WASHINGTON -- A bundled payment model for emergency medicine, a model to enhance primary care, and a model to improve care for complex chronically ill patients were supported by the Physician-Focused Payment Model Technical Advisory Committee ().
PTAC was established by Congress to advance new physician payment models in government programs. The committee recommended three of four models it reviewed during a .
A Model for ED Docs
The American College of Emergency Physicians' (ACEP) aims to reduce inappropriate inpatient admissions or observation stays, improve care coordination after discharge, and avoid post-emergency department (ED) safety events, return visits, and their associated costs.
Under the model, an episode begins with a qualifying ED visit, and ends after 30 days or with the patient's death. All of the Medicare services in that 30-day window are included in the bundle or episode and quality and costs are tracked.
Qualifying ED visits include abdominal pain, chest pain, altered mental status, and syncope; other conditions could be added in future iterations.
The model would also leverage certain waivers, such as those allowing ED physicians to offer telehealth services and bill for transitional management codes, as well as permit clinical staff to offer home visits.
Participants earn savings when Medicare spending for a specific condition is lower than a facility-specific, historical cost. Reducing admissions for the four targeted conditions would provide participants with the greatest chance to earn savings, members of the PTAC's preliminary review group explained.
Performance in the model would be based on patient experience, care coordination, and outcomes measures, or the percent of "eligible cases where an unscheduled ED revisit, hospitalization, or death did not occur within 30 days" versus the same measure during a pre-set time period at the same facility.
Nine members of the committee voted for implementation, and two of nine suggested limited-scale implementation. Two members voted for implementation with "high-priority" (the strongest endorsement) and five recommended "full implementation." Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, recused himself from the vote as he said he had previously assisted ACEP with the design of several alternative payment models (APM).
PTAC member Paul Casale, MD, interventional cardiologist and executive director for in New York City, expressed concerns over ED physicians being responsible for total cost of care for 30 days, along with what he said was a lack of attention to care coordination. These aspects go hand-in-hand, he noted.
"If you're going to take 30 days total cost of care, clearly you're going to need a lot of integration and care coordination," Casale said.
Len Nichols, PhD, director of the Center for Health Policy Research and Ethics and a professor of health policy at George Mason University in Fairfax, Virginia, recommended full implementation with high priority.
"We've recommended some damn good proposals before; we've had some thoughtful applicants before. None beat this group [ACEP], in my opinion, for how much care you put into it," he said.
During discussions, members worried about the problem of using facility-specific benchmarks, which might allow perverse incentives for worse-performing facilities. ACEP representatives said they were open to including regional benchmarks in the future. They also showed a willingness to remove categories in its model that made distinctions between observation and non-observation stays in the ED, as some PTAC members said they viewed them as unnecessary complex.
New Approach to Primary Care
Jean Antonucci, MD, a family physician in Farmington, Maine, and founder of the nonprofit Ideal Medical Practice, submitted ". The model offers increased resources for primacy care physicians, while reducing their administrative burden and giving more flexibility to provide supplemental services.
PTAC members voted for limited-scale testing of IMPC APM.
Payment for the model relies on a risk-stratified per beneficiary per month (PBPM) payment in place of "virtually all current fees," and a performance-based payment created through a 15% withhold of that PBPM payment. A participating practice would get back the withheld amount only if it met certain performance-based standards, which the PTAC's preliminary review team noted were not specified in the proposal.
A core element of the proposal is its use of , a 15-minute online patient survey. Monthly payments would be risk-stratified based on elements of the survey that indicate patients are at higher risk of hospital admission.
Using patient-reported outcomes for performance benchmarking is still "in its infancy," noted Tim Ferris, MD, MPH, a primary care internal medicine physician and CEO of the Massachusetts General Physicians Organization, who was one of the three members of the preliminary review team.
The proposal also failed to meet many of the criteria PTAC has established for a model to qualify as a physician-focused APM, including its payment methodology and the ability to be evaluated.
But IMPC APM is "so creative I just hate to kill it without a pathway forward," commented Nichols, adding that neither Merit-based Incentive Payment System (MIPS) nor "Meaningful Use" are "perfect. So, if you've got a way to begin down a different path... for a subset of the world... that is truly hemorrhaging people ... to me [IMPC APM] ought to be in the mix."
Miller agreed, stating that "this [model] needs to get to the Centers for Medicare and Medicaid Services (CMS)."
The committee disagreed over the designation of the limited-scale testing category. Nichols called it the "the kiss of death," and noted that CMS had not taken the limited-scale testing category seriously in the past.
Ultimately, two PTAC members voted against a recommendation, six called for limited-scale testing, and one recommended full implementation. One PTAC member recused himself because he had previously reviewed the proposal.
Jeffrey Bailet, MD, PTAC chair and an otolaryngologist and executive vice president for Health Care Quality and Affordability for Blue Shield of California, voted against recommending the proposal. He stated that because performance measures in IMPC APM are still unclear, there's currently no way for physicians to know how they can earn back their withhold.
Comprehensive Care for Chronic Illness
The " model submitted by University of Chicago Medicine also received a limited-scale testing designation.
The model seeks to improve care for complex chronically ill patients, who are frequently hospitalized, by paying physicians continuity-of-care fees to see certain patients both in ambulatory and hospital settings, provided they meet certain performance benchmarks.
In a study funded by the Centers for Medicare and Medicaid Innovation, researchers compared the University of Chicago program to standard care and found "CCP significantly improves patient satisfaction with care and self-rated mental health status, decreases hospitalization 15%-20% and lowers annual Medicare spending care by ~$3,000 per patient per year," according to the submitted proposal.
PTAC preliminary reviewer Kavita Patel, MD, an internal medicine physician and nonresident Senior Fellow for the Brookings Institution, questioned the generalizability of the model, and if the results could be replicated across other settings.
PTAC members said they worried that physicians potentially could unenroll and re-enroll patients to gain more payments.
Some committee members suggested to David Meltzer, MD, PhD, chief of the section of hospital medicine at the Chicago institution, that care continuity is being addressed by Accountable Care Organizations.
Meltzer said he disagreed. "This just isn't happening," he said, adding that the CCP model represents a dramatic shift in the way care is being delivered. "This is a lifestyle decision," he added.
PTAC member Rhonda Medows, MD, executive vice president of Population Health at Providence St Joseph Health, asked if "in the real world," physicians are interested in following patients in and out of the hospital.
Meltzer responded that younger physicians, and those working in community hospitals, are interested in this type of model.
Three PTAC members voted to recommend the model "for attention," six voted for limited-scale testing, and one -- Grace Terrell, MD, internal medicine physician and CEO of Envision Genomics -- recommended full implementation.
Terrell said the CCP approach was "revolutionary" and represented "what I thought I was being trained to do, and what I would love to do." Implementing this model "could be one of the best quick wins for PTAC and ... for the country," she said.
Improving Dialysis
Finally, Dialyze Direct submitted a model for in skilled nursing facilities that redirects unused transportation payments to pay for delivering more frequent dialysis in nursing homes. Participants would also receive a bonus for educating patients about their care.
Ferris praised the model, but questioned if a better solution might be new codes and changes to anti-kickback statues, which currently won't allow this approach, to create safe harbors.
The committee unanimously gave the model a new category, "recommended for attention," but stopped short of a more robust recommendation.