Alternative Payment Models (APMs) require physicians to take on risk and responsibility for their own cost and quality performance. There are many different styles of APMs. This page is intended to explain some of the common types and provide details on existing models for radiation oncologists.
To be an Advanced APM, an APM must meet the following 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); and
3. Either: (1) be a Medical Home Model expanded under CMS Innovation Center authority; or (2) require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses.
Participants are eligible for a yearly 5 percent incentive payment in the Quality Payment Program (QPP) for participating in an Advanced APM.
Advanced APMs include the Oncology Care Model with two-sided risk, the Medicare Shared Savings Program, a designated Health Care Quality Demonstration Program and Federally Mandated Demonstrations. A radiation oncology specific APM does not yet exist; however, ASTRO is actively working with the CMS to make this option available in the near future. Unless the Oncology Care Model is applicable, ASTRO recommends that radiation oncologists participate in the MIPS program in 2018.
MIPS APMs are designated by CMS. Those physicians participating in the one-sided risk version of the Oncology Care Model or physicians who do not meet Advanced APM requirements can participate in MIPS APMs. They are not excluded from MIPS reporting requirements and may be scored using a special APM scoring standard. Additionally, MIPS APMS do not qualify for the 5 percent annual incentive payment that applies to Advanced APMs. MIPS APMs are those APMs that meet these three criteria: • The APM Entities participate in the APM under an agreement with CMS; • The APM requires that APM Entities include at least one MIPS clinician on a Participation List; and • The APM bases payment incentives on performance (either at the APM Entity or clinician level) on cost/utilization and quality measures.
A MIPS APM is scored using a special APM scoring standard, designed to account for activities already required by the APM. For example, the APM scoring standard eliminates the need for MIPS clinicians to duplicate submission of Quality and Improvement Activity performance category data and allows them to focus instead on the goals of the APM. All of the MIPS clinicians scored under the APM scoring standard will get a MIPS final score based on the APM entity’s combined performance. This method helps you to work with others to improve the quality of care. It also lowers your reporting burden by aligning the reporting requirements for MIPS and the reporting requirements required as part of participating in your APM. If you participate in two or more MIPS APMs, CMS will use the highest final score to calculate your MIPS payment adjustment.
There are limited MIPS APM options for oncology. Some Accountable Care Organizations (ACO) would meet the requirements depending on the architecture of the model. The Oncology Care Model, using one-sided risk, qualifies as a MIPS APM. Also, there are a number of state run models, like Maryland and Vermont that comply with requirements.