More on Reimbursement

American Medical Association urges creation of APMs focused on at-risk populations

AMA is advocating for appropriate risk adjustment of performance results based on clinical and social determinants to avoid penalizing physicians.

Susan Morse, Managing Editor

The American Medical Association is advocating for appropriate risk adjustment of performance results based on clinical and social determinants of health to avoid penalizing physicians whose performance and aggregated data are impacted by factors outside of the physician's control, the AMA said at its annual meeting on Tuesday.

The current payment model may inadvertently be creating disincentives for physicians to care for vulnerable or high-risk populations, the AMA said.

The AMA released three new policies to incentivize care for these patients, including: supporting advanced alternative payment models that link quality measures and payment to outcomes specific to these populations; encouraging the development and implementation of physician-focused APMs that provide services to improve the health of these patients; and continuing to advocate for appropriate risk adjustment of performance results.

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Physicians may be reluctant to take on the financial risk of the current advanced alternative payment model, because of the way risk adjustment is structured.

But APMs are typically designed to be flexible to compensate for care that is not traditionally reimbursed, so they present the better opportunity to care for and serve vulnerable populations, the AMA said.

APMs also offer the incentive of greater reimbursement, but the model has financial risks.


Under the Medicare Access and CHIP Reauthorization Act of 2015, the Centers for Medicare and Medicaid Services created two paths for providers to achieve MACRA's quality payment mandates: MIPS and APMs.

The Merit-based Incentive System, or MIPS, bases reimbursement on a composite performance score based on quality, resource use, clinical practice improvement and meaningful use of certified electronic health records.

Physicians in Alternative Payment Models, or APMs, can earn up to a 5 percent incentive by taking on risk related to their patients' outcomes. APMs can apply to a specific clinical condition, care episode or a population.


"We know that disparities in health outcomes are commonly related to non-medical factors, including geography and socioeconomic status, which are among the factors in the social determinants of health. To affect change and truly realize optimal health for all, we must encourage care to specifically meet the needs of vulnerable populations," said Dr. William E. Kobler, an AMA board of trustees member. "If patients' basic needs are not met, they are unlikely to stay healthy, regardless of the quality of care received."

Twitter: @SusanJMorse
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