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   RE: opportunity for imps Please respond?
 From: Peter Liepmann
 To: Member Forum
 Posted: 05-13-2017 21:54
 Message: Hi all,
I just uploaded text of the final rule for the Advanced APM criteria and CMS's discussion about them in the rulemaking, under
"Advanced APM criteria" in the IMP library.
There are links to the Federal Register source.

My head is spinning from reading this rulemaking stuff.  I believe that a plan submitted through PTAC comes under section 1115A(c) of MACRA, and qualifies under the 'Medical Home' part of the statute, but IANAL.
That would mean the plan would need less risk exposure to have "more than nominal" risk. It doesn't actually make much difference, because the risk in the PCMH program is 3% vs. 8%, of the total paid by Medicare, as a maximum loss.
(Current FFS payment is about $33-40 pmpm. This would increase to $92-97pmpm, plus $3-8 pmpm at risk.)

My reading of the rules is that in order to get out of MIPS, you have to be in an "Advanced APM."
In turn, that requires 
• The AAPM must require >50% of participants to use CEHRT;
• The AAPM must provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS;  (In the discussion files, I've highlighted sections that I believe show how HYH could meet that requirement)
• The AAPM must either require that participating AAPM Entities bear risk for monetary losses of a more than nominal amount under the APM, or
• be a Medical Home Model expanded under section 1115A(c) of the Act. For a discussion of Medical Home Models under this criterion, see section II.F.4.b.(6) of this final rule with comment period. (PCMHs still take risk, but may take less.)
First, in order to use HYH as a 'quality measure similar to MIPs', it either has to be registered by NQF (hasn't happened,AFAIK) or have been submitted for consideration by NQF, (which I believe Dr Wasson did,) OR it has to be "endorsed by a consensus-based entity" and be evidence-based, reliable and valid. HYH is undoubtedly evidence-based, reliable and valid.  I respectfully suggest that IMP, being a "consensus-based entity," formally "endorse" HYH as a quality measure. The simplest way to do that would be to poll the members of IMP with SurveyMonkey.


to take the survey.  (Of course, if IMP decided they want to restrict this to paid IMP members, you could create a similar poll and put it in a site restricted to such members.) If members endorse it, it can be used.

Second, the AAPM regs allow for some of the risk to be based on cost performance, but requires some to be based on quality measures. For simplicity, I would recommend it all be based on quality.
(Note this doesn't have to be success on those quality measures, just using the quality measures.)

The general standard is 8%; the PCMH risk amount is 3% for 2018.
So the language could say something like, "AAPM entities will also receive (3% if PTAC submission qualifies this AAPM as a PCMH AAPM, or 8% if not) of total reimbursement as risk-based payments, based on performance on HYH."

That percentage would be 3% or 8% of the 12%, of course, ~$3-8 PMPM.
The reg:

"(c) Financial risk. To be an Advanced APM, an APM must either meet the financial risk standard under paragraph (d)(1) or (2) of this section and the nominal amount standard under paragraph (d)(3) or (4) of this section or be an expanded Medical Home Model under section 1115A(c) of the Act.

(1) Generally applicable financial risk standard. Except for paragraph (c)(2) of this section, to be an Advanced APM, an APM must, based on whether an APM Entity's actual expenditures for which the APM Entity is responsible under the APM exceed expected expenditures during a specified QP Performance Period, do one or more of the following:

(i) Withhold payment for services to the APM Entity or the APM Entity's eligible clinicians;

(ii) Reduce payment rates to the APM Entity or the APM Entity's eligible clinicians; or

(iii) Require the APM Entity to owe payment(s) to CMS.

(2) Medical Home Model financial risk standard. The following standard applies only for APM Entities that are participating in Medical Home Models, and, starting in the 2018 QP Performance Period, such APM Entities must be owned and operated by an organization with fewer than 50 eligible clinicians whose Medicare billing rights have been reassigned to the TIN(s) of the organization(s) or any of the organization's subsidiary entities. The APM Entity participates in a Medical Home Model that, based on the APM Entity's failure to meet or exceed one or more specified performance standards, which may include expected expenditures, does one or more of the following:

(i) Withholds payment for services to the APM Entity or the APM Entity's eligible clinicians;

(ii) Reduces payment rates to the APM Entity or the APM Entity's eligible clinicians;

(iii) Requires the APM Entity to owe payment(s) to CMS; or

(iv) Causes the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments.

(3) Generally applicable nominal amount standard. (i) Except as provided in paragraph (c)(4) of this section, the total amount an APM Entity potentially owes CMS or foregoes under an APM must be at least equal to either:

(A) For QP Performance Periods 2017 and 2018, 8 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities; or

(B) 3 percent of the expected expenditures for which an APM Entity is responsible under the APM.

(4) Medical Home Model nominal amount standard. (i) For a Medical Home Model to be an Advanced APM, the total annual amount that an Advanced APM Entity potentially owes CMS or foregoes must be at least the following amounts:

(A) For QP Performance Period 2017, 2.5 percent of the estimated average Start Printed Page 77550total Medicare Parts A and B revenues of participating APM Entities.

(B) For QP Performance Period 2018, 3 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities;

(C) For QP Performance Period 2019, 4 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities.

(D) For QP Performance Period 2020 and later, 5 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities.

(5) Expected expenditures. For the purposes of this section, expected expenditures is defined as the beneficiary expenditures for which an APM Entity is responsible under an APM. For episode payment models, expected expenditures mean the episode target price.

(6) Capitation. A full capitation arrangement meets this Advanced APM criterion. For purposes of this part, a capitation arrangement means a payment arrangement in which a per capita or otherwise predetermined payment is made under the APM for all items and services for which payment is made through the APM furnished to a population of beneficiaries, and no settlement is performed to reconcile or share losses incurred or savings earned by the APM Entity. Arrangements between CMS and Medicare Advantage Organizations under the Medicare Advantage program (42 U.S.C. 422) are not considered capitation arrangements for purposes of this paragraph."

CMS seems to conflate 'full capitation' with 'capitation', and doesn't seem to consider primary care capitation except as an approximate payment mechanism, adjustable to match FFS.
However, it also seems one could read para (6) to mean primary care capitation.
I would say it makes sense to put in the 'at risk' part of the payment based on quality w (or using) HYH, just to keep PTAC from getting confused.

So to summarize, the AAPM program would: 
  • Require use of CEHRT by more than half of participants
  • Baseline primary care capitation would be 12% of expected global Medicare payments, risk adjusted.
    • Risk adjust with HHS-HCC (used in the CPC+ program.)  Since primary care risk is about half as skewed as global cost risk (NIHCM data) make
      • half the capitation based on the average cost (so, 6% of the expected average global Medicare payments) and
      • half the capitation based on the HHS-HCC adjusted cost (so, 6% of the risk-adjusted expected global Medicare payments.)
  • Somehow, get the diagnoses to Medicare so they can calculate HCC.
  • if HYH quality measures fail ....... reduce the NEXT year's payments by some amount, (0-3% or 0-8%)
  • Patients would sign up with a practice on a website, or could be attributed based on claims.
One option would be to submit 'claims' on all the enrolling patients, with all their diagnoses, a few months before the start, so CMS can calculate HCC, and use the same claim to enroll the person in this AAPM, to start at some future date.  Medicare could assign some code for this, e.g., 'G-Assign', with a minimal payment to cover the cost of extracting all that information.

I do NOT think you should require practices to be IMPs-that would severely limit the applicability, (and reduce the chance PTAC would approve it) for no compelling reason.
The AAPM could be a single practice(=AAPM 'entity') or a group of practices that decided to do this together, though payments would still be made directly to the practices from Medicare. I see no requirement the AAPM has to be bigger than a single practice.

See the discussion in the AAFP AAPM plan submission.

Sorry this is so long.
Lets brainstorm!

Peter Liepmann MD FAAFP MBA
My mission is to fix US health care
Bakersfield CA
Original Message:
Sent: 05-13-2017 10:18
From: Jean Antonucci
Subject: opportunity for imps Please respond?

Thank you Mamantha Scott and Mike

I did make an error and now have had long talk with Gordon Moore about details
(I do get 1.00 a day myself from a small plan plus incentive not mediciad mike,  Medicaid in Maine   by political action,FOR PCPS THAT ARE  INDEPENDENT  is paid at medicare rates. but anyway...)
Current proposal is 2.00/day/patient  and for  people with high burden of disease 3.00/day
Suppose 1000 medicare patients for the sake of simple  math MOst of us have  more like 100-300--- 2/3 are low burden  so 2$ x 365 for 666  is 481,800  and 1/3 very ill  361, 350    so make that 100 patients  48,180 + 36,135= over 83,000 a yr  for 100 of your patients  You can take care of  people for  that !!  If your overhead is low you can do really well  and if you want  increase it  to buy a nurse and increase your panel  which helps the shortage and  help[s you earn more

 IMP should help you lower your overhead and do the imp basics. eg if you have a phone tree that says  please allow three days for a rf,  uh uh  not much of an imp 

 Flu shots and immunizations cost you so are a carve out-- do not count.
There are many people you see never or once a year and others 5-7 average is 2 1/2 to 3 and roughly 500  dollars a yr average( so 100 patietns average 500 a yr is only 50000 AND THAT IS WITH MIPS  crap
Some  docs are good at milking- doing the depression screen and adv  care stuff at wellness visits etc Some of us cannot remember to do all that at that type of visit only and do the codes for that  I am after simple fair sustainable
There are some details to work out but I will not wrangle.  We have to move, here folks.

  One problem is that some  of you are not lowoverhead butt his still should work    1.00 a day  is fabulous for low overhead

 You will need to be an IMP for this- superb access continuity comprehensive care  care corodination

I have  gotten multiple positive responses already but ALMOST NONE from  the imps from thislist servs.

 THe MAine group and the AFFP group seem to get it MAybe no one reads this forum

 What I cannot do is post to AAFP small practice group and if you are on  there I need you to post   for me
I need 5000 patietns minimum and  prob have access to 1000 now


     Jean Antonucci MD
     115 Mt Blue Circle
     Farmington ME 04938
ph 207 778 3313   fax 207 778 3544

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