Form CMS-10620 National Data Collection Metric

Generic Clearance for the Heath Care Payment Learning and Action Network (CMS-10575)

National_Data_Collection_Metric_508c

Tracking the Adoption of Alternative Payment Models (CMS-10620)

OMB: 0938-1297

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1297 can be found here:

Document [pdf]

Download: pdf | pdf

Introduction
The Health Care Payment Learning and Action Network's (LAN) goal is to bring together private payers,
providers, employers, state partners, consumer groups, individual consumers, and other stakeholders to
accelerate the transition to alternative payment models.
To measure the nation's progress, the LAN launched the National APM Data Collection Effort. This
workbook will be used to collect health plan data according to the original APM Framework and line of
business to be aggregated with other plan responses.

Contents
Introduction
Introducing the workbook and providing important instructions

General Information

Background description about health plan data submission

Commercial Metrics

Metrics to report commercial dollars flowing through APMs

Medicare Advantage Metrics

Metrics to report Medicare Advantage dollars flowing through APMs

Medicaid Metrics

Metrics to report Medicaid dollars flowing through APMs

Cross Checking

Questions to identify whether there are outliers and data needs correction

Definitions

Defines key terms
If you have any questions, please view the Frequently Asked Questions or email Andrea Caballero at
acaballero@catalyze.org

General Information
Question
Please contact name e-mail and
phone for the health plan
respondent.
What is the total number of
members covered by the health
plan by line of business?
Question
In which state(s) does the health
plan have business? Please
specify which line of business
next to the state name.
(C- commercial, MA – Medicare
Advantage, MCO – Medicaid)

Name
E-mail
Phone
Comm
MA
MCO

Information

State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio

Question
In which state(s) does the health
plan have business? Please
specify which line of business
next to the state name.
(C- commercial, MA – Medicare
Advantage, MCO – Medicaid)

State
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

Question
What is the plan’s total health
Care spend (in-and out of
network) by line of business?
Please specify if you are using CY
2016 data or most recent 12
months. Please specify if the time
Reporting differs by line of
Business
If you are using most recent 12
months, please specify the 12
month
Does your submission include
the prescription drug claims data
under the pharmacy benefit in
denominator (total spend)?If yes,
what percent of the pharmacy
benefit spend is included?
Does your submission include
behavioral health claims data
In the denominator (total spend)?
If yes, what percent of the
behavioral health spend is
included?
Please list other assumptions,
qualifications, considerations, or
limitations related to the data
submission.

Information

Comm
MA
MCO

Question
How many hours did it take your
Organization to complete this
Survey by line of business? Please
Report your response in?

Commercial
Hours:
Medicare
Advantage
Hours:
Medicaid
Hours:

Information

Commercial Metrics
Goal/Purpose = Track total dollars paid through legacy payments and alternative payment methods
(APMs) in calendar year (CY) 2016 or most recent 12 months, as specified.
The goal is NOT to gather information on a projection or estimation of where the plan would be if their
contracts were in place the entire calendar year. Rather it is based on what the plan actually paid in
claims for the specified time period.

Methods
The metrics should report actual dollars paid through APMs CY 2016 or during the specified time period.
For example, if a provider is paid $120,000 for the entire year, but entered a shared savings contract
with the plan on July 1, 2016, the payments the provider received from January 1, 2016 through June 31,
2016 ($60,000) would be reported as fee-for-service and the payments the provider received from July
1, 2016 through December 31, 2016 ($60,000) would be reported as shared savings, if the reporting
period is for CY 2016. An acceptable approach is annualizing dollars paid in APMs based on a point in
time, e.g. on a single day such as December 31, 2016, only if the APM contract existed for the full 12month period. For example, a provider in a shared savings arrangement received $300 (a combination
of $285 base payment plus $15 in shared savings), which, if multiplied by 365 (annualized), would be
reported as $109,500 in shared savings CY 2016. An unacceptable approach is counting all of dollars paid
to the provider as being in APMs for the entire year, regardless of when the contract was executed (e.g.
considering the first example, counting $120,000 in shared savings even though the contract was only in
place for half of the reporting year). NOTE: this method is much more vulnerable to variation from
actual spending depending on the representativeness of the time period annualized.
Plans should report the total dollars paid, which includes the base payment plus any incentive, such as
fee-for-service with a bonus for performance (P4P), fee-for-service and savings that were shared with
providers, etc.
To the extent payment to a provider includes multiple APMs, the plans should put the dollars in the
dominant APM. For example, if a provider has a shared savings contract with a health plan and the
provider is also eligible for performance bonuses for meeting quality measures (P4P), the health plan
would report the FFS claims, shared savings payments (if any), and the P4P dollars in the shared savings
subcategory (Category 3).

Metrics
Please note that the dollars paid through the various APMs (numerator) are actual dollars paid to
providers’ CY 2016 or most recent 12 months unless another method, such as annualizing, is used.
Numerators should not be calculated based on members attributed to APMs unless the provider is held
responsible for all care (in network, out of network, inpatient, outpatient, behavioral health, pharmacy)
the patient receives.

Alternative Payment Model Framework – Category 1 (Metrics below apply to
total dollars paid for commercial members. Metrics are NOT linked to quality)
# Numerator
1 NA

2 Total dollars paid
to providers
through legacy
payments
(including FFS
without a quality
component and
DRGs) payments
in CY 2016 or
most recent 12
months.

Numerator
Value
NA

Denominator
Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.
Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator Metric
Value
0
Denominator to
inform the metrics
below

Metric
Value
NA

Dollars under
legacy payments
(including FFS
without a quality
component, DRGs,
and capitation
without quality):
Percent of total
dollars paid
through legacy
payments
(including FFS
without a quality
component and
DRGs) in CY 2016
or most recent 12
months.

Alternative Payment Model Framework – Category 2
(All methods below are linked to quality).
# Numerator
3 Dollars paid for
foundational
spending to
improve care
(linked to
quality) in CY
2016 or most
recent 12
months.
4 Total dollars paid
to providers
through FFS plus
P4P payments
(linked to
quality) in CY
2016 or most
recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

5 Total dollars paid
in Category 2 in
CY 2016 or most
recent 12
months.

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Denominator Metric
Value
0
Foundational
spending to
improve care:
Percent of dollars
paid for
foundational
spending to
improve care in CY
2016 or most
recent 12 months.
0
Dollars in P4P
programs: Percent
of total dollars
paid through FFS
plus P4P (linked to
quality) payments
in CY 2016 or most
recent 12 months.
* CPR historic
metric - trend.
0
Payment Reform APMs built on FFS
linked to quality:
Percent of total
dollars paid in
Category 2.

Metric
Value
NA

Alternative Payment Model Framework – Category 3
(All models below are linked to quality).
#

Numerator

Total dollars paid to
providers through FFSbased shared-savings
(linked to quality)
payments in CY 2016
or most recent 12
months.

Numerator
Value
0

Denominator
Total dollars paid to
providers (in and
out of network) for
commercial
members in CY
2016 or most
recent 12 months.

Denominator
Value
0

Metric
Dollars in shared-savings
(linked to quality)
programs: Percent of
total dollars paid
through FFS-based
shared-savings
payments in CY 2016 or
most recent 12 months..

Metric
Value

Numerator

Numerator
Value

Total dollars paid
to providers
through FFS-based
shared-risk (linked
to quality)
payments in CY
2016 or most
recent 12 months.

Total dollars paid
to providers
through
procedure-based
bundled/episode
payments (linked
to quality)
programs in CY
2016 or most
recent 12 months.

Total dollars paid
to providers
through
population-based
payments that are
not conditionspecific (linked to
quality) in CY 2016
or most recent 12
months.

Total dollars
paid to
providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

10 Total dollars paid
in Category 3 in CY
2016 or most
recent 12 months.

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator

Total dollars
paid to
providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.
Total dollars
paid to
providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value

Metric

Metric
Value

Dollars in shared0
risk programs:
Percent of total
dollars paid through
FFS-based sharedrisk (linked to
quality) payments in
CY 2016 or most
recent 12 months.

Dollars in
procedure-based
bundled/episode
payments (linked to
quality) programs:
Percent of total
dollars paid through
procedure-based
bundled/episode
payments in CY
2016 or most recent
12 months.
Population-based
payments to
providers that are
not conditionspecific and linked
to quality: Percent
of total dollars paid
through populationbased (linked to
quality) payments
that are not
condition-specific in
CY 2016 or most
recent 12 months.
Payment Reform APMs built on FFS
architecture:
Percent of total
dollars paid in
Category 3.

Alternative Payment Model Framework – Category 4
(All models below are linked to quality).
#

Numerator

Total dollars
paid to
providers
through
populationbased
payments for
conditions
(linked to
quality) in CY
2016 or most
recent 12
months.
Total dollars
paid to
providers
through
conditionspecific,
bundled/episod
e payments
(linked to
quality) in CY
2016 or most
recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Denominator Metric
Value
0
Population-based
payments for
conditions (linked
to quality):
Percent of total
dollars paid
through
condition-specific
population-based
payments linked
to quality in CY
2016 or most
recent 12 months.
0
Dollars in
condition-specific
bundled/episode
payment
programs (linked
to quality):
Percent of total
dollars paid
through
condition-specific
bundled/episodebased payments
linked to quality in
CY 2016 or most
recent 12 months.

Metric
Value
NA

Numerator

Total dollars
paid to
providers
through full or
percent of
premium
populationbased
payments
(linked to
quality) in CY
2016 or most
recent 12
months.

Total dollars
paid in
Category 4 in
CY 2016 or
most recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Denominator Metric
Value
0
Dollars in full or
percent of
premium
population-based
payment
programs (linked
to quality):
Percent of total
dollars paid
through full or
percent of
premium
population-based
payments in CY
2016 or most
recent 12 months.
0
Payment Reform Population-based
APMs: Percent of
total dollars paid
in Category 4.

Metric
Value
0

Aggregated Metrics (Comparison between Category 1 and Categories 2-4)
#

Numerator

Numerator
Value
0

Denominator
Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value
0

Metric
Denominator to
inform the
metrics below

Metric
Value
NA

Numerator

Total dollars
paid to
providers
through legacy
payments
(including FFS
without a
quality

Total dollars
paid to
providers
through
payment
reforms in
Categories 3
and 4 in CY
2016 or most
recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value
0

Metric
Payment Reform
Penetration Dollars in
Categories 2-4:
Percent of total
dollars paid
through payment
reforms in
Categories 2-4 in
CY 2016 or most
recent 12
months.
Dollars under
legacy payments
(including FFS
without a quality
component,
DRGs, and
capitation
without quality):
Percent of total
dollars paid
through legacy
payments
(including FFS
without a quality
component and
DRGs) in CY 2016
or most recent
12 months.

Metric
Value
0

Medicare Advantage Metrics
Goal/Purpose = Track total dollars paid through legacy payments and alternative payment methods
(APMs) in calendar year (CY) 2016 or most recent 12 months, as specified.
The goal is NOT to gather information on a projection or estimation of where the plan would be if their
contracts were in place the entire calendar year. Rather it is based on what the plan actually paid in
claims for the specified time period.

Methods
he metrics should report actual dollars paid through APMs CY 2016 or during the specified time period.
For example, if a provider is paid $120,000 for the entire year, but entered a shared savings contract
with the plan on July 1, 2016, the payments the provider received from January 1, 2016 through June 31,
2016 ($60,000) would be reported as fee-for-service and the payments the provider received from July
1, 2016 through December 31, 2016 ($60,000) would be reported as shared savings, if the reporting
period is for CY 2016. An acceptable approach is annualizing dollars paid in APMs based on a point in
time, e.g. on a single day such as December 31, 2016, only if the APM contract existed for the full 12month period. For example, a provider in a shared savings arrangement received $300 (a combination
of $285 base payment plus $15 in shared savings), which, if multiplied by 365 (annualized), would be
reported as $109,500 in shared savings CY 2016. An unacceptable approach is counting all of dollars paid
to the provider as being in APMs for the entire year, regardless of when the contract was executed (e.g.
considering the first example, counting $120,000 in shared savings even though the contract was only in
place for half of the reporting year). NOTE: this method is much more vulnerable to variation from
actual spending depending on the representativeness of the time period annualized.
Plans should report the total dollars paid, which includes the base payment plus any incentive, such as
fee-for-service with a bonus for performance (P4P), fee-for-service and savings that were shared with
providers, etc.
To the extent payment to a provider includes multiple APMs, the plans should put the dollars in the
dominant APM. For example, if a provider has a shared savings contract with a health plan and the
provider is also eligible for performance bonuses for meeting quality measures (P4P), the health plan
would report the FFS claims, shared savings payments (if any), and the P4P dollars in the shared savings
subcategory (Category 3).

Metrics
Please note that the dollars paid through the various APMs (numerator) are actual dollars paid to
providers CY 2016 or most recent 12 months unless another method, such as annualizing, is used.
Numerators should not be calculated based on members attributed to APMs unless the provider is held
responsible for all care (in network, out of network, inpatient, outpatient, behavioral health, pharmacy)
the patient receives.

Alternative Payment Model Framework – Category 1 (Metrics below apply to
total dollars paid for commercial members. Metrics are NOT linked to quality)
# Numerator
1 NA

2 Total dollars paid
to providers
through legacy
payments
(including FFS
without a quality
component and
DRGs) payments
in CY 2016 or
most recent 12
months.

Numerator
Value
NA

Denominator Metric
Value
0
Denominator to
inform the metrics
below

Metric
Value
NA

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Metric
Value
NA

Alternative Payment Model Framework – Category 3
(All models below are linked to quality).
#

Numerator

Total dollars
paid to providers
through FFSbased sharedsavings (linked
to quality)
payments in CY
2016 or most

Numerator Denominator
Value
0
Total dollars
paid to
providers (in and
out of network)
for commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value
0

Metric
Dollars in sharedsavings (linked to
quality) programs:
Percent of total
dollars paid
through FFS-based
shared-savings
payments in CY

Metric
Value
NA

Numerator

Numerator Denominator
Value

recent 12
months.
Total dollars
0
paid to providers
through FFSbased sharedrisk (linked to
quality)
payments in CY
2016 or most
recent 12
months.
Total dollars
0
paid to providers
through
procedurebased
bundled/episode
payments
(linked to
quality)
programs in CY
2016 or most
recent 12
months.
Total dollars
0
paid to providers
through
populationbased payments
that are not
conditionspecific (linked
to quality) in CY
2016 or most
recent 12
months.

10 Total dollars
paid in Category
3 in CY 2016 or
most recent 12
months.

Denominator
Value

Total dollars
paid to
providers (in and
out of network)
for commercial
members in CY
2016 or most
recent 12
months.

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY

Metric
2016 or most
recent 12 months..
Dollars in sharedrisk programs:
Percent of total
dollars paid
through FFS-based
shared-risk (linked
to quality)
payments in CY
2016 or most
recent 12 months.
Dollars in
procedure-based
bundled/episode
payments (linked
to quality)
programs: Percent
of total dollars paid
through
procedure-based
bundled/episode
payments in CY
2016 or most
recent 12 months.
Population-based
payments to
providers that are
not conditionspecific and linked
to quality: Percent
of total dollars paid
through
population-based
(linked to quality)
payments that are
not conditionspecific in CY 2016
or most recent 12
months.
Payment Reform APMs built on FFS
architecture:
Percent of total

Metric
Value
0

Numerator

Numerator Denominator
Value

2016 or most
recent 12 months.

Denominator
Value

Metric
dollars paid in
Category 3.

Metric
Value

Alternative Payment Model Framework – Category 4
(All models below are linked to quality).
#

Numerator

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Metric
Value
NA

Numerator

Total dollars
paid to
providers
through full or
percent of
premium
populationbased
payments
(linked to
quality) in CY
2016 or most
recent 12
months.

Total dollars
paid in
Category 4 in
CY 2016 or
most recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Metric
Value
0

Aggregated Metrics (Comparison between Category 1 and Categories 2-4)
#

Numerator

Numerator
Value
0

Denominator
Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value
0

Metric
Denominator to
inform the
metrics below

Metric
Value
NA

Numerator

Total dollars
paid to
providers
through legacy
payments
(including FFS
without a
quality

Total dollars
paid to
providers
through
payment
reforms in
Categories 3
and 4 in CY
2016 or most
recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value
0

Metric
Value
0

Medicaid Metrics
Goal/Purpose = Track total dollars paid through legacy payments and alternative payment methods
(APMs) in calendar year (CY) 2016 or most recent 12 months, as specified.
The goal is NOT to gather information on a projection or estimation of where the plan would be if their
contracts were in place the entire calendar year. Rather it is based on what the plan actually paid in
claims for the specified time period.

Metrics
Please note that the dollars paid through the various APMs (numerator) are actual dollars paid to
providers CY 2016 or most recent 12 months unless another method, such as annualizing, is used.
Numerators should not be calculated based on beneficiaries attributed to APMs unless the provider is
held responsible for all care (in network, out of network, inpatient, outpatient, behavioral health,
pharmacy) the patient receives.

Alternative Payment Model Framework – Category 1 (Metrics below apply to
total dollars paid for commercial members. Metrics are NOT linked to quality)
# Numerator
1 NA

2 Total dollars paid
to providers
through legacy
payments
(including FFS
without a quality
component and
DRGs) payments
in CY 2016 or
most recent 12
months.

Numerator
Value
NA

Denominator Metric
Value
0
Denominator to
inform the metrics
below

Metric
Value
NA

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Metric
Value
NA

Alternative Payment Model Framework – Category 3
(All models below are linked to quality).
#

Numerator

Total dollars
paid to providers
through FFSbased sharedsavings (linked
to quality)
payments in CY
2016 or most

Numerator Denominator
Value
0
Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator Metric
Value
0
Dollars in sharedsavings (linked to
quality) programs:
Percent of total
dollars paid
through FFS-based
shared-savings
payments in CY

Metric
Value
NA

Numerator

Numerator Denominator
Value

10 Total dollars
paid in Category
3 in CY 2016 or
most recent 12
months.

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.
Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Denominator Metric
Value
2016 or most
recent 12 months..
0
Dollars in sharedrisk programs:
Percent of total
dollars paid
through FFS-based
shared-risk (linked
to quality)
payments in CY
2016 or most
recent 12 months.
0
Dollars in
procedure-based
bundled/episode
payments (linked
to quality)
programs: Percent
of total dollars paid
through
procedure-based
bundled/episode
payments in CY
2016 or most
recent 12 months.
Population-based
0

Metric
Value

payments to
providers that are
not conditionspecific and linked to
quality: Percent of
total dollars paid
through populationbased (linked to
quality) payments
that are not
condition-specific in
CY 2016 or most
recent 12 months.

Payment Reform APMs built on FFS
architecture:
Percent of total
dollars paid in
Category 3.

Alternative Payment Model Framework – Category 4 (All models below are linked to
quality).
#

Numerator

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Metric
Value
NA

Numerator

Total dollars
paid to
providers
through full or
percent of
premium
populationbased
payments
(linked to
quality) in CY
2016 or most
recent 12
months.

Total dollars
paid in
Category 4 in
CY 2016 or
most recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12 months.

Metric
Value
0

Aggregated Metrics (Comparison between Category 1 and Categories 2-4)
#

Numerator

Numerator
Value
0

Denominator
Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value
0

Metric
Denominator to
inform the
metrics below

Metric
Value
NA

Numerator

Total dollars
paid to
providers
through legacy
payments
(including FFS
without a
quality

Total dollars
paid to
providers
through
payment
reforms in
Categories 3
and 4 in CY
2016 or most
recent 12
months.

Numerator
Value
0

Denominator

Total dollars paid
to providers (in
and out of
network) for
commercial
members in CY
2016 or most
recent 12
months.

Denominator
Value
0

Metric
Value
0

Cross-Checking
Questions
For the look back metrics only,
what payment models were in
effect during specified the
period of reporting? Please
specify the line of business
(Comm, MA, MCO).

For each program Identified
in the prior question, Indicate
When the program was
launched. Please specify the
line of business
(Comm, MA, MCO).

For each program identified
In the first question,
describe its current stage
Of implementation
(Pilot, Expansion, Fully
Implemented) *. Please
specify the line of business
(Comm, MA, MCO)

Responses
Select all that apply
Foundational spending to improve care
FFS plus Pay for Performance
FFS-based Shared Savings
FFS-based Shared Risk
Procedure-based Bundled/Episode Payments
Population-based Payments not condition-specific
Population-based Payments condition-specific
Condition-Specific Bundled/Episode Payments
Full or Percent of Premium Population-based Payment
Launch date (Mont/Year in column B)
Foundational spending to improve care
FFS plus Pay for Performance
FFS-based Shared Savings
FFS-based Shared Risk
Procedure-based Bundled/Episode Payments
Population-based Payments not condition-specific
Population-based Payments condition-specific
Condition-Specific Bundled/Episode Payments
Full or Percent of Premium Population-based Payment
Indicate Pilot, Expansion, or Fully Implemented*in
Foundational spending to improve care
FFS plus Pay for Performance
FFS-based Shared Savings
FFS-based Shared Risk
Procedure-based Bundled/Episode Payments
Population-based Payments not condition-specific
Population-based Payments condition-specific
Condition-Specific Bundled/Episode Payments
Full or Percent of Premium Population-based Payment

*Pilot mode (e.g. only available for a subset of members and/or providers)
*Expansion mode (e.g. passed initial pilot stage)
*Fully implemented (e.g. generally available)

Definitions per the original APM Framework
Note: The revised APM Framework will be published in Summer 2017. For purposes of 2017 measurement, please
refer to the original category definitions below.

Terms

Alternative Payment Model (APM)

Category 1

Category 2

Definitions

Health care payment methods that use
financial incentives to promote or leverage
greater value - including higher quality care
at lower costs - for patients, purchasers,
payers and providers. This definition is
specific to this exercise. If you are interested
in MACRA's definition, please reference
MACRA for more details.
APM Framework White Paper
MACRA Website
Fee-for-service with no link to quality. These
payments utilize traditional FFS payments
that are not adjusted to account for
infrastructure investments, provider
reporting of quality data, for provider
performance on cost and quality metrics.
Diagnosis-related groups (DRGs) that are not
linked to quality are in Category 1.
Fee-for-service linked to quality. These
payments utilize traditional FFS payments,
but are subsequently adjusted based on
infrastructure investments to improve care
or clinical services, whether providers report
quality data, or how well they perform on
cost and quality metrics.

Terms

Category 3

Category 4

Commercial members/
Medicare Advantage members/
Medicaid beneficiaries

Definitions

Alternative payment methods (APMs) built
on fee-for-service architecture. These
payments are based on FFS architecture,
while providing mechanisms for effective
management of a set of procedures, an
episode of care, or all health services
provided for individuals. In addition to taking
quality considerations into account,
payments are based on cost performance
against a target, irrespective of how the
financial benchmark is established, updated,
or adjusted. Providers that meet their cost
and quality targets are eligible for shared
savings, and those that do not may be held
financially accountable.
Population-based payment. These payments
are structured in a manner that encourages
providers to deliver well-coordinated, high
quality person level care within a defined or
overall budget. This holds providers
accountable for meeting quality and,
increasingly, person centered care goals for a
population of patients or members.
Payments are intended to cover a wide range
of preventive health, health maintenance,
and health improvement services, among
other items. These payments will likely
require care delivery systems to establish
teams of health professionals to provide
enhanced access and coordinated care.
Health plan enrollees or plan participants.

Terms

Condition-specific bundled/episode
payments

CY 2016 or most recent 12 months

Diagnosis-related groups (DRGs)

Fee-for-service

Foundational spending

Definitions

A single payment to providers and/or health
care facilities for all services related to a
specific condition (e.g. diabetes). The
payment considers the quality, costs, and
outcomes for a patient-centered course of
care over a longer time period and across
care settings. Providers assume financial risk
for the cost of services for a particular
condition, as well as costs associated with
preventable complications. [APM Framework
Category 4A]
Calendar year 2016 or the most current 12month period for which the health plan can
report payment information. This is the
reporting period for which the health plan
should report all of its "actual" spend data - a
retrospective "look back."
A clinical category risk adjustment system
that uses information about patient
diagnoses and selected procedures to
identify patients that are expected to have
similar costs during a hospital stay - a form of
case rate for a hospitalization. Each DRG is
assigned a weight that reflects the relative
cost of caring for patients in that category
relative to other categories and is then
multiplied by a conversion factor to establish
payment rates.
Providers receive a negotiated or payerspecified payment rate for every unit of
service they deliver without regard to quality,
outcomes or efficiency. [APM Framework
Category 1]
Includes but is not limited to payments to
improve care delivery such as outreach and
care coordination/management; after-hour
availability; patient communication
enhancements; health IT infrastructure use.
May come in the form of care/case
management fees, medical home payments,
infrastructure payments, meaningful use
payments and/or per-episode fees for
specialists. [APM Framework Category 2A]

Terms

Full or percent of premium populationbased payments

Legacy payments

Linked to quality

Pay for performance

Population-based payment for conditions

Definitions

A fixed dollar payment to providers for all the
care that a patient population may receive in
a given time period, such as a month or year,
(e.g. inpatient, outpatient, specialists, out-ofnetwork, etc.) with payment adjustments
based on measured performance and patient
risk. [APM Framework Category 4B]
Payments that utilize traditional payments
and are not adjusted to account for
infrastructure investments, provider
reporting of quality data, or for provider
performance on cost and quality metrics. This
can include fee-for-service, diagnosis-related
groups (DRGs) and per diems. [APM
Framework Category 1].
Payments that are set or adjusted based on
evidence that providers meet a quality
standards or improve care or clinical services,
including for providers who report quality
data, or providers who meet threshold on
cost and quality metrics. The APM
Framework does not specify which quality
measures qualify for a payment method to
be "linked to quality."
The use of incentives (usually financial) to
providers to achieve improved performance
by increasing the quality of care and/or
reducing costs. Incentives are typically paid
on top of a base payment, such as fee-forservice or population-based payment. In
some cases, if providers do not meet quality
of care targets, their base payment is
adjusted downward the subsequent year.
[APM Framework Categories 2C & 2D].
A per member per month (PMPM) payment
to providers for inpatient and outpatient care
that a patient population may receive for a
particular condition in a given time period,
such as a month or year, including inpatient
care and facility fees. [APM Framework
Category 4A].

Terms

Population-based payment not conditionspecific

Procedure-based bundled/episode payment

Provider

Shared risk

Definitions

A per member per month (PMPM) payment
to providers for outpatient or professional
services that a patient population may
receive in a given time period, such as a
month or year, not including inpatient care or
facility fees. The services for which the
payment provides coverage is predefined and
could be, for example, primary care services
or professional services that are not specific
to any particular condition. [APM Framework
Category 3B].
Setting a single price for all services to
providers and/or health care facilities for all
services related to a specific procedure (e.g.
hip replacement). The payment is designed
to improve value and outcomes by using
quality metrics for provider accountability.
Providers assume financial risk for the cost of
services for a particular procedure and
related services, as well as costs associated
with preventable complications. [APM
Framework Categories 3A & 3B].
For the purposes of this workbook, provider
includes all providers for which there is
health care spending. For the purposes of
reporting APMs, this includes medical,
behavioral, pharmacy, and DME spending to
the greatest extent possible.
A payment arrangement that allows
providers to share in a portion of any savings
they generate as compared to a set target for
spending, but also puts them at financial risk
for any overspending. Shared risk provides
both an upside and downside financial
incentive for providers or provider entities to
reduce unnecessary spending for a defined
population of patients or an episode of care,
and to meet quality targets.

Terms

Shared savings

Total Dollars

Definitions

A payment arrangement that allows
providers to share in a portion of any savings
they generate as compared to a set target for
spending. Shared savings provides an upside
only financial incentive for providers or
provider entities to reduce unnecessary
spending for a defined population of patients
or an episode of care, and to meet quality
targets.
The total estimated in- and out-of-network
health care spend (e.g. annual payment
amount) made to providers in calendar year
(CY) 2016 or most recent 12 months.

File Type	application/pdf
File Title	National Data Collection Metric
Author	Kristian Motta
File Modified	2017-05-10
File Created	2017-05-10