"(c) Financial risk. To be an Advanced APM, an APM must either meet the financial risk standard under paragraph (d)(1) or (2) of this section and the nominal amount standard under paragraph (d)(3) or (4) of this section or be an expanded Medical Home Model under section 1115A(c) of the Act.
(1) Generally applicable financial risk standard. Except for paragraph (c)(2) of this section, to be an Advanced APM, an APM must, based on whether an APM Entity's actual expenditures for which the APM Entity is responsible under the APM exceed expected expenditures during a specified QP Performance Period, do one or more of the following:
(i) Withhold payment for services to the APM Entity or the APM Entity's eligible clinicians;
(ii) Reduce payment rates to the APM Entity or the APM Entity's eligible clinicians; or
(iii) Require the APM Entity to owe payment(s) to CMS.
(2) Medical Home Model financial risk standard. The following standard applies only for APM Entities that are participating in Medical Home Models, and, starting in the 2018 QP Performance Period, such APM Entities must be owned and operated by an organization with fewer than 50 eligible clinicians whose Medicare billing rights have been reassigned to the TIN(s) of the organization(s) or any of the organization's subsidiary entities. The APM Entity participates in a Medical Home Model that, based on the APM Entity's failure to meet or exceed one or more specified performance standards, which may include expected expenditures, does one or more of the following:
(i) Withholds payment for services to the APM Entity or the APM Entity's eligible clinicians;
(ii) Reduces payment rates to the APM Entity or the APM Entity's eligible clinicians;
(iii) Requires the APM Entity to owe payment(s) to CMS; or
(iv) Causes the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments.
(3) Generally applicable nominal amount standard. (i) Except as provided in paragraph (c)(4) of this section, the total amount an APM Entity potentially owes CMS or foregoes under an APM must be at least equal to either:
(A) For QP Performance Periods 2017 and 2018, 8 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities; or
(B) 3 percent of the expected expenditures for which an APM Entity is responsible under the APM.
(4) Medical Home Model nominal amount standard. (i) For a Medical Home Model to be an Advanced APM, the total annual amount that an Advanced APM Entity potentially owes CMS or foregoes must be at least the following amounts:
(A) For QP Performance Period 2017, 2.5 percent of the estimated average Start Printed Page 77550total Medicare Parts A and B revenues of participating APM Entities.
(B) For QP Performance Period 2018, 3 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities;
(C) For QP Performance Period 2019, 4 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities.
(D) For QP Performance Period 2020 and later, 5 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities.
(5) Expected expenditures. For the purposes of this section, expected expenditures is defined as the beneficiary expenditures for which an APM Entity is responsible under an APM. For episode payment models, expected expenditures mean the episode target price.
(6) Capitation. A full capitation arrangement meets this Advanced APM criterion. For purposes of this part, a capitation arrangement means a payment arrangement in which a per capita or otherwise predetermined payment is made under the APM for all items and services for which payment is made through the APM furnished to a population of beneficiaries, and no settlement is performed to reconcile or share losses incurred or savings earned by the APM Entity. Arrangements between CMS and Medicare Advantage Organizations under the Medicare Advantage program (42 U.S.C. 422) are not considered capitation arrangements for purposes of this paragraph."
I think one other feature we ought to include in this program is allowing MCR members to opt out on a month's notice, so they're protected against deliberate undertreatment. "Stinting" in the words of CMS:
-- Kathy Saradarian, MD Solo since 2003 Always Private, Small Group since 1990 Practice Partner since 2003 Branchville, NJ
Jean,It might be easier to put in proposal what IS included in Capitation, as opposed to what is not. So less need (incentive) to use all the codes many of us have become adept at using to make a living.In addition, there is now some incentive to primary care doctors to offer even more comprehensive care and provide some of the services that patients are referred to Urgent Care, Specialists, etc.CapitationE/M: 99201-99205, 99211-99215Preventative codes: 99381-99387, 99391-99397Weight loss management,depression screenMMSEAWV / Welcome to medicare:Hospital transition:CCM:Home Health Care orders:CPO:Hospice:PFTSEKG:Waived labs:Immunization admin(I am sure there are other codes I have overlooked that are appropriately apart of capitation and some may disagree with. Others may want to make additions to this list and add the actual codes.)Anything / everything else is still FFS. ie: GYN / Pap - this is a difficult one. Politically probably still better to reimburse for this.Immunizationsbiopsieslaceration repairminor fracture codesI and Dmeds, injectables? All other CPT codes that do not start with 9****NO copay / deductible at primary care. Incentivizes patients to start with primary care. That should save CMS lots of money.i
Second, to be considered an Advanced APM, an APM must meet all three of the following criteria, as required under section 1833(z)(3)(D) of the Act. The criteria are:
The second criterion for an APM to be an Advanced APM is that it provides for payment for covered professional services based on quality measures comparable to measures under the performance category described in section 1848(q)(2)(B)(i) of the Act, which is the MIPS quality performance category. We interpret this criterion to require the APM to incorporate quality measure results as a factor when determining payment to participants under the terms of the APM....
The statute also established priorities for both the quality domains of measures to be developed and the types of measures to be prioritized in the measure development plan, which are located, respectively, at sections 1848(s)(1)(B) and (D) of the Act. The priority measure types include outcome, patient experience, care coordination, and measures of appropriate use of services such as measures of overuse.
We wanted to ensure that APMs have the latitude to base payment on quality measures that meet the goals of the APM and assess the quality of care provided to the population of patients that the APM participants are serving. It is important to note that many APMs include some common measures that are proposed for inclusion in MIPS. For example, many of the quality measures used in the Shared Savings Program and the Next Generation ACO Model are also proposed for inclusion in MIPS.
However, APMs that focus on patients with specific clinical conditions such as end-stage renal disease (ESRD), or on patients undergoing specific surgical procedures, would have valid reasons for including different quality measures than those that target more general populations. Similarly, some APMs may focus on specialist eligible clinicians for whom there may be only a small number of valid and relevant quality measures. Lastly, we cannot predict the specific care goals and payment designs of future PFPMs and other APMs. Consequently, we did not want to impose measure requirements that would prevent us from including quality measures that may be better suited to the specific aims of new innovative APMs.
We proposed that the quality measures on which the Advanced APM bases payment must include at least one of the following types of measures provided that they have an evidence-based focus, and are reliable, and are valid:
(1) Any of the quality measures included on the proposed annual list of MIPS quality measures;
(2) Quality measures that are endorsed by a consensus-based entity;
(3) Quality measures developed under section 1848(s) of the Act;
(4) Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act; or
(5) Any other quality measures that CMS determines to have an evidence-based focus and be reliable and valid.
We believe that quality measures that are endorsed by the National Quality Forum (NQF) would meet these criteria. Because each APM Entity is different, there needs to be the flexibility to determine which measures are most appropriate for use in their respective APM for the purpose of linking those measures to payment under the APM. Measures that could be used in both MIPS and APMs are beneficial to eligible clinicians who may switch from one program to the other, but we also do not want to restrict APMs from including new innovative measures that may not be included in MIPS initially, or until later years of the program."
Under section 1848(q)(2)(D)(v) of the Act, the final annual list of quality measures must include, as applicable, measures from under section 1848(k), (m), and (p)(2) of the Act, including quality measures among:(1) Measures endorsed by a consensus-based entity;(2) measures developed under section 1848(s) of the Act; and(3) measures submitted in response to the "Call for Quality Measures" required under section 1848(q)(2)(D)(ii) of the Act.Any measure selected for inclusion that is not endorsed by a consensus-based entity must have an evidence-based focus. Further, under section 1848(q)(2)(D)(ix), the process under section 1890A of the Act is considered optional."