- MACRA’s Quality Payment Program offers 5 percent maximum incentive payments if eligible clinicians sufficiently participate in an Advanced Alternative Payment Model (APM) from 2017 to 2022. But many specialists are still waiting for CMS to develop and approve more specialty-specific Advanced APMs so they can reap the financial rewards.
Some healthcare stakeholders expressed disappointment that the final MACRA implementation did not contain more Advanced APM options. The American Hospital Association, one of those stakeholders, voiced concern “that CMS continues to narrowly define Advanced Alternative Payment Models, which means that less than ten percent of clinicians will be rewarded for their care transformation efforts.”
Fortunately for eligible clinicians, CMS committed to expanding Advanced APM opportunities as the Quality Payment Program matures. The federal agency also called on providers and stakeholders to help them.
Through the development of the Physician-Focused Payment Model Technical Advisory Committee, healthcare stakeholders can submit proposals for Quality Payment Program APMs.
The physician-focused payment models must have Medicare as a payer, include a physician or group practice as the participating entity, and focus on physician care quality and costs.
The models can also qualify for Advanced APM status if they require certified EHR use and “more than nominal” financial risk. The APMs must also calculate value-based reimbursements based on quality measures similar to those in the Merit-Based Incentive Payment System.
Since the committee opened proposal submissions in December 2016, stakeholders have submitted four proposals. The proposals include APMs for colorectal cancer care, several procedure-base care episodes, Inflammatory Bowel Disease, and asthma and COPD.
Comprehensive Colonoscopy Advanced APM for Colorectal Cancer Screening, Diagnosis and Surveillance
The Digestive Health Network Inc., a Delaware-based stock corporation, proposed the Comprehensive Colonoscopy Advanced APM for better colorectal screening and follow-up care.
In 2016, providers identified over 134,000 new cases of colorectal cancer, leading colorectal cancer to become the fourth most common cancer in country.
Earlier colorectal cancer detection, though, is linked to a higher chance of surviving five years after diagnosis. However, only three-fifths of individuals aged 50 to 75 years are up-to-date on screenings.
Through an outpatient, prospective bundled payment model, the Digestive Health Network intends to improve timely colorectal care screening, particularly through colonoscopies, and reimburse providers for key follow-up care.
The bundled payment model centers on a one-year colonoscopy episode that includes:
• Pre- and post-colonoscopy evaluation and management services
• Anesthesia and/or moderate sedation
• Radiology services needed to complete colon examinations
• Emergency room visit to manage some complications occurring seven days after colonoscopy
• Facility costs
• Preparation agent
Sedation pharmaceutical agents
Participating providers would receive a prospective reimbursement that would be re-adjusted every year based on redone procedure rates and ambulatory surgery center use. Providers would also get a one-time payment to boost patient engagement, allow for more outcome data collection, expand care access to 24/7, add more post-procedure services, implement stop-loss premium for emergency department use, and reconciling endoscopist office services.
The physician-focused payment model will also include downside financial risk. Providers may face downside payment adjustments if they do not meet re-do procedure rate, ambulatory surgical use, and care quality for follow-up care benchmarks.
The proposal added that the colonoscopy bundled payment model would also significantly expand APM options for specialists in gastroenterology, general and endoscopic surgery, colorectal surgery, internal medicine and family practice.
ACS-Brandeis Advanced APM for Episodic Care
The proposed American College of Surgeon (ASC) and Brandeis physician-focused payment model builds on the traditional bundled payment model. But the ASC touted that the model’s innovation comes from its “bundled of bundles” structure.
“The ACS-Brandeis design goes beyond a single episode by nesting acute condition episodes within chronic condition episodes, and by clustering episodes within an Advanced APM, all with the intention of creating business efficiencies in a multi-payer environment,” stated the proposal.
Using the CMS and Brandeis Episode Grouper for Medicare, the model currently supports 54 procedural episodes in 10 clinical areas that spans up to 75 specialties.
In addition, the model can expand to 29 acute condition episodes, including pneumonia, acute myocardial infarction, and acute exacerbations of chronic conditions. The physician-focused payment model can also support another 38 chronic condition episodes, such as COPD, heart failure, and osteoarthritis.
Under the retrospective APM, participating providers would still be reimbursed via the Medicare Physician Fee Schedule for the care episode. However, CMS would either allow providers to share in the savings if they reduce actual care episode costs compared to a target price or require providers to repay some financial losses if actual care episode costs exceed the target price.
Participating providers would also face value-based incentive payments under the model. CMS would evaluate providers on episode- and all patient-based quality measures. Based on quality performance, providers will be divided into tiers, which have specific target discount factors that impact savings or losses shared with the participant.
“The better the quality, the smaller the discount CMS applies, the more positive savings shared with the entity, or less negative savings owed by the entity,” ACS explained.
The ACS intends for the physician-focused payment model to qualify as an Advanced APM.
Project Sonar Physician-Focused Payment Model Centers on IBD
Project Sonar is an intensive medical home targeting inflammatory bowel diseases, such as Crohn’s disease, which are high-cost and high-utilization chronic conditions.
Crohn’s disease patients alone have annual healthcare costs of $11,000 based on 2011 data, the proposal stated. Over one-half of the costs were for inpatient care to manage complications and only 3.5 percent was for gastroenterology care.
To reduce healthcare costs and avoidable resource use, the Illinois Gastroenterology Group and SonarMD developed Project Sonar, a chronic disease management program that focuses on controlling, costs, hospitalizations, complications, and inflammation. The program also relies heavily on strong patient engagement.
Key to Project Sonar is a sonar system that pings patients on a periodic basis. Through regular patient engagement, specialists would monitor disease severity, identify depressed or at-risk patients, and help patients adhere to care plans.
In 2014, Blue Cross Blue Shield of Illinois collaborated with the Illinois Gastroenterology Group to expand Project Sonar to a specialty-based intensive medical home. Using supplemental per member per month and value-based incentive payments, inpatient costs for Crohn's disease patients dropped 51.14 percent by 2016 stemming from similar reductions in complications and hospital admissions.
In effort to help more specialists participate in APMs, the Illinois Gastroenterology Group and Sonar MD submitted a similar supplemental per member per month APM as a physician-focused payment model.
Participating providers would prospectively receive $70 per member per month for care management services, with a $200 enrollment visit payment. Providers whose budget stays below the target price keep the cost savings, whereas providers whose budget exceeds the price must repay losses according to their CMS contract.
Based on quality and cost performance, providers can also receive value-based incentive payments. High-performing providers could receive a maximum 10 percent incentive payment and low-performing could be penalized by up to 5 percent.
“The payment model of PS [Project Sonar] represents negotiation of a transition from fee-for-service to fee-for-value for physicians who may not ready or able to take on full risk, but are capable and should be ready to accept accountability for the care they provide,” stated the proposal.
The COPD and Asthma Monitoring Project
The Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group Inc. developed the COPD and Asthma Monitoring Project (CAMP) to bring improved chronic disease management to lung conditions.
Through interactive remote monitoring of COPD and asthma Medicare patients, the organization intends for the physician-focused payment model to complement existing primary care provider and specialist relationships.
“We are proposing this payment model as an umbrella or add-on service to existing forms of patient management,” stated the proposal. “CAMP is not designed to disrupt current relationships that exist between the patient and their providing physicians, but represents an opportunity in population-based chronic disease management.”
Patients attributed to the APM will receive a smartphone app or a tool to track their COPD or asthma in real-time. Using a peak flow meter device, patients regularly submit lung function and staff at monitoring centers will evaluate if patients need provider attention.
Based on patient lung function updates and trends, monitoring center staff can either send recommendations to primary care providers or pulmonary specialists at CAMP can make appropriate care plans and document them in the patient’s EHR.
To implement the physician-focused payment model, the proposal called on CMS to give providers a $200 payment per Peak Flow Meter participant and a $175 per member per month care management fee.
In terms of risk sharing, the proposed model would risk adjust each enrolled patient based on number of chronic conditions.
While the proposal acknowledged that CAMP implementation would require initial investments because it is a novel care umbrella system, model developers intend for the monitoring tool to prevent costly adverse events, resulting in Medicare savings.