Pin Down the Innovation Models in the Quality Payment Program

Posted on 31 May, 2017 |comments_icon 4|By Jeff G Lawson

In a nutshell, the Quality Payment Program rolled out January 2017 creates an environment where you—the eligible clinician—compete for incentive dollars.

In this new program, you may earn incentive payments by participating in Advanced Alternative Payment Models (APMs), which involve meeting specified criteria and accepting some risk for your patients’ quality and cost outcomes.


Each Innovation Models falls into one of seven categories:

  1. Accountable Care

Accountable Care Organizations (ACO) and similar care models are designed to incentivize healthcare providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, high quality and efficient service delivery.

  1. Episode-based Payment Initiatives

Under these models, healthcare providers are held accountable for the cost and quality of care beneficiaries receive during an episode of care, which usually begins with a triggering healthcare event (such as a hospitalization or chemotherapy administration) and extends for a limited period of time.

  1. Primary Care Transformation

Primary care providers are a key point of contact for patients’ healthcare needs. Strengthening and increasing access to primary care is critical to promoting health and reducing overall healthcare costs. Advanced primary care practices — also called “medical homes” — utilize a team-based approach, while emphasizing prevention, health information technology, care coordination, and shared decision making among patients and their providers.

  1. Initiatives Focused on the Medicaid and CHIP Population

Medicaid and the Children’s Health Insurance Program (CHIP) are administered by the states, but are jointly funded by the federal and state governments. Initiatives in this category are administered by the participating states.

  1. Initiatives Focused on the Medicare-Medicaid Enrollees

The Medicare and Medicaid programs were designed with distinct purposes. Individuals enrolled in both Medicare and Medicaid (the “dual eligibles”) account for a disproportionate share of the program’s expenditures. A fully integrated, person-centered system of care that ensures that all their needs are met could better serve this population in a high quality, cost effective manner.

  1. Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models

Many innovations necessary to improve the healthcare system will come from local communities and healthcare leaders from across the country. By partnering with these local and regional stakeholders, CMS can help accelerate the testing of models today that may be the next breakthrough tomorrow.

  1. Initiatives to Speed the Adoption of Best Practices

Recent studies indicate that it takes nearly 17 years on average before best practices – backed by research – are incorporated into widespread clinical practice — and even then the application of the knowledge is very uneven. The Innovation Center is partnering with a broad range of healthcare providers, federal agencies professional societies and other experts and stakeholders to test new models for disseminating evidence-based best practices and significantly increasing the speed of adoption.

You can learn more about the Quality Payment Program through the MACRA Final Rule.

Read the “Final Rule” at the Federal Register or read the “Executive Summary of the Rule” at

To learn more about which Innovation Model best suits your practice—and to stay on track for optimum reimbursement with strategies to avoid payment cuts in the coming years—pick up your copy of Guidebook to Medicare Access and CHIP Reauthorization Act of 2015.


Jeff G Lawson

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