An expected alternative payment roadmap from HHS this fall may accelerate the creation of physician-focused APMs, an industry analyst says.


Sept. 11—Physician groups say their members are increasingly frustrated by the lack of advanced alternative payment model (APM) options from which they can choose.

APMs will take on an increasingly important role for physicians who are paid though Medicare, with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) dividing them between those in APMs and those who must meet complex quality-reporting requirements under the Merit-based Incentive Payment System (MIPS) to avoid cuts of up to 9 percent of their overall Part B pay. Those who participate in APMs can instead garner a 5 percent bonus for five consecutive years.

But MACRA began this year, and relatively few qualifying APMs are available. That situation continued September with the decision by Tom Price, MD, secretary of the U.S. Department of Health and Human Services to not move forward with several proposed physician-focused models.

“We continue to be frustrated by a lack of APM participation options available to specialty physicians, given the intent of MACRA to move physicians away from traditional fee-for-service and into payment models that better focus on cost and quality,” 13 specialty societies wrote to the Centers for Medicare & Medicaid Services (CMS) in August.

Physician groups, such as the American Medical Association (AMA), supported CMS’s decision to extend and widen a phase-in of MIPS through 2018, MACRA’s second performance year, during which most MIPS-related reporting requirements would be delayed. However, the AMA and others have urged that prepared practices be allowed to opt in to MIPS reporting so they can still obtain available bonus payments.

Although the vast majority of physicians are expected to remain in MIPS during MACRA’s early years, CMS expects most to eventually shift into APMs. But physicians and their advocates say that won’t happen with so few models available.

The extent to which physicians—especially specialty physicians—are limited by the available Medicare APMs was highlighted this week in a Leavitt Partners analysis. Only 18 of Medicare’s 45 payment models qualify as APMs under MACRA, the analysis found. And the number of available APMs shrank from 10 for primary care physicians to six for surgeons, three for respiratory therapists, and none for emergency physicians or audiologists.

“It surprised me how some physicians have a number of options and others really don’t have options,” said David Muhlestein, chief research officer for Leavitt Partners and an author of the report.

Rebecca Parker, MD, president of the American College of Emergency Physicians (ACEP), acknowledged in an August letter to CMS that emergency physicians “have little or no experience in taking financial risk (aside from uncompensated care due to EMTALA duties) as a component of their medical practices.” But ACEP is trying to develop APMs, an effort that represents “a significant investment with yet unknown results.”

Part of the reason for the lack of specialty models is CMS’s previous focus on models—such as accountable care organizations (ACOs)—that were broadly appealing, according to Muhlestein.

PTAC Focus

To spawn more physician-specific APMs, MACRA set up the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to recommend specific models. In the spring, PTAC endorsed two new models to CMS, and 15 models have been submitted for the committee’s consideration, according to its website.

“We know from those that have been proposed that they are almost always specialty-focused because there is this recognition that there are so many specialists out there that are going to be subject to MACRA but don’t have an APM option; they are stuck in MIPS for the time being,” Muhlestein said in an interview.

Physician groups have raised growing concerns that CMS is not providing PTAC or APM applicants with the technical support needed to advance their models and that it is taking too long to consider implementing the two proposed models from PTAC.

“More than two months have passed since the PTAC provided its reports on these recommendations without any response from CMS or the secretary” of the Department of Health and Human Services (HHS), Scott Blickensderfer, DO, president of the American College of Osteopathic Surgeons, wrote in August to CMS.

Blickensderfer urged HHS to respond to APM proposals from PTAC within 60 days. The call came after Price wrote the American College of Surgeons recently to say he would need more information before moving forward on their proposed model, which had been endorsed by PTAC.

In letters to the applicants, Price rejected two other models—including one that did not get PTAC’s endorsement—for different reasons.

One development that may speed up the number of available APMs is the expected release in the fall of an overall alternative payment strategy from HHS, similar to one issued by former Secretary Sylvia Burwell in which she committed the department to shift a specific percentage of fee-for-service payments within a specific time frame.

“That would hopefully spell out what their plans are and more of their approach to building these alternative payment models,” Muhlestein said. “That would give also an indication of the timing for building these models.”

Model Pushback

Physician calls for a proliferation of APMs for various types of physicians has drawn challenges from some quarters, including the influential Medicare Payment Advisory Commission (MedPAC).

The body, which Congress created to craft congressional policy advice, noted that overlapping beneficiaries, providers, and savings among various APMs will be challenging for CMS and could easily confuse participants in the models or lead providers to not participate.

“Single-specialty based episode-based payment models coming from the [PTAC] could add to this complexity,” MedPAC wrote to CMS in August.

However, the meaningful care provided by different specialties is distinct, and often includes no overlap in quality measurement, according to Muhlestein.

“If you want a system that focuses on value, one size is not going to fit all,” Muhlestein said.

Ultimately, the technical challenge of developing new models is likely to leave the variety far short of that sought by various specialists and subspecialists.

“When you start to get into a model that is unique for respiratory therapists, for example, you still need a lot of technical expertise—but there are hundreds of potential models that you would need to put the same dedicated resources into, and there is just not the same ROI in terms of the number of physicians or number of providers that would be covered by these very technical, small models,” Muhlestein said. “The reality is for MACRA a lot of providers aren’t going to have a viable APM pathway; it’s going to be MIPS for the foreseeable future.”


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Monday, September 11, 2017