ILLUSTRATION: Chris Whissen PHOTOS: shutterstock.com

The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) established new opportunities for physicians to participate in alternative payment models (APMs) in Medicare. To help spur the development of new models, MACRA created an independent committee called the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which reviews proposed physician-focused payment models received directly from health care providers and organizations and makes recommendations to the secretary of the U.S. Department of Health and Human Services on their consideration.

In August 2015, after MACRA passed, ACEP established a task force to help develop an APM geared toward emergency medicine. Until that point, most alternative payment arrangements were not designed to include emergency care in any meaningful way. The APM Task Force spent its first year evaluating numerous concepts centered around improving value and quality of emergency services. After intense internal work by the task force and inclusion of additional data analysis performed by a retained consultant, ACEP submitted a proposal for a new APM, the Acute Unscheduled Care Model (AUCM): Enhancing Appropriate Admissions, to the PTAC in September 2017. If recommended by the PTAC and then approved by the secretary, the AUCM will serve as an advanced APM, allowing emergency physicians who choose to participate to potentially be eligible to receive a five percent Medicare Part B payment bonus. (Advanced APMs are APMs that meet certain criteria established by MACRA, including the requirement that participants take on a nominal amount of financial risk for the services they provide under the model.)

How AUCM Works

The goal of this bundled payment model is to improve quality and reduce Medicare costs by emergency physicians accepting some financial risk for the decisions they make around discharges for certain episodes of unscheduled acute care. It uses an annual retrospective reconciliation, which compares actual spending for each episode to its target price. Target prices for select conditions are calculated based on three years of facility-specific historical claims and a specified discount percentage for the initial emergency department visit plus all costs incurred for 30 days postdischarge. The AUCM model also includes waivers that would allow emergency physicians to be more comfortable with discharge decisions by reimbursing for certain discharge-associated services that are currently unavailable. These include care coordination, postdischarge visits, and certain telehealth services.

Savings in the proposed model are generated when the actual amount spent for emergency department services and 30-day postdischarge services are below the facility-specific, targeted price for that episode. Participating emergency physicians will be able to keep these savings if they meet certain quality metrics. However, if spending for patients is more than the target for an episode, the emergency physicians would also be liable for those losses (capped at a maximum of 10 to 20 percent, depending on participation level).