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"Advanced" Alternative Payment Models

Psychiatrists, other physicians, and non-physician practitioners may qualify for Medicare payment incentives for participating in new models of care and delivery that improve quality, lower health care spending, or both.

Some may be eligible for 5% incentive payments, from 2019 through 2024, if they have sufficient revenue or patients tied to these new models of care to be considered a "qualifying participant" in an "Advanced" Alternative Payment Model (APM). They are also exempt from the MIPS program and will receive slightly higher annual payment increases starting in 2026.

Those with slightly lower levels of revenue or patients tied to Advanced APMs may be considered "partially qualifying participants." They can elect not to do MIPS reporting, and not incur a penalty.

To be considered an Advanced APM, a model must be approved by CMS and meet the following criteria:

  1. Requires participants to use certified EHR technology;
  2. Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and
  3. Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a significant financial risk.

There is currently no Advanced APM strictly for mental health or substance use disorders.

The Physician-Focused Payment Model Technical Advisory Panel (PTAC) reviews proposals for new APMs. But current policies make it very difficult to develop Advanced APMs for mental health. Psychiatrists who are currently underpaid would have to risk up to an 8% payment reduction if the APM fails to produce cost savings. Meeting the CEHRT requirements is also a challenge. Unless these policies improve, psychiatrists will probably continue to see few options for participating in Advanced APMs.

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