Alternative Payment Models (APMs)
The Patient-Centered Asthma Care Payment (PCACP) model was developed by the American College of Allergy, Asthma & Immunology (ACAAI). It is designed to give asthma specialists and primary care providers the resources and flexibility they need to more accurately diagnose, treat, and manage patients with asthma and asthma-like symptoms.
The PCACP model would create two new flexible monthly payments for asthma specialists:
Both of these new payments would replace standard evaluation and management (E/M) payments during the months the patients are receiving the services.
In addition, for patients who have achieved control of their asthma following an initial period of treatment, both asthma specialists and primary care providers would be able to bill and be paid for non-face-to-face visits in addition to traditional E/M services in order to support continued successful care of the patients' asthma.
Patient-Centered Oncology Payment (PCOP) was developed by the American Society of Clinical Oncology (ASCO). It is designed to enable medical oncology practices to function as a community-based "oncology medical home" that provides high-quality care to patients with most types of cancer.
Under PCOP, oncology practices would receive three types of Care Management Payments (CMP) in addition to current payments for office visits and administration of chemotherapy:
Making Accountable Sustainable Oncology Networks (MASON) was developed by Barbara McAneny, MD and Innovative Oncology Business Solutions, Inc. It is intended to provide oncology practices with adequate, flexible payments needed to support high-quality care for patients with cancer and to control the cost of cancer care.
MASON would create a set of Oncology Payment Categories (OPC), each of which defines a group of patients who have the same type of cancer, similar comorbidities, and similar treatment plans. A "target price" would be established for each OPC based on the expected costs of cancer-related care for patients with those characteristics. The oncology practice would have the flexibility to deliver services that are not adequately supported by fee-for-service payments as long as the total cost of care is within the target price.
In order to ensure the quality of care, the practice would be responsible for following evidence-based clinical pathways in the treatment of the patient.
The Center for Healthcare Quality and Payment Reform (CHQPR) developed Patient-Centered Payment for Care of Chronic Conditions. It is intended to enable patients who have chronic conditions to receive high-quality care from a specialist when needed in addition to care from their primary care practice. Although every chronic disease is different, physicians face similar barriers in treating most chronic conditions under current payment systems, and these barriers could be resolved using this patient-centered payment approach.
Under Patient-Centered Payment for Care of Chronic Conditions, a specialist physician practice could receive the following payments to support diagnosis, care planning, and/or condition management services for an individual who has the symptoms of a chronic disease or who has been diagnosed with a chronic condition:
The Comprehensive Colonoscopy APM was developed by the Digestive Health Network. It is intended to provide adequate, flexible payments to support high-quality screening colonoscopies, and to make the cost of colonoscopies more predictable and comparable.
Instead of separate payments for each individual service, a single bundled payment would be paid that covers all of the services required for a colonoscopy, including the physician performing the procedure, the facility where the procedure is performed, anesthesiology, radiology, and pathology. In addition, the payment would also have to cover the cost of any ED visits needed to evaluate complications that occur within 7 days of the colonoscopy.
The Acute Unscheduled Care Model (AUCM) was developed by the American College of Emergency Physicians (ACEP). It is designed to give emergency physicians the time and resources necessary to enable more patients to be treated and safely discharged to home rather than being admitted to the hospital.
The AUCM APM would be used for patients who come to an Emergency Department (ED) with a condition such as abdominal pain, chest pain, altered mental status, or syncope that often result in unnecessary hospital admissions. Under the APM, emergency physicians could be paid for transitional care management services to a patient prior to and following discharge, and for telehealth visits and home visits with the patient after discharge. The physician would be accountable for reducing the total cost of services delivered to the patients during the 30 days following discharge, including the cost of return ED visits and inpatient admissions.
The Incident End-Stage Renal Disease (ESRD) APM was developed by the Renal Physicians Association (RPA). It is designed to enable nephrologists to deliver high-quality care to patients who have advanced chronic kidney disease (CKD) and are beginning dialysis therapy. Many patients experience complications during the first few months of dialysis due to failure to prepare adequately for the transition and due to lack of care management support during the transition. The APM is intended to reduce the frequency and severity of these complications by enabling and encouraging improved services.
Under the Incident ESRD APM, a nephrologist would take responsibility for the total cost of services to a CKD patient during the six months following initiation of dialysis. If the nephrologist can reduce this cost through better preparation of the patient for dialysis or better care management during the initial months of dialysis, the nephrologist would receive a share of the savings.
Patient-Centered Epilepsy Care Payment (PCECP) was developed by the American Academy of Neurology. It is designed to give neurologists and primary care physicians the resources and flexibility they need to make accurate diagnoses and to deliver appropriate, cost-effective treatment for patients with epilepsy.
Patient-Centered Epilepsy Care Payment (PCECP) would replace current evaluation and management (E/M) services payments with flexible monthly payments that could be used to deliver a range of services to patients without the restrictions in the current fee-for-service system. Because epilepsy patients need different types of care during different phases of the diagnosis and treatment process, PCECP payments would be divided into nine categories corresponding to these different phases of care:
Patient-Centered Headache Care Payment (PCHCP) was developed by the American Academy of Neurology. It is designed to give neurologists, primary care physicians, and other headache specialists the resources and flexibility they need to make accurate diagnoses and to deliver appropriate, cost-effective treatment for patients with headaches and migraines.
Because different services are needed by patients during different phases of their care, there would be three categories of PCHCP payments:
The Project Sonar APM was developed by Lawrence Kosinski, MD. It is intended to support the delivery of effective care management services to patients with inflammatory bowel disease (IBD) and also to patients with other chronic conditions that have high rates of avoidable hospitalizations.
Under the Project Sonar APM, the physician practice managing the care of a patient with inflammatory bowel disease (or the chronic condition the practice is managing) would receive a monthly payment to support the cost of care management staff and a communications system that proactively contact patients to monitor their symptoms and intervene early to prevent or reduce the severity of disease exacerbations.
The SMARTCare APM was developed by the American College of Cardiology and the Center for Healthcare Quality and Payment Reform. It is intended to enable patients with chest pain and other symptoms associated with heart disease to be accurately diagnosed and successfully treated while avoiding unnecessary tests and invasive procedures.
Under the SMARTCare APM, a team of cardiologists and other physicians and providers could receive three new payments for patients with suspected and diagnosed stable ischemic heart disease:
The Maternity Care APM was developed by the Center for Healthcare Quality and Payment Reform. It is designed to enable more women to deliver babies in birth centers rather than hospitals, reduce the frequency of Cesarean sections in low-risk births, support more extensive prenatal and postpartum care services for higher-risk women, and improve outcomes for both mothers and babies.
Under the APM, a Maternity Care Team would receive five different types of payments during the different phases of perinatal care:
The Maternity Care Team would receive no payment during a month or phase of care if the Team failed to provide all evidence-based care to the woman or if a "never event" occurred (i.e., death of the mother, unexpected death of the infant, or iatrogenic injury to the infant). Payments to the Team would be reduced if desirable outcomes (e.g., physiologic childbirth, successful breastfeeding) were not achieved during a particular phase of care.
The Patient and Caregiver Support for Serious Illness (PACSSI) payment model was developed by the American Academy of Hospice and Palliative Medicine (AAHPM). It is intended to enable interdisclipinary palliative care teams to deliver community-based palliative care to patients with a serious illness.
Under the PACSSI APM, palliative care teams would receive monthly care management payments instead of payments for evaluation and management (E/M) services. Payments would be higher for patients with more functional limitations.
Patient-Centered Primary Care Payment is designed to provide adequate, flexible payments to primary care practices to support the three principal types of services they deliver: (1) wellness care, (2) chronic condition management, and (3) non-emergency acute care. Additional payments would be available to support the delivery of integrated behavioral health services.
Patient-Centered Primary Care Payment would have separate payments for each of these types of services in order to ensure that each patient can receive the combination of services they need and want, and also to ensure that primary care practices with different types of patients can be paid adequately for the specific types of services they need to provide:
The practice would only receive monthly payments for wellness care and chronic condition management for patients who explicitly enroll with the practice to receive those services. The practice would continue to receive standard evaluation and management payments for non-enrolled patients, and it would continue to receive fees for delivering procedures and tests.
This APM was developed by Jean Antonucci, MD, a solo family physician practicing in Farmington, Maine. It is intended to provide adequate, predictable, and flexible payments that support the delivery of high-quality services to patients by small primary care practices.
Under this APM, a primary care practice would receive a monthly payment for each patient that would support all of the primary care services that patient needs. A higher amount would be paid for patients at higher risk of poor outcomes as determined by the patient’s responses to the questions in the “What Matters Index” from the How’s Your Health patient-reported outcomes survey.