What is—and isn’t—an Advanced APM in 2018

CMS has outlined which alternative payment models (APMs) qualify as Advanced APM under the Quality Payment Program (QPP) this year, thus giving participating providers a 5 percent payment bonus.

Advanced APMs have to meet three criteria:

  1. Require participants to use certified electronic health record technology (CEHRT).
  2. Provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of the Merit-based Incentive Payment System (MIPS).
  3. Either be a Medical Home Model expanded under CMS Innovation Center authority or require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses.

CMS has 38 total APMs, of which only 10 qualify as Advanced APMs:

  1. Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)
  2. Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 - CEHRT)
  3. Comprehensive ESRD Care (CEC) Model (LDO arrangement)
  4. Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement)
  5. Comprehensive Primary Care Plus (CPC+)
  6. Medicare Accountable Care Organization (ACO) Track 1+ Model
  7. Medicare Shared Savings Program (MSSP) ACO Tracks 2 & 3
  8. Next Generation ACO
  9. Oncology Care Model (OCM) (two-sided risk arrangement)
  10. Vermont Medicare ACO Initiative

Opportunities for Advanced APM were reduced in 2017 when CMS cancelled two mandatory bundled payment models. Specialty groups have been taking it upon themselves to develop new models, such as one proposed by the American Academy of Family Physicians.

Some of the qualifying models have related tracks that don’t involve any downside risk. While they don’t meet the standards of Advanced APMs, they are classified as MIPS APMs, which have special scoring requirements and are scored using the “APM scoring standard,” which means no duplicative submission of performance data related to the quality and improvement activities categories.

The MIPS APMs are:

  1. Comprehensive ESRD Care (CEC) Model (non-LDO arrangement one-sided risk arrangement)
  2. MSSP ACO Track 1
  3. Oncology Care Model (OCM) (one-sided risk arrangement)

With the exception of CJR, the other Advanced APMs can also be MIPS APMs for clinicians which fall below thresholds on patients served or payments received through an Advanced APM. They will then be scored under the MIPS APM standard.