Dermatologists looking for a way to participate in an advanced alternative payment model under Medicare’s new Quality Payment Program will likely need to develop their own and get it approved.

Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher-value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they do not appeal to everyone.

“The likelihood that a private practice dermatologist is going to participate in a risk-bearing APM is, I think, possible but challenging,” said Kathryn Schwarzenberger, MD, chair of the American Academy of Dermatology’s Workgroup on Innovation in Payment and Delivery. “To have a fully qualified, double-sided risk APM for most private practitioners is going to be difficult. The advanced APMs, unless you are in a group, we have figured most dermatologists wouldn’t be interested.”

A physician-created APM might be a different story, however.

Getting approval for this type of APM – technically known as physician-focused payment models (PFPMs) – is tough. Of the first three PFPMs reviewed by Medicare’s Physician-Focused Payment Model Technical Advisory Committee (PTAC), two were recommended for limited trial periods only. A third proposal was not recommended. None of these early proposals were dermatology focused.

Not jumping into the process early was a prudent move, according to Dr. Schwarzenberger.

“We learned that it is probably good to sit back at this point and watch and see what is happening,” she said. “I think the rules have become much more clear. I think now that PTAC has provided us with some better guidelines for how to develop a successful APM, we have a much better chance of doing so.”

In this earliest review, each proposed APM was assigned to three commissioners, including at least one physician, for review against 10 criteria:

• Scope of proposed PFPM (high priority).

• Quality and cost (high priority).

• Payment methodology (high priority).

• Value over volume.

• Flexibility.

• Ability to be evaluated.

• Integration and care coordination.

• Patient choice.

• Patient safety.

• Health information technology.

While each proposal met a few of the criteria, none met all three high-priority criteria, and none was recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.

“We recommended the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence are required before they may be ready.”

The two models that got the limited recommendation were:

• Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a Web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.

• American College of Surgeons–Brandeis APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.

The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacramento.

PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.

“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”

She offered advice to those who are contemplating submission of a payment model: “Really understand the criteria and review the request for proposals. I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straightforward.”

She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”

Most of all, the highest priority when it comes to the models is related to quality of care and cost.

“We are not soliciting models that are essentially tweaks to fee for service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”

Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.

“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”

Dr. Schwarzenberger said that while the AAD working group is looking at some dermatology-specific conditions that might be good for a PFPM a broader approach may be better. Perhaps the focus should be “where dermatology’s involvement with other physicians, where we might be able to help them practice medicine better or save money,” she said. “Maybe where we can make our biggest financial and potentially quality impacts.”

gtwachtman@frontlinemedcom.com

Physician-created APMs: Dermatology aims to learn from early recommendations