Advanced Primary Care Alternative Payment Model

AAFP Accepts Challenge, Submits Primary Care-based Payment Proposal

April 24, 2017 11:55 am News Staff

After months of work, the AAFP has responded to a request for proposals(aspe.hhs.gov) from the newly formed Physician-Focused Payment Model Technical Advisory Committee (PTAC) by submitting a detailed plan outlining the Academy's vision for an alternative payment model (APM) that focuses on physicians, is primary care-based, improves patient care, reduces costs and carries other benefits.

The proposal,(38 page PDF) titled "Advanced Primary Care: A Foundational Alternative Payment Model (APC-APM) for Delivering Patient-Centered, Longitudinal and Coordinated Care," was sent to the committee via an April 14 letter signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa.

"Primary care is the primary access point to the health care system for millions of Americans across a diverse range of communities," said the AAFP, adding that its APC-APM proposal would ensure that more Medicare beneficiaries have access to health care provided through advanced APMs.

The letter noted that longstanding inequities in payment have had a particularly negative impact on primary care and said these wrongs must be addressed and corrected rather than blindly incorporated into new value-based payment models.

Story Highlights
  • The AAFP recently sent a proposal detailing its advanced primary care alternative payment model (APM) to the newly formed Physician-Focused Payment Model Technical Advisory Committee for review.
  • The AAFP's APM is built on the principle that patient-centered primary care is comprehensive, continuous, coordinated, connected and accessible from the patient's first contact with the health system.
  • The model would institute a four-part payment methodology deemed critical to its success.

"We request that the PTAC review the model, provide feedback to the AAFP on it, and promptly recommend it to HHS for approval and nationwide expansion," said the AAFP.

The letter makes a strong case for family medicine's foundational role in delivering high-quality health care to patients, noting, for example, that one in every five office visits -- more than 192 million patient visits each year -- is made to a family physician.

AAFP Proposal Highlights

First and foremost, the AAFP's APM is built on the principle that patient-centered primary care is "comprehensive, continuous, coordinated, connected and accessible from the patient's first contact with the health system."

Of course, the AAFP intends for the proposal to improve health care quality, but the broader goal is to use the delivery of "coordinated, longitudinal care" to improve patient outcomes and reduce health care spending in a variety of ways including decreasing patient hospitalizations and ER visits.

The AAFP's proposal aims to accomplish these goals by instituting a payment methodology that would utilize four components.(224 KB PNG) Those components, critical to the success of the model, are

  • monthly prospective, risk-adjusted primary care global payments for direct patient care;
  • monthly prospective, population-based payments covering non-face-to-face patient services;
  • fee-for-service payments that cover only services not included in the global payment; and
  • quarterly prospective, performance-based incentive payments related to patient experience, clinical quality and utilization measures.

What the Heck Is PTAC?

For readers curious about the creation of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), an HHS FAQ(aspe.hhs.gov) explains how the Medicare Access and CHIP Reauthorization Act mandated creation of this committee for the express purpose of reviewing physician-focused payment models put forth by stakeholders such as the AAFP.

The PTAC's 11 members are charged with evaluating whether submitted proposals meet specific criteria outlined by the HHS secretary. The committee and the Center for Medicare and Medicaid Innovation aim to increase the number and variety of advanced APMs and, in turn, drive up the rate of participation among all physicians -- including those in small practices and rural communities.

The committee discusses its assessment of proposals in public meetings and makes recommendations to the HHS secretary, who then must provide a detailed response but is not required to accept the committee's recommendations.

Regarding the scope of its proposal, the AAFP envisions availability of the APC-APM to all physicians with primary care specialty designations, those being family medicine, general practice, geriatric medicine, general pediatric medicine and general internal medicine.

The AAFP estimated that nearly 195,000 primary care physicians could be involved with such an advanced APM.

"Given the evident merits of the model, the push from CMS to tie more Medicare payments to quality and value, and the current small number of advanced APMs under MACRA (the Medicare Access and CHIP Reauthorization Act), we anticipate that many of these physicians would express interest and willingness to participate in the model if it is approved and expanded to scale," wrote the AAFP.

Furthermore, the AAFP estimated that if its proposal were enacted on a national scale, it would impact more than 30 million Medicare patients and address patient safety. That's because patients can leave an APM entity if they don't like the care they are receiving -- giving physicians affiliated with an APM added incentive to deliver high-quality coordinated care.

And when it comes to spending, the AAFP cited research to bolster its recommendation that the percentage of total health care dollars spent on primary care be increased to at least 12 percent -- nearly double current estimates of 6 percent to 8 percent.

The AAFP also cited the multipayer functionality of its APC-APM model. "We believe this is a strength of the proposal, as it can improve care quality and reduce costs for other patient populations."

Digging Down

The AAFP's proposal is divided into specific topic areas that match PTAC criteria. For example, as part of the Quality and Cost section of its proposal, the AAFP notes the simplicity of its value proposition. "We believe it will improve quality of care and outcomes and reduce overall costs (especially use of acute services) based on our analyses and early CPC (Comprehensive Primary Care initiative) results."

This section dives into care delivery impacts, barriers and risks, evaluation strategies, and data issues.

In the proposal's Payment Methodology section, the AAFP takes on topics such as financial risk, coding and claims, and barriers created by the traditional fee-for-service payment system.

According to the proposal, "The AAFP recommends a payment method that will compensate APM entities for care not captured through traditional fee-for-service billing and empower them to commit temporal and supportive resources to their patients, particularly those of high complexity."

This approach, said the Academy, would address many of the current financial barriers to delivering advanced primary care and ultimately would "enhance value across the health care system."

In the area of Integration and Care Coordination, the AAFP noted implementation of its APM depends on team-based care with primary care physicians serving as team leaders who guide nonphysician team members.

Furthermore, according to the AAFP, an advanced primary care practice must follow the Joint Principles of the Patient-Centered Medical Home(3 page PDF) and provide

  • access and continuity of care,
  • planned care and population health,
  • care management,
  • patient and caregiver engagement, and
  • comprehensiveness and coordination.

The AAFP noted that these five key functions would drive success when implemented along with other equally important pieces such as enhanced payment, continuous data-driven quality improvement, health information technology, and a certified electronic health record that includes either a data registry or repository capability.

In addition, the AAFP considers diagnosis and treatment of mental illness -- and the promotion of mental health -- "integral components" of primary care; therefore, they are included in the comprehensive care outlined in the proposal.

"Entities applying to participate in the APC-APM would be expected to attest to the fact that they perform these five key functions, or otherwise have a plan to do so within a reasonable time after entering the program," said the AAFP.

The Academy's proposal also includes sections that address issues related to flexibility, evaluation, patient safety and health information technology.

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MACRA: The Medicare Access and CHIP Reauthorization Act

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