Skip to main content

What to expect from CMS’ second decade of APM programs

CMS has introduced more than 50 innovative care delivery models designed to drive health system transformation over the last decade. Only six of those produced significant savings; of those, only four met the requirements to be expanded.

As the second 10-year period of the program gets underway, which includes $10 billion in new funding, CMS’ Center for Medicare and Medicaid Innovation is considering numerous changes to improve the overall success of these programs and, in turn, drive overall gains in care outcomes and health equity. When evaluating what has worked in the past and what changes are needed moving forward, it is important to review what success looks like for Alternative Payment Model programs. 

CMMI relies on three benchmarks to measure levels of success:

  1. The gold standard: improving quality of care while simultaneously reducing expenditures.
  2. Improving quality of care without impacting expenditures.
  3. Reducing expenditures without impacting quality of care.

To better meet these metrics, major adjustments must be made moving forward to enable health systems to improve the value for the communities. CMS has identified the hurdles involved and has proposed next steps, including steps to 1) simplify programs, 2) increase health equity, and 3) drive further provider participation. 

Here is more on the key changes CMS must make to advance these goals:

  1. Fewer and more parsimonious models that simplify overlap issues. Complex payment policies and model overlap rules can make participation difficult due to conflicting or opposing incentives and rules, high administrative burden and prohibitive investments. To address this, CMS must make APM requirements as transparent and easy to understand as possible, while integrating with other APMs and value-based care programs. This will simplify scaling and integration into broader CMS operations for participants.
  2. An emphasis on health equity must be considered with any new model designs. Currently, APMs do not reflect the full diversity of beneficiaries represented in Medicare and Medicaid, and their success has not been assessed across diverse populations. For future models, CMMI is working to understand barriers to participation, reducing implicit bias in model design and implementation, and better analyzing the impact of its models across more diverse populations.
  3. CMS must drive additional provider participation and minimize selection bias.  Model participation has been limited and affected by selection bias since providers are able to opt in to models only if they project savings. This can ultimately impact the evaluation of existing models’ success. Selection bias issues can be addressed by reducing risk of participation, especially to those who serve traditionally underserved communities, and adjusting model design to encourage participation.  

Data analytics is the key for future APM participation

As CMMI begins to employ these changes, providers can prepare for and more successfully participate in APMs through emerging digital health options. As the industry continues to digitize, processing data efficiently will become a requirement, rather than an option. A strong data analytics infrastructure can offer an indication of which programs are right for you, measure performance of existing programs and quantify results. 


Popular posts from this blog

BPCI Advanced – take advantage of the model extension now

The Bundled Payment for Care Improvement (BPCI) Advanced Model is now open for applications until May 31, 2023. This model provides a unique opportunity to acute care hospitals and physician group practices who are looking to: evaluate their bundle performance; rejoin if they have previously dropped out due to being under a convener; or take advantage of the changes to the model. With a small window to sign the participation agreement, you’ll need experts to process data quickly and accurately for evaluation. BPCI Advanced Program Details The Centers for Medicare & Medicaid Services (CMS) announced in October 2022 that this program will extend from January 2024 to December 2025. Data used for evaluation will be taken from the baseline period between October 2018 and September 2022. A participation agreement will be sent out in September 2023 and needs to be signed by October 2023 in order to participate. Those who apply before the May 31 deadline will benefit

BPCI Advanced Model Extension

CMS recently made several major announcements about the Bundled Payments for Care Improvement Advanced Model.  The model, which was due to expire at the end of 2023 (Model Year 6), will be extended for an additional two years through Dec. 31, 2025.  New applications will be accepted in 2023 for the two-year extension. Participants still active in Model Year 6 can continue without reapplying by signing an amended and restated participation agreement for Model Year 7.  New methodological changes will be implemented for Model Year 6, which starts on Jan. 1, 2023. Methodological changes include that: the CMS Discount Factor for medical clinical episodes will be reduced from 3% to 2%;  the Peer Group Trend Factor Adjustment cap for all clinical episodes will be reduced from 10% to 5%; the Major Joint Replacement of the Upper Extremity clinical episode category will become a multi-setting episode category by allowing episodes to be triggered when the procedure is performed in the hospital ou

You’ve been accepted to the Enhancing Oncology Model. Now what?

The Centers for Medicare and Medicaid Services Innovation Center recently announced approved applicants for the new Enhancing Oncology Model. If your facility has been selected by CMS, are you still weighing your options during the current baseline evaluation period?  Two deciding factors may include the program data that CMS provides and whether EOM is enough of an improvement over the prior Oncology Care Model to make your investment worthwhile. Another factor to consider: Will you have the resources in place to conduct a baseline evaluation before EOM’s program start on July 1, 2023? How EOM differs from OCM EOM aims to improve the coordination of oncology care, drive practice transformation and reduce Medicare fee-for-service spending through episode-based payment. It includes three major updates: Fewer cancer types. Compared with OCM’s 21, EOM will be limited to seven common cancer types: breast, prostate, lung, small intestine/colorectal, multiple myeloma, lymphoma and chronic le