Alternative Payment Model for ACR members

Transcription

1 Vision - Opportunity - Value Alternative Payment Model for ACR members Kwas Huston Ed Herzig Doug White The APM work group

2 Development of the Rheumatoid Arthritis APM Opportunity to develop a new model from the ground up Pilot testing then roll out Should ACR Develop an APM? Engage Expert Take APM to PTAC/CMS Create RA APM Draft Form APM Workgroup

3 Who benefits from the Alternative Payment Model Private Practice Employed Rheumatologist Academic Divisions

4 Why Consider the Alternative Payment Model Do you think the standard E&M payments are adequate? Does it make sense to count the points for HPI, ROS, PE in your notes? Do you enjoy prior authorizations? Are you happy with MIPS?

5 Payment for High Value Services Non face-to-face communication Between PCP and rheumatologist Between other specialists and rheumatologist Interactions with patients Phone calls, , telemedicine Nurses or other staff to help chronic disease management

6 Flexibility Provides resources for diverse communities Co-manage patients in certain settings Rural areas Shortage of rheumatologists Difficult travel conditions Details can vary based on local needs Payments not tied to office visits

7 Treatment Pathway Standard approach to treating RA Based on ACR guidelines Opportunity to reduce total spending for RA care Lessen current variability in initiation of expensive medications Versatile enough to allow for unique patients Attest to 75% adherence for reporting subject to audit

8 Model Overview 1) Diagnosis and Treatment Planning for Patients with Potential Rheumatoid Arthritis 2) Support for Primary Care Practices in Evaluating Joint Symptoms 3) Initial Treatment of Patients with Rheumatoid Arthritis 4) Continued Care for Rheumatoid Arthritis

9 Diagnosis and Treatment Planning (DTP) One-time payment to support all of the costs of evaluation, testing, diagnosis and treatment planning for a patient who: has symptoms that potentially indicate RA has not previously been diagnosed or treated for RA has been treated unsuccessfully for RA by other physicians Develop RA treatment plan

10 Support for Primary Care Practices in Evaluating Joint Symptoms (EJS) Rheumatologist or NP/PA working under supervision of rheumatologist Patient has symptoms that could represent RA Expedite referrals for high risk patients Payment does not require referral to rheumatologist

11 Initial Treatment for RA (ITRA) Rheumatologist or NP/PA working with rheumatologist PCP who has a formal arrangement with rheumatologist to support early treatment of RA Intended for rural areas without direct access to rheumatology Specify how payments are shared Specify who is responsible for each aspect of accountability requirements and treatment pathway Can vary based on local needs Monthly payment for 6 months Payments stratified based on patient characteristics to reflect time, resources and effort required by the RA care team

12 Continued Care for RA (CCRA) Rheumatologist or NP/PA working with rheumatologist PCP who has a formal arrangement with rheumatology practice Monthly payment Replaces E&M for office visits related to RA Includes typical lab tests and imaging Allows flexibility for non face-to-face communications Allows enhanced services for higher risk patients Payments stratified based on patient characteristics

13 Outcome Measure for CCRA At least [some%] of patients with low disease activity remained in low disease activity At least [some%] of patients with moderate disease activity remained in the same or a lower disease activity category At least [some%] of patients with high disease activity had a lower disease activity category

14 Performance-Based Payment Adjustments Performance on Disease Activity Outcome Measure: Adherence to Treatment Pathways Poor Good Excellent -2% +4% Good -4% +2% Poor -8% 0%

15 Rheumatoid Arthritis APM Advantages Pay for high value services Avoid MIPS penalties and burdens Reduce documentation requirements and prior authorizations Not responsible for the price of drugs More control over performance measures

16 Future Development of the Rheumatoid Arthritis APM Fall 2019 Expand & Implement Refine Treatment Pathway November 2017 Analyze RISE Data - Outcome Thresholds Fall 2018 Pilot Testing - Refine APM Submit to PTAC/CMS February 2018 November-January Model 2017 Financial Impact via Practice Data

17 APM Work Group Name Position Practice Type Name Position Practice Type W. Harvey MACRA Univ E. Herzig ACO MS Group D. White CORC MS Group S. Ott -- MS Group A. Worthing GAC Group K. Ferguson PCSP/NCQA -- S. Fahey ISC Group T. Laing RUC/CPT Academic J. Hargrove -- Group A. Abelson Div Dir Academic H. Blumstein ASC Group M. Danila -- Hybrid S. Lakhanpal EC Group J. Lee CMMI Fellow K. Weselman -- MS Group C. Edgerton CORC Group A. Limanni QMS/CMS Group E. Perkins -- Solo H. Miller Lead PTAC N. Ellis NORM ARHP Group R. Myslinski CORC/RISE ACR Staff K. Huston -- Group A. Cooper GAC ACR Staff K. Nola PBM -- M. Strozier ISC T. Barholow Payer WEAT/WHIO A. Miller Quality G. Huffstutter -- Group K. Amodeo GAC/APM ACR Staff

18 CMS RFI: The Innovation Center is interested in increasing the availability of specialty physician models to improve quality and lower costs and engage specialty physicians in alternative payment models, especially for independent physician practices. Suggestion: Lower threshold to 15% for QP and 10% for partial QP for foreseeable future. Development of a physician focused APM is a multi-year process and thresholds should not be as high as those for APMs focused on large organizations.

19 Alternative Payment Models Can Be Win-Win-Win $ Total Spending Relevant to the Physician s Services Physician Practice Revenue Fee-for-Service Payment (FFS) Avoidable Spending Payments to Other Providers for Related Services FFS Payments to Physician Practice Unpaid Services Physician-Focused Alternative Payment Model Savings Avoidable Spending Payments to Other Providers for Related Services Flexible, Adequate Payment for Physician s Services Win for Payer: Lower Total Spending Win for Patient: Better Care Without Unnecessary Services Win for Physician: Adequate Payment for High-Value Services