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.

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