An Alternative Payment Model (APM) is a payment approach that offers incentive payments for providing high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
On November 1, 2018, the final 2019 Medicare Physician Fee Schedule (PFS) was released by the US Centers for Medicare and Medicaid Services (CMS). The rule contains changes to the Quality Payment Program, including the new requirement for certain physical therapists in private practice to participate in the Quality Payment Program (QPP) through 1 of 2 tracks: either the Merit-based Incentive Payment System (MIPS) or Advanced APMs. (Review more information on MIPS). Advanced APMs are a subset of APMs that let practices earn more rewards in exchange for taking on risk related to patient outcomes.
In the Advanced APM track of QPP, you may earn a 5% incentive for achieving threshold levels of payments or patients, and participation in the Advanced APM exempts you from the MIPS reporting requirements (the other QPP track).
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Current Medicare Bundled APMs
Bundled Payment for Care Improvements Advanced (BPCI Advanced)
BPCI Advanced is a new voluntary episodic payment model that will test bundled payments for episodes of care related to 32 conditions or procedures, from acute myocardial infarction to urinary tract infection. BPCI Advanced qualifies as an Advanced APM under QPP. An episode of care begins either with an inpatient admission to an acute care hospital (called an anchor stay) or with the start of an outpatient procedure (called an anchor procedure). Anchor stays are identified by MS-DRGs, and anchor procedures are identified by HCPCS codes. The episode ends 90 days after the end of the anchor stay or anchor procedure. The first group of participants starts October 1, 2018; CMS will offer a second application period in spring 2019, for a January 2020 start. The program is scheduled to end December 31, 2023. Physical therapists are eligible to participate.
Review CMS's overview of BPCI Advanced.
Comprehensive Care for Joint Replacement Model (CJR)
CJR is a payment model being tested for episodes of care related to total knee and total hip replacements (MS-DRG 469 and 470) under Medicare. One track of the CJR model qualifies as an Advanced APM under QPP. The model began April 1, 2016, and will run through December 31, 2020. CJR holds participant hospitals financially accountable for the quality and cost of an episode of care and incentivizes increased coordination among participating hospitals, physicians, and postacute care providers such as physical therapists. An episode of care begins with a patient's hospital admission, continues upon hospital discharge, and ends 90 days postdischarge to cover the patient's complete period of recovery.
As of February 1, 2018, about 465 hospitals in 67 metropolitan statistical areas are participating in CJR. Physical therapists in these areas are encouraged to consider affiliation with these hospitals.
Review CMS's overview of CJR.
Bundled Payments for Care Improvement (BPCI) Initiative
BPCI comprises 4 broadly defined models that link payments for the multiple services beneficiaries receive during an episode of care, making the service providers jointly accountable for the patient's care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care.
Review CMS's overview of BPCI.
Current Medicaid APMs
Maternal Opioid Misuse (MOM) Model
The Maternal Opioid Misuse (MOM) Model will serve pregnant women with opioid use disorder (OUD) who are covered by Medicaid and the Children's Health Insurance Program and elect to participate in the model. Beneficiaries will be covered during the prenatal, peripartum, and postpartum periods. The model addresses the need to better align and coordinate care of this vulnerable population. The key participants are a state Medicaid agency and a health system or payer, which partners with clinicians to deliver care. The state Medicaid agency will be responsible for ensuring that beneficiaries participating in the model have access to a set of essential physical and behavioral health services. The model will have a 5-year performance period with funding to be provided in 3 phases: pre-implementation (Year 1); transition (Year 2); and full implementation (Years 3-5). Care delivery will begin in Year 2. Up to 12 states will be awarded funding for the model, and a Notice of Funding Opportunity is expected in early 2019 to solicit applications. The 5-year performance period is expected to run from fall 2019 to fall 2024.
Review CMS's overview of MOM Model.
InCK Model is a child-centered local service delivery and state payment model that aims to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and the Children’s Health Insurance Program (CHIP). The InCK Model will support state and local provider efforts to conduct early identification and treatment of children with behavioral and physical health-related needs. Participants will be required to integrate care coordination and case management across physical and behavioral health and other local service provider settings to provide child-and family-centered care. The key participants are a state Medicaid agency and a local entity designated as the lead organization. The model will include a 2-year pre-implementation period followed by a 5-year model implementation period. A Notice of Funding Opportunity is expected in fall 2018, with funding to be awarded as early as spring 2019.