Advanced Alternative Payment Models

Most ophthalmologists do not currently have an Advanced APM available that is relevant to their practice. As a result, the vast majority must participate in MIPS — the default Quality Payment Program (QPP) pathway — because existing Advanced APM models have been developed primarily for primary care or hospital-based services rather than specialty care.

The Academy continues to encourage CMS to support the development of Advanced APMs that are appropriate and relevant for ophthalmologists and their patients. We emphasize the importance of voluntary participation and small-scale testing when developing new payment models to reduce unintended consequences for physician practices and Medicare beneficiaries.

Until Advanced APMs become more widely available to ophthalmologists, the Academy will continue supporting ophthalmologists participating in MIPS through advocacy, education, and reporting through the IRIS® Registry.

The Academy monitors new and proposed Advanced APM models and engages with CMS's Center for Medicare and Medicaid Innovation (CMMI) to advocate for the development of specialty-relevant payment models. We have consistently emphasized that Advanced APMs must be designed with meaningful ophthalmology-specific measures, appropriate risk structures, and voluntary on-ramps to avoid inadvertently penalizing ophthalmologists or limiting patient access to specialized eye care.

The Academy also works with the Surgical Coalition and other specialty societies to advocate for a CMMI innovation pipeline that reflects the needs of surgical and procedural specialties, not just primary care and hospital-based providers.

Check your eligibility and participation status using the CMS QPP Participation Study Tool to determine whether you are required to participate in MIPS or whether you qualify as a Qualifying APM Participant (QP) — an eligible clinician who participates in an Advanced APM and meets CMS participation thresholds. QPs are excluded from MIPS reporting requirements and receive a higher annual Medicare fee schedule conversion factor update than non-QPs.

If you are currently participating in MIPS, visit the Academy's MIPS Hub and the IRIS® Registry for resources to support your reporting.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Quality Payment Program (QPP) as the framework for Medicare physician payment based on quality and value. The QPP offers two participation pathways: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

Clinicians who meet participation thresholds in an Advanced APM can become Qualifying APM Participants (QPs). QPs are exempt from MIPS reporting and payment adjustments. Beginning in payment year 2026, QPs also receive a higher annual Medicare Physician Fee Schedule conversion factor update (0.75%) than clinicians who are not QPs (0.25%).  

Despite these incentives, the majority of ophthalmologists have no relevant Advanced APM available to them. CMMI has historically focused on broad primary care and hospital-based models; only recently has it begun developing models relevant to specialty care.