Frequently Asked Questions

An Alternative Payment Model (APM) is a payment approach that considers quality and cost-efficiency of care in addition to fee for service in determining payments to clinicians. In some cases, payments may be reduced (downside risk) if quality and cost targets are not met. APMs can be developed for a specific clinical condition, a care episode, or a population. Medicare and other insurers are increasingly turning to APMs to help reduce healthcare costs while demonstrating either maintenance or improvement in quality outcomes.

Physician anesthesiologists have a vital role in improving health outcomes and reducing care costs, which contribute to the success of many APMS. Anesthesiologists with their perioperative surgical home teams have contributed to their institution’s successes. Here are some examples:

• Saved 1.5 million
• Reduced readmission rates
• Reduced cost per case

Advanced APMs are a subset of APMs identified by the Centers for Medicare and Services (CMS) under the QPP. Unlike other APMs, Advanced APMs require that the model include financial risk, quality reporting and use of Certified Electronic Health Record Technology (CEHRT) by a majority of the APM participants. Clinicians who have significant participation in an Advanced APM and meet payment or patient volume thresholds are referred to as Qualifying APM Participants (QPs). They are not subject to Merit-based Incentive Payment System (MIPS) and qualify for financial bonuses. Practices can earn more for taking on some risk related to their patients' outcomes. For example, a QP can earn a 5% incentive payment by taking on risk through an Advanced APM. A partial qualifying APM participant (Partial QP) may choose whether they want to participate in MIPS. If these clinicians do not participate in MIPS, they will not be required to report to MIPS and will not receive a MIPS payment adjustment. If they choose to participate in MIPS, they must meet all MIPS reporting and scoring requirements. As is true for QPs, Partial QPs are not subject to MIPS.

CMS has also identified a subset of APMs that do not meet the criteria for an Advanced APM. Participants of these APMs, referred to as MIPS APMs, do not qualify for the financial incentive of Advanced APMs and they are subject to MIPS. In acknowledgement of the quality reporting and CEHRT requirements that are typically part of these types of organizations, CMS has established reduced MIPS reporting requirements known as the APM Scoring Standard.

For participants in a MIPS APM, the scoring standard for the Medicare Shared Savings Program or Next Generation ACO model allows for Quality to count for 50% of your score, improvement activities (IAs) are worth 20% of your score and the Promoting Interoperability (PI) score is set at 30% of your score. The cost component is not scored. The total score is a reflection of the APM entity’s combined performance – each MIPS clinician scored under the APM scoring standard will receive the same MIPS score their MIPS APM received.

CMS will identify eligible clinicians participating in Advanced APMs using (1) an APM Entity's Participation List and/or (2) an Affiliated Practitioner List. These lists are compiled by the APM and submitted to CMS. During the QP Performance Period (January 1- August 31) CMS will take three “snapshots” (March 31, June 30, August 31) to determine which clinicians are participating in an Advanced APM and whether they meet the thresholds to become Qualifying APM Participants.

You can determine if you need to participate in the Quality Payment Program by using the Qualifying APM Participant (QP) lookup tool. The tool includes data for clinicians in Advanced and Merit-based Incentive Payment System (MIPS) APMs.

The ASA MACRA Workgroup developed an Alternative Payment Model (APM) framework to help you. This framework PDF document asks a series of critical questions to guide you in assessing a proposed APM. However, the assessment of any individual APM ultimately depends on your unique practice characteristics.

CMS has published a comprehensive list of APMs that CMS operates.

This voluntary episode payment model will evaluate a new iteration of bundled payments for 35 Clinical Episodes, including many surgical and procedural episodes of care, and aims to align incentives among participating health care providers for reducing expenditures and improving quality of care for Medicare beneficiaries. BPCI Advanced will qualify as an Advanced APM beginning with the 2019 Performance Period. Visit the BPCI Advanced page for specifics.