Alternative Payment Models (APMs) What You Need to Know...Alternative Payment Models (APMs) – What You Need to Know Find out if your organization will benefit from APM participation

Alternative Payment Models (APMs) –What You Need to KnowFind out if your organization will benefit from APM participation

Presented by:Dr. Dan Mingle

President and CEO

©2018 Mingle Analytics1

What we plan to cover:✓ What APMs are and the different types✓ Benefits of a practice joining an APM✓ APM Solutions™ by Mingle Analytics

Q&AWe’ll stay on after the presentation

to answer your questions!

©2018 Mingle Analytics 2

Introducing Mingle Analytics

Analytics for Value Based Health Care• #1 registry by volume for Group

submissions in 2015• Trusted by more than 30,000 providers• 99%+ submission success rate

More that 50 team members dedicated to helping you succeed with Medicare reporting


Healthcare Payment is ChangingFrom Volume to Value


What are they and the different types?

Alternative Payment Models (APMs)


Alternative Payment Models

• Payment Incentive for high-quality and low-cost care• Can apply to:

– specific clinical condition– care episode– population


• APM defined as an agreement with CMS or by law or regulation

• Must have at least one MIPS-eligible clinician• The APM entity must adjust provider payment on

quality and cost metrics

MIPS APM Criteria


An Advanced Alternative Payment Model (AAPM) =

An APM with more than a nominal amount of financial risk

Advanced APMs

CMS Quality Payment Program©2018 Mingle Analytics 8

• Participants use certified electronic health record technology (CEHRT)

• Quality is measured similar to the quality performance category of the Merit-based Incentive Payment System (MIPS)

• Provider payment is adjusted based on quality metrics • Bear more than a nominal amount of financial risk for monetary

losses• OR be a Medical Home Model expanded under CMS

Innovation Center authority• There are Volume Thresholds by $ or Patient Count to be

• Qualified Participant (QP)• Partially Qualified Participant (Partial QP)

Advanced APM Criteria


• 5 percent Medicare bonus payment in payment years 2019-2024 • Added to upside gains• Offset downside risks

• Higher fee schedule updates starting in 2026.

Financial Benefit to Advanced APM


APM Framework*

*Developed by the Health Care Payment Learning and Action Network

Category 1 – FFS – No MIPSCategory 2 – FFS - MIPSCategory 3 – MSSP, Next Gen ACOCategory 4 –


APM Type Appeals to Primary Features Advanced APM?

Medicare Shared Savings Program (MSSP) ACO starting point Track 1 – Upside only N

Testing risk Track 1+ - Minimal risk Y

Orgs with risk bearing experience Tracks 2, 3 – Full Risk, Higher shared savings

Y

Next Generation Accountable Care Organization (NGACO)

Orgs willing to take on higher levels of risk and reward than MSSP

Payment flexibility, benchmarking, beneficiary communication

Y

Comprehensive Primary Care Plus (CPC+) Primary care practices positioned to engage in patient-centered practice

Care coordination payments Y

Bundled Payments for Care Improvement Advanced (BPCI Advanced)

Practices experienced with care and coordination of specific episodes of care

Payment rewards the quantity of services offered by providers rather than the quality of care furnished

Y

Oncology Care Model – (OCM) Oncology care providers with a strong care coordination capability

Two sided risk model Y

Comprehensive End Stage Renal Disease Care Model (CEC)

Specialists with care coordination capabilities

Two sided risk model Y


APM, MIPS, and Qualified Participants


Quality Payment Program(QPP)

First Pathway Second Pathway

(MIPS)Merit-Based

IncentivePayment System

(APM)Alternative Payment Models

Meet or Exceed QP Thresholds

Earn APM BonusExcluded from MIPS

Below QP but Meet or Exceed Partial QP Threshold

No APM BonusChoose if participate in MIPS

Below Partical QP Threshold

MIPS APM

Other Payer APM Participation ThresholdsPatient Count Method

From the Final Rule

Other Payer APM Participation ThresholdsPayment Method

From the Final Rule

How do you determine the risks and benefits of joining an APM?

Benefits• Better care for patients• Potential to bring positive change

to practice• Added resources• Potential for additional revenue• Insight into practice performance• MIPS considerations

Risks• Impact of change (fatigue)• Additional work• Costs of change• Resistance (negativity, etc) • Failure• Contracting with APM Entity


2016 Research Results by Berenson, et al on Whether ACOs Help or Hinder Primary Care

Deliver High Quality Care Benefits• streamlined communications with

specialists• access to ACO-funded staff such as

nurses and care coordinators• support for data analysis• enhanced ability to deliver team-

based care• increased prestige.

Drawbacks• added bureaucracy• loss of autonomy• referral restrictions• incentive or payment systems that

fail to make a clean break with fee-for-service.


Conclusions From The Berenson 2016 ACO Study

• joining an ACO could help a practice’s deliver high-quality care• Some requirements are counterproductive• Small practices seem to have higher risks and benefits


Succeeding as an APM or AAPM • Quality performance + Cost efficiency – informed through• Data-driven decision making and care of patients

• Population health strategies• Risk stratification• Annual wellness visits• Chronic Care Management• Coordination of care

• Using available data• CCLF files• Managing Risk• Monitoring Performance


Population Health• Identifying Population (Attribution)• Predictive and current risk of each attributed member• Use of annual wellness exam

• Benefits to Attribution• Identify and remediate Risks• Identify service opportunities – improve quality

scores• Care management strategy and use of CCM codes• Developing and maintaining referral channels (Planned

Care)©2018 Mingle Analytics 20

Data available from CMS: (CCLF)• Analyze for:

• High cost users – coordination opportunities• Leakage/ Network Integrity • Rising risk – management opportunities, risk

mitigation• Care gaps – performance improvement


22

APM Solutions™Maximize potential for APM incentive and bonus payments.Regularly monitor and analyze quality measure performance.

Manage all components of the program in one place.

Analyze and track your performance.

Our tools help you track the status of your reporting and stay informed about your progress.

Review performance by practice and provider on a regular basis. Extend your reporting capability with data integration.

Understand the measures that are best for you and your practice.

Send your data to Medicare for all programs and payment models.

Research eligibility, specifications, and use our analyzers to make an informed decision about the

measures most applicable to your organization.

✓ Qualified Registry for QPP (MIPS & APMs)✓ Data Submission Vendor (DSV)✓ ACO Reporting

©2017 Mingle Analytics

Beginning at $759 per provider

Track Performance Across Practices


Drill-Down by Practice, Provider, and Measure


APM Solutions™

Submission is the easy part.Let us help you with the hard part.✓ Create a plan to avoid penalty and report to CMS✓ Optimize incentive and potential bonus✓ Select the right measures✓ Analyze and improve performance✓ Successfully submit data to Medicare

Sign up today to get started.https://mingleanalytics.com/get-started/


APM Solutions™

Q&A

Tiffany asks:

If you are apart of an ACO do you still file MIPS separately outside of that ACO?


Q&A

Janet asks:

How do you determine the risk and benefit of joining an APM? What questions to ask.


Q&A

Heather asks:

How do we involve resistant providers in the process?


Q&A

Gail asks:

We are a Track 1 ACO (MIPS APM). We were advised the new exceptions/exclusions for small practices do not apply if the small practice is part of a MIPS APM. Is this correct?


Q&A

Sela asks:

What is the minimum months that we need to participate with APM?


Q&A

Barbara asks:

What are common ACO EHR requirements?


Q&A

Maria asks:

I would like to understand the risks with MSSP track 1+ and benchmarking.


Questions?

Ask questions now or email: [email protected]

Your Partner for Value-Based Healthcare Contact us today to succeed with MIPS, APMs,

and the Quality Payment Program.

Register for webinars or Access Recordings @ http://mingleanalytics.com/webinars


mailto:[email protected]

http://mingleanalytics.com/webinars

Documents

Alternative Payment Models (APMs) What You Need to Know...Alternative Payment Models (APMs) – What You Need to Know Find out if your organization will benefit from APM participation