Quality Management and APMs

Quality Management and APMs

Roseanne Fischoff, M.P.P.; Zach Hochstetler, M.P.P., M.B.A.

ASA Monitor 06 2017, Vol.81, 22-23.

By now you’ve heard of the sweeping changes undergoing Medicare payment as a result of the passage of the landmark Medicare Access and CHIP Reauthorization Act (MACRA) legislation. Passed in 2015, this legislation created the Quality Payment Program (QPP), which implemented several new reporting requirements as well as the consolidation of previous reporting programs. One of the largest changes to the Medicare program, as a result of this legislation, was the creation of a second payment pathway. Medicare providers will now have the opportunity to choose whether to report under the Merit-based Incentive Payment System (MIPS) or the more innovative program – Advanced Alternative Payment Models (APMs).

Even if you know the basics of this expansive program, it remains difficult to understand where you and your practice fit into this shifting landscape. The purpose of this article is to provide more information about the lesser-known of the two pathways, advanced APMs, as well as what we here at ASA are doing to ensure reporting opportunities are expanded under this pathway.

What Is an Advanced APM?

Prior to defining Advanced APMs, let’s first make the important distinction between an APM and an advanced APM. Alternative Payment Models are new approaches to paying for medical care through Medicare that incentivize quality and value. An APM can apply to three primary buckets: 1) A specific clinical condition, 2) a care episode and/or 3) a patient population.

Advanced APMs are a subset of APMs that allow eligible clinicians and practices to earn greater rewards for taking on some risk related to their patient’s outcomes. In order to be considered an advanced APM, the model must meet three specific criteria: 1) quality reporting requirements, 2) certified electronic health record technology (CEHRT) use requirements and 3) nominal risk requirements.

Advanced APMs will be an attractive reporting option for many clinicians because of the incentives built into the program. For those clinicians who have a substantial amount of either their patients or Medicare payments come through the advanced APM, a 5 percent lump sum bonus will be paid for the first five years. Following this initial five-year phase, participants will receive a 0.75 percent annual update to their Medicare payments each year thereafter. Another benefit of participating in an advanced APM is that eligible clinicians do not have to report under the MIPS pathway.

Current Landscape

One of the biggest negatives facing the advanced APM pathway is the lack of available options for participation. For 2017, there are seven models that meet the criteria for qualification, and many of these options focus on primary care and/or the management of chronic diseases. For specialists, like anesthesiologists, relatively few options exist. The Centers for Medicare & Medicaid Services (CMS) has acknowledged these limitations and anticipates that at the start of the program, more than 90 percent of all physicians in Medicare will report under the MIPS pathway.

To help support the development of future physician-focused APMs, MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The committee has two primary tasks. First, it will review proposals that are submitted by the public. During this review process, the committee will seek public comment and develop its recommendations. Second, the committee will, following its review, submit formal comments and recommendations to CMS. Importantly, the PTAC has no formal power to accept a recommended payment model. CMS is the sole decision maker. The committee submitted its first round of recommendations to CMS in April 2017 and, at the time of writing, CMS has not formally responded in rule-making.

“Already in 2017, CMS has twice delayed the implementation of several new or revised APMs. It is still unclear whether the proliferation of APMs will cease under the new administration.”

Finally, it’s important to understand that the expansion of new advanced APM models and retrofitting existing APM models to meet new criteria are the two areas most in flux under the current administration. Already in 2017, CMS has twice delayed the implementation of several new or revised APMs. It is still unclear whether the proliferation of APMs will cease under the new administration. However, we do know from public statements and federal rulemaking that CMS is taking a close look at its current portfolio and is remaining cautious about expansion.

What Is ASA Doing?

Given that the environment around APMs is constantly shifting, ASA has been hard at work not only analyzing this complex system but also in thinking strategically about how anesthesiologists can increase their participation in the program.

One area of focus has been the Perioperative Surgical Home (PSH), an initiative within ASA’s Strategic Plan. Over the past nearly four years, we have been organizing and working with other medical specialties to implement the PSH model in health care organizations across America. The PSH is a patient-centered, physician-led, interdisciplinary and team-based system of coordinated patient care, which spans the entire experience from decision to do surgery to discharge from the acute care facility and beyond. The PSH strives to achieve the triple aim of better patient experience, better health care, and reduced expenditures for all patients undergoing surgery and invasive procedures.

ASA leaders have met several times with CMS officials to discuss the benefits of the PSH and how it can fit into the current advanced APM landscape. The PSH, as an innovative, multidisciplinary care model, is well suited to have a varied and robust impact on health care delivery reform. Given this, we are currently evaluating three potential pathways forward.

PSH Delivery Model

Under this pathway, the PSH would be recognized as a delivery model, which can be integrated into any system or model. It provides a systematic approach that would embed measurable quality metrics and enhance patient care. ASA has already completed work toward this goal by proposing PSH-specific Improvement Activities (IA) under the MIPS program for the 2018 reporting cycle. CMS will review these submissions in the coming months.

PSH Integration Into Existing Models

Under this pathway, the PSH would be integrated into an existing advanced payment model. The PSH would work with an existing APM to provide the necessary team-based care integration that is vital for these APMs to be successful. The advantage to this approach is that we can leverage the existing work that has been done on these payment models to expand participation for specialists who have limited opportunities currently.

PSH Integration Into a New Advanced APM

The final pathway consists of building the PSH into a new advanced APM. Under this approach, the PSH delivery model would be merged with a financial risk model to develop an entirely new APM. The advantage of this pathway is that not only could it expand opportunities for specialists to participate, it could also expand the availability of APMs to exist in more settings outside of hospitals such as ambulatory surgical centers and outpatient hospitals.

As we assess the feasibility of these pathways, we recognize that none of these activities are mutually exclusive. Given the flexibility of the PSH model, multiple approaches could be utilized in parallel. That is why ASA’s physician leadership is closely monitoring federal rule-making and is in communication with administration officials to determine the best approach moving forward. We remain committed to the concept that APMs are an essential part of health care delivery and payment reform.