Ideas for New Doctor Payment Models Coming From Medical Groups

By Mindy Yochelson

Five very different alternative payment models are being critiqued by a federal committee to determine if they could become options for paying physicians under Medicare.

The five are the first to be submitted to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) and range from limited inclusion of professionals who just deal with a specific clinical condition, such as lung disease, or a population, such as individuals with advanced illness.

An APM is a payment approach that can give doctors added incentive payments to provide high-quality and cost-efficient care in a collaborative setting.

First Groups to Propose New medicare Payment Models

The models, if approved, could expand options for doctors who want to move away from being paid under traditional fee-for-service Medicare. Instead, they would be part of an entity that would hold them responsible for cost and quality of care and potentially reward them for good performance. Providers in eligible models must use certified technology, report quality measures comparable to measures developed by the Medicare agency, and bear financial risk in excess of a nominal amount.

Genesis in MACRA

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created a new payment system that basically gives physicians two options—continue being paid under the Medicare fee-for-service system and be graded by quality measures that could result in payment cuts or increases, or join an APM appropriate for their specialty and practice. In an APM they’d be protected from cuts they might receive under the new quality grading program, known as the Merit-Based Incentive Payment System. Also, if their model meets the qualifications of an advanced APM, they could receive a 5 percent bonus in their reimbursements.

The 11-member PTAC was established by MACRA to consider whether models submitted by stakeholders qualify as Medicare alternative payment models.

Doctors started submitting their proposals Dec. 1, 2016. The committee has said it will take about four months to recommend a submission be sent to the Department of Health and Human Services to consider including in the Medicare quality payment program.

Some of the first proposals focus just on a specific health condition or a procedure, while another could encompass most medical professionals. Still another is aimed at medical professionals who provide care just for patients in the last stages of life.

The five were submitted by the American College of Surgeons; the Coalition to Transform Advanced Care; Digestive Health Network; the Illinois Gastroenterology Group and SonarMD LLC; and Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group Inc. of Sacramento, Calif.

Political Climate

The political climate is right for a welcome reception—and implementation—for models developed by medical professionals and not just handed down by the federal government, John Feore, director at Avalere Health, a consulting company, told Bloomberg BNA Feb. 21.

HHS Secretary Tom Price, a surgeon by trade, has reacted negatively to mandatory government models for doctors, Feore said, and is more likely to be inclined toward projects that come from medical groups and have had public input, he said.

Diverse Populations

Among the projects is a medical home intended to improve the management of patients with a particular chronic condition. It’s been used by a gastroenterology practice for their patients with inflammatory bowel disease.

Another medical group submitted a proposal that would use “remote interactive monitoring” for patients with lung disease. Among the technologies used is a smart phone application and a remote monitoring center to track input into the app, as well as video conferencing.

Also, a network of digestive health clinics has proposed team-based care for patients undergoing colorectal cancer screening that uses a bundled payment model.

‘Pretty Different.’

The submissions are “pretty different,” Feore said.

The diversity is desirable, he said. “The government can’t do it all” when it comes to developing innovative payment models, he said. “You need stakeholder involvement,” he said.

“Some of these are ambitious projects that are tackling high cost and vulnerable populations,” Darryl Drevna, director, regulatory and public policy for AMGA, which represents multispecialty medical groups, told Bloomberg BNA.

“It’s early, and ultimately these models will need to be tested, but what these ideas are showing is an appetite to try new ways to take accountability for cost and quality,” he said.

Elizabeth Mitchell, PTAC’s vice chair, told Bloomberg BNA she believes there are “quite a few” submissions at this point, considering the amount of work it takes to put together a proposal.

Review Teams

Right now the committee’s preliminary review teams are examining most of the proposals and will report to the full committee, Mitchell said. One is still within the three-week public comment period.

The teams will draft a report on each for consideration by the full committee.

Proposals that meet criteria in the November 2016 MACRA rule, such as encouraging coordinated care, could be recommended to HHS, at least for smaller scale testing.

Others may not pass the committee’s scrutiny.

“For example, if we get a proposal that does not have the same downside risk as is required for an advanced alternative payment model, it wouldn’t qualify,” Mitchell said. In a model that includes “downside risk,” physicians may be financially penalized for increased expenditures and care that fails to meet quality and efficiency standards.

The committee’s next meeting is March 13-14 and it may vote on a proposal, she said.

Paying for Patients With Advanced Disease

The model presented to PTAC by one of the groups, the Coalition to Transform Advanced Care, already has been used in the private sector and to a limited extent in the public sector. The nonprofit coalition supports patients with advanced illness.

The model is intended to improve care for those “stuck between long-term care and hospice,” and to eventually help them transition to palliative care, Jon Broyles, the executive director, told Bloomberg BNA. The model uses home visits and calls for an interdisciplinary team to work with family members.

Although provider organizations have subsidized this type of care in their current programs, a barrier to getting the model into more common use has been in structuring a payment model, Khue Nguyen, chief operating officer for C-TAC Innovations, said. The group submitted the model to PTAC with that in mind.

Broad Application

In contrast, the American College of Surgeons submitted a much broader model for a variety of specialties and patients than those proposed by CTAC and other groups.

The model is designed as an “episode-based payment system” that accounts for the quality of care provided by all providers involved in a patient’s care, Frank Opelka, medical director for quality and health policy for the group, told Bloomberg BNA.

It doesn’t require a hospitalization, “allowing inclusion of procedures performed in the outpatient setting as well as episodes for acute and chronic conditions cared for by medical specialties,” according to the group.

The model includes an initial core set of 800 episodes intended to be a “starter set” and which could scale up quickly, Opelka said.

“The whole team is accountable for how the patient did,” Opelka said. The shared risk for those involved is “asymmetrical” in that there’s more upside reward than downside penalty.

Under this model, software developed by the Centers for Medicare & Medicaid Services and Brandeis University uses claims data to gather episodes of care. “Given that this model is built upon existing software that is familiar to CMS, implementation could begin in stages as early as January 2018,” the group said.

More on the Horizon

Other models are in the pipeline.

The American Medical Association is developing a “broad framework” that could apply to multiple specialties and help them with their submissions, an AMA representative said at a 2016 PTAC meeting.

AMA staff have met with specialty societies working on proposals to help get them off the ground.

One professional group, the American Society for Radiation Oncology, is among those with a model under development. The group sent a letter of intent to PTAC last October describing its Radiation Oncology Total Cost of Care model.

The model is based on an episode of care that begins with treatment planning and concludes 90 days after the last radiation therapy. If a provider’s payments are below the spending target, he or she would be eligible for a percentage of shared savings based on quality measures.

But if payments exceed the target, CMS would be able to recoup the funds up to a predetermined amount, the letter said.

Help for Interested Groups

New submissions are welcome, Mitchell said. The committee has a rolling submission policy in that it will accept letters of intent at any time.

In addition, a committee webinar will be held Feb. 27 that will offer submission tips and address common questions.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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