The Critical Questions Your APCM Plan Needs to Answer

Advanced Primary Care Management (APCM) is an exciting opportunity — don’t blow it

We see increasing excitement about Medicare’s new Advanced Primary Care Management (APCM) program. Done well, APCM could be transformative for primary care practices and their patients. APCM provides fee-for-service reimbursement for providers to deliver high-value, proactive care across entire populations. APCM will be a financial lifeline for physicians, enabling them to invest in staffing and services that will directly benefit patients.

But to see those benefits, you have to do APCM well.

A poorly-executed APCM launch will disrupt your operations and destabilize your finances. Worst of all, low-quality APCM will diminish the trust your patients have in your practice. You must have a thoughtful, comprehensive plan for your APCM program.

KEY TAKEAWAYS

1. Advanced Primary Care Management (APCM) and Chronic Care Management (CCM) are fee-for-service Medicare reimbursement programs. Both help providers invest in value-based care, but APCM is geared toward primary care.
2. Success in APCM means creating value for patients, providers, and Medicare. You need a well-thought-out plan to do this.
3. A comprehensive plan should cover patient identification, enrollment, care management, and billing.
4. You must also have a compliance strategy that supports excellent care and long-term financial sustainability.

Elements of a Strong APCM Plan

Care management contributes to better health outcomes and reduces the total cost of care (TCoC), two primary goals for CMS. APCM is a fee-for-service reimbursement program that creates incentives for providers to move toward value-based care.

Advanced Primary Care Management vs. Chronic Care Management

To learn more about APCM and CCM, watch our on-demand webinar. This comprehensive comparison will help you evaluate which program is the best fit for your practice. Watch Now

If you want your APCM program to achieve long-term financial sustainability, consider 5 key elements of your plan:

1. Patient Identification
2. Patient Enrollment
3. Care Management
4. Billing
5. Compliance

What Drives APCM Program Success?

A successful APCM program will create value for all stakeholders:

• Your healthcare organization
• Medicare (and taxpayers)
• Your patients

In my last article, I explained that APCM success hinges on creating value for your patients. Many patients will have a cost sharing responsibility. To retain patients in APCM, your practice must deliver excellent care management at scale.

Here are descriptions of each pillar, and some key questions you should ask as you develop your APCM plan.

1. Patient Identification

Currently, patients enrolled in Traditional Medicare are eligible for APCM. We expect Medicare Advantage plans will eventually reimburse practices for APCM. However, reimbursement may vary considerably compared to Traditional Medicare.

As you think about identifying eligible patients, consider the following questions:

• How many of your patients have Traditional Medicare?
• For the future: how many of your patients have Medicare Advantage plans? (This may be more challenging to determine at the start of the year given churn.)
• Qualified Medicare Beneficiaries have no cost-sharing but may be harder to reach. How many of those patients do you have? Do you have good channels and community partnerships to help engage them?
• Can you segment your population by the number of chronic conditions?

2. Patient Enrollment

Patient enrollment is more complex than you might think! Medicare seems to expect every patient to be enrolled, which sounds great:

“An initiating visit is not needed: (1) if the beneficiary is not a new patient (has been seen by the practitioner or another practitioner in the same practice within the past three years) or (2) if the beneficiary received another care management service (APCM, CCM, or PCM) within the previous year with the practitioner or another practitioner in the same practice.”

• What are your enrollment goals? How quickly do you need to get to critical program mass? How will you capture and document patient consent?
• How many of your existing Medicare patients will not require an initiating visit? This will determine your ability to do mass outreach and rapid enrollment at scale. (Do you have the tools you will need to facilitate that outreach?)

3. Care Management

High-quality care management is the essence of APCM. Good care drives outcomes and creates value for patients– critical when many patients will have cost-sharing responsibility.

4. Billing

Smart billing ensures financial sustainability for your program. You may be familiar with time-based reimbursement for CCM. APCM reimbursement is different.

5. Compliance

Compliance is not a “check-the-box” activity. It’s about doing the job right, every step of the way. A good APCM compliance strategy ensures that your program aligns regulatory requirements, operational workflows, and care management best practices.