CAPG’s Guide to Alternative Payment Models

Case Studies of Risk-Based Coordinated Care

Welcome to CAPG’s Guide to Alternative Payment Models. In this special CAPG publication, several of our members share their firsthand experiences with existing, tested, and proven alternative payment models (APMs). By learning about their experiences, you will gain valuable insights into how these models work—and how you can succeed with them.

This knowledge is critical. Medicare is engaged in a concerted push toward risk-based coordinated care. Last year, Health and Human Services Secretary Sylvia Burwell announced goals to transform Medicare from volume to value by increasing physician participation in APMs. President Obama later signed the Medicare Access and CHIP Reauthorization Act (MACRA), which includes a 5 percent incentive payment for participating in advanced APMs. The nation is now clearly on its way toward risk-based APMs.

This guide is designed to help you understand these new models. The case studies illustrate the payment foundation for risk-based coordinated care across a variety of payer types, including Medicare, Medicaid, and commercial health plans. Each vignette explains the form of payment from the payer to the physician organization, and then the payment from the physician organization to the individual physician or provider.

You’ll also learn where each model is successful and strong, and where each has room for improvement. Key areas where CAPG members are demonstrating success in APMs include:

  • Improving the quality and efficiency of care for patients. These APMs align physician payment to the achievement of performance objectives.

  • Encouraging team-based care and a commitment to primary care.

  • Innovating to better meet the needs of patients, particularly those with chronic conditions.

In addition to the significant progress our members are making in improving patient care and innovation, several themes have emerged where there is room for improvement:

  • Improving data sharing with payers to continue to drive care improvements.

  • Engaging patients in new payment approaches, particularly in accountable care organizations (ACOs).

  • Aligning quality measures across programs. This will play an important role in reducing the burden on physician practices and getting actionable information to consumers.

As physicians across the nation embark on this journey toward risk-bearing arrangements, we hope you find this paper a practical, helpful, and invaluable guide. We would like to offer a special thank you to the CAPG members who so generously shared their experiences.

PDF icon APMGuideFinal.pdf1.48 MB
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