Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.

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 may not appeal to everyone. That’s where physician-created APMs come in.

Getting approval for this type of APM – technically known as a physician-focused payment models (PFPMs) – is tough. Of the first three PFPMs submitted for review, two were recommended for limited trial periods only. A third proposal was not recommended.

Proposals are routed through the Physician-focused Payment Model Technical Advisory Committee (PTAC), comprising physicians and experts in value-based health care systems. Commissioners are appointed by the Comptroller General of the United States.

Each proposals 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 were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.

“We are recommending 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 is 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.
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 Sacremento, Calif.

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,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”

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.”

gtwachtman@frontlinemedcom.com

Physician-created APMs: Early recommendations offer insight