How Healthcare will change completely with the APMs?

The MACRA rule proposed by the CMS includes a dual track Quality Payment Program and has many healthcare organizations considering their options. One of them is the much talked-about Merit-based Incentive Payment System, or MIPS and the other is Alternative Payment Models (APMs). APMs are being touted as an encouraging way to help the healthcare industry transition from fee-for-service to value-based care and improve the quality of care and contain costs. Despite some uncertainties, APMs are here to stay and will be a significant component in a value-based ecosystem.

What are APMs?

The Alternative Payment Models include the Medicare Shared Savings Program, all the CMS Innovation Center Initiatives except Health Care Innovation awards, and a few demonstration programs. The final MACRA rule demands that all the payments made under an APM be based on quality measures comparable to the ones in MIPS. There are certain criteria APMs must meet:

• Utilizing a certified EHR system.
• Experience of more than a nominal level of financial risk.
• Recognition as a Medical Home Model as defined under Section 1115A(c) of MACRA.

Models under APMs

There are only 6 models within the proposed MACRA rule that qualify as APMs:

• Comprehensive ESRD Care Model
• Comprehensive Primary Care Plus
• Medicare Shared Savings Program – Track 2
• Medicare Shared Savings Program – Track 3
• Next Generation ACO Model
• Oncology Care Model: Two-sided Risk Arrangement

Key Issues Healthcare Providers May Face

There are some practical issues that have to be addressed before providers step into APMs and become a part of a larger systematized workflow:

• Access to timely data: It’s important for providers to gain access to actionable data about the care patients receive and subsequently share it in a timely fashion through interoperability. The need to have accurate data also comes up during contract negotiations and pinpointing the areas for enhanced efforts.  
• Defined patient attribution: To assess the delivery of urgent care and quality metrics, there needs to be a proactively defined list of patients that have been attributed to different Primary Care Physicians. The lack thereof, can be frustrating and pose roadblocks in managing the population in a performance period.

• Data transparency: Without proper data transparency, it can be hard for providers to have an estimate of their performance around certain metrics, ensure clear attributions, and learn about their growth and shortfall and have every stakeholder pointing in the same direction.

• Measure definitions: Aligning measure definitions across systems is important to ensure both payers and providers are measuring the same metrics by the same yardstick. Having an unstandardized system of measurement and reporting can affect synchronization and outcomes.

• Integration networks: The lack of a strong integration network can cause barriers in sharing information and understanding how every physician in the network delivers on quality improvement goals and later on, challenge overall performance improvement.

5 Must-Knows to Succeed in APMs

To succeed in value-based care, and more importantly, in APMs, here are five key elements healthcare organizations should understand and take care of before stepping into Alternative Payment Models:

• Actionable data: Access to meaningful and updated performance data at the right time is crucial for providers to track and monitor their performance in real-time, complete with a robust feedback loop.  

• Patient assignment: Every aspect of assigning a patient – whether to an individual physician or a group practice, to referrals and lab orders, reconciliation of costs, or emergency care among many others should be looped into one system where it can be tracked and understood together.

• Real-time decision making: Succeeding in APMs require providers to have a 3600 view of their population with complete documentation of disease registries, lab results, clinical decisions, supported by advanced data analytics to remove guesswork and have a near real-time decision making support setup.

• Patient-level quality data: It is critical for providers to have access to patient-level data that helps them identify high-need, high-cost patients and make informed decisions about the quality of care and resource allocation, as well as effective follow-ups post episode to avoid readmissions.

• Term and payment: Providers need to make a strategic decision beforehand on the term of agreement and the timeframe for payment and reconciliation. Decisions should also be made on the processes for appeal and deductions.

In this transformative era for U.S. healthcare, Alternative Payment Models are just one of the many changes. The federal government along with every healthcare organization are committed to providing the required resources and doing their needful to support and guide the medical practices in making the right choices and achieving better health outcomes. Understanding the basic elements and moving forward towards a landscape of quality healthcare is the key for APMs and to drive stronger outcomes in the long run.

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