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).
For the first two to three years, the model will focus on episodes around four high-volume emergency department conditions: abdominal pain, chest pain, altered mental status, and syncope. More episodes will be added over time. Performance on a set of quality measures will determine a participant’s eligibility for savings as well as the size of a discount percentage, which is built into the target price. That discount guarantees at least some savings for the Medicare program.
The AUCM model will be flexible enough to allow the full spectrum of emergency physicians to participate, should they so choose. Ideally, participation will range from those with dedicated infrastructure and experience with reporting and meeting quality metrics and taking downside risk to smaller groups of physicians who do not have as much experience in these areas. Specifically, it will include an alternative quality-scoring methodology with more achievable standards as well as three options for risk sharing that enable emergency physicians to either take on downside risk immediately or accept more risk over time.
A preliminary review team within the PTAC is currently reviewing the model, and ACEP has been actively engaged in answering all of the team’s technical questions. After the preliminary review team finishes its review, the model will be considered by the full PTAC during a public meeting. The next PTAC public meeting is in June, and ACEP hopes that the AUCM model will make it on the agenda. Even if the PTAC does discuss the AUCM model in June and decides to recommend it to the secretary of Health and Human Services, there is still a long road ahead before the model would be operationalized. However, we are prepared to continue to push for this model to be developed and implemented either through the PTAC process or, if necessary, through some other legislative or regulatory vehicle.
While there is still much work to do to get this model across the finish line, we are encouraged by the considerable progress to date. Most importantly, we feel privileged to have had the opportunity to design a payment model that reflects and values the significant role that emergency physicians play in the health care system. Stay tuned for more as the process moves forward.
Dr. Bettinger and Dr. Pilgrim are co-chairs of the ACEP APM Task Force.