Alternative payment models (APM) could soon be a reality for most physicians—and specialty societies already have begun developing payment models for the conditions and episodes of care that their members treat. Some physicians are even piloting initial models in practice. Find out how you can get involved in making sure these new payment models will enhance the care your patients receive.

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It’s important for physicians in every medical specialty to begin working now toward APMs that solve the specific barriers they face in the current payment system. “A doorway has been opened that has not been opened before,” said Harold Miller of the Center for Healthcare Quality and Payment Reform, who is also a member of the new federal Physician-Focused Payment Model Technical Advisory Committee (PTAC). “Physician effort and input is needed in the development of these new payment models.”

The Medicare Access and CHIP Reauthorization Act (MACRA)—the legislation which repealed Medicare’s sustainable growth rate formula last year—provides incentives and funding to develop APMs that could give physicians the resources and flexibility to deliver care in new and better ways. 

PTAC, a permanent committee created by Congress to advise CMS on APMs, held its first meeting earlier this month. The AMA and several medical specialty societies told the Committee that more specialty-specific APMs were needed.

“Physicians and specialty societies are going to need help to develop these models and in ways that meet the requirements for MACRA and that are feasible for Medicare and payers to implement,” Miller said. One of the roles of PTAC will be to provide that help.

“Designing a good alternative payment model is basically a three-step process,” Miller said. “First, what are the opportunities for improving care for patients that could result in savings? Second, what are the barriers in the current payment system that prevent those improvements? Then, what kind of payment model enables the physician to overcome those barriers and achieve those opportunities?”

For example, the current payment system does not support taking calls from patients after hours, coordinating with emergency services and hospitals, hiring care managers, or even taking time to consult with other physicians. Many specialties are developing models that can solve these problems, improve patient care and lower spending. 

How physicians and specialty societies are working together

Physicians should start working now through their specialty societies to develop these models, Miller said. “There are a number of examples around the country of physicians in various specialties who have been able to improve care for their patients and lower costs through payers through a grant or a supportive health plan, and those would be good places to start in developing APMs that could enable all physicians in the specialty to deliver similar benefits for their patients.”

For example, Barbara L. McAneny, MD, immediate past-chair of the AMA Board of Trustees and an oncologist in New Mexico, has been leading a project to reduce the frequency at which patients who are undergoing chemotherapy end up in the emergency department or hospital due to complications.

“They have achieved dramatic results, but they won’t be able to sustain the changes unless there are changes in the way they are paid,” Miller said.

Dr. McAneny worked with the American Society of Clinical Oncology (ASCO) to develop the Patient-Centered Oncology Payment proposal. “Dr. McAneny’s experience helped the ASCO to develop an APM that would work for a broad range of practices,” Miller said.

Another society, the American Association of Clinical Endocrinologists (AACE), is discussing a condition-based APM for managing patients with diabetes. An APM is needed to support educating patients about their diabetes, checking blood sugars, phone calls to change therapy, arranging necessary consultations, communicating with the primary care physician and other consultants, and office visits.

Physician input is critical to making sure these payment models work. Additionally, it is important for specialty societies to work together to develop payment models that support coordinated care of patient health problems that are treated by multiple specialties.

Making sure new payment models work

It is important that the criteria for physician-focused APMs allow physicians to take accountability for costs and outcomes they can influence but not hold them responsible for costs they cannot control or to impose new administrative burdens, Miller said.

In order to help accelerate efforts to develop physician-designed APMs in all specialties, the AMA compiled a process that physicians and their specialty societies can use to develop payment models that will meet the specialty-specific needs of physicians’ practices and patient populations:

  • Identify specific ways in which patient care could be improved that will result in lower health care spending.
  • Identify the specific barriers that current payment systems create that make it difficult or impossible for physicians to implement these improvements in patient care.
  • Identify the changes in payment needed to overcome these payment barriers. Not all changes in payment systems actually overcome the barriers to payment, and many payment changes can create new problems for physicians.
  • Analyze whether the benefits for patients and the savings for payers and patients are sufficient to justify any costs associated with appropriate payment changes.
  • Design a payment model that removes the barriers to improving care so that physicians can improve outcomes for patients and achieve savings for payers.

How physicians are leading payment reform efforts

At the first PTAC meeting, the AMA testified that it is important to involve physicians at every part of the payment model development process and for PTAC to work with specialty societies to ensure that APMs adopted under MACRA are truly beneficial models.

More than 100 state and specialty medical associations recently joined the AMA in sending a letter (log in) recommending 10 principles that the Centers for Medicare & Medicaid Services (CMS) should follow in implementing the MACRA, including principles as to how APMs should be developed and implemented.

To help physicians and specialty societies in the effort to create these payment models, the AMA worked with Miller to develop the “Guide to Physician-Focused Alternative Payment Models.”

For more on alternative payment models, check out the three traits of successful payment models and the most common barriers in the current payment system. Also, find out who is using new delivery and payment models and learn about seven payment models that address physician needs.

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