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of the ACOs currently in existence. Although ACOs clearly would benefit from the services of registered nurses (RNs), advanced practice registered nurses (APRNs), and other clinicians, certain exclusions in the rules minimize the impact of such groups in recognizing their contributions or sharing cost savings.

While most programs within the ACOs are still difficult for APRNs to participate in effectively, the Primary Care First Model Options is a set of voluntary five‐year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First prioritizes the doctor–patient relationship: enhancing care for patients with complex chronic needs and high need as well as for seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes (https://innovation.cms.gov/innovation‐models/primary‐care‐first‐model‐options).

      Primary Care First Model Options will begin in 2021 in 26 states. Practices will be incentivized to deliver patient‐centered care that reduces acute hospital utilization. Primary Care First is oriented around comprehensive primary care functions: (a) access and continuity; (b) care management; (c) comprehensiveness and coordination; (d) patient and caregiver engagement; and (e) planned care and population health. Eligible providers must meet numerous qualifications, including being primary care practitioners (MD, DO, CNS, NP, and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine; providing primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location; and having primary care services that account for at least 70% of the practice's collective billing based on revenue.

      Paying Providers Based on Value, Not Volume

      Provisions in the ACA tie provider payments to the quality of care they provide. Providers are expected to see their payments modified so that those who provide higher‐value care will receive higher payments than those who provide lower‐quality care. This provision took place in progressive stages. In FY 2013–2015, hospitals became accountable in both reporting and receipt of payment for specific domains of care that expanded to include an additional domain each year. These domains include the clinical process of care domain measures such as venous thromboembolism prophylaxis, appropriate surgical use of postoperative antibiotics, and urinary catheter removal postoperatively; the patient experience of care domain such as nurse communication, doctor communication, hospital staff responsiveness, pain management, medicine communication, and discharge information; the outcome domain measures such as acute myocardial infarction (AMI) 30‐day mortality rate, heart failure (HF) 30‐day mortality rate, pneumonia (PN) 30‐day mortality rate, central line–associated bloodstream infection (CLABSI); and in 2015 the efficiency domain, which focuses on Medicare spending per beneficiary. CMS assesses each hospital’s performance by comparing its scores on achievement and improvement related to each measure of performance (https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/Value‐Based‐Programs/HVBP/Hospital‐Value‐Based‐Purchasing). The following quality domains and weights are being applied for FY 2020: clinical outcomes (25%); person and community engagement (25%); safety (25%); and efficiency and cost reduction (25%).

      The Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. MACRA required CMS to create the Quality Payment Program that repealed the Sustainable Growth Rate formula; changed the way that Medicare rewards clinicians for value over volume; streamlined multiple quality programs under the new Merit‐Based Incentive Payments System (MIPS); and gave bonus payments for participation in eligible alternative payment models (APMs).

MIPS was designed to tie payments to quality and cost‐efficient care, drive improvement in care processes and health outcomes, increase the use of health care information, and reduce the cost of care. Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Clinicians included in MIPS and APMs include nurse practitioners if they meet the thresholds required. These thresholds have been lowered over time to encourage greater participation. Performance in MIPS is measured through the data clinicians report in four areas: quality, improvement activities, promoting interoperability (formerly advancing care information), and cost. MIPS was designed to update and consolidate previous programs, including Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value‐Based Payment Modifier (https://qpp.cms.gov/mips/overview). The stated value of the MIPS is to incentivize providers, including APRNs, to practice by providing measurable high‐quality care that is also cost efficient. One of the criticisms of the program has been that it allows providers to choose measures that best reflect the patients served in that provider’s practice. While this makes sense in terms of each individual provider, there is such a wide array of options that it is difficult to aggregate data that will evaluate all providers on similar measures, thus making it difficult to ascertain the relative quality and cost savings.

      Partnership for Patients

      Partnership for Patients is a national partnership initiated in 2011 by HHS that was projected to save 60,000 lives by preventing injuries and complications in patient care over three years. HHS stated upon its inception that the Partnership for Patients also had the potential to save up to $35 billion in health care costs, including up to $10 billion for Medicare. At that time it was estimated that over 10 years, the Partnership for Patients could reduce costs to Medicare by $50 billion and save billions more in Medicaid. More than 3,500 hospitals, physician and nurse groups, consumer groups, and employers pledged their commitment to the Partnership for Patients. Oversight for this program has been under CMS’s Center for Medicare and Medicaid Innovations.

      The partnership asked hospitals to focus on nine types of medical errors and complications where the potential for dramatic reductions in harm rates has been demonstrated by pioneering hospitals and systems across the country. Examples included preventing adverse drug reactions, pressure ulcers, childbirth complications, and surgical site infections. The CMS Innovation Center pledged to help hospitals adapt effective, evidence‐based care improvements to target preventable patient injuries on a local level, developing innovative approaches to spreading and sharing strategies among public and private partners in all states. Members of the partnership were to identify specific steps they will take to reduce preventable injuries and complications in patient care.

      The Partnership for Patients, a public–private partnership, was invested in reforms that help achieve two shared goals:

       Keeping hospital patients from getting injured or sicker. Achieving this goal meant approximately 1.8 million fewer injuries to patients, with more than 60,000 lives saved from 2010 to 2013. From 2014 to 2017, hospital‐acquired conditions (HACs) fell by 13%, saving about 20,700 lives and about $7.7 billion in health care costs.

       Helping patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another were expected to decrease so that all hospital readmissions would be reduced by 20% compared with those of 2010. Achieving this goal meant that more than 1.6 million patients recovered from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge. Similar outcomes were reported for 2017, the last year of reporting.

How has the Partnership for Patients done so far in meeting these goals? As reported by Blumenthal Abrams, and Nuzum (2015), 30‐day readmission rates for Medicare enrollees declined nationally

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