Quality Payment Program: Alternative Payment Models
The Medicare Accessibility and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) introduced changes to the physician reimbursement framework in 2015 through the Quality Payment Program (QPP) that emphasize value and quality of care over volume.
Under the QPP, clinicians can participate in either the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models to avoid downward payment adjustments.
Advanced Alternative Payment Models
An Alternative Payment Model (APM) is a payment model based on risk and reward for providing coordinated, high-quality, efficient care. Advanced APMs are a subset of APMs that take on risk linked to reported measures, use of electronic health records, reduced cost and increased quality. If the APM can meet these requirements, they become an Advanced APM and the affiliated clinicians become qualified participants (QPs).
For payment years 2026 and beyond, payment rates under the Medicare Physician Fee Schedule for covered professional services furnished by the QPs will be updated annually by the 0.75% qualifying APM conversion factor. Payments to non-QPs will be updated annually by a 0.25% conversion factor. APM Incentive Payments are paid two years after the QP Performance Period. The 2022 QP Performance Period/2024 payment year was the last time that QPs could receive a 5% APM Incentive Payment.
ACR® is following the development of Advanced APMs and continues to track how radiology may fit into such models.
Accountable Care Organizations
Accountable Care Organizations (ACOs) are groups of doctors, hospitals and other healthcare providers that voluntarily come together to give coordinated, high-quality care to the patients they serve.
Medicare Shared Savings Program
The Medicare Shared Savings Program (MSSP) is an alternative payment model that encourages groups of doctors, hospitals and other healthcare providers to come together as an ACO to provide coordinated high-quality care to their Medicare beneficiaries. CMS is encouraging providers to participate in ACOs through the MSSP, which allows for different participation options/tracks that best fit an organization. Among these different levels and tracks, there are several that qualify as Advanced APMs.
Bundled Payments for Care Improvement Advanced Model
The Bundled Payments for Care Improvement (BPCI Advanced) Model aims to encourage clinicians to adopt best practices, reduce expenditures and improve quality throughout a clinical episode. This model qualifies as an Advanced APM, operates under a total cost of care concept and eligible inpatient clinical episodes included in the model are stroke and simple pneumonia.