Physicians Designing Unique APMs for MACRA

In the shift to value-based care, The Medicare Access and CHIP Reauthorization Act's (MACRA's) Alternative Payment Models (APMs) offer incentives to physicians who provide high-quality and cost-efficient care as it applies to a specific clinical condition, care episode, or population. Examples include Comprehensive Primary Care Plus and the Oncology Care Model.

But, what if CMS let physicians design their own APMs based on how care is actually delivered? The MACRA law allowed for that in the form of the Physician-Focused Payment Model, an opportunity for physicians to work with CMS to develop new types of APMs. CMS has already received 16 full proposals and 17 letters of intent from physician organizations seeking to create payment models. Six have had hearings before the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which provides recommendations to the Department of Health and Human Services (HHS).

"We think the current system is broken and not sustainable," says Frank Opelka, MD, medical director of quality and health policy for the American College of Surgeons (ACS). "Coming to the clinical side of the house and asking us to develop alternative payment models that fit the transformation of the clinical business models is extremely prudent."

The ACS presented one of the first physician-focused models to the PTAC, and is currently working through issues with CMS before its ACS-Brandeis Advanced Alternative Payment Model is tested.

Opelka says the model is different from traditional bundles of care. "We describe an episode of care that a patient goes through and measure the quality of care the patient receives from the whole team, not individual elements of the team," he says. The model would measure the patient's success, and if the team saves money and provides optimal care, the team is eligible for shared savings rewards. If not, it is subject to team-based penalties.

Opelka stressed that beyond surgeons, episodes of care involve anesthesiologists, primary care doctors, post-acute care, radiologists, and pathologists. "Everybody is involved in the team. That is how care is delivered. Trying to parse it out into fee-for-service elements doesn't reflect how patients are cared for."

During a Sept. 7 PTAC hearing, Albert Siu, MD, an internist and geriatrician at the Icahn School of Medicine at Mt. Sinai Hospital in New York, described Hospital at Home Plus (HaH-Plus), a Physician-Focused Payment Model designed to engage physicians and other professionals in ordering, providing, and managing hospital-level services at home for beneficiaries with certain acute illnesses who would otherwise be hospitalized. He says that traditional fee-for-service Medicare does not provide adequate payment for such care. HaH-Plus is a bundle covering the acute episode and an additional 30 days of transition services.

The goal is to reduce cost and complications in the hospital and improve transitions of care after hospitalization. "Hospital at Home sits in a place that does not exist in the current system," Siu says. "It is not hospital, not physician services, and not home care, so regulatory agencies don't know how to deal with it. We have struggled to find a place for this program." 

All of these new models involve measuring quality in new ways, which ACS's Opelka admits is challenging. However, modern informatics and digital technology make it possible, he says. "We had to design an episode-based measure framework and we rely heavily on patient-reported outcomes, because those are the most valuable."

Developing the models is also time-consuming and resource-intensive. In fact, work on the ACS model began more than three years ago. "We began this work as a solution to the sustainable growth rate (SGR) that Medicare lived under," Opelka explained. After Congress got rid of the SGR and moved forward with the transition to APMs, our work was easy to transition to APMs because that was how we were already thinking."