Over the last several years, there has been a movement away from reimbursing health care practitioners based on the volume of services toward rewarding them for the quality or “value” of care provided.
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 accelerated health care payment reform efforts by establishing the Quality Payment Program (QPP), the main quality reporting program in Medicare. There are two tracks in the QPP: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). MIPS includes four performance categories: quality, cost, improvement activities, and promoting interoperability (formerly electronic health record “meaningful use”). Performance in these four categories (which are weighted) rolls up into an overall score that translates to a bonus that physicians receive on their Medicare payments two years after the performance period (for example, performance in 2020 impacts Medicare payments in 2022). Physicians and other health care practitioners who actively participate in certain Advanced APMs are exempt from MIPS and can receive a 5 percent payment bonus through 2024 and a higher payment fee schedule update starting in 2026.
Most emergency physicians participate in MIPS because there simply aren’t any opportunities to be in an Advanced APM. However, given the fundamental role emergency physicians play in our health care system, ACEP strongly believes that emergency physicians are well-positioned to be meaningful participants in APMs if given the opportunity.
Successful participation in MIPS has been a top priority for ACEP. In addition to working with the Centers for Medicare & Medicaid Services (CMS) to simplify MIPS requirements, ACEP provides members with resources to ease the reporting process. Thousands of emergency physicians are now using ACEP’s Clinical Emergency Data Registry (CEDR) and participating in the Emergency Quality Network (E-QUAL) to meet reporting and attestation requirements.
A brief word about CEDR. It was developed as the first EM specialty-wide registry to measure acute care quality, outcomes, practice patterns, and trends in emergency care. The CEDR registry ensures that you, rather than other parties or payers, are identifying what works best for your clinical practice and patients. In 2018, 100 percent of CEDR customers were in a positive MIPS scoring bracket and 40 percent of customers’ quality scores were above 70, qualifying them for exceptional bonus. Learn more about CEDR.
And what is E-QUAL? The E-QUAL Network is a virtual learning community designed to accelerate knowledge translation by disseminating evidence-based practices in a low-burden, high-impact manner. Emergency departments participate in an E-QUAL initiative by joining a learning collaborative offered annually focusing on a single clinical topic. Each learning collaborative has a six- to nine-month learning period during which the ED champion interacts with the virtual E-QUAL portal and reports on local quality improvement activities. Activities include engaging eligible providers in the local quality improvement project and providing access to educational toolkits, webinars, podcasts, benchmarking data, and self-assessment tools. Participation in E-QUAL can earn clinicians improvement activity credit. Learn more about E-QUAL at www.acep.org/equal.
When MACRA passed, ACEP immediately identified the gap in available emergency medicine–focused Advanced APMs. In 2015, ACEP formed the APM Task Force co-chaired by Jeff Bettinger, MD, FACEP, and Randy Pilgrim, MD, FACEP. The task force reviewed various APM proposals and eventually developed the Acute Unscheduled Care Model (AUCM, fondly known as “Awesome”). In 2017, ACEP submitted the AUCM proposal to a federal advisory committee called the Physician-Focused Payment Model Technical Advisory Committee (PTAC) for consideration.
The PTAC is tasked with recommending physician-focused APM proposals to the secretary of the Department of Health and Human Services (HHS) for consideration based on criteria established by the HHS secretary. Dr. Bettinger, Dr. Pilgrim, and Susan Nedza, MD, MBA, FACEP, presented the AUCM proposal before the PTAC on Sept. 6, 2018, and the PTAC recommended the AUCM to the HHS secretary for full implementation. The AUCM met all 10 of the established criteria, and the PTAC gave one of the criteria (scope) a “deserves priority consideration” designation since the PTAC felt the model filled an enormous gap in terms of available APMs to emergency physicians and groups.
A year later, on Sept. 27, 2019, the HHS secretary responded to the PTAC’s recommendation by stating he believes that core concepts of the AUCM should be incorporated into APMs being developed by the Center for Medicare & Medicaid Innovation (CMMI). The response paves the way for emergency physicians to finally be in a Medicare Advanced APM.
ACEP’s Next Steps
The HHS secretary’s supportive response is an important step in the process of getting an EM-focused APM like the AUCM implemented, but ACEP’s work is not finished. Now it is up to CMMI to carry out the HHS secretary’s request.
Since the CMMI timeframe for incorporating the AUCM into the Medicare APMs is unclear, ACEP has started our own initiative to promote participation in EM-focused APMs being offered by other payers like Medicaid and private insurers. As Medicaid and private payers move away from fee-for-service contracts toward value-based payment arrangements, an appropriately modified non-Medicare version of the AUCM would be an ideal APM construct for these payers to pursue. However, while ACEP encourages Medicaid and private payers to incorporate core concepts of the AUCM into EM-focused APMs, we anticipate some features of the APM will be different from the AUCM, depending on the specific patient population.
ACEP has developed resources to help emergency physicians and others understand more about the landscape of health care payment reform and how a model like the AUCM could help improve emergency care and lower costs; one such resource is a FAQ to help clarify any misperceptions about the AUCM, the QPP, or APMs in general. Dr. Bettinger, Dr. Pilgrim, and Dr. Nedza, along with Avi Baehr, MD, Heather Marshall Vaskas, MD, and Jennifer Wiler, MD, MBA, FACEP, co-authored an article in the Annals of Emergency Medicine called “Enhancing Appropriate Admissions: An Advanced Alternative Payment Model for Emergency Physicians,” which highlights the key features of the AUCM. All these materials and more are found on ACEP’s APM Strategic Initiative website.
Here to Help
As both public and private payers begin to explore developing EM-specific APMs, ACEP will help you make sense of it all. Email me your questions at firstname.lastname@example.org.
Mr. Davis is ACEP director of regulatory affairs.
What is an APM?
CMS defines an APM as a payment approach that gives physicians and other providers added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. Examples of APMs include accountable care organizations (ACOs), medical homes, and bundled payment models.
Advanced APMs are a subset of APMs with additional requirements, such nominal financial risks. Financial risk means that a provider participant in the APM is held financially accountable if the services they provide wind up costing more than a predetermined target. In other words, participants must owe back some or all “losses” for which they are deemed responsible.
What is the AUCM?
ACEP created the Acute Unscheduled Care Model (AUCM, pronounced “awesome”), a Medicare Advanced APM proposal designed for emergency physicians.
The AUCM would provide a voluntary alternative to the traditional fee-for-service payments for Medicare patients who receive emergency care. It is structured as a bundled payment model, focusing on specific “episodes” of unscheduled acute care. Under a bundled payment approach, if the cost of an episode of care is less than a predetermined price for that episode, then a participating provider or group can keep that difference. However, if the cost winds up being more than the predetermined price, participants would be responsible for those losses and owe Medicare the difference.
The AUCM is designed to last five years and be flexible enough to allow the full spectrum of emergency physicians to participate, should they choose, from those with dedicated infrastructure and experience accepting financial risk to smaller groups of physicians who do not have as much experience in this area. Emergency physicians and groups could participate regardless of employment model (independent group, regional group, national group, employed physicians).
The overall goal of the AUCM is to improve the ability of emergency physicians to reduce inpatient admissions and observation stays when appropriate through enhanced care coordination. 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-ED services, and avoiding post-ED discharge safety events that lead to follow-up ED visits or inpatient admissions.
Effect of ACOs on EM Payment and Care Redesign
A recent qualitative study in Annals of Emergency Medicine interviewed emergency department leaders and Accountable Care Organization (ACO) participants to assess how accountable care has affected emergency care redesign and payment. The study found a lack of evidence-based policy solutions to inform accountable and value-based care in the emergency department. The Acute Unscheduled Care Model is designed to address this critical gap. Read “Effect of Accountable Care Organizations on Emergency Medicine Payment and Care Redesign: A Qualitative Study”.