Oncology Care Model (all tracks).

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An Advanced APM is defined even more narrowly and must meet all of the following criteria: It is an APM that requires its participants to use an EHR certified to the 2015 edition, provides payment to its members based on defined quality measures, and accepts “more than nominal risk” (meticulously defined in the proposed rule), or is a medical home model. The only APMs that meet these additional criteria are Comprehensive ESRD Care, Comprehensive Primary Care Plus, Medicare Shared Savings program (track II or III), Next Generation ACO, and the Oncology Care Model (two-sided risk).

MACRA also established a concept known as the “Physician Focused Payment Model” (PFPM)-an APM wherein Medicare is a payer, which includes physician group practices or individual physicians as APM entities and targets the quality and costs of physician services. CMS anticipates that specialty societies and other stakeholders would apply for certification as a PFPM alternative payment model, but such models would also need to meet the aforementioned criteria to be considered an Advanced APM. The proposed rule sets a very high bar for PFPMs, including a rigorous set of criteria and a significant application process.

Next: APM vs. Advanced APM


APM vs. Advanced APM

The distinction between an APM and an Advanced APM is important. Under MACRA, all physicians will be subject to MIPS unless they meet one of three exceptions: They are in their first year of participation in Medicare, they do not exceed a low volume threshold of patients or payments, or they are a qualifying participant in an Advanced APM. These qualifying participants will receive a 5% lump-sum bonus (based on professional services only) in addition to any shared savings (or losses) in the APM itself, and not be subject to MIPS payment adjustments.

In order to be considered a “qualifying participant in an Advanced APM,” the providers in that APM must collectively exceed a proportional threshold of Medicare beneficiaries or payments seen or received through the Advanced APM-20% of beneficiaries or 25% of payments in the first 2 years of the program. APM participants who do not meet this threshold will be subject to MIPS, but are eligible for favorable scoring under MIPS by virtue of participating in an APM (see below).

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A provider’s status under MACRA is not an election, selection, or option on the part of the eligible clinician-it is determined by CMS each year, and the details of this complex determination process are clearly spelled out in the proposed rule. In summary, prior to the beginning of each performance year, CMS will post a list of APMs and Advanced APMs. At the end of each performance year, CMS will determine whether an eligible professional was assigned to one or more APMs based on official participation lists submitted by the APM.

Next, CMS will determine for each Advanced APM whether participating groups (known as APM entities) collectively met the qualifying thresholds for that year; for providers/entities that participate in more than one APM, CMS has proposed using the calculation that is most favorable to the professional/entity. Those that exceed the threshold will be “qualifying participants”; there is also a lower bar for “partial qualification,” which earns the provider an option whether to participate in MIPS, though they do not qualify for the 5% bonus; everyone else will be subject to MIPS under APM scoring.

Next: APMs confer MIPS score advantage

APMs confer MIPS score advantage

APM participation confers a significant advantage in the calculation of the MIPS composite score. First, MIPS APM entity participants will be treated as a group for the purposes of MIPS APM scoring-all providers in the entity would receive the same MIPS composite score. Second, MIPS APM participants are given substantial (50%) credit in the Clinical Practice Improvement Activity score simply for their participation. Third, CMS has proposed to reduce the reporting burden by using the quality measures already being submitted by the MIPS APM (a Medicare Shared Savings Program, for example) and not requiring separate reporting under MIPS.

Fourth, the MIPS APM entity would not be assessed on resource use. Finally, the MIPS categories would be favorably reweighted for MIPS APM participants.

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Bottom line: Urologists wishing to participate in an APM have very few options available to them today beyond a Medicare Shared Savings Program (without risk) or a Next Generation ACO, and most will be subject to MIPS even if they are in one of these APMs. Specialty physician-focused payment models are unlikely to be available in the first few performance years under MACRA.

CMS is expected to release a final rule regarding MACRA in the fall. In the meantime, urologists may wish to survey available APMs in their community (see http://bit.ly/Savingsprograms and http://bit.ly/NextgenACOs), review conditions of participation, and determine whether the benefits of participation-including favorable treatment under MACRA-outweigh the risks.

More from Urology Times:

My $4.07 check from an insurer: A sign of the times

IRAs: How to make an early withdrawal

AACU on MACRA: Delay rollout, adjust low-volume threshold

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