What urologists need to know about APMs
Alternative models offer advantages, but opportunities for specialists are limited
As 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.