MACRA & the Role of Physician-Focused Payment Model Technical Advisory Committee (PTAC)

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created new ways for the Medicare program at CMS to pay physicians for the care they provide to Medicare beneficiaries. MACRA also creates incentives for physicians to participate in Alternative Payment Models (APMs), including the development of physician-focused payment models (PFPMs).

MACRA created the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to make comments and recommendations to the Secretary of the Department of Health and Human Services (the Secretary, HHS) on proposals for PFPMs submitted by individuals and stakeholder entities.

The Secretary is required by MACRA to establish criteria for PFPMs and to respond to the recommendations of PTAC. Ten criteria were outlined in the MACRA final rule with comment period that was made public on October 14, 2016 and published in the Federal Register on November 4, 2016.

Definition of a PFPM

The MACRA final rule published in the Federal Register on November 4, 2016 defines a PFPM as an APM in which:

• Medicare is a payer.
• Eligible clinicians that are eligible professionals (EPs) as defined in section 1848(k)(3)(B) of the Social Security Act (SSA) are participants and play a core role in implementing the APM’s payment methodology.
• Targets are the quality and costs of services that EPs participating in the APM provide, order, or can significantly influence.

Ten Criteria Outlined in MACRA

• Value over volume: Provide incentives to practitioners to deliver high-quality health care.
• Flexibility: Provide the flexibility needed for practitioners to deliver high quality health care.
• Quality and Cost: PFPMs are anticipated to improve health care quality at no additional cost, maintain health care quality while decreasing cost, or both improve health care quality and decrease cost.
• Payment Methodology: Pay APM Entities with a payment methodology designed to achieve the goals of the PFPM criteria. Addresses in detail through this methodology how Medicare and other payers, if applicable, pay APM Entities, how the payment methodology differs from current payment methodologies, and why the Physician-Focused Payment Model cannot be tested under current payment methodologies.
• Scope: Aim to either directly address an issue in payment policy that broadens and expands the CMS APM portfolio or include APM Entities whose opportunities to participate in APMs have been limited.
• Ability to be Evaluated: Have evaluable goals for quality of care, cost, and any other goals of the PFPM.
• Integration and Care Coordination: Encourage greater integration and care coordination among practitioners and across settings where multiple practitioners or settings are relevant to delivering care to the population treated under the PFPM.
• Patient Choice: Encourage greater attention to the health of the population served while also supporting the unique needs and preferences of individual patients.
• Patient Safety: Aim to maintain or improve standards of patient safety.
• Health Information Technology: Encourage use of health information technology to inform care.

PTAC intends to evaluate the extent to which proposed models meet the Secretary’s criteria and to make recommendations regarding the proposed model including limited-scale testing, implementation, high priority implementations, or not recommend. The PTAC provides a unique opportunity for individuals and stakeholders to have a key role in the development of new APMs and to ensure that proposals recommended to the Secretary meet the established criteria and are well-developed.

CMS expects that the PTAC will assist HHS with improving the process for model development. By engaging with stakeholders early in the development of criteria and review processes, HHS anticipates that PTAC will encourage and facilitate submission of models that have a high likelihood of being implemented and represent the diversity of care provided by physicians across the country.

In future performance years, CMS anticipates that the following models may be Advanced APMs:

• New Voluntary Bundled Payment Model
• Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)
• ACO Track 1+

For more information on the PTAC including where to find information on the background of the Committee and its members, information on how to submit a proposal to PTAC, how PTAC will review and evaluate proposals, and information for upcoming and past public meetings go to the U.S. Department of Health and Human Services, Office of The Assistant Secretary For Planning And Evaluation website at https://aspe.hhs.gov.

To learn more about key elements that stakeholders are considering in designing Alternative Payment Models—and to stay on track for optimum APM reimbursement—pick up your copy of Guidebook to Medicare Access and CHIP Reauthorization Act of 2015.

Resources:

Federal Register / Vol. 81, No. 214 / Friday, November 4, 2016 / Rules and Regulations