New opportunities for gastroenterology leadership in the evolving payment reform landscape

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

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On this front, there is more bipartisan agreement on the direction of reform. Payment reform, through the establishment of Alternative Payment Models (APMs), will continue to be the primary vehicle. APMs shift payments away from fee-for-service toward new models that better align incentives for physicians to provide more effective care while reducing waste and overutilization, ensuring they remain accountable for patient results and total cost of care.² The new administration has reaffirmed its broad support of payment reform, an indication these programs will continue and grow over the coming years.

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.

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The lack of available APMs for specialists, including gastroenterologists, represents one of the greatest challenges going forward.⁴ Some specialists can take part in an APM by participating in an Accountable Care Organization (ACO) – through the Medicare Shared Savings Program and related programs – or in a bundled episode payment model with downside risk. These options may be viable for some gastrointestinal (GI) physicians employed by a hospital-based or integrated system, but they may not be practical or available for those in independent or smaller practices. Moreover, although a growing number of gastroenterologists participate in bundled episode payments for their commercial and Medicare Advantage patients, the Centers for Medicare & Medicaid Services (CMS) has not yet specified how this could count toward meeting APM requirements for MIPS exemptions or bonuses.

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.

PTAC began accepting submissions in December 2016, reviewed its first proposals in April 2017, and reviewed three more in September. Two of the April proposals focused on GI care. Project Sonar, an intensive medical home designed to improve care coordination for patients with Crohn’s disease, was recommended for limited testing. The Comprehensive Colonoscopy APM, which established episode-based payments for colonoscopies and cancer screening, was withdrawn before the meeting, after critical feedback from PTAC’s preliminary reviews. (Two other models also were reviewed in this timeframe – an episode model from the American College of Surgeons and a chronic obstructive pulmonary disease and asthma monitoring program. The first was recommended for limited testing, and the latter was not recommended.)

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.

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The response of then-HHS Secretary Tom Price to PTAC’s initial proposals reveals some additional challenges for payment model development going forward. HHS does not have to follow PTAC’s recommendation, and rejected it for Project Sonar largely due to the program’s use of proprietary technology. PTAC has had similar debates over technology in other submissions, and this will be an important concern going forward. With no programs tested as of yet, PTAC and submitters will also benefit from more guidance on what limited testing looks like. Through PTAC and CMMI’s Request for Information proposal, we have a strong sense of what the administration wants in new models, but submitters also need to know how models will be put into practice.