Frequently asked questions

National APM Data Collection
Frequently Asked Questions
Last updated on 5/17/17
Please note this document may be updated and improved periodically based on feedback from
health plans and other stakeholders.
Q1 - Where can I find more information on the 2016 effort?
A1 - The full report and additional information can be found at the LAN 2016 Measurement
Effort website.
Q2 - Why are the 2017 updates in the Framework not reflected in the metrics workbook?
A2 – The APM Framework went through a refresh in Spring 2017 to reflect the evolving nature
of health care payments. However, for trend and consistency purposes, in 2017 we will measure
APMs using the same metrics and methodology as 2016. Future measurement efforts is
expected to reflect the changes to the APM Framework.
Q3 - How is the commercial market segment defined?
A3 - For the purposes of this survey, the commercial market segment includes individual, small
group, large group, fully insured, self-funded and exchange business. To the extent a health plan
provides benefits for the Federal Employee Health Benefit (FEHB) program, this business
should be considered commercial and included in the survey. Responses to the survey will
reflect dollars paid CY 2016 or most recent 12 months. See “General Information” tab in the
Excel workbook for more information.
Q4 - How is the Medicaid market segment defined?
A4 - For the purposes of this survey, the Medicaid market segment includes both business with a
state to provide health benefits to Medicaid eligible individuals and state-run programs
themselves. Data submitted for this survey should exclude the following: health care spending
for dual-eligible beneficiaries and health care spending for long-term care (LTC). Responses to
the survey will reflect dollars paid CY 2016 or most recent 12 months. See “General
Information” tab in the Excel workbook for more information.
Q5 - How is the Medicare Advantage market segment defined?
A5 - For the purposes of this survey, the Medicare Advantage market segment includes a type of
Medicare health plan offered by a private company that contracts with Medicare to provide all
Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance
Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, and Special
Needs Plans. To the extent the Medicare Advantage plan has Part D or drug spending under its
operations, it should include this information in its response. Responses to the survey will reflect

dollars paid CY 2016 or most recent 12 months. See “General Information” tab in the Excel
workbook for more information.
Q6 - How is “providers” defined?
A6 - For the purposes of this survey, “providers" include all health care providers for whom
there is health care spending. This includes, for example, pharmacy, behavioral health, and
durable medical equipment (DME) spending in addition to physicians, hospitals and other
traditional health care providers. If the plan does not provide a pharmacy benefit or behavioral
health benefit (e.g. those services are provided by a different health plan or entity) and therefore
does not spend dollars on these services, it should input 0 dollars for those services. There are
cells on the “General Information” tab of the survey where the plan can indicate whether it is
including the pharmacy benefit or behavioral health in their response and, if so, what percent of
the spending either or both represent.
Q7 - What is a “legacy payment?”
A7 - For the purposes of this survey, “legacy payment” includes any payment that does not
include a quality component. Examples include: traditional fee-for-service payment, diagnosisrelated group (DRG) payments, and traditional capitation without quality. Following the original
APM Framework, legacy payments fall into category 1.
Q8 - Should plans report just the incentive portion of the alternative payment model
(APM) or all of the dollars going to the provider under that arrangement?
A8 - Plans should report the total dollars, which includes the underlying 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. For APMs in which the provider is responsible for
the total cost of a member or beneficiary’s health care, the total costs incurred by the member or
beneficiary covered under that plan should be included in the numerator. See Q12 for more
detail.
Q9 - The survey says plans can report data from CY 2016 or the most recent 12 months.
Does this mean plans will be reporting on different time periods?
A9 - Potentially. Given the timing of this survey, some plans may not have access to final CY
2016 data to report. Under these circumstances, the plan should report the most recent 12
months for which it has data. Under the “General Information” tab, we ask plans whether they
are using CY 2016 data or a different 12-month period. If a plan reports data using the most
recent 12-month approach, it must specify the term and use this same 12-month period for all
metrics. Differing reporting periods will be addressed in communicating the findings of this
measurement effort such that it is clear what proportion of spending was reported in any

explicitly identified reporting period, and the range of reporting periods included in any more
global statement.
Q10 - Should plans count payments on an annual basis or on an annualized basis?
A10 - Annual. For example, if the plan enters into a shared savings contract effective August 1,
2016, (and the reporting period is CY 2016) the plan should report the total dollars paid to that
provider under the shared savings arrangement from August 1, 2016 – December 31, 2016
whereas it would report dollars paid to the provider between January 1, 2016 and July 30, 2016
under as Category 1. Remember, plans are to report ALL of the dollars flowing through that
payment arrangement, not just the bonus or savings. The bonus or savings amounts may not be
reconciled for some time so it is acceptable for the plan to estimate the bonus or savings payment
amount (if any).
Q11 - What is the preferred method for calculating the metrics?
A11 - 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. Another 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 12-month 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.
Q12 - What should be counted in the numerator if an entity or provider is responsible for
all of a patient’s care?
A12 - If a plan (commercial, Medicaid, or MA) operates an APM where a physician group,
primary care physician, or other physician is held responsible for ALL of the attributed
member’s health care spending, including outpatient, inpatient, specialists, pharmacy, out-ofnetwork, etc., all of the dollars associated with the attributed members can be included in the
numerator.

Q13 - There are a lot of categories and subcategories. Is there an expectation that plans
will have dollars to report in each category and subcategory?
A13 - No; however, most, if not all plans, will report some dollars under Category 1. In most
cases, plans are experimenting with different payment methods that span across Categories 2
through 4. Plans should report the alternative payment models they had in effect in 2016. For
example, a plan may have shared-risk arrangements planned for 2017, but if they did not have
any of those arrangements effective during the reporting period (CY 2016, for example), then the
plan would report $0.00 under the shared-risk item under Category 3, Question 7.
Q14 – In the original APM Framework, how would a pay-for-performance (P4P) contract
that affects the future fee-for-service base payment be categorized?
A14 - Under the APM Framework, this arrangement is aligned to Category 2D. The 2016 survey
combined 2C and 2D. Dollars paid under this scenario would be reported under Category 2C;
Question 4. Under the current metrics, 2C and 2D are consolidated.
Q15 - What are the differences between the three population-based payment arrangement
types?
A15 - All population-based payment methods are paid on a per member per month (PMPM)
basis for a given time period, such as a month or year, and are tied to quality performance.
However, there are several distinctions among the various population-based payment methods.
Full or percent of premium population-based payment tied to quality (4B): A per member per
month (PMPM) payment for all of the care (e.g. inpatient, outpatient, specialists, pharmacy, outof-network, etc.) that attributed members receive. The other two population-based payment
arrangement types are not comprehensive and do not cover all of the health care that an
attributed member receives.
Population-based payment for conditions tied to quality (4A): A per member per month (PMPM)
payment to providers for inpatient and outpatient care that an attributed member population may
receive for a particular condition in a given time period, such as a month or year, including
inpatient care and facility fees.
Population-based payment not condition-specific tied to quality (3B): A per member per month
(PMPM) payment to providers for outpatient or professional services that an attributed member
population may receive in a given time period, such as a month or year. The services for which
the payment covers are predefined and not specific to any particular condition.
Q16 - Does the health plan count covered members and dollars in APMs that another
health plan manages?

A16 - No. If the health plan does not directly manage those members, neither the lives nor
dollars should be counted. The health plan that manages those lives should count those members
and dollars, if it is participating in the data collection effort.
For example, Blue Cross Blue Shield Plan of State A has a national employer account with the
majority of its covered lives in State A, as well as some covered lives in State B. Under these
circumstances, the employer’s covered lives in State B are reported by BCBS of State B; BCBS
of State A reports dollars and covered lives that it manages for the employer in State A. BCBS
of State B reports dollars and covered lives that it manages for the employer in State B, even if
some of the State B lives originated as part of the relationship with the employer in State A.
Q17 - Will the health plan’s specific data be shared with the public?
A17 - No. Data will be aggregated by line of business. It will not be shared on an individual plan
basis.
Individual plan data will be collected and securely stored by MITRE and its sub-contractor,
Catalyst for Payment Reform, for this measurement effort. The Center for Medicare and
Medicaid Services, the Center for Medicare and Medicaid Innovation, LAN members, or
participating payers will not have access to individual plan spending data.
Q18 – Where can I find the original HCP-LAN APM Framework white paper?
A18 – The 2017 APM Measurement Website includes a link to the original HCP - LAN APM
Framework white paper. Please review this document for questions related to examples of
subcategories or distinctions between categories.