This year’s Congressional debate over repealing or reforming key provisions of the Affordable Care Act was contentious in large part because of the high and rising costs of health care. Though a new health care reform bill is now unlikely, it remains critical to continue the discussion on how to deliver and pay for care in a way that addresses these high costs and makes coverage more affordable through more efficient and high-quality approaches.1
Illustrating the bipartisan nature of payment reforms, the Medicare Access and CHIP Reauthorization Act (MACRA) passed with more than 90% support in both the House and Senate in 2015. MACRA provides a 5% bonus payment for physicians who receive a significant part of their Medicare payments in an advanced APM, which involves some downside financial risk. In addition, any physician who participates significantly in a broader range of Medicare APMs, including many without downside risk, receives an exception from the reporting requirements for the new Merit-Based Incentive Payment System (MIPS) and would report on APM performance measures instead.
However, the details of payment reform are challenging and will benefit from engagement and leadership by physicians – including in gastroenterology. A new survey shows that the Department of Health and Human Services has achieved its goal of having 30% of health care payments tied to APMs by the end of 2016.3 It hopes to have 50% by the end of 2018.
Physician-Focused Payment Model Technical Advisory Committee’s role in recommending new payment models
The paucity of APMs was one reason the MACRA law established the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Organizations can submit proposals for new Medicare payment models to PTAC, which then are reviewed according to 10 established criteria. The criteria place particular emphasis on the scope of the APM, the APM’s ability to increase quality while maintaining or decreasing costs, and whether the payment methodology improves on current policy. PTAC then makes recommendations to CMS for full implementation of a proposal, limited testing (a pilot program), or no implementation.
The fate of the two GI APMs offers broad insight on the path forward for new specialized-care models. Although PTAC focuses on physician payment, its criteria and critiques emphasize that the primary focus of any APM should be on the full spectrum of patient care. Project Sonar likely received a positive recommendation because it focused on shifting payment to improving chronic care and avoiding complications. Although the colonoscopy proposal was withdrawn, we can gain a sense of PTAC’s concerns through the preliminary review.5 The review argues the proposal did not sufficiently address how it would lead to a more efficient, better integrated, and higher quality screening that improves patient health. More specifically, the review criticized the proposal for focusing primarily on a site-of-service shift and offering fewer details on how the APM would reduce overutilization.
Overall, PTAC’s deliberations at both its April and September meetings suggest that it will deeply scrutinize models focusing only on a single procedure or specialty, or ones that it believes do not sufficiently coordinate with primary care or other specialties, because it does not believe that such models have a sufficiently comprehensive patient focus. These PTAC reviews also suggest that the Committee will recommend programs with ideas they find viable, even if committee members have expressed concerns about certain aspects. Indeed, despite preliminary recommendations against 6 initial proposals, the full Committee has approved 3 of them for limited testing. The Committee was receptive to the argument that without testing APMs in the real world, even if those programs have limitations, the field cannot move forward.