Advanced alternative payment models (APM) are one option for physician practices to participate in the Quality Payment Program (QPP), and several have already been submitted to the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which reviews and evaluates Advanced APMs. One of these submissions seeks to encourage physicians from multiple specialties to collaborate and coordinate care across settings to more effectively manage patients who require colonoscopy for colorectal cancer screening and diagnosis.
Joel Brill, MD, an internist and gastroenterologist, helped develop the Comprehensive Colonoscopy Advanced Alternative Payment Model for Colorectal Cancer Screening, Diagnosis and Surveillance.
“If a patient needs a colonoscopy, they’re still going to get the colonoscopy. We’re trying to reduce the barriers to people getting the procedure done,” Dr. Brill told AMA Wire®. Dr. Brill and his colleagues asked several questions when they decided to look at a bundled payment model for colonoscopy cancer screening coordination.
“Being proactive and not reactive, how do we help to address something that, unlike orthopedic procedures, is not generated by hospitalization—something that primarily takes place in the outpatient setting?” he said. “How do we look at things in a way to reduce waste, reduce overuse, reduce unnecessary services, so that there is more money in the system to provide care for people?”
And there were other questions that also required answers, Dr. Brill said.
“How do we make it easier for patients to get the medically necessary services they need?” he said. “How do we optimize the costs? How can we be humanistic in meeting the needs of the patient and their caregivers and family members?”
Looking at Medicare data files, Dr. Brill and his colleagues analyzed every detail of the procedure including cost, setting, reason for colonoscopy, complications and much more, which resulted in a bundled payment that reduces the number of copays, encourages better pre-procedure prep and coordinates care across specialties.
“One of the barriers is that Medicare has some fairly different ways of approaching preventive services,” Dr. Brill said. For example, if a patient is asymptomatic and comes in for a colonoscopy and a polyp or something that needs to be removed is found, “it’s no longer a screening service, that patient has financial responsibility.”
“How do we remove those barriers?” he said. When a patient undergoes a colonoscopy, they are most often sedated. The patient is not the only person who loses a day of work, but so does the patient’s caregiver or family member who is present to make sure they get home safely. If care is coordinated efficiently, as this APM intends to accomplish, there is more transparency in what the cost, time burden and preparation will be.
For Dr. Brill and his colleagues, the development of this APM had one goal, he said: “The right care, the right time, the right setting, the right patient, the right cost.”
“The patient knows now that there’s a price, it covers the medically necessary services they need,” Dr. Brill said. And if there’s a complication, “there’s nothing extra out of their pocket.”
The colonoscopy APM is aligned with quality measures under the QPP’s Merit-based Incentive Payment System (MIPS). “We’re encouraging reporting on quality measures … that are related to colonoscopy.”
When it comes to care coordination, the colonoscopy APM is designed for close collaboration with primary care physicians. “Any patient going into a facility is going to have a history of physicals, so why not capture information that we normally would capture—blood pressure, do you smoke, alcohol use, BMI [body mass index]—and if we notice that something is abnormal we can send that information back to the primary care physician to make sure they can follow up on it,” Dr. Brill said.
Because Medicare does not pay for a beneficiary to have a pre-procedure evaluation and management service and a lot of the instruction for patients happens over the phone, Dr. Brill and his colleagues built this into the APM “to ensure that people get the appropriate care [and] instructions, and let’s find out why people might have poor prep.”
Michael Weinstein, MD, vice chairman of the Digestive Health Physicians Association, told AMA Wire the physician organization was excited to support the colonoscopy APM. “The regulatory burdens that seem to be on the horizon for MIPS caused us to investigate what were the opportunities for independent gastroenterologists to participate in some type of alternative payment model.”
“We started this advocacy association because these practices absolutely believe that there must be a better … way to deliver health care that can be better for patients, engaging for patients, and could lower the cost—that’s our goal,” Dr. Weinstein said. “We think that the model of independent practices is still a good model.”
“You look at the data … and how much money is spent on colon cancer prevention,” he said “There are definitely issues in the system that can be addressed with an alternative payment model like this.”
Another GI APM up for consideration by the PTAC is an initiative called Project Sonar, an intensive medical home for the management of Crohn’s disease. Through a web-based platform, SonarMD, physicians can track patient symptoms and get out ahead of any complications or progressing medical issue before an emergency occurs.
The “sonar” system pings patients in between their face-to-face visits with a set of questions to make sure they are not experiencing any major issues and to look for any minor issues that could turn into problems.
“Patients are like submarines … out there submerged,” said Lawrence Kosinski, MD, a gastroenterologist and founder and chief medical officer of SonarMD. “We can’t see them; we don’t know how they are [because] they only come in when they’re in trouble. Which means that, number one, they have to recognize that they’re in trouble and, number two, realize that they can’t fix it themselves …. So we need a sonar system to ping them.”
Listen to a ReachMD podcast interview with Dr. Kosinski.
Surgical care is very team-based and coordination with specialists, primary care and all other segments of the delivery system involved play an important role in improving patient care. The American College of Surgeons (ACS) saw opportunity in the APM option of the QPP and developed the ACS-Brandeis Advanced Alternative Payment Model.
The surgical APM is an episode-based payment model build on an updated version of the Episode Grouper for Medicare software that has been used by CMS for physician resource use reporting. It processes Medicare claims data using clinical specifications to create condition-specific episodes to assess utilization and costs.
Triggering an episode in the APM does not require a hospitalization, meaning that the framework is applicable to multiple care settings. This kind of flexibility is important because many specialties currently lack opportunities to participate in APMs due to their geography, practice patterns or a lack of specialty-specific models.
“With 50 diagnostic and therapeutic procedures, we see more than 60 provider specialties including general, orthopedic, and other surgical specialties, internal medicine, emergency medicine, and critical care among others,” David B. Hoyt, MD, executive director of ACS, wrote in a letter of intent to the PTAC. “Additional episodes will be added in future years, expanding the depth and breadth of the model.”
“As the committee moves forward with its review and evaluation … we urge you to keep in mind the model’s flexibility and potential for expansion and future development,” the AMA and several other medical societies wrote in a letter to the PTAC. “Its unique, physician-reviewed resource use methodology logically extends itself to other forms of specialty care, including care for acute and chronic medical conditions.”
The AMA is holding an Advanced APM Workshop on March 20, in Washington, D.C., where physician leaders in developing these and other models are participating to share their experiences and help identify solutions to some key challenges in developing physician-focused APMs.