Centers for Medicare and Medicaid Services Health Care Payment Learning and Action Network: Draft Framework on Alternative Payment Models

The Centers for Medicare and Medicaid Services (CMS) Health Care Payment Learning and Action Network‘s Alternative Payment Model (APM) Framework and Progress Tracking Work Group has published a draft framework for APMs. The draft framework will be presented and discussed at the first HCPLAN summit on October 26 and during a webinar on November 10.  The Work Group is seeking public comments on the draft framework by November 20.

The CMS Health Care Payment Learning and Action Network is working to support the U.S. Department of Health and Human Services goal of having 30% of U.S. health care payments in APMs or population-based payment by 2016, and 50% by 2018.

The framework begins with the following principles:

Principle 1: The Work Group recognizes that changing the financial reward to providers is only one way to stimulate and sustain innovative approaches to the delivery of patient-centered care. In the future, the Work Group believes it will be important to monitor progress in initiatives that empower patients (via meaningful performance metrics, financial incentives, and other means) to seek care from high-value providers and become active participants in clinical and shared decision-making.

Principle 2: As delivery systems evolve, the goal is to drive a shift towards shared-risk and population-based payment models, in order to incentivize delivery system reforms that improve the quality and efficiency of patient- centered care.

Principle 3: To the greatest extent possible, value-based incentives should reach providers who directly deliver care.

Principle 4: Payment models that do not take quality and value into account will be classified in the appropriate category with a designation that distinguishes them as a payment model that is not value-based. They will not be considered APMs for the purposes of tracking progress towards payment reform.

Principle 5: In order to reach our goals for health care reform, the intensity of value-based incentives should be high enough to influence provider behaviors and it should increase over time. However, this intensity should not be a determining factor for classifying APMs in the Framework. Intensity will be included when reporting progress toward goals.

Principle 6: When health plans adopt hybrid payment reforms that incorporate multiple APMs, the payment reform as a whole will be classified according to the more dominant APM. This will avoid double-counting payments through APMs.

Principle 7: Centers of excellence, patient-centered medical homes, and accountable care organizations are delivery models, not payment models. These delivery system models enable APMs and, in many instances, have achieved successes in advancing quality, but they should not be viewed as synonymous with a specific APM. Accordingly, they appear in multiple locations in the Framework, depending on the underlying payment model that supports them.

The framework outlines four progressive categories of payment models that move towards increased implementation of APMs:

Category One: Fee-for-Service with No Link to Quality and Value

Category Two: Fee-for-Service Linked to Quality and Value, with sub-categories of infrastructure support (e.g. care coordination, electronic health records); pay-for-reporting; pay-for-performance; and both pay-for-performance and penalties

Category Three: APMs Built on Fee-for-Service Architecture, with sub-categories of shared savings opportunities (with no down-side risks); and shared savings with both upside and downside risks

Category Four: Population-Based Payment, with sub-categories limited to certain sets of condition-, specialty-, or facility-specific services; and capitated or population-based for all health care

The issuance of this draft framework by key stakeholders convened by CMS is occurring at the same time that CMS is seeking responses to its pre-rulemaking request for information on APMs as part of the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA).  That public comment period was just extended to November 17, 2015.

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