WASHINGTON -- Two new payment models, a capitated model for primary care and one for end-stage renal disease (ESRD), made their way to federal healthcare officials this week.
The Physician-focused Payment Technical Advisory Committee (PTAC), a group of policy experts and physicians tasked with identifying new Medicare payment models that reward value rather than volume, recommended the two proposals to the U.S. Department of Health and Human Services (HHS).
An episode payment model submitted by the Renal Physicians Association (RPA) targets the first 6 months of dialysis for ESRD patients, and was given a full recommendation.
The global or capitated payment model from the American Academy of Family Physicians (AAFP) was recommended for limited-scale testing.
PTAC was established by Congress to vet proposals to the Center for Medicare & Medicaid Innovation (CMMI) under the Medicare Access and CHIP Reauthorization Act (MACRA), which repealed the sustainable growth rate (SGR) formula.
While PTAC's recommendations will be sent to HHS, the office of HHS secretary remains vacant. Former HHS Secretary Tom Price, MD, resigned in September, and President Trump named Alex Azar, JD, as a replacement. Azar has yet to be confirmed.
ESRD Payment Model
ESRD patients make up 1% of the Medicare population, but their costs amount to roughly 7% of the Medicare spend, according to the RPA's proposal.
The model's primary goal is to reduce hospitalizations, complications, and the high mortality rates that characterize the first 6 months of dialysis for ESRD patients. The model also aims to lower costs by incentivizing "optimal transitions to dialysis," improving care coordination, and increasing the likelihood of shared decision-making, the proposal also noted.
Jeff Giullian, MD, MBA, vice president of medical affairs and national group medical director of DaVita Healthcare Partners, was one of the presenters of the RPA model and explained that mortality and complications are higher among this group because of cardiac events and infections, which often happen when dialysis is begun "non-optimally."
"When we place a dialysis catheter into a patient, it not only increases inflammation, which increases the likelihood of a cardiac event, but it's obviously a conduit for bacteria," he stated.
The design of the model would also lead fewer of those "last-ditch" patients to start dialysis, by providing an "indirect incentive" to clinicians to have difficult conversations with patients, explaining that dialysis may not improve their longevity, but may reduce their quality of life, Giullian explained.
The conversation would likely benefit the model, by reducing the number of "high-utilizers" from starting dialysis, he added.
The two core components of the models are shared savings or shared losses based on total cost of care in an episode, and a $3,000 bonus to physicians for kidney transplants.
Physicians enrolled in the program would receive a total quality score from 1-100 based on "pre-specified patient-centric quality metrics," according to the proposal. Scores would ultimately determine the total shared savings or losses a physician incurs.
Only 10% of nephrologists are currently participating in a similar model, the Comprehensive ESRD Care (CEC), the RPA noted.
The PTAC voted unanimously to recommend the ESRD payment model. Seven members voted a recommended the model to the secretary for full implementation, while three voted for full implementation with priority consideration, and only one member suggested limited-scale testing.
Two members emphasized the need to monitor the program's implementation to ensure that it's targeting the right population.
Some PTAC members described the "transplant bonus" as "problematic" and "unnecessary," and the committee voted with the expectation that it would be eliminated from the model. Instead, quality measures related to transplant could be included, the group suggested.
Global Payment for Primary Care
AAFP explained its aim of strengthening primary care, reducing fragmentation in services, easing administrative burden, and providing up-front dollars for clinicians to transform their practices, as well as provide a predictable revenue stream.
The AAFP model includes four payment mechanisms:
- A risk adjusted per member per month (PMPM) payment for evaluation/management (E/M) services
- A risk adjusted PMPM for care management (mostly non-face-to-face services)
- A prospective incentive payment based on performance, repaid if performance is poor
- Continued payment for fee-for-services activities not included in the E/M monthly payment
A similar model, Comprehensive Primary Care Plus (CPC+), is not available to all primary care clinicians, noted Michael Munger, MD, AAFP president-elect. Only 13,000 clinicians have currently enrolled, but there are over 70,000 primary care clinicians in the AAFP alone.
When talking with primary care physicians, Munger said they complain that they don't have the resources to invest in the infrastructure that could improve the way they deliver care.
"So far, we've been in this game of 'You show me results and we'll increase payments,'" he noted, adding that capital is necessary to achieve those results.
A PTAC member noted that the CPC+ model had not delivered on savings. But Amy Mullins, MD, AAFP medical director for quality improvement, explained that the CPC+ model draws in patients who haven't received medical care in a long time. A 2-3-year pilot program can't show improvements, such as the costs saved by an increase in screening mammograms or colonoscopies, in that short time period, she said.
While several PTAC members expressed reservations about the possibility of "stinting" in a capitated payment model, Mullins argued that a physician who continually refers patients out to other providers, will see them "vote with their feet." Additionally, she noted that the AAFP would be open to including a referral evaluation.
When members criticized the lack of patient-centric quality measures in the model, the AAFP noted that the measure set is "fluid," and that a survey, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) evaluation, could be incorporated.
Ultimately, six PTAC members voted for limited-scale testing, one member voted to recommend full implementation, and four voted for full implementation with high priority.
Other Proposals
Proposals that failed to get a green light from PTAC:
- An alternative payment model from the for the initial therapy of newly diagnosed patients with organ-confined prostate cancer
- A multi-provider, bundled episode-of-care payment model for treatment of chronic hepatitis C virus from
- The (3VBPP) from Zhou Yang, PhD, MPH, of Emory University in Atlanta
- Annual at rural health clinics from Mercy Accountable Care Organization
- A proposal for from the Minnesota Birth Center