CMS faces challenges in attracting specialty medical practices to Medicare’s value-based payment models. While CMS aims for broader adoption of accountable care organizations (ACOs) and value-based arrangements, specialty practices find the current models inadequate. An MGMA survey reveals that 79% of respondents lack clinically relevant APMs for their specialties. The Physician-Focused Payment Model Technical Advisory Committee (PTAC) also struggles, with no models adopted by HHS. Efforts continue to develop appropriate models for specialty care and involve stakeholders in refining APMs.
The Centers for Medicare & Medicaid Services (CMS) are encountering a series of difficulties in their endeavors to entice fee-for-service medical practices towards embracing Medicare’s accountable care organizations (ACOs) and other value-based payment structures.
“Value-based payment programs tie provider reimbursements to enhanced performance demonstrated by healthcare providers. This reimbursement approach ensures that healthcare providers are responsible for both the cost and quality of care they offer,” stated CMS in a recent press release highlighting the achievements of their flagship ACO, the Medicare Shared Savings Program. ACOs are collaborative networks of doctors, hospitals, and other healthcare providers who voluntarily collaborate to provide well-coordinated care for Medicare beneficiaries. CMS aims to have 100% of traditional Medicare beneficiaries participating in an ACO or another accountable care arrangement by 2030.
To shift more providers towards these models, CMS has introduced a range of what they call “alternative payment models” (APMs), encompassing ACOs, episode-based payments, and bundled payment structures such as the comprehensive joint replacement model.
Emphasis on Primary Care-Centric Approaches
A recent survey conducted by the Medical Group Management Association (MGMA), a representative body for medical practices, unveiled that 79% of respondents felt that Medicare lacked a clinically relevant advanced APM suitable for their specialty, despite the majority expressing interest in such a model. Although the survey garnered 208 responses from around 3,500 MGMA members enrolled to receive survey inquiries, Anders Gilberg, Senior Vice President for Government Affairs at MGA, clarified that this survey wasn’t scientifically comprehensive. Nonetheless, he added, “These findings are consistent with other surveys we’ve conducted on the same topic. We conduct an annual regulatory burden survey, and I believe we’ve posed similar questions that yield similar outcomes.”
So, what’s deterring more practices from adopting these models? Specialty practices argue that one reason is the CMS’s existing payment models, which primarily cater to primary care.
“Despite over a decade of Medicare’s venture into value-based care programs, there remains a scarcity of alternative payment models tailored to specialty physicians, including neurosurgeons,” noted Katie Orrico, Senior Vice President for Health Policy and Advocacy at the American Association of Neurological Surgeons/ Congress of Neurological Surgeons. Orrico lamented that despite ongoing appeals from professional associations, CMS hasn’t engaged in collaborative efforts with the physician community to craft specialty APMs. Instead, she claimed, the agency continues to advocate for a standardized approach to value-based care, centered around primary care, chronic care management, and large ACOs.
Challenges Surrounding PTAC
Another complication arises from the Physician-Focused Payment Model Technical Advisory Committee (PTAC), established by Congress in 2015. PTAC’s mission was to evaluate proposals from physician groups for APMs and recommend potential models for adoption by HHS and CMS. However, despite evaluating more than thirty models and offering several recommendations, not a single proposal has been integrated by HHS.
Orrico expressed her concern, stating, “Regrettably, it might take congressional intervention to restore relevance to PTAC. It’s perplexing why CMS has disregarded PTAC’s efforts, which have assessed and forwarded several promising APMs to CMS for review and implementation. Ignoring these PTAC-endorsed models belittles the substantial resources invested by medical specialty societies and hampers progress towards a more value-based Medicare system.”
Gilberg concurred, highlighting the disconcerting absence of adopted PTAC-recommended models. He emphasized the necessity for clinically applicable ACOs to facilitate practice transition away from fee-for-service. He observed, “We frequently encounter situations where federal solutions don’t align well with existing value-based contracts held with commercial payers and are ill-suited for specialties beyond primary care.”
Puzzling Lack of Progress
Susan Dentzer, President and CEO of America’s Physician Groups, an organization committed to value-based care, characterized the lack of success in PTAC’s efforts and the adoption of physician-centric APMs as intricate. She highlighted that those who supported PTAC and had their models excluded from the Medicare program formerly aimed their discontent at HHS secretaries. Presently, however, the focus has shifted to CMS and Elizabeth Fowler, who heads the Center for Medicare & Medicaid Innovation (CMMI).
Dentzer commended Fowler’s engagement with PTAC and physician groups proposing models but noted that CMMI and CMS must adhere to the evidence-based criteria established for model integration into Medicare. She revealed that certain specialties and procedures, such as oncology, kidney care, and joint replacement, have seen APM development by CMMI. Dentzer cited an ongoing RFI that solicits feedback on creating new payment episodes and bundles, acknowledging the input of the broader medical community.
The American Medical Association welcomed CMMI’s efforts to expand APMs, urging increased transparency in model development and implementation. The association’s Executive Vice President and CEO, James Madara, highlighted the need for involvement from practicing physicians during both phases.
Striving for Precision in Approach
Aisha Pittman, Senior Vice President of Government Affairs at the National Association of ACOs (NAACOS), suggested a shift in PTAC’s role from recommending specific models to leveraging it as a stakeholder group. Pittman noted the inefficacy of the current approach and proposed using PTAC to gather input for potential model enhancements.
Pittman also drew attention to challenges surrounding current models, like incorporating specialists into “total cost of care” arrangements. She advocated for PTAC to address these challenges and offer multi-stakeholder input for resolutions, instead of designing entirely new models.
Reflecting on the Medicare Access and CHIP Reauthorization Act’s implementation in 2018, Pittman acknowledged the aspiration to attain 60% adoption of APMs by the end of the initial 6-year period. Given the complexity involved, Pittman emphasized the need for careful model design to ensure clinician success while maintaining reasonable compensation. Implementing these models effectively also requires time.
CMS did not provide a response at press time regarding their efforts to attract more physicians to APMs.
