Jacqueline M. Kocinski, MPP
First there was the SGR. Now it’s MACRA, MIPS, and APMs. It’s a dizzying alphabet soup you wish you could ignore…except, if you’re reading this, you likely can’t, as it may well impact how you will be paid under Medicare.
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 repealed the Sustainable Growth Rate (SGR)—the formula that was used for nearly 2 decades to determine Medicare payment for clinician services—and established instead a new framework for rewarding value over volume in the fee-for-service Medicare program. The Quality Payment Program (QPP) was created to execute this transformation, streamlining previous quality reporting programs into one new system—the Merit-Based Incentive Payment System (MIPS)—and incentivizing participation in qualifying Alternative Payment Models (APMs).
Although APMs are one of two primary pathways to QPP participation, they provide the largest payment incentives for participation and performance. APM participation requires providers not only to deliver higher-quality care, but also to assume responsibility for controlling or reducing cost. Abundant data exist to demonstrate that palliative care drives both higher quality and lower cost for seriously ill patients, creating key opportunities for hospice and palliative care providers to potentially thrive in APMs, including through Physician-Focused Payment Models (PFPMs). These APMs, for which Medicare is the payer, include physician group practices or individual physicians as APM Entities and target the quality and costs of physician services.
Envisioning Better Care
Recognizing the opportunities and challenges for Academy members as fundamental changes in care payment and delivery take shape, AAHPM convened an APM Task Force in fall 2016 to develop a strategy to support members in engaging and succeeding in APMs. The overarching aim was to ensure sustainability of high-quality palliative care and hospice services that improve quality of care and quality of life for patients with serious illness and their caregivers. Phil Rodgers, MD FAAHPM, a leading national expert in palliative care payment and delivery innovation and past chair of AAHPM’s Public Policy Committee and Emerging Payment and Delivery Models Workgroup, was appointed to lead the task force. Fifteen additional Academy members were invited to serve based on their recognized leadership in key aspects of APM development, including quality measurement and improvement, delivery innovation, novel collaboration and partnerships, and community engagement. These Academy thought leaders include representatives of palliative care provider organizations; hospices; health systems; and payers serving urban, suburban, and rural communities.
“The task force approached its work with the mindset that better payment is really about better care for patients and families,” Rodgers said. “In the current model, there’s no way to pay for what people want and value,” added APM Task Force member Dana Lustbader, MD FCCM FCCP FAHPM.
The central problem the task force addressed was that many patients who have serious illnesses are not well-served by the current fragmented, intervention-oriented healthcare system. “Although high-quality, interdisciplinary palliative care services provide significant benefits for patients, caregivers, and payers, the current fee-for-service payment system does not adequately reimburse community-based, interdisciplinary palliative care services and thus does not enable palliative care teams to deliver those services to the right patient, in the right place, at the right time,” Rodgers explained.
The task force first met for an all-day brainstorming session in November 2016 to begin developing a payment model that would support the delivery of palliative care services to patients in all stages of serious illness who are not yet eligible for or willing to enroll in hospice care. Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, was contracted to facilitate the session and draft an initial model based on the goals and specifications set forth by the group. Key questions the group considered included
- Which providers should be eligible?
- Which patients should be eligible?
- How big should payments be to support adequate care?
- Should payment amounts differ for patients with differing levels of need and risk?
- Will savings be sufficient to offset the cost of higher payments and avoid increasing total spending?
- For what aspects of spending should the palliative care team be accountable?
- How do patients and payers know the palliative care team is delivering high-quality care?
- How does the palliative care team APM relate to accountable care organizations and other APMs?
The task force worked over several months to address these key questions and, ultimately, produced two payment reform proposals designed to enable patients with serious illness to receive palliative care across a wide range of healthcare settings in urban, suburban, rural, and underserved communities.
Under the first model, Palliative Care Support to a Medical Home (PCS), payments are designed to allow palliative care teams to provide support to accountable entities—such as a Medical Home, Oncology Care Model practice, Comprehensive Primary Care Plus practice, or even Medicare Advantage plan—in addressing unmet needs of patients with serious illness who are assigned or attributed to those providers.
The PCS model includes one-time payments to provide comprehensive assessment and care planning services and monthly payments to allow for comanagement of patients with ongoing needs. Both payments would be tiered based on a patient’s health and functional status so as to align with the intensity of interdisciplinary services required. PCS services would be subject to quality measurement, but PCS payments would not qualify as an “advanced APM” under MACRA because they do not require palliative care teams alone to assume “more than nominal” financial risk. Rather, they are designed to assist other quality- and cost-accountable providers in the care of their patients with serious illness.
A second model, titled Patient and Caregiver Support for Serious Illness (PACSSI), was crafted to qualify as a MACRA APM by allowing palliative care teams themselves to become accountable for the quality and cost of the care they provide. Monthly PACSSI payments would support interdisciplinary palliative care teams and be tiered similarly to PCS. In addition, payments would be adjusted up or down based on performance on both quality and cost measures related to the services delivered. There also would be an option under PACSSI for palliative care teams to receive bundled payments, which would require greater accountability for service delivery and total cost of care.
Rodgers and Miller presented a draft of the task force proposals to attendees at the 2017 Annual Assembly of Hospice and Palliative Care. A detailed discussion draft was subsequently posted for review by Academy members, who were invited to provide feedback through an online survey. More than 100 members responded with input on priorities, design parameters, expected participation, and more. AAHPM also reached out to nearly 20 external organizations to solicit input. These include hospice and palliative care stakeholders, such as national associations representing other disciplines or entities involved in providing palliative care (nurses, social workers, physician assistants, chaplains, pharmacists, hospice organizations), and other medical specialty societies (geriatrics, home care medicine, post-acute and long-term care, clinical oncology). Payers and palliative care researchers also were consulted. Finally, Academy leaders met with staff of the Center for Medicare & Medicaid Innovation (CMMI) to discuss AAHPM’s draft payment reform proposals.
Because PCS would not quality as an APM under MACRA, CMMI staff indicated it might be confusing to advance it for consideration by the Physician-Focused Payment Model Technical Advisory Committee (PTAC), the body established under the law to review proposed models and make recommendations to the Secretary of Health & Human Services for testing and implementation of APMs. The task force therefore decided that AAHPM’s PTAC submission would focus solely on PACSSI, and committed to pursue other strategies to advance the goals of PCS, including submitting new payment code proposals for consideration by the American Medical Association’s Current Procedural Terminology Editorial Panel.
Advancing a New Payment Model
In August 2017, AAHPM submitted to the PTAC a proposal for the PACSSI payment model. The final proposal reflects substantial changes compared to the discussion draft circulated four months prior. “These revisions were based on iterative and wide-ranging feedback AAHPM solicited from numerous stakeholders representing hospice and palliative medicine practices of many sizes and types, interdisciplinary leaders, payers, and noted researchers in the field, as well as CMMI,” Rodgers noted.
The PACSSI model is designed to provide patients and caregivers in all types of communities with access to high-quality palliative care from many types of palliative care teams working through “APM Entities” willing to be accountable for both quality and cost of care. These APM Entities could include PCTs working as independent provider organizations or associated with hospices, home health organizations, hospitals, businesses focused on palliative care delivery, or integrated health systems through direct employment or contracting. In addition to physicians and other clinicians eligible to bill Medicare, PCTs also will include clinicians not reimbursed under the Medicare program (eg, nurses, pharmacists, social workers, or spiritual care professionals) who work in conjunction with patients’ other care providers and provide psychosocial and spiritual support. “Seriously ill patients and their caregivers more often need a social worker or nurse and not a billing provider,” Lustbader explained.
PACSSI-participating PCTs would be required to demonstrate the capability to perform assessments and deliver services through an interdisciplinary team structured in accordance with the essential elements of the National Consensus Project (NCP) Clinical Practice Guidelines for Quality Palliative Care as well as to respond appropriately on a 24/7 basis to patient and caregiver requests for advice and assistance in managing issues associated with the patient’s health conditions and functional limitations. This includes the ability to provide face-to-face services in all care settings when needed (either in person or through videoconference services) as well as telephonic responses.
“Many different services are being offered now under the guise of palliative care, advanced illness management, and care coordination. We need to be sure that people living with serious illness know what they are getting and that the care can deliver on its promise,” said AAHPM Chief Medical Officer Joe Rotella, MD MBA HMDC FAAHPM. “In that respect, it has been most helpful to have the NCP Guidelines as a guidepost to define what services the palliative care team must deliver.”
Under the PACSSI model, interdisciplinary PCTs could participate in one of two tracks that would have increasing levels of accountability and risk. In both tracks, PCTs would receive tiered monthly payments to support interdisciplinary community-based palliative care delivered to patients who meet eligibility criteria that include a diagnosis of a serious illness or multiple chronic conditions, functional limitations, and a pattern of healthcare utilization. These payments would replace fee-for-services payments for evaluation and management (E/M), chronic care management, and advance care planning services to provide financial support and flexibility for PCTs to manage patients’ care. PCTs would work in collaboration with the full spectrum of primary and specialty care clinicians to develop and execute a care plan consistent with patients’ needs and preferences.
Under Track 1, PCTs would be subject to positive and negative payment incentives of up to 4% of total PACSSI care management fees received for a year, based on their performance on quality and spending. Under Track 2, PCTs would become responsible for not only quality but also total cost of care, sharing either in savings or losses for the patients enrolled. Quality performance in PACSSI would assess PCTs across three categories of metrics: patient-reported outcomes regarding the experience of palliative care, completion of care processes that are proven to drive quality, and utilization of healthcare services that are generally desirable or undesirable for patients at the end of life. Because several of the proposed measures are new measures that require additional testing and do not currently have sufficient evidence to establish benchmarks, PACSSI phases in accountability for performance on this subset of measures over time. When fully phased in, PCTs’ accountability for quality performance would be based on a composite score that equally weights performance across each of the three quality categories.
“When designing accountability for quality in this model, the Academy’s intention was to strike a balance between acknowledging the significant gaps in where the development and implementation of palliative care quality measures is now and driving toward where we expect to be in a few years,” Rotella said. “If we were to use only established measures exactly as they are currently specified, we would be limited mostly to process measures for narrowly defined subgroups of the seriously ill population, for example, only those with advanced cancer, receiving specialty palliative care consultation in a hospital or enrolled in hospice. On the other hand, if we were to leapfrog to our desired future and outpace quality development in our field, we would risk ineffective measures, unintended consequences, and excessive burdens on participating providers.”
“The payment incentives in PACSSI are well structured to drive improvements in both quality and cost performance,” Rodgers added. “There’s an option for smaller or less risk-ready practices to participate and grow in Track 1, where PACSSI payments are adjusted based on quality and spending performance. Track 2 will provide larger, more risk-experienced programs the opportunity to drive greater shared savings while also being accountable for quality.” Rodgers noted that the phased-in approach to pay-for performance will also allow critical time and resources for palliative care teams to strengthen necessary clinical and reporting infrastructure.
A PTAC review team assigned to the PACSSI model has already provided AAHPM with an initial list of questions as part of its examination of the Academy’s proposal. The reviewers may engage AAHPM leaders in multiple rounds of dialogue before making a preliminary recommendation to the full committee. A public hearing will then be held during which the PTAC will vote on whether to recommend PACSSI for testing.
“The Academy’s open and inclusive development process helped to yield a diverse and impactful demonstration of support for the PACSSI model such that AAHPM was able to include letters of support from 20 organizations as part of its PTAC submission,” Rodgers said. Additional letters of support were received by PTAC during a public comment period. Many of the supporting organizations indicated they would look forward to participating in PACSSI, should it be recommended for testing by PTAC and implemented by the Centers for Medicare & Medicaid Services, or that they would encourage their members to do so.
APM Task Force member Todd R. Coté, MD HMDC FAAFP FAAHPM, believes PACSSI will offer opportunities for hospices to work more closely with nonhospice palliative services to offer a true continuity of care. “As chief medical officer of a large hospice organization, I appreciate how access to nonhospice palliative services can increase the timeliness to hospice referral. Hospices still struggle with patients coming to hospice services far too late in the last few days of life. PACSSI not only includes important quality metrics that encourage the appropriate referral to and use of hospice, but I feel PACSSI will allow us to expand and increase our nonhospice palliative services in all our communities, especially throughout the rural Appalachian areas we serve.”
Lustbader already oversees a home-based palliative care program that has seen impressive results: “PACSSI would allow us to expand ProHEALTH’s current program and provide services that matter to patients and families, services that are not reimbursable in a fee-for-service environment but would be covered in the PACCSI APM.”
Going forward, Rodgers expects there will be opportunities to continue to refine the Academy’s payment reform proposals and looks forward to further engagement by members and stakeholders to assist the Academy in its efforts: “We have before us a unique and unprecedented opportunity to help shape fundamental changes in care payment and delivery for our patients and the field.”
AAHPM APM Task Force Goals:
- Ensure access to high-quality, interdisciplinary palliative care for patients and caregivers throughout their journey with serious illness (all stages of illness and care needs).
- Create a new payment model for palliative care teams managing patients with serious illness that could qualify as an APM under MACRA.
- Determine how palliative care teams can add value to providers working in other APMs and accountable models (including commercial health plans).
- Provide flexibility in our models to maximize participation by a broad diversity of interdisciplinary palliative care teams, serving patients and caregivers in all settings and all geographies.
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