How specialty-specific alternative payment models could revolutionize ASC care

Specialty physicians, including gastroenterologists, are struggling to participate as the healthcare arena adapts to Alternative Payment Models. At a recent Medicare Payment Advisory Commission meeting, several commissioners noted the lack of opportunities for specialists to enter into Advanced APMs. Proposals introduced in late 2016 could change that.

The Illinois Gastroenterology Group submitted the “Project Sonar Advanced APM” and the Digestive Health Network proposed its “Comprehensive Colonoscopy Advanced APM for Colorectal Cancer, Screening, Diagnosis and Surveillance” models to the HHS Payment Model Technical Advisory Committee, which could allow specialty physicians to participate in APMs.

The Digestive Health Physicians Association and its Vice Chair Dr. Michael Weinstein support the measures. Dr. Weinstein says the specialty fields need these models as APMs currently do not meet specialty medicine's unique needs.

“Specialists, whether they're gastroenterologists or another kind, are left out of participating in these models because we don't do primary care,” Dr. Weinstein says. “The problem with specialists working with primary care APMs is that we are subcontractors with not enough risk to qualify for exemption from MIPS. We basically end up doing fee-for-service for an ACO.”

The proposals entered public comment in December 2016, and although CMS expressed interest in them, they are years away from implementation. Yet, Dr. Weinstein and the DHPA already see the potential of these policies for gastroenterologists.

For example, ASCs perform 50 percent of eligible colonoscopies today, despite centers' abilities to perform the procedure at costs lower than hospital outpatient settings, Dr. Weinstein says. With specialty APMs, ASCs would be a more attractive option for colonoscopies as CMS lowers reimbursement. Dr. Weinstein believes up to 80 percent of colonoscopies could shift to ASCs as a result.

“If the value is set there, it will be a huge driver to move the patients out of hospital outpatient departments,” he says.

The DHPA is not alone in its support. The Digestive Health Network, which drafted the colonoscopy-facing proposal, pledged the support of the 1,000 physicians that make up the network.

In a letter signed by DHPA President Fred Rosenberg, MD, and Chair of Health Policy Lawrence Kim, MD, the organization said of the colonoscopy-facing proposal, “This is precisely the type of forward thinking Physician Focused Payment Model that this Committee should embrace, and DHPA recommends that CMS implement this proposed payment model as a high priority.”

Here's what you should note about the models:

The “Comprehensive Colonoscopy Advanced APM” is a bundled payment model that encourages providers to collaborate and coordinate care across settings to manage patients who need colonoscopies for colorectal cancer screening, diagnosis and surveillance.

The “Project Sonar Advanced APM” is a care management program designed to improve chronic disease management. Gastroenterologists have used the program thus far to manage Crohn's disease. The model allows for decreased cost of care, earlier identification of high-risk patients, the proper channeling of patients and heightened patient engagement.

Since IGG first rolled out the program in 2013, Project Sonar has employed evidence-based medicine coordinated with proactive patient engagement to improve outcomes among sufferers of Crohn's Disease. As part of their treatment plan, patients are:

Assessed with biopsychosocial measures
Enrolled into a web-based communication program
Seen on a monthly basis; with frequency intensified as needed

Providers use a team-based approach through the model, while administrators analyze clinical and financial data, revising care management algorithms, as needed.

Project Sonar allows for providers to “intervene before patients even realize they need care.”

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