2022 Alternative Payment Models

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created incentives for physicians to participate in APMs and a pathway for development of new payment models. The goal of APMs is to improve the quality and value of care, reduce growth in health care spending, or both. Surgeons who are considered Qualifying Participants (QPs) in an Advanced APM qualify for a 5-percent lump-sum Medicare incentive payment and are exempt from MIPS. However, it is important to note, that the 2022 performance period is the last year to qualify for the 5 percent APM payment incentive, payable in 2024.

MIPS APM

Participation in an APM does not, in and of itself, exempt a clinician from MIPS or ensure that the clinician is eligible for the 5 percent incentive payment. Certain APMs are considered MIPS APMs and their participants may be required to participate in MIPS, but also may be eligible for certain scoring benefits to recognize their efforts through the APM and avoid duplicative accountability. As such, a MIPS APM participant reports under traditional MIPS (at any level, including the APM Entity level) they will automatically receive 50 percent credit for the Improvement Activities performance category. To be considered a MIPS APM, participating entities must maintain a participation list of MIPS-eligible clinicians, base payment incentives on clinicians' performance with respect to cost and quality measures, and maintain a participation agreement with CMS or otherwise be approved as a model by law or regulation.

Advanced APM

MACRA created incentives for participation in certain more robust APMs that require participating entities to accept more financial risk, use certified electronic health record technology (CEHRT), and adjust payment based on quality measures equivalent to those in MIPS. CMS created the designation A-APMs, which is essentially a subset of APMs that have been certified by CMS to meet these three requirements. A clinician must be a QP in an A-APM to be exempt from MIPS and qualify for the 5 percent incentive payment under the QPP.

**While one of the goals of the QPP is to transition clinicians and practices into APMs and CMS offers a number of APMs, many of the available models do not recognize the importance of surgeon leadership and the team-based nature of surgical care.

All-Payer/Other Payer APM Option

Eligible clinicians may also become QPs through the All-Payer Combination Option. In order to do so, a clinician must be in a Medicare Advanced APM, but can combine their participation with an Other-Payer Advanced APM to meet the QP criteria.

Other-payer Advanced APMs are payment arrangements that can fall under Medicaid, Medicare Health Plans—Medicare Advantage, Medicare-Medicaid Plans, 1876 Cost Plans, Programs of All Inclusive Care for the Elderly (PACE) plans—CMS Multi-Payer 4 Models, Commercial and private payer arrangements categories. They also must meet the following Other-Payer Advanced APM criteria:

• The use of certified EHR technology (CEHRT). The other payer payment arrangement requires at least 75 percent of Eligible Clinicians in each participating APM entity group to use CEHRT to document and communicate clinical care information.
• Payments for covered professional services must be based on quality measures that are comparable to the MIPS Quality performance category. There must be evidence-based, reliable, and valid quality measures, with at least one outcome measure if available on the MIPS measure list.
• Participants must bear a certain amount of financial risk. A payment arrangement meets the financial risk if actual expenditures exceed expected aggregate expenditures, or be a Medicaid Medical Home Model that meets criteria comparable to Medical Home Models.

CMS will post a list of Other-Payer Advanced APMs online before the QP Performance Period.

Surgeons or practices who participate sufficiently in an Advanced APM are considered Qualifying Participants or QPs. To become a QP, you must receive at least 50 percent of your Medicare Part B payments or see at least 35 percent of Medicare patients through an Advanced APM entity during the QP performance period (January 1–August 31). In addition, 75 percent of practices within an Advanced APM entity must be using certified EHR Technology (CEHRT). If a surgeon qualifies as a QP, they have an opportunity to receive a 5 percent APM incentive payment and are excluded from MIPS.

Surgeons can also be Partial QPs, meaning that they may choose whether or not they want to participate in MIPS. To qualify as a Partial QP, you must receive at least 40 percent of your Medicare Part B payments or see at least 25 percent of Medicare patients through an Advanced APM Entity during the QP performance period. Surgeons should use the QPP Participation Status Lookup Tool to determine if they are meet the thresholds of a QP and/or Partial QP and if they are eligible to participate through an Advanced APM entity.

If you participate in a MIPS APM, but not at a volume to achieve QP status, you still must participate in MIPS to avoid a penalty. Clinicians in MIPS APMs may participate in the APP or traditional MIPS at the individual, group, virtual group or APM Entity level in 2022. However, reporting requirements and scoring accommodations will depend on which track is selected.

CMS APMs Overview

CMS MIPS APMs Overview

CMS Advanced APMs Overview