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May 5, 2022

No Alternative Payment Model for Emergency Physicians and other Specialists…The AMA Has a Proposed Solution

This week’s Leadership and Advocacy Conference (LAC) was a great success! We had over 300 emergency physicians from across the country (including some of you!) come to DC and speak to legislators about critically important issues. It was wonderful to see many of you, in all stages of your careers, so passionate about advocacy and willing to take time out of your busy schedules to push for needed legislative changes.

As you may recall from my last blog (or if you attended LAC), one issue we focused on during LAC was Medicare physician payment reform. In our discussions on this topic during the conference, some participants mentioned that it was impossible for emergency physicians to participate directly in alternative payment models (APMs). Participating in APMs was one of the clear goals of a major Medicare bill passed in 2015 called the Medicare Access and CHIP Reauthorization Act (MACRA). However, seven years later, the majority of you as emergency physicians are unfortunately still stuck in the broken Medicare fee-for-service (FFS) system and have no choice but to receive FFS payments that do not keep up with inflation. During the conference, some of you expressed a strong desire to “get on the train” of value-based care and receive performance-based incentives that go along with participating in APMs. You also stated your extreme disappointment about the federal government’s lack of action since 2015 towards making this goal a reality.

I share your disappointment. I have written numerous blog posts about ACEP’s proposed APM, the Acute Unscheduled Care Model (AUCM), which, if implemented, would be the first, and only, APM specifically designed for emergency physicians. The model would reward emergency physicians for reducing inpatient admissions and observation stays when appropriate. Emergency physicians would become key members of the continuum of care, as the model focuses on ensuring follow-up care for emergency patients, minimizing redundant post-emergency department (ED) services, and avoiding post-ED discharge safety events.

The AUCM was highly recommended by a federal advisory committee called the Physician-Focused Payment Model Technical Advisory Committee (PTAC) and endorsed by the former Secretary of the U.S. Department of Health and Human Services (HHS). However, ever since the former HHS Secretary endorsed the AUCM in 2019, we’ve been waiting on the Centers for Medicare & Medicaid Services’ (CMS’) Center for Medicare and Medicaid Innovation (CMMI) to adopt the model’s framework.

Unfortunately, over two years later, CMMI has now made it abundantly clear that it is not moving towards adopting the AUCM—or other specialty-specific models for that matter. In fact, although many specialists, not just emergency physicians, can’t directly participate in APMs, CMMI has no intention of creating new specialty-specific models. In fact, CMMI wants to REDUCE the overall number of APMs that it is currently operating.

So where does that leave us? Was all that work developing and promoting the AUCM for naught? The answers to those questions are hopefully NO—thanks to a new concept developed by the American Medical Association (AMA).

The AMA recognizes that many PTAC models, like the AUCM, aren’t going anywhere with CMMI. However, many of these proposed APMs share the same overarching goal: to get specialists engaged in delivering higher-value care. Therefore, the AMA has developed a new concept for an APM called “Payments for Accountable Specialty Care” (PASC).

The PASC model would serve as an additional component to existing accountable care organization (ACO) initiatives. For those of you who don’t know, ACOs are groups of providers that come together with the shared goal of improving quality and reducing costs for a defined set of patients that are “assigned” to the ACO. ACOs in the Medicare program operate under a “shared savings/losses” construct with CMS, whereby they can keep a portion of any savings that they experience if their total spending for their assigned Medicare beneficiaries is less than a pre-determined cost benchmark but must owe back money to CMS if their total spending comes in above the benchmark. ACOs are primary care-centric and, up to this point, have not effectively engaged specialists to help meet their cost targets and quality metrics. The AMA (and I) believes that there is a lot of potential for ACOs to perform even better if they get specialists more involved in the care of their assigned patients.

Using existing ACO initiatives as a platform for engaging specialists in APMs is a smart move for two main reasons.

  • First, ACOs are already a well-established type of APM. There is a national ACO program called the Medicare Shared Savings Program and there have been a number of ACO models tested by CMMI over the years. The Medicare Shared Savings Program currently includes 483 participating ACOs that serve 11 million Medicare beneficiaries. Thus, by building off ACOs, the PASC model is really just a modification to a current APM construct. In other words, it doesn’t technically count as a new APM and wouldn’t necessarily violate CMMI’s stated goal to reduce the number of models.
  • Second, it helps achieve one of CMMI’s objectives from its strategic plan, which is to get all Medicare and the vast majority of Medicaid beneficiaries in “a care relationship with accountability for quality and total cost of care” by 2030. In the strategic plan, CMMI envisions ACOs being one of the major mechanisms by which to get patients into an accountable care relationship. And, to CMMI’s credit, it does make the important realization that focusing on primary care alone doesn’t lead to net reductions in the overall cost of care. To truly manage costs and improve quality of care, specialists also must be engaged—and therefore, CMMI has stated that it wants to “test incentives to drive coordination between providers responsible for accountable care relationships and specialty providers accountable for delivering high-cost episodic and/or complex care.” As you will see, the PASC model would allow CMMI to check this box.

Under the PASC concept, ACOs could enter into performance-based agreements (called PASC agreements) with different specialty groups. Specialists would then agree to take accountability for delivering specific types of services to patients assigned to the ACO in a way designed to improve outcomes and/or reduce avoidable spending, thereby helping the ACO to meet its cost and quality goals. In return, the specialists would receive enhanced condition services (ECS) payments that would compensate them for the additional work it takes to manage patients and improve care coordination. The ECS payments to the specialists would be counted in the total spending for the ACO when shared savings or losses for the ACO are calculated. Consequently, if the specialists’ services do not result in sufficient reductions in spending or improvements in quality to meet the ACO’s goals, the ACO’s shared savings would be lower, or its shared losses would be higher than they would have been otherwise.

There would be three different kinds of ECS payments available.

  1. (Standard) ECS Payments. The standard Enhanced Condition Services Payment would be a one-time payment for up to one month of services related to diagnosis, treatment planning, treatment of an acute condition, or initial treatment of a chronic condition. For example, the payment could allow the specialist to engage in a shared decision-making process with the patient about the type of treatment needed or to provide education and training for the patient and family about how to successfully manage their condition.
  2. Continued ECS Payments. For patients who need to continue receiving services from the specialist for longer than a month, the PASC Agreement could include a provision enabling the specialist to receive a Continued Enhanced Condition Services Payment for one or more additional months. For example, the specialty practice could provide condition-specific symptom monitoring and care management services designed to avoid exacerbations of a complex chronic condition or to avoid complications from surgery or cancer treatment.
  3. Special ECS Payments. If a patient has characteristics that will make care of their health problem significantly more challenging (e.g., language barriers, food insecurity, lack of housing or transportation, etc.), and if the patient’s primary care physician and specialist agree that the specialty practice should provide additional services to the patient to address these issues, the PASC Agreement could specify that the specialist would be paid a Special Enhanced Condition Services Payment for that patient in addition to either the ECS Payment or Continued ECS Payment.

The agreements between ACOs and specialists and the ECS payments themselves would be designed and used differently depending on the specialty type. That makes sense, since some specialists manage patients with chronic conditions, while others mostly treat patients with acute illnesses. With respect to emergency physicians, the ECS payments would be used similar to how the additional payments under the AUCM would be: to help with ED discharge planning, coordination with primary care physicians and other specialists, and transitional care management after discharge. For example, emergency physicians could receive an initial ECS payment when an individual assigned to the ACO comes to the ED. The payment could be used to help set up the infrastructure and staffing necessary to enable the emergency physician to coordinate with the patient’s primary care physician to determine whether the patient should be admitted or could be safely discharged to the patient’s home. As with the AUCM, the emergency physician could help reduce overall costs by reducing admissions to the hospital.

Emergency physicians could also be eligible to receive special ECS payments in cases where patients need additional assistance in order to be safely discharged from the ED. For example, for patients with social risk factors, the payments could be used by the emergency physician group to help hire a community health worker that would assist patients in obtaining medications and food after discharge and ensure that patients see their primary care physician for follow-up care.

All in all, the PASC model does successfully incorporate some elements of the AUCM and may be one of our best chances of getting emergency physicians to directly participate in APMs. Now comes the hard part of convincing CMMI (as well as HHS and the White House) to adopt the PASC model. However, the AMA isn’t alone here, as other specialty societies, including ACEP, will also be pushing this concept as well. I will keep you updated as we continue to try to achieve the goal of getting more emergency physicians into APMs!

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs!

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