Quality Payment Program: Alternative Payment Models

The Medicare Accessibility and CHIP Reauthorization Act (MACRA) introduced several changes to the physician reimbursement framework. MACRA replaced the Sustainable Growth Rate formula with the Quality Payment Program (QPP) to provide incentives that emphasize value and quality of care over volume.

Under the QPP, clinicians can participate in either the Merit-based Incentive Payment System (MIPS) or in Advanced Alternative Payment Models (APMs) to avoid downward payment adjustments and potentially receive upward adjustments. CMS estimates for the first few performance years a majority of clinicians will follow the MIPs track, however CMS' goal is for all physicians to participate under APMs.

More information on the Quality Payment Program and MIPS »

What are Advanced Alternative Payment Models

An APM is a payment model based on risk and reward for providing coordinated, high-quality, efficient care. Advanced APMs are a subset of APMs that take on risk linked to reported measures, use of electronic health records and reduced cost and increased quality. If the APM can meet these requirements, they become an Advanced APM and the affiliated clinicians become qualified participants (QPs).

As a QP, you may earn a 5% Medicare incentive payment during 2019 through 2024 and be exempt from MIPS if you have sufficient annual participation in an Advanced APM, based on a percentage of Part B payments or patients.

The ACR is following the development of Advanced APMs and continues to track how radiology may fit into such models.

Advanced Alternative Payment Models Overview

Accountable Care Organizations

ACOs are groups of doctors, hospitals and other health care providers who voluntarily come together to give coordinated, high-quality care to the patients they serve.

Radiation Oncology Model

On September 18, 2020, the Centers for Medicare and Medicaid Services (CMS) released a mandatory Radiation Oncology (RO) Model final rule. Certain RO providers in randomly selected areas are required to participate in the payment model, and these affected practices are listed on CMS’ Participating Zip Code List. The RO Model will include 30% of RO episodes in eligible geographic areas.

The RO Model will qualify as an advanced alternative payment model (APM) under the Quality Payment Program (QPP). The RO Model will require participants to annually certify their intent to use Certified Electronic Health Record Technology (CEHRT), include quality measure performance as a factor when determining payments, and require RO participants to bear more than a nominal amount of financial risk. Within 30 days of the start of PY1, the RO participant would be required to certify its intent to use CEHRT. Participants who do not meet the QP threshold will not qualify for the APM incentive payment and, instead, will be assigned to a MIPS APM.

In December 2021, the RO Model was further delayed by Congressional action. The model was set to begin on January 1, 2022, and end December 31, 2026. Due to the delay, Under the RO Model, Medicare will pay participating providers and suppliers a prospective, modality agnostic, site-neutral, episode-based payment for specified technical and professional RT services furnished during a 90-day episode to Medicare fee-for-service beneficiaries diagnosed with 16 different cancer types. The base payment amounts for RT services included in the model will be the same for hospital outpatient departments (HOPDs) and freestanding radiation therapy centers. The ACR continues advocacy efforts to improve the payment methodology of the model.

Questions regarding the RO Model may be submitted to economics staff via Smartsheet.

Medicare Shared Savings Program

The Medicare Shared Savings Program (MSSP) is an alternative payment model that encourages groups of doctors, hospitals, and other health care providers to come together as an ACO to give coordinated, high quality care to their Medicare beneficiaries. CMS is encouraging providers to participate in ACOs through the MSSP, which allows for different participation options/tracks that best fit an organization. Among these different levels and tracks, there are several of which qualify as Advanced APMs.

Bundled Payments for Care Improvement Advanced (BPCI Advanced)

The BPCI Advanced Model aims to encourage clinicians to adopt best practices, reduce expenditures, and improve quality throughout a clinical episode. This model qualifies as an advanced APM, operates under a total-cost-of-care concept, and eligible inpatient clinical episodes included in the model are stroke and simple pneumonia.

Articles on APMs

Additional Resources