Conference Coverage

Federal changes in GI payment models most likely through CMS



– With the approaching midterm elections and Congress’ relative silence on health care policy this year, new health care legislation is unlikely in the immediate foreseeable future. But that does not mean the door to federal changes in health care policy is completely closed, according to Robert S. Saunders, PhD, of the Duke–Margolis Center for Health Policy, Durham, N.C.

It’s simply more likely to come from the new leadership at the Department of Health & Human Services including Secretary Alex Azar, Center for Medicare & Medicaid Services Administrator Seema Verma, and Center for Medicare & Medicaid Innovation Director Adam Boehler. In his keynote address for the American Gastroenterological Association’s Partners in Value meeting, Dr. Saunders gave attendees an overview of the current landscape in Washington and what they might expect in the coming months.

“Assuming congressional gridlock continues, HHS is a primary outlet for policy,” Dr. Saunders said, also noting CMMI’s pledge to make value-based payment a priority.

Broadly speaking, six goals comprise the current administration’s future vision within CMS, Dr. Saunders said. CMS has been encouraging payment reform innovation and benefit flexibility in Medicare Advantage and promoting private sector leadership with payment reform.

Three other goals include using CMMI to increase alternative payment model availability to specialists, expanding patients’ access to their own health data, and adding more outcomes measures but reducing the total number of measures.

  • CMS is also collecting information on how it might reform the Stark Law to streamline value-based payment (VBP) arrangements or establish a mechanism for direct provider contracting.

Dr. Saunders highlighted two health policy developments already announced. First, CMS will continue to offer bundled payment options through the Bundled Payments for Care Improvement Advanced initiative, Dr. Saunders said. That program presents opportunities related to treatment of GI hemorrhage, GI obstruction, and most liver disorders (excepting cancer, cirrhosis, and alcoholic hepatitis).

Then, CMS is proposing several changes to existing programs, though it remains to be seen how those will develop. One of those is the proposed modification of the Accountable Care Organization program to shorten the period ACOs can spend in upside risk, thereby pushing for more downside risk taking. Instead of having 6 years in upside risk getting 50% of savings, the proposed Pathways to Success would reduce that period to 2 years of upside risk, after which the ACOs would be responsible for shared losses in adddition to potentially receiving savings.

Another proposed change is to make payments sites neutral so that Medicare clinical visits are charged the same regardless of whether they occur at a doctor’s office or in a hospital outpatient setting. Currently, hospital outpatient visits are reimbursed at a higher amount than are those in private physicians offices.

Finally, a new proposed rule would collapse payments for evaluation and management services into two tiers, which would apply only to office and outpatient E/M codes.

But it’s not clear yet how hard CMS will push for implementation of these changes. For example, the proposed rule on E/M policy is the most significant push so far to reduce documentation from this administration, Dr. Saunders said, but medical groups, particularly specialists, oppose the rule because they argue it incentivizes short, repeat visits.

The three probable scenarios are that CMS moves forward with the new rule, that CMS scales back and retains the existing system, or that the “medical community pushes for an alternative to E/M with a framework that rewards doctors for their time,” Dr. Saunders said. The final rule, likely to come down by November, will also offer some insight into how forcefully CMS will promote its agenda, according to Dr. Saunders.

Hearing these points “helps confirm that we are all headed toward this value-based world, and so we should start to ready our practices in the way that we internally compensate physicians and the way we engage with patients toward that value-based world,” Michael Weinstein, MD, president of the Digestive Health Physicians Association, said in an interview following the keynote.

But Dr. Weinstein expressed skepticism about CMS’ power to alter regulations sufficiently to really move forward into value-based care more broadly. He pointed out the various obstacles in the private sector that simply require legislative fixes, such as Stark Law modernization; increased transparency on price, outcomes, and quality measures; and interoperability between systems; among others.

“You have to keep knocking CMS to make the changes, but if CMS makes changes, it only makes changes for Medicare,” Dr. Weinstein said. Many states have laws requiring commercial carriers to follow the same federal rules that are set up for Medicare, but those are not universal and remain limited in scope.

Dr. Saunders also discussed the Physician-Focused Payment Model Technical Advisory Committee (PTAC), created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to review new options for alternative payment models.

Since beginning to accept submissions in December 2016, PTAC has reviewed two GI models in 2017: Project Sonar and a comprehensive colonoscopy APM. Project Sonar focuses on creation of an IBD/Crohn’s medical home. Despite reservations about proprietary technology and about the evidence on Project Sonar, PTAC has recommended the program for further testing. The comprehensive colonoscopy APM, however, was withdrawn after preliminary reviews because the PTAC was concerned the proposal “was too reliant on site-of-service shift and wanted more information on how it would lead to better integrated care,” Dr. Saunders explained.

Though PTAC’s existence led to hope early on that it might stimulate the creation of APMs and help them spread, the reality has been much shakier.

“CMS has not implemented any of the models PTAC has approved for use, and CMS has also not yet created a formal pathway for limited testing,” Dr. Saunders said. That has left members uncertain about the future.

Next Article: