Physician Focused Payment Models: Exploring the Potential of MACRA’s Community-Designed APMs

By Elizabeth Mitchell, NRHI President and CEO; Co-Chair, PTAC

There’s been a great deal of discussion about MIPS, APMs and Advanced APMs since the passage of MACRA. And while the conversation started with trying to understand what each designation will mean for the physicians and practices they’ll affect, it quickly shifted to a more pertinent question: “Where will everyone fit in this new regime of acronyms?”

While that answer might not be entirely clear until the final rules are released in November, many providers are uneasy with any of the available options. Fortunately, Congress included a provision to encourage payment model innovation reflective of provider priorities.

Referred to as Physician-Focused Payment Models (PFPMs), this speculative construct is very broadly defined in the draft rules. These new models are subject to initial review by the aptly-named Physician-Focused Payment Model Technical Advisory Committee (PTAC). Established in April 2015 under MACRA, the PTAC’s duties are “to review physician-focused payment models submitted by individuals and stakeholder entities…prepare comments and recommendations’ for the Secretary of the Department of Health and Human Services. Those approved by the Secretary will be included in the APM portfolio for payment.

In its early, formative months, the PTAC worked to consider application of the criteria, translating it from the theoretical to the practical, readying the guidelines for use in reviewing the expected flow of PFPM applications from stakeholders throughout the country. And while the final rules have yet to be released, feedback suggests that there’s plenty of energy to explore the potential of PFPMs to provide alternative payment and practice models beyond those currently envisioned under the MIPS/APM regime. Based on the input, PTAC made a number of modifications to the draft process and a description of the revised process is here. The Committee’s responses to the comments it received are summarized here.

There’s a lot of interest in developing APMs for review because, under the proposed rules, only six advanced APMs were listed as qualified for the beginning of the program. Medical professionals in qualifying models will be eligible to receive a 5 percent incentive payment based on their Medicare claims.

It’s worth noting that PFPMs aren’t a panacea. They’re tools – and they’ll only yield meaningful improvements if they’re implemented in the spirit, not just the letter of the law. Ill designed PFPMs could be pursued to achieve one-sided objectives that don’t effectively serve MACRA’s larger objectives of better care and better value. But well designed PFPMs could enable innovative ideas that will move us closer to healthcare affordability, improved outcomes and big-picture improvements to health.

The revised process is still a draft and further revisions and refinements are likely in response to:

  • The final criteria for physician-focused payment models that are established by the Secretary of HHS in rulemaking
  • The PTAC’s experience in reviewing and making recommendations regarding proposed payment models after proposals begin to be submitted
  • Additional feedback PTAC receives from the public. The PTAC welcomes comments and suggestions at any time; comments may be submitted by email to PTAC@hhs.gov or by mail to PTAC c/o Scott R. Smith, ASPE, 200 Independence Ave. SW, Washington DC 20201. The PTAC will also accept oral comments at its upcoming meeting September 16, 2016