Taking Alternative Payment Models one step at a time

There’s been a lot of talk about quality payment programs – we’ve been publishing articles on it, and it’s been everywhere you look. We’ve covered the new payment policy changes, MIPs, and now, we’re looking at Alterative Payment Models, (APMs). The Advocacy Council of ACAAI has even been hard at work developing an asthma APM for our specialty. So, what’s the big deal?

APMs 101

Under the MACRA legislation, physicians who meet participation thresholds in advanced alternative payment models (AAPMs) will qualify for a 5% lump sum payment bonus and will not have to participate in the MIPS program. The program takes effect January 1, 2017; however based on CMS’ proposal, it appears that very few physicians will be able to qualify for these payments, at least in 2017.

To qualify as an AAPM, the entity must bear at least “nominal risk.” CMS has narrowly defined nominal risk so as to exclude about 95% of Medicare Shared Savings or Accountable Care Organizations (ACOs) as well as patient-centered medical homes. Instead, only those ACOs or entities that have downside risk will qualify. In addition to being risk bearing, AAPMs must also tie payment to quality benchmarks and 50% of participants must use a certified EHR.

Participation thresholds for 2017 and 2018 require that 25% of payments or 20% of patients be through an AAPM. Those percentages increase to 75% and 50% by 2024. Physicians who participate in APMs but do not meet the bonus criteria may be able to use their APM participation to improve their MIPS score or opt out of MIPs. CMS intends the APM program be flexible so physicians can move easily between MIPs and APMs.

Creating an APM step by step

The good news: the APM rule encourages specialties to develop APMs that address specific health problems they can control, rather than the one-size-fits-all nature of previous quality reporting programs. That’s why the College is working to develop APMs just for allergists. 

The Advocacy Council has initially focused on developing an APM for asthma. The APM sub-committee has 11 members, including seven advocacy experts, one practice manager and three outside consultants. We are fortunate to be guided by two APM experts:  Harold Miller from the Center for Health Care Quality & Payment Reform and Sandy Marks from the AMA.

First we determined which APMs to develop. We identified the top health conditions for our specialty along with the associated barriers and opportunities for providing quality care and improved value. This narrowed our focus to three potential APMs:  asthma; allergic rhinitis and chronic sinusitis; and immunotherapy. We decided to focus on asthma first, and we reviewed and refined several iterations of an asthma APM – including an all-day working session in Chicago. 

So what are the next steps for our asthma APM?

  • Finding practices willing to test it.
  • Collecting and analyzing practice claims, utilization and clinical data.
  • Developing a financial model to justify APM implementation to payers.
  • Getting feedback from A/I physicians.
  • Getting feedback from PCPs.

If your practice is interested in learning more about being a pilot test site for the asthma APM, please contact Jennifer Pfeifer at jenniferpfeifer@acaai.org

APM development and approval takes time. A/I physicians should plan on participating in MIPS in 2017, and possibly in 2018. Be assured the Advocacy Council will continue to focus on developing APMs for our specialty and will keep you informed about steps you need to take to participate in MIPS next year.

Advocacy Issue: 
Billing, Coding & Payments
APMs