The Changing APM Landscape

25 Pages·2016·1.46 MB·English

The Changing APM
Landscape: Opportunities
and Challenges
Pamela M. Pelizzari, MPH, Milliman
Erin Smith, JD, naviHealth
Agenda
Key pressures for CMS
• 2018 Goal of 50% of FFS payments through APMs
• MACRA – opportunities for physicians to participant
• Demonstrating success – nearing a decade post-ACA
Case study: Advanced BPCI
• Expectations
• What’s this say about the future of bundled payment models
Developing new APMs
• Key financial analyses
• Operational challenges
2
Key Pressures for CMS
3
HHS goals for shifting from volume to value
HHS Timeline for Transition to Value (% Medicare Payments)
Traditional FFS
Payments
20% 30% 50% FFS Linked to
Quality or Value
FFS Paid Through
60% APMs
55% ES1
40%ES3
20%
15% 10%
2014 2016 2018
4
Slide 4
ES1 These percentages all add up to 100%, but they aren't the same size. it's kind of confusing. Also these are the
percentages for linking payment to value or quality.
Erin Smith, 5/9/2016
ES3 From HHS: "HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value
through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements
by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying
85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs
such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs."
Erin Smith, 5/9/2016
MACRA Implementation
MACRA incentivizes physicians to join Advanced Alternative Payment Models
(Advanced APMs)
• Avoid downward payment adjustments from MIPS
• Earn a 5% lump sum incentive payment for 5 years
• Receive larger physician fee schedule updates
• Reduced burden of reporting for MIPS
However, there are only a small number of advanced APMs currently available
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Advanced APMs
2017 – Confirmed Advanced APMs 2018 – Expected Additions
• Comprehensive Primary Care Plus • Comprehensive Care for Joint
Replacement – Track 1
• Comprehensive ESRD Care Model –
LDO arrangement and non-LDO • Episode Payment Models – Track 1
two-sided risk arrangement
• Medicare Shared Savings Program
• Next Generation ACO Model ACO Track 1+
• Oncology Care Model – two-sided • New voluntary BPCI-like Model
risk arrangement
• Medicare Shared Savings Program
ACO – Tracks 2 and 3
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Advanced BPCI
Next phase of BPCI
7
CMS intends to continue BPCI-like voluntary models
“[B]uilding on the BPCI initiative, the  Expected to be a graduation from BPCI
Innovation Center intends to Classic
implement a new voluntary bundled • Looking to ACOs as an example –
payment model for CY 2018 where Next Gen allows new opportunities for
the model(s) would be designed to Pioneer ACOs
meet the criteria to be an Advanced • CMS will not want to appear as if
APM.” penalizing early adopters
- Advancing Care Coordination Through Episode • CMS wants to hold on to participants
Payment Models (EPMs) Proposed Rule (81 FR and gain new ones
50810)
 Voluntary models must provide strong
incentives to participate
 Required to either expand the model
(with certification from OACT) or test a
new payment model
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Expectations for Advanced BPCI
• Participation
o Multiple provider types may participate
o Voluntary = no rulemaking
• Streamline model options – Models 1 and 4 will not be included
• Continue with complete cost of care models, include everything unless
specific exception – similar to BPCI Classic
• Continue current risk bearing structure – w/ convener and episode initiator
• Advanced model will be open to new participants
• Longer performance periods – shifting away from quarterly recon period
• Target prices prospectively
• Advanced APM
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