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

AGA Institute

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.

AGA Institute

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.

AGA Institute

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.

 

Implications for gastrointestinal practice and planning

Despite the many challenges in payment model development, the broader march toward APMs will continue, driven by increasing pressures to provide access to quality care while controlling costs. Further developments in several areas bear watching because they could accelerate opportunities for gastroenterologists.

Most notable is the considerable payment model innovation underway in private health insurance plans and state Medicaid plans, models that could develop into PTAC submissions. Project Sonar was first implemented in collaboration with a private payer in Illinois. Similarly, the inflammatory bowel disease specialty medical home was developed at the University of Pittsburgh. Both successfully have achieved the Triple Aim, improving patient experience and population health while decreasing medical costs.⁶ The private sector can serve as a testing ground for new APMs and the new administration’s desire to support innovative private sector models of care reform makes CMS likely to take further steps to support these approaches.

Second, working with both private and public payers, gastroenterologists could expand the concept of a specialty medical home or a primary-specialty coordinated medical home by incorporating more aspects of GI care. Chronic liver disease, chronic pancreatitis, and irritable bowel syndrome all could benefit from these approaches.⁷ Medical home models generally include a shift from fee-for-service payments by providing per-patient payments (potentially risk-adjusted) to the coordinating physician for a period of time. That per-member per-month payment may enable additional patient-centric services such as extending access to care, regular patient outreach to monitor changes in health status, and partnering with primary care and other providers to help patients access treatment for comorbid conditions.

Third, as evidenced by the PTAC critique on the Comprehensive Colonoscopy APM, a revised approach is needed for bundled episode payment reforms to better support endoscopists focused on performing high-quality procedures. Given their procedural focus, these physicians will need to show the value of endoscopic services in well-coordinated patient care. Site-of-service shifts are helpful where appropriate, but bundle proposals also must consider coordination with primary care providers on appropriate referrals, encouragement of non-endoscopic approaches, preparation technique to minimize the number of procedures that have to be repeated, and reducing anesthesia care for low-risk patients. These considerations generally suggest a broader episode payment model related to the goals of the procedure, rather than endoscopy-based bundles alone.

For example, a bundled payment for colorectal cancer screening, covering a full episode of treatment beyond a single colonoscopy, would make it easier for gastroenterologists to work more effectively with primary care providers to reduce gaps in colorectal cancer screening rates at the lowest possible overall cost. This bundle could be implemented by a specialized GI practice in conjunction with a primary care medical home or an ACO. If such a broad bundle is too much of a practice shift, an endoscopy-based episode payment could include performance measures and limited additional payments related to these same patient-focused objectives.

The kinds of reforms described earlier could work well with both primary care–focused and ACO models. However, there are technical challenges in dealing with overlapping payment reforms, and gastroenterologists should look for further guidance from CMS on how bundled episode payments and other specialized-care payment reforms will interact with APMs for primary care, such as ACOs and the Project Sonar model recommended by PTAC.⁸

Despite the broader shift toward APMs, it remains likely that many gastroenterologists will participate in the fee-for-service–based MIPS program in the near term. These physicians still will face fundamental pressures to deliver better value. Here, there may be opportunities to improve coordination in the MIPS program through additional care coordination payments for chronic disease, complementing the chronic care management payments that primary care physicians receive. Such payments would encourage further development and testing of more meaningful and outcome-oriented performance measures related to GI care.

Finally, GI care would benefit from better evidence for all GI-related payment reforms. Many of these reforms will be implemented outside of Medicare, but do not have results reported in a manner that make it easy to assess their impact and potential for broader implementation. Building an evidence base is feasible without imposing large costs or additional burdens on practices, especially when evaluations are implemented along with payment reforms, and offers the best way for organizations to learn and improve based on what works and what does not.⁹

Conclusions

Though the health care debate has ended in Congress for now, the march toward payment reform will continue. To accelerate progress, continued leadership from gastroenterologists is needed, especially in finding solutions that move beyond traditional GI practice. Collaborative incremental models that advance population health and are feasible to implement will provide the best opportunity for practice reform. Effective partnerships with primary care are particularly important to help avoid traditional gatekeeper approaches, and move toward a patient-centric model of shared accountability in which specialists function as a key partner in a medical neighborhood.10 Gastroenterologists can shape these steps, not only through PTAC and Medicare APMs, but through the other steps described earlier, and have a unique role in developing new models that leverage their specialty expertise. However, these models cannot be developed in isolation, and increased collaboration with primary care and other medical and nonmedical specialists will be critical. Physicians should start identifying opportunities to improve their practices and build these relationships now. These investments will allow them to thrive as new payment models come online.

 

References

1. Dzau V.J., McClellan M.B., McGinnis J.M. Vital directions for health and health care: priorities from a National Academy of Medicine initiative. JAMA 2017;317:1461-70.

2. Alternative Payment Model Framework Progress Tracking Work Group. Alternative payment model (APM) framework. Health

Care Payment Learning and Action Network. Available from: https://hcp-lan.org/workproducts/apm-whitepaper.pdf. Accessed: January 12, 2016.

3. Health Care Payment Learning and Action Network. APM Measurement: Progress of Alternative Payment Models. Available from: http://hcp-lan.org/workproducts/measurement_discussion%20article_2017.pdf Accessed November 2, 2017.

4. McClellan M., McStay F., Saunders R. The roadmap to physician payment reform: what it will take for all clinicians to succeed

under MACRA. Health Affairs Blog. Available from: http://healthaffairs.org/blog/2016/08/30/the-roadmap-to-physicianpayment-reform-what-it-will-take-for-all-clinicians-to-succeedunder-macra/. Accessed: August 30, 2016.

5. Medows R., Casale P., Berenson R. Preliminary review team report to the physician-focused Payment Model Technical Advisory Committee (PTAC). Physician-Focused Payment Model Technical Advisory Committee. Available from: https://aspe.hhs.gov/system/files/pdf/255906/DHNPRTReport.pdf. Accessed: March 22, 2017.

6. Regueiro M., Click B., Holder D., et al. Constructing an inflammatory bowel disease patient–centered medical home. Clin Gastroenterol Hepatol. 2017;15:1148-53.

7. Meier S.K., Shah N.D., Talwalkar J.A., et al. Adapting the patient-centered specialty practice model for populations with cirrhosis. Clin Gastroenterol Hepatol. 2016;14:492-6.

8. Pham H., Chernew M., Shrank W., et al. Market momentum, spillover effects, and evidence-based decision making on payment reform. Health Affairs Blog. Available from: http:// healthaffairs.org/blog/2017/05/24/market-momentum-spillovereffects-and-evidence-based-decision-making-on-paymentreform/. Accessed: May 24, 2017.

9. McClellan M., Richards R., Japinga M. Evidence on payment reform: where are the gaps? Health Affairs Blog. Available from: http://healthaffairs.org/blog/2017/04/25/evidence-onpayment-reform-where-are-the-gaps/. Accessed: April 25, 2017.

10. Huang X., Rosenthal M.B. Transforming specialty practice – the patient-centered medical neighborhood. N Engl J Med 2014;370:1376-9.

Mr. Japinga, Dr. Saunders, and Dr. McClellan are at the Duke-Margolis Center for Health Policy, Washington; Dr. Gellad is in the division of gastroenterology at the Duke University School of Medicine and at the Durham VA Medical Center, Durham, N.C. Dr. Gellad was supported by a Career Development Award from Veterans Affairs Health Services Research (CDA 14-158). The authors had no conflicts of interest.

 

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

AGA Institute

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.

AGA Institute

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.

AGA Institute

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.

 

Implications for gastrointestinal practice and planning

Despite the many challenges in payment model development, the broader march toward APMs will continue, driven by increasing pressures to provide access to quality care while controlling costs. Further developments in several areas bear watching because they could accelerate opportunities for gastroenterologists.

Most notable is the considerable payment model innovation underway in private health insurance plans and state Medicaid plans, models that could develop into PTAC submissions. Project Sonar was first implemented in collaboration with a private payer in Illinois. Similarly, the inflammatory bowel disease specialty medical home was developed at the University of Pittsburgh. Both successfully have achieved the Triple Aim, improving patient experience and population health while decreasing medical costs.⁶ The private sector can serve as a testing ground for new APMs and the new administration’s desire to support innovative private sector models of care reform makes CMS likely to take further steps to support these approaches.

Second, working with both private and public payers, gastroenterologists could expand the concept of a specialty medical home or a primary-specialty coordinated medical home by incorporating more aspects of GI care. Chronic liver disease, chronic pancreatitis, and irritable bowel syndrome all could benefit from these approaches.⁷ Medical home models generally include a shift from fee-for-service payments by providing per-patient payments (potentially risk-adjusted) to the coordinating physician for a period of time. That per-member per-month payment may enable additional patient-centric services such as extending access to care, regular patient outreach to monitor changes in health status, and partnering with primary care and other providers to help patients access treatment for comorbid conditions.

Third, as evidenced by the PTAC critique on the Comprehensive Colonoscopy APM, a revised approach is needed for bundled episode payment reforms to better support endoscopists focused on performing high-quality procedures. Given their procedural focus, these physicians will need to show the value of endoscopic services in well-coordinated patient care. Site-of-service shifts are helpful where appropriate, but bundle proposals also must consider coordination with primary care providers on appropriate referrals, encouragement of non-endoscopic approaches, preparation technique to minimize the number of procedures that have to be repeated, and reducing anesthesia care for low-risk patients. These considerations generally suggest a broader episode payment model related to the goals of the procedure, rather than endoscopy-based bundles alone.

For example, a bundled payment for colorectal cancer screening, covering a full episode of treatment beyond a single colonoscopy, would make it easier for gastroenterologists to work more effectively with primary care providers to reduce gaps in colorectal cancer screening rates at the lowest possible overall cost. This bundle could be implemented by a specialized GI practice in conjunction with a primary care medical home or an ACO. If such a broad bundle is too much of a practice shift, an endoscopy-based episode payment could include performance measures and limited additional payments related to these same patient-focused objectives.

The kinds of reforms described earlier could work well with both primary care–focused and ACO models. However, there are technical challenges in dealing with overlapping payment reforms, and gastroenterologists should look for further guidance from CMS on how bundled episode payments and other specialized-care payment reforms will interact with APMs for primary care, such as ACOs and the Project Sonar model recommended by PTAC.⁸

Despite the broader shift toward APMs, it remains likely that many gastroenterologists will participate in the fee-for-service–based MIPS program in the near term. These physicians still will face fundamental pressures to deliver better value. Here, there may be opportunities to improve coordination in the MIPS program through additional care coordination payments for chronic disease, complementing the chronic care management payments that primary care physicians receive. Such payments would encourage further development and testing of more meaningful and outcome-oriented performance measures related to GI care.

Finally, GI care would benefit from better evidence for all GI-related payment reforms. Many of these reforms will be implemented outside of Medicare, but do not have results reported in a manner that make it easy to assess their impact and potential for broader implementation. Building an evidence base is feasible without imposing large costs or additional burdens on practices, especially when evaluations are implemented along with payment reforms, and offers the best way for organizations to learn and improve based on what works and what does not.⁹

Conclusions

Though the health care debate has ended in Congress for now, the march toward payment reform will continue. To accelerate progress, continued leadership from gastroenterologists is needed, especially in finding solutions that move beyond traditional GI practice. Collaborative incremental models that advance population health and are feasible to implement will provide the best opportunity for practice reform. Effective partnerships with primary care are particularly important to help avoid traditional gatekeeper approaches, and move toward a patient-centric model of shared accountability in which specialists function as a key partner in a medical neighborhood.10 Gastroenterologists can shape these steps, not only through PTAC and Medicare APMs, but through the other steps described earlier, and have a unique role in developing new models that leverage their specialty expertise. However, these models cannot be developed in isolation, and increased collaboration with primary care and other medical and nonmedical specialists will be critical. Physicians should start identifying opportunities to improve their practices and build these relationships now. These investments will allow them to thrive as new payment models come online.

 

References

1. Dzau V.J., McClellan M.B., McGinnis J.M. Vital directions for health and health care: priorities from a National Academy of Medicine initiative. JAMA 2017;317:1461-70.

2. Alternative Payment Model Framework Progress Tracking Work Group. Alternative payment model (APM) framework. Health

Care Payment Learning and Action Network. Available from: https://hcp-lan.org/workproducts/apm-whitepaper.pdf. Accessed: January 12, 2016.

3. Health Care Payment Learning and Action Network. APM Measurement: Progress of Alternative Payment Models. Available from: http://hcp-lan.org/workproducts/measurement_discussion%20article_2017.pdf Accessed November 2, 2017.

4. McClellan M., McStay F., Saunders R. The roadmap to physician payment reform: what it will take for all clinicians to succeed

under MACRA. Health Affairs Blog. Available from: http://healthaffairs.org/blog/2016/08/30/the-roadmap-to-physicianpayment-reform-what-it-will-take-for-all-clinicians-to-succeedunder-macra/. Accessed: August 30, 2016.

5. Medows R., Casale P., Berenson R. Preliminary review team report to the physician-focused Payment Model Technical Advisory Committee (PTAC). Physician-Focused Payment Model Technical Advisory Committee. Available from: https://aspe.hhs.gov/system/files/pdf/255906/DHNPRTReport.pdf. Accessed: March 22, 2017.

6. Regueiro M., Click B., Holder D., et al. Constructing an inflammatory bowel disease patient–centered medical home. Clin Gastroenterol Hepatol. 2017;15:1148-53.

7. Meier S.K., Shah N.D., Talwalkar J.A., et al. Adapting the patient-centered specialty practice model for populations with cirrhosis. Clin Gastroenterol Hepatol. 2016;14:492-6.

8. Pham H., Chernew M., Shrank W., et al. Market momentum, spillover effects, and evidence-based decision making on payment reform. Health Affairs Blog. Available from: http:// healthaffairs.org/blog/2017/05/24/market-momentum-spillovereffects-and-evidence-based-decision-making-on-paymentreform/. Accessed: May 24, 2017.

9. McClellan M., Richards R., Japinga M. Evidence on payment reform: where are the gaps? Health Affairs Blog. Available from: http://healthaffairs.org/blog/2017/04/25/evidence-onpayment-reform-where-are-the-gaps/. Accessed: April 25, 2017.

10. Huang X., Rosenthal M.B. Transforming specialty practice – the patient-centered medical neighborhood. N Engl J Med 2014;370:1376-9.

Mr. Japinga, Dr. Saunders, and Dr. McClellan are at the Duke-Margolis Center for Health Policy, Washington; Dr. Gellad is in the division of gastroenterology at the Duke University School of Medicine and at the Durham VA Medical Center, Durham, N.C. Dr. Gellad was supported by a Career Development Award from Veterans Affairs Health Services Research (CDA 14-158). The authors had no conflicts of interest.

 

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

AGA Institute

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.

AGA Institute

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.

AGA Institute

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.

 

Implications for gastrointestinal practice and planning

Despite the many challenges in payment model development, the broader march toward APMs will continue, driven by increasing pressures to provide access to quality care while controlling costs. Further developments in several areas bear watching because they could accelerate opportunities for gastroenterologists.

Most notable is the considerable payment model innovation underway in private health insurance plans and state Medicaid plans, models that could develop into PTAC submissions. Project Sonar was first implemented in collaboration with a private payer in Illinois. Similarly, the inflammatory bowel disease specialty medical home was developed at the University of Pittsburgh. Both successfully have achieved the Triple Aim, improving patient experience and population health while decreasing medical costs.⁶ The private sector can serve as a testing ground for new APMs and the new administration’s desire to support innovative private sector models of care reform makes CMS likely to take further steps to support these approaches.

Second, working with both private and public payers, gastroenterologists could expand the concept of a specialty medical home or a primary-specialty coordinated medical home by incorporating more aspects of GI care. Chronic liver disease, chronic pancreatitis, and irritable bowel syndrome all could benefit from these approaches.⁷ Medical home models generally include a shift from fee-for-service payments by providing per-patient payments (potentially risk-adjusted) to the coordinating physician for a period of time. That per-member per-month payment may enable additional patient-centric services such as extending access to care, regular patient outreach to monitor changes in health status, and partnering with primary care and other providers to help patients access treatment for comorbid conditions.

Third, as evidenced by the PTAC critique on the Comprehensive Colonoscopy APM, a revised approach is needed for bundled episode payment reforms to better support endoscopists focused on performing high-quality procedures. Given their procedural focus, these physicians will need to show the value of endoscopic services in well-coordinated patient care. Site-of-service shifts are helpful where appropriate, but bundle proposals also must consider coordination with primary care providers on appropriate referrals, encouragement of non-endoscopic approaches, preparation technique to minimize the number of procedures that have to be repeated, and reducing anesthesia care for low-risk patients. These considerations generally suggest a broader episode payment model related to the goals of the procedure, rather than endoscopy-based bundles alone.

For example, a bundled payment for colorectal cancer screening, covering a full episode of treatment beyond a single colonoscopy, would make it easier for gastroenterologists to work more effectively with primary care providers to reduce gaps in colorectal cancer screening rates at the lowest possible overall cost. This bundle could be implemented by a specialized GI practice in conjunction with a primary care medical home or an ACO. If such a broad bundle is too much of a practice shift, an endoscopy-based episode payment could include performance measures and limited additional payments related to these same patient-focused objectives.

The kinds of reforms described earlier could work well with both primary care–focused and ACO models. However, there are technical challenges in dealing with overlapping payment reforms, and gastroenterologists should look for further guidance from CMS on how bundled episode payments and other specialized-care payment reforms will interact with APMs for primary care, such as ACOs and the Project Sonar model recommended by PTAC.⁸

Despite the broader shift toward APMs, it remains likely that many gastroenterologists will participate in the fee-for-service–based MIPS program in the near term. These physicians still will face fundamental pressures to deliver better value. Here, there may be opportunities to improve coordination in the MIPS program through additional care coordination payments for chronic disease, complementing the chronic care management payments that primary care physicians receive. Such payments would encourage further development and testing of more meaningful and outcome-oriented performance measures related to GI care.

Finally, GI care would benefit from better evidence for all GI-related payment reforms. Many of these reforms will be implemented outside of Medicare, but do not have results reported in a manner that make it easy to assess their impact and potential for broader implementation. Building an evidence base is feasible without imposing large costs or additional burdens on practices, especially when evaluations are implemented along with payment reforms, and offers the best way for organizations to learn and improve based on what works and what does not.⁹

Conclusions

Though the health care debate has ended in Congress for now, the march toward payment reform will continue. To accelerate progress, continued leadership from gastroenterologists is needed, especially in finding solutions that move beyond traditional GI practice. Collaborative incremental models that advance population health and are feasible to implement will provide the best opportunity for practice reform. Effective partnerships with primary care are particularly important to help avoid traditional gatekeeper approaches, and move toward a patient-centric model of shared accountability in which specialists function as a key partner in a medical neighborhood.10 Gastroenterologists can shape these steps, not only through PTAC and Medicare APMs, but through the other steps described earlier, and have a unique role in developing new models that leverage their specialty expertise. However, these models cannot be developed in isolation, and increased collaboration with primary care and other medical and nonmedical specialists will be critical. Physicians should start identifying opportunities to improve their practices and build these relationships now. These investments will allow them to thrive as new payment models come online.

 

References

1. Dzau V.J., McClellan M.B., McGinnis J.M. Vital directions for health and health care: priorities from a National Academy of Medicine initiative. JAMA 2017;317:1461-70.

2. Alternative Payment Model Framework Progress Tracking Work Group. Alternative payment model (APM) framework. Health

Care Payment Learning and Action Network. Available from: https://hcp-lan.org/workproducts/apm-whitepaper.pdf. Accessed: January 12, 2016.

3. Health Care Payment Learning and Action Network. APM Measurement: Progress of Alternative Payment Models. Available from: http://hcp-lan.org/workproducts/measurement_discussion%20article_2017.pdf Accessed November 2, 2017.

4. McClellan M., McStay F., Saunders R. The roadmap to physician payment reform: what it will take for all clinicians to succeed

under MACRA. Health Affairs Blog. Available from: http://healthaffairs.org/blog/2016/08/30/the-roadmap-to-physicianpayment-reform-what-it-will-take-for-all-clinicians-to-succeedunder-macra/. Accessed: August 30, 2016.

5. Medows R., Casale P., Berenson R. Preliminary review team report to the physician-focused Payment Model Technical Advisory Committee (PTAC). Physician-Focused Payment Model Technical Advisory Committee. Available from: https://aspe.hhs.gov/system/files/pdf/255906/DHNPRTReport.pdf. Accessed: March 22, 2017.

6. Regueiro M., Click B., Holder D., et al. Constructing an inflammatory bowel disease patient–centered medical home. Clin Gastroenterol Hepatol. 2017;15:1148-53.

7. Meier S.K., Shah N.D., Talwalkar J.A., et al. Adapting the patient-centered specialty practice model for populations with cirrhosis. Clin Gastroenterol Hepatol. 2016;14:492-6.

8. Pham H., Chernew M., Shrank W., et al. Market momentum, spillover effects, and evidence-based decision making on payment reform. Health Affairs Blog. Available from: http:// healthaffairs.org/blog/2017/05/24/market-momentum-spillovereffects-and-evidence-based-decision-making-on-paymentreform/. Accessed: May 24, 2017.

9. McClellan M., Richards R., Japinga M. Evidence on payment reform: where are the gaps? Health Affairs Blog. Available from: http://healthaffairs.org/blog/2017/04/25/evidence-onpayment-reform-where-are-the-gaps/. Accessed: April 25, 2017.

10. Huang X., Rosenthal M.B. Transforming specialty practice – the patient-centered medical neighborhood. N Engl J Med 2014;370:1376-9.

Mr. Japinga, Dr. Saunders, and Dr. McClellan are at the Duke-Margolis Center for Health Policy, Washington; Dr. Gellad is in the division of gastroenterology at the Duke University School of Medicine and at the Durham VA Medical Center, Durham, N.C. Dr. Gellad was supported by a Career Development Award from Veterans Affairs Health Services Research (CDA 14-158). The authors had no conflicts of interest.