Value-Based Care: Alternative Payment Models

Audiologists and speech-language pathologists (SLPs) are used to having their health care services reimbursed under a fee-for-service (FFS) payment model. This model establishes set rates for each specific service provided based on time, complexity, and the skill needed to deliver the service. The fee-for-service system, in some cases, can establish competing priorities between what is best for the patient and what is best for the financial health of the provider organization. Value-based care is an attempt to align the priorities of patients, providers, and payers. Payment is no longer tied directly to transactional services. Instead, it’s tied to desired results or comprehensive delivery of care with emphasis on quality, efficiency, and outcome. Under value-based care, value equals quality of care for the amount of money spent. Alternative payment models are one way that payers incentivize providers to transition from fee-for-service to value-based care payment models.

Alternative Payment Models (APMs)

The Affordable Care Act and a part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) developed a new reimbursement model called Alternative Payment Models (APMs). The intent of APMs is to improve the patient experience by encouraging collaboration between providers, improving quality of care, and making services more affordable. APM participants receive payments that reward them for the value of—rather than the volume of—services provided. Value, in this context, is outcomes of the intervention as related to cost.

On this page:

• Rethinking the Way Audiologists and SLPs Practice Under APMs
• Understanding the Types of APMs
• Audiologists and SLPs Can Learn More About APMs and the Impact on Reimbursement
• ASHA Is Actively Engaged on The Issue of APMs

Rethinking the Way Audiologists and SLPs Practice Under APMs

With the shift in reimbursement from quantity to quality, audiologists and SLPs must take accountability for increasing the quality and lowering the costs of care that they provide. Taking accountability means that some of the financial risk of providing services will shift to audiologists and SLPs.

All payers (Medicare, Medicaid, and private insurance) are moving toward a value-based system that focuses on the quality of services provided to the patient in the most cost-effective manner. In 2018, 35.8% of U.S. health care payments, representing 77% of the covered population, flowed through APMs.

Understanding the Types of APMs

There are many types of APMs that audiologists and SLPs may come across. Each presents varying challenges and opportunities when you consider whether engaging with an APM will be beneficial for your practice.

There are several types of APMs:

• Patient-centered medical homes that deliver a primary single point of care to maximize care coordination.
• Episodic or bundled payment models that provide a fixed payment, typically for both acute and post-acute care for a specified length of time.
• Accountable Care Organizations (ACOs) that take system-wide responsibility for the care of an individual across all their health care needs. This arrangement can be with or without financial risk for excess costs.
• Population-based capitated payment models that pay an entity for managing the care needs for a whole population, often with a financial risk/reward arrangement for costs and savings.
• Direct contracting models that allow clinicians and practices to engage with APMs for specific services or patients—essentially, subcontracting for specific care.

The Centers for Medicare & Medicaid Services (CMS) developed several types of APMs to prioritize health care outcomes over cost of care and improve the value of health care. In the CMS Quality Payment Program (QPP), there are traditional APMs—such as the ACO Shared Savings Program Track 1, BASIC. CMS’s QPP program also developed Advanced APMs such as the Comprehensive Care for Joint Replacement Payment Model, which requires the integral use of a certified electronic health records system.

Audiologists and SLPs Can Learn More About APMs and the Impact on Reimbursement

• Helpful Tips on Alternative Payment Models (APMs)
• Learn more about APMs in this handout [PDF].
• The ASHA Leader: New Value-Based Payment Model to Focus on Health Equity, Care Coordination, and Transparency
• The ASHA Leader: Show Us the Merit: Alternative payment models are the way of the future. Here’s what you need to know.
• The ASHA Leader: Change Ahead for Medicare Outpatient Quality Reporting and Payment: Medicare payments for outpatient audiology and speech-language services will fundamentally change in 2019. Will you be ready?
• This Perspectives article, Value-Based Health Care: Adjusting Speech-Language Pathology Practice to Fit the Model, examines key components of value-based care, including how SLPs can provide their services effectively and efficiently and can analyze the value-based reimbursement model in their setting to identify ways to demonstrate their value beyond direct service provision.
• Medicare’s Quality Payment Program (QPP) website provides additional information on APMs, including eligibility and participation.
• The Center for Medicare & Medicaid Innovation (a.k.a. the Innovation Center) within CMS supports the development and testing of innovative health care payment and service delivery models.

ASHA Is Actively Engaged on the Issue of APMs

ASHA supports the inclusion of audiologists and SLPs in payment and delivery models that demonstrate their value to patients, other providers, and payers by incorporating relevant quality outcomes and providing evidence-based care in the most cost-effective manner. The following timeline summarizes ASHA’s advocacy activities during the past several years in relation to APMs:

• December 22, 2020 – ASHA successfully advocates to freeze APM thresholds at the 2020 levels for the next 2 years.
• October 22, 2018 – ASHA submits recommendations to the Office of the Inspector General (OIG) on issuing guidance documents [PDF] for APM entities and providers of existing safe harbors and on safeguarding Medicare beneficiary protections. This was done in response to the OIG’s request for information regarding the impact of the anti-kickback and beneficiary inducement statutes on value-based care and care coordination.
• April 21, 2018 – ASHA submits recommendations to CMS for implementing safeguards and requiring the use of quality metrics [PDF] to ensure that patient referrals are improving quality and outcomes if changes are made to the physician self-referral law.
• October 30, 2017 – ASHA submits comments to the Physician-Focused Payment Model Technical Advisory Committee [PDF] on the Advanced Care Model Service Delivery and Advanced Alternative Payment Model proposal.
• March 17, 2017 – ASHA submits recommendations for removing access barriers to telehealth [PDF] for audiologists and SLPs in response to the CMS request for information on pediatric APMs.

Questions? Email reimbursement@asha.org.