SLIDE 7
In 2018, for the participants of the Advanced APM to achieve Qualifying APM Participant status and become eligible for 5% lump sum bonus payments, they must have either 25% of payments through the Advanced APM or 20% of patients. Those thresholds increase significantly in future program years, reaching 75% and 50% respectively in the year 2021.
SLIDE 8
Clinicians who participate in Advanced APMs but do not meet the QP threshold, may become Partial Qualifying APM Participants or Partial QPs by meeting lower threshold requirements. In 2018, these thresholds are set at 20% of payments or 10% of patients. And like the regular QP thresholds, these too increase over time, reaching 50% of payments and 35% of patients in the year 2023.
SLIDE 9
Alternative Payment Models not meeting the requirements for Advanced APM status, but still meeting specific base criteria are considered MIPS APMs within the Quality Payment Program. To be a MIPS APM, the APM entity must participate in a model under an agreement with CMS. The APM entity must include at least one MIPS eligible clinician on a participant list. And the entity must base payment incentives on the performance of cost and quality measures. MSSP Track 1 ACOs, which make up the vast majority of Medicare ACOs today, are considered MIPS APMs. The benefits available within Advanced APMs do not apply to MIPS APMs. MIPS APM members must participate in MIPS to receive any favorable payment adjustments, they do not qualify for the annual 5% lump sum bonus, and they are not eligible for the higher fee schedule updates beginning in the year 2026. However, MIPS APM participants DO receive favorable program benefits. Besides the embedded APM-specific rewards already contained in the APMs payment model, in 2018 MIPS APM participants automatically receive full credit in the Improvement Activities MIPS performance category. Also, MIPS APM members are able to maximize their physician fee schedule rates by participating in the MIPS path. Those potential positive adjustments continue indefinitely versus the 5% lump sum bonus only available for the first 6 years of the program.
Learn about the latest fee schedule changes moving from Fee for Service to Value or Quality based payment methodologies, via MACRA/ MIPS/ QPP.
To help clarify some of the terms surrounding Medicare Access and CHIP Reauthorization Act (MACRA), the AMA has compiled a list of acronyms, terms and definitions.
ABC™ - Achievable Benchmark of Care
ACO - accountable care organization
AHRQ - Agency for HealthCare Research and Quality
APM - alternative payment model
APRN - advanced practice registered nurse
ASPE - HHS’ Office of the Assistant Secretary for Planning and Evaluation
AUC - appropriate use criteria
BPCI - bundled payments for care improvement
CAH - critical access hospital
CAHPS - Consumer Assessment of Healthcare Providers and Systems
CBSA - non-core based statistical area
CDS - clinical decision support
CEHRT - certified EHR technology
CFR - Code of Federal Regulations
CHIP - Children’s Health Insurance Program
CJR - comprehensive care for joint replacement
CMMI - Center for Medicare & Medicaid Innovation (CMS Innovation Center)
CMS - Centers for Medicare and Medicaid Services
COI - collection of information
CPIA - clinical practice improvement activity
CPOE - computerized provider order entry
CPR - customary, prevailing and reasonable
CPS - composite performance score
CPT - Current Procedural Terminology
CQM - clinical quality measure
CY - calendar year
DPP - diabetes prevention program
eCQM - Electronic Clinician Quality Measure
ED - Emergency Department
EHR - electronic health record
EP - eligible professional
ESRD - End-stage Renal Disease
FFS - fee for service
FQHC - federally qualified health center
FR - Federal Register
GAO - Government Accountability Office
GPCI - Geographic Practice Cost Index
HAC - hospital-acquired condition
HCAHPS - Hospice Consumer Assessment of Healthcare Providers and Systems
HHS - Department of Health & Human Services
HIE - Health Information Exchange
HIPAA - Health Insurance Portability and Accountability Act of 1996
HITECH - Health Information Technology for Economic and Clinical Health
HOPD - Hospital Outpatient Department
HPSA - health professional shortage area
HRSA - Health Resources and Services Administration
IHS - Indian Health Service
IPAB - Independent Payment Advisory Board
IT - information technology
LDO - large dialysis organization
MA - medical assistant
MAC - Medicare Administrative Contractor
MACRA - Medicare Access and CHIP Reauthorization Act of 2015
MedPAC - Medicare Payment Advisory Commission
MEI - Medicare Economic Index
MIPAA - Medicare Improvements for Patients and Providers Act of 2008
MIPS - Merit-based Incentive Payment System
MLR - minimum loss rate
MSPB - Medicare spending per beneficiary
MSR - minimum savings rate
MU - Meaningful Use
MUA - medically underserved area
NCQA - National Committee for Quality Assurance
NPI - National Provider Identifier
NQF - National Quality Forum
OCM - Oncology Care Model
OIG - Office of the Inspector General
ONC - Office of the National Coordinator for Health Information Technology
PCMH - patient-centered medical home
PCORI - Patient-centered Outcomes Research Institute
PECOS - Medicare Provider Enrollment, Chain and Ownership System
PFPMs - physician-focused payment models
PFS - physician fee schedule
PHS - public health service
PPS - prospective payment system
PQRS - Physician Quality Reporting System
PTAC - Physician-focused Payment Model Technical Advisory Committee
QCDR - qualified clinical data registry
QIO - quality improvement organization
QP - qualifying APM participant
QPP - Quality Payment Program
QRDA - quality reporting document architecture
QRUR - quality and resource use reports
RAC - recovery audit contractor
RBRVS - Resource-based Relative Value Scale
RFI - request for information
RHC - rural health clinic
RIA - regulatory impact analysis
RVU - relative value unit
SGR - sustainable growth rate
TCPI - Transforming Clinical Practice Initiative
TIN - tax identification number
VBM - value-based payment modifier
VPS - volume performance standard