Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

2 APMs Take Next Step As MACRA Physician-Focused Payment Models

A federal committee approved two alternative payment model proposals for limited-scale testing as MACRA physician-focused payment models while rejecting one model.

Two alternative payment model proposals will be considered for testing as MACRA physician-focused payment models

Source: Thinkstock

By Jacqueline LaPointe

- Two proposed physician-focused payment models will go to the HHS Secretary for possible limited-scale testing, while one model was stopped from becoming a potential alternative payment model under MACRA, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) recently announced.

The committee approved Project Sonar, a gastroenterology-focused alternative payment model, and a bundled payment model for surgical episodes called the American College of Surgeons (ACS)-Brandeis Advanced Alternative Payment Model (Advanced APM).

However, the group did not recommend the COPD and Asthma Monitoring Project proposed by the Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group.

Two physician-focused payment models approved for potential MACRA testing

HHS Secretary Tom Price will soon review Project Sonar, an intensive medical home centered on inflammatory bowel disease care proposed by the Illinois Gastroenterology Group and SonarMD.

Under the model, providers would use a ping system to regularly monitor patient health outside of the office. Through the pings, providers would check disease severity, identify depressed or at-risk patients, and encourage patients to adhere to care plans.

READ MORE: What We Know About Value-Based Care Under MACRA, MIPS, APMs

The alternative payment model would continue to reimburse providers under the Medicare Physician Fee Schedule. However, Medicare would retrospectively adjust payments based on quality and cost performance.

Participating providers who go over the benchmark price for a patient’s inflammatory bowel disease care would repay a portion of the financial losses, whereas providers who spend less than the target price would share in the savings.

In addition, providers would receive a supplemental per member per month payment to cover infrastructure costs.

PTAC approval for the Project Sonar model garnered support from industry heavy-hitters, such as the American Medical Association (AMA).

“The American Medical Association is extremely pleased that Project Sonar is the first alternative payment model nationally to be recommended to the HHS Secretary by the PFPM Technical Advisory Committee,” stated. “This model holds great promise to improve patient care for serious chronic diseases while lowering spending on avoidable hospitalizations, as well as provides a means for specialist physicians who have had few opportunities to participate in alternative payment models to effectively do so.”

READ MORE: CMS Timelines for Stage 3 Meaningful Use, MACRA Implementation

Additionally, the ACS-Brandeis Advanced APM will also be subject to further HHS review. The bundled payment model for surgical episodes would utilize updated Episode Grouper for Medicare (EGM) software from Brandeis University to help providers create care teams and develop personalized care plans.

The physician-focused payment model would include 54 procedural episodes in 10 clinical areas. Researchers also touted that the episodes would span about 75 specialties.

Providers would receive Medicare reimbursement under the Physician Fee Schedule, but CMS would retroactively adjust payments based on quality and cost performance. Care quality level and costs per episode would determine if providers share in the savings or repay CMS some of the financial losses for care episodes.

PTAC questioned the physician-focused payment model’s software use as well as its payment and risk methodology, The Hill reported. But the ASC Medical Director Frank Opelka emphasized that a limited-scale test would help to develop the model.

“There are some outstanding issues that only the government can answer moving forward and we could not bake those answers into the proposal,” he told the news source. “So, we wanted to leave that flexibility for the government.”

COPD and asthma care model stopped from progressing to MACRA implementation

READ MORE: Understanding the Quality Payment Program’s Advanced APM Track

After approving two models, PTAC rejected the COPD and Asthma Monitoring Project (CAMP) model.

The proposed alternative payment model focused on interactive remote monitoring of COPD and asthma patients covered by Medicare. Through a smartphone application and a peak flow meter device, the model intended to help providers monitor asthma and COPD patients at home.

Patients would regularly send lung function data from the application to a monitoring center that would either recommend care if necessary or pass along patient information to providers.

Providers would receive a per member per month care management payment for participating in the alternative payment model as well as a $200 supplemental payment for the meter. The proposal added that the model would require initial investments to create the “umbrella” care system.

PTAC did recommend the CAMP model because of care coordination and payment methodology inadequacies.

The committee evaluated the proposed physician-focused payment models based on 1ten criteria listed in the final MACRA implementation rule. The criteria were:

• Value over volume: provides incentives to clinicians to furnish high-quality care

• Flexibility: provides flexibility to allow clinicians to deliver high-quality care

• Quality and cost: aims to improve health outcomes without additional costs, maintain outcomes while reducing costs, or both

• Payment methodology: addresses how reimbursement structures achieve physician-focused payment model goals

• Scope: intends to extend CMS alternative payment model portfolio or include clinicians whose opportunity to participate in alternative payment models has been limited

• Ability to be evaluated: contains assessable goals for care quality, costs, and other physician-focused payment model goals

• Integration and care coordination: promotes increased care coordination among clinicians and across settings

• Patient choice: encourages greater patient engagement

• Patient safety: expects to maintain or improve patient safety

• Health IT: promotes use to inform care

Through the physician-focused payment model opportunity, HHS intended for providers to help develop alternative payment models for MACRA after industry groups expressed concerns about limited specialty options.

The American Hospital Association (AHA) stated “that CMS continues to narrowly define Advanced Alternative Payment Models, which means that less than 10 percent of clinicians will be rewarded for their care transformation efforts.”

Organizations focused on radiology and oncology also came forward to voice their disappointment with limited specialty options. Both organizations suggested that specialists develop physician-focused payment models to fill the MACRA alternative payment model gap.

The two approved models will now go to the HHS Secretary for potential testing as physician-focused payment models under MACRA. Price will decide whether to implement the models as CMS Innovation initiatives.

PTAC also plans to vote on three other proposed MACRA physician-focused payment models later in 2017.


Join 30,000 of your peers and get free access to all webcasts and exclusive content

Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...