April 14, 2017

PTAC Assesses PhysicianFocused Payment Models

The Physician-Focused Payment Model Technical Advisory Committee (PTAC) recommended two of three proposed Physician-Focused Payment Model (PFPMS) considered at its April 10–11 meeting.

Project Sonar, a model proposed by the Illinois Gastroenterology Group and SolarMD, LLC, to be initially applied to the clinical management of Crohn’s disease patients, and the American College of Surgeons (ACS) - Brandeis Advanced APM, an episode-based alternative practice model that measures resource use, financial risks and practice performance quality, received high enough ratings to earn the committee’s recommendation with limited-scale testing.

The proposed COPD and Asthma Monitoring Project (CAMP) fell short in satisfying enough of the 10 criteria articulated by the secretary of the Department of Health and Human Service (DHHS) in the MACRA final rule to qualify as a physician-focused payment model.

These 10 criteria cover these requirements:

  • Scope of Proposed PFPM (High Priority). The proposal aims to broaden or expand CMS’ APM portfolio by either: (1) addressing an issue in payment policy in a new way, or (2) including APM Entities whose opportunities to participate in APMs have been limited.
  • Quality and Cost (High Priority). The proposal is anticipated to (1) improve health care quality at no additional cost, (2) maintain health care quality while decreasing cost, or (3) both improve health care quality and decrease cost.
  • Payment Methodology (High Priority). Pay APM entities with a payment methodology designed to achieve the goals of the PFPM criteria. Addresses in detail through this methodology how Medicare and other payers, if applicable, pay APM entities, how the payment methodology differs from current payment methodologies and why the PFPM cannot be tested under current payment methodologies.
  • Value Over Volume. The proposal is anticipated to provide incentives to practitioners to deliver high-quality health care.
  • Flexibility. Provide the flexibility needed for practitioners to deliver high quality health care.
  • Ability to Be Evaluated. Have evaluable goals for quality of care, cost and any other goals of the PFPM.
  • Integration and Care Coordination. Encourage greater integration and care coordination among practitioners and across settings where multiple practitioners or settings are relevant to delivering care to the population treated under the PFPM.
  • Patient Choice. Encourage greater attention to the health of the served population while supporting the unique needs and preferences of individual patients.
  • Patient Safety. Aim to maintain or improve patient safety standards.
  • Health Information Technology. Encourage use of health information technology to inform care.

Project Sonar and the ACS-Brandeis APM both received ratings of 2, which earned them positive recommendations with need for limited-scale testing and responses to extensive comments expressed by PTAC members at the meeting.

Project Sonar is a health care management program development by community-based gastroenterologists to improve the management of patients with chronic diseases and help facilitate a shift from fee-for-service to value-based clinical practice. Focusing initially on Crohn’s disease, the program’s creators worked with American Gastroenterological Association’s care pathway guidelines to develop a team-based approach deploying clinical decision support tools to guide health care professionals on the selection of optimal care, the appropriate use of anti-tumor necrosis factor, and the use of nurse care managers for engaging and managing patients. After four years of clinical experience, Project Sonar resulted in a significantly lower hospitalization rates and lower inpatient, emergency department, and injectable biologics costs, according to its organizers.

The ACS-Brandeis Advanced APM is based on an updated version of the Episode Grouper for Medicare (EGM) software now used by the Centers for Medicare and Medicaid Services to measure resource use. It also assesses financial risks and, according to its developers, incorporates a rigorous quality measurement framework that can be used to adjust payments according to the quality of health care delivery.

PTAC was authorized by MACRA to make recommendations to the DHHS secretary on the creation, development and operation of PFPMs. Its 11-member board, appointed by the U.S. Comptroller General, is comprised of physicians and national health care policy experts. Visit the DHHS Office of the Assistant Secretary for Planning and Evaluation website to learn more about PTAC.