Two New Advanced APMs Could Be the Answer for Medical Specialists

The proposed payment models could fill a void for gastroenterologists, a key field for Medicare given the high number of enrollees treated for colorectal cancer.

The enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will fundamentally alter payment to physicians treating Medicare patients. MACRA incentivizes physicians through 2 payment systems: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MIPS is a modified fee-for-service system which distributes a portion of physician payments based on quality of care, resource use, meaningful use of electronic health records and clinical practice improvements. APMs require a physician to take on risk and provide compensation based on quality of care. Providers may be eligible to receive a Medicare payment bonus if a majority of their reimbursements come from APMs.

The lack of opportunities for specialists to participate in APMs has been a very real and alarming issue. Lacking the ability to take part in APMs, gastroenterologists are finding themselves stranded in a system that does not adequately account for the high-quality care they provide.

In an effort to remedy this issue, the Digestive Health Physicians Association (DHPA) is supporting 2 proposals that were submitted to the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The Illinois Gastroenterology Group submitted the Project Sonar Advanced APM, and the Digestive Health Network proposed the Comprehensive Colonoscopy Advanced APM for Colorectal Cancer, Screening, Diagnosis and Surveillance. Both proposals are designed to promote the delivery of high-quality care at reduced costs to Medicare and, if accepted by the Centers for Medicare and Medicaid Services (CMS), will enable gastroenterologists in a variety of practice settings to participate in Advanced APMs.

The benefits of these initiatives are substantial and far-reaching. Their value lies in the ability to improve healthcare quality, reduce unnecessary services and cost to the Medicare system and enhance patient safety while preserving patient choice. Models such as the Project Sonar and Colonoscopy APM are particularly beneficial to specialties that have typically been left out of the traditional APMs, which were originally developed for primary care. Specialists working in primary care APMs end up as subcontractors with not enough risk to qualify for the APM (or an exemption from MIPS).

The proposed Colonoscopy Advanced APM is a comprehensive, episode of care payment model designed to encourage physicians across specialties to coordinate care and collaborate more effectively. Enhanced cooperation among providers improves patient care and outcomes in the diagnosis and treatment of colorectal cancer—the second-leading cause of cancer death in the country, according to the American Cancer Society.

Screening is a critical tool in fighting colorectal cancer, as this type of cancer carries a survival rate of 90% with early detection and treatment. Yet, 40% of Americans over the age of 50 are not up to date with their screenings. Amongst other concerns, patients often cite the uncertainty of financial costs when colorectal cancer screening leads to a diagnostic or therapeutic procedure. The Colonoscopy Advanced APM addresses this concern, representing a significant step toward reducing deaths from colorectal cancer that could be avoided with timely screening.

Project Sonar is a care-management program designed to improve the treatment of patients with Crohn’s disease. The Project Sonar Advanced APM promotes the identification of high-risk patients before their complications ensue, encourages connected and efficient channeling of patients to their health care professionals and engages patients in identifying early warning signs. It fosters a true partnership between clinicians and our patients—with a documented tripling of patient engagement up to 80% over a 20-month study period.

More than 1.5 million Americans are affected by inflammatory bowel disease. The Project Sonar APM will enable caregivers to provide better medical management and decrease the complication rate, resulting in reductions of emergency department visits and inpatient admissions through physician identification and assessment of high-risk patients before complications arise. In addition to enhancing the patient’s quality of life and improving medication adherence, the cost of managing the patient drops significantly.

Not only will these proposals give specialists an opportunity to navigate MACRA more efficiently by allowing them to participate in APMs, they promote improved care at lower costs to patients. Ensuring our patients receive the best possible care is always our top priority and these are precisely the types of innovative, team-based, physician-focused payment models that the PTAC should embrace and recommend to CMS for implementation. The Digestive Health Physicians Association and the more than 1,600 gastroenterologists in its 66 member practices who provide care to patients in urban, suburban, rural, academic and community-based settings throughout the United States strongly believe that the Centers for Medicare and Medicaid Services should make implementation of both of these proposed advanced alternative payment models a high priority.

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