The Medicare Access and CHIP Reauthorization Act's (MACRA's) Advanced Alternative Payment Models (AAPMs) offer incentives to physicians who provide high-quality and cost-efficient care as it applies to a specific clinical condition, care episode, or population. Examples include the Comprehensive Primary Care (CPC) Plus and the Oncology Care Model.
MACRA also calls for physicians to design their own AAPMs based on how care is actually delivered. In December 2017, the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which provides recommendations to the Health and Human Services (HHS) Secretary, voted to recommend that HHS test the Advanced Primary Care APM developed by the American Academy of Family Physicians, which has more than 84,000 actively practicing physicians as members. The AAFP expects that primary-care physicians currently not in CPC Plus regions would be most interested in participating in the APC-APM. Any fee-for-service Medicare beneficiary not attributed to another APM could receive care under the APC-APM, so the potential impact is huge.
Physicians Practice recently asked three AAFP representatives to talk about the payment model they have proposed and the PTAC’s response. We spoke with Michael Munger, MD, AAFP president; Amy Mullins, MD, medical director for quality improvement; and Kent Moore, senior strategist for physician payment.
Physicians Practice: Dr. Munger, when you addressed the PTAC committee evaluating your proposal, you said that the undervaluation of primary-care services and fragmentation driven by our current payment system are well understood. You even noted that payment experts on the PTAC panel have pointed out that building APMs on flawed physician fee schedules would simply perpetuate current inequities in payment. Why did you think that was an important point to stress?
Munger: In family medicine, we are primarily getting payment based on who is right in front of us and how much we can do to them. Furthermore, if you look at the relative valuation of an E&M [evaluation and management] code vs. some of the procedural codes, that is where you start to see inequities. For instance, look at the value placed on spending 25 minutes seeing an established patient about three or four chronic conditions vs. doing a colonoscopy in the same length of time. The procedural code for the colonoscopy is worth almost three times more than the E/M visit focused on chronic care management. Also, many aspects of family medicine are not done face-to-face. I can’t drop a code around coordinating care or managing conditions between visits unless a certain threshold of time and other requirements are met. To build anything on our current system is really going to miss out on the comprehensiveness of what we deliver in family medicine.
PP: MACRA established two payment pathways. Physicians can participate via the Merit-based Incentive Payment System (MIPS) or in AAPMs. Why was it important that the MACRA statute include the capability for physicians to propose their own tailored payment models?
Mullins: It is important that we realize there are not enough AAPMs available for physicians to participate in. As the law is structured, MIPS is a complicated program. We believe the intent of the law is to move physicians and clinicians into the AAPM track, but the onramp to the AAPM track is narrow and steep right now. There needs to be an AAPM that will be available for the majority of primary-care physicians to participate in as an alternative to MIPS.