2019 Quality Payment Program Overview: APMs

Although Advanced Alternative Payment Models (APMs) haven’t spread like wildfire across the industry, the incentive to earn a 5% lump sum of yearly Medicare Part B payments and the ability to sidestep the MIPS program deserves attention. Although only ≈200,000 eligible clinicians are currently participating in Advanced APMs, most payers consistently experiment with risk-based payment models that increasingly involve APM characteristics. Ultimately, this could entice providers to avoid MIPS altogether by accepting risk on their commercially managed population and/or organizing their commercial contracting and operational behaviors in concert with MSSP ACO participation. Here are the highlights of the 2019 proposed rule APM updates.

What Changes to APMs?

• Most notably, the 8% revenue-based nominal risk standard for APMs will be standardized through 2024 to provide longer term APM strategic planning for physicians and health systems.
• Many APM measures will align with MIPS to avoid confusing reporting burdens for eligible clinicians trying to understand their reporting needs for either program.
• The Advanced APM CEHRT threshold will require that at least 75% of eligible clinicians use 2015 CEHRT as of January 1, 2020.
• Further All-Payer flexibility will allow Other Payer Advanced APMs to satisfy risk-based requirements for eligible clinicians to be eligible for APM participation with their non-Medicare population.
• Increased clarity on requiring MIPS APMs to assess quality and cost/utilization performance in a manner reflecting the APM scoring standards.
• Updated allowance for Qualifying Participant (QP) determinations under the All-Payer option to allow TIN level participation to reflect commercial contracting realities for ASCs in the commercial space.
• Multi-Year Other Payer APM Determinations will be streamlined for multi-year contracting realities to reduce the administrative burden imposed by the original yearly re-submission requirement for APM eligibility.
• Vitally, CMS proposed to reword the MIPS APM criteria that APMS “base payment on cost/utilization and quality measures,” that unintentionally limited APM’s ability to be eligible with their own payment arrangements. This provides much needed clarity to allow payers and qualifying participants to base their payments on similar cost and quality measures without having to realign their methodologies with CMS’ programs to satisfy their eligibility.

Stay tuned for the final rule expected later this fall. Please review further detail regarding the proposed rule’s impact on MIPS participants or MSSP ACO participants or contact our office.