What Are Physician-focused Payment Models?

With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), new ways for Medicare to pay physicians for services provided to Medicare patients were created. One of the new programs created by MACRA include Alternative Payment Models (APMs), and the newly development of Physician-focused Payment Models, or PFPMs.

Physician-focused Payment Models

One of the main concerns with current APMs is that they are geared more towards primary care providers, leaving specialists wondering if they were even eligible to participate in APM, and receive incentives from these. PFPMs, are APMs that address a new condition, or issue, or specialty compared with existing APMs, which will in turn create a wider variety of APMs including many different specialties.

According to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) website, MACRA defines a PFPM as an APM in which:

  • Medicare is a payer.
  • Eligible clinicians are “participants and play a core role in implementing the APM’s payment methodology.”
  • Targets are the cost and quality of services that eligible providers can significantly influence.

The following is the set criteria for PFPMs:

  • Value over volume: Provide incentives to practitioners to deliver high-quality health care.
  • Flexibility: Provide the flexibility needed for practitioners to deliver high quality health care.
  • Quality and Cost: PFPMs are anticipated to improve health care quality at no additional cost, maintain health care quality while decreasing cost, or both improve health care quality and decrease cost.
  • Payment methodology: Pay APM Entities with a payment methodology designed to achieve the goals of the PFPM criteria. Addresses in detail through this methodology how Medicare and other payers, if applicable, pay APM Entities, how the payment methodology differs from current payment methodologies, and why the Physician-Focused Payment Model cannot be tested under current payment methodologies.
  • Scope: Aim to either directly address an issue in payment policy that broadens and expands the CMS APM portfolio or include APM Entities whose opportunities to participate in APMs have been limited.
  • Ability to be evaluated: Have evaluable goals for quality of care, cost, and any other goals of the PFPM.
  • Integration and Care Coordination: Encourage greater integration and care coordination among practitioners and across settings where multiple practitioners or settings are relevant to delivering care to the population treated under the PFPM.
  • Patient Choice: Encourage greater attention to the health of the population served while also supporting the unique needs and preferences of individual patients.
  • Patient Safety: Aim to maintain or improve standards of patient safety.
  • Health Information Technology: Encourage use of health information technology to inform care.

 

Three Proposed Physician-focused Payment Models

 

According to APM Plus’ sister company, Strategic Health Care, three PFPMs were proposed and discussed during a recent (April 10-11,2017) public PTAC meeting:

 

  1. Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD. It proposes specialty-based intensive home care for managing chronic diseases such as Crohn’s Disease. To view this Advanced APM proposal, click here.
  2. The COPD and Asthma Monitoring Project – “CAMP” – submitted by the Pulmonary Medicine, Infectious Disease, and Critical Care Consultants Medical Group (PMA). COPD and asthma patients would receive Bluetooth peak flow meter. Data transmitted to central server, could trigger clinical intervention to reduce early exacerbation and provide for a timely response to infection detection. To view the proposed CAMP PFPM, click here.
  3. The ACS-Brandeis Advanced Alternative Payment (A-APM) proposed PFPM, submitted to the PTAC by the American College of Surgeons (ACS). To view the ACS proposal, click here.

 

Ultimately, the PTAC will recommend two of the proposed payment models – Project Sonar and the ACS-Brandeis A-APM – to CMS for “limited-scale testing.” The PTAC rejected the CAMP proposal. However, several members of the PTAC stated the project “has promise but needs to be further developed before it could be implemented, even on a limited scale.” To view the presentations and meeting minutes, click here.

 

The PTAC’s next public meeting is scheduled for June 6, 2017.

 

For more information about PFPMs and other APMs, please contact us by filling out the form below.

 

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