Practices Need Smooth Handoff to New APM Model, AAFP Says

June 3, 2021, 5:21 p.m. News Staff — In three recent letters, the AAFP, alongside other medical groups and scores of primary care practices, called on CMS’ Center for Medicare and Medicaid Innovation to improve alternative payment models.

In particular, the AAFP recommended several technical enhancements to the Primary Care First model — changes rendered more urgent by the agency’s recently announced plan to phase out the Comprehensive Primary Care Plus model at the end of 2021, a year ahead of schedule. The Academy and its co-signatories also offered counsel on how best to implement and invest in APMs that advance health equity while increasing physician participation and incentive payments.

The letters were sent to CMMI Deputy Administrator and Director Elizabeth Fowler.

From CPC+ to PCF

In a May 3 letter, the Academy and the American College of Physicians called on CMMI to create a pathway for CPC+ practices stranded by the model’s unexpected termination to transition to a different APM. Without such a bridge, the letter warned, CPC+ practices face difficulties such as staffing cuts or care delivery changes and are likely to return to fee-for-service medicine, which “does not adequately value advanced primary care services” and would “undermine CMMI’s mission of moving to value-based payment.”

“As the CPC+ model sunsets, practices are facing a stark financial cliff,” the AAFP and the ACP said. “While transitioning to PCF for these practices may ultimately result in high performance-based adjustments, those payments do not begin until the third quarter of the second program year, which will result in practices having to make drastic decisions impacting their care delivery in the meantime.

“We recommend CMMI offer a bridge to CPC+ practices entering PCF that would allow them to continue to provide enhanced primary care services to their patients and communities without disruption. One such bridge that would not result in a net increase in spending to the program would be to prospectively estimate the performance-based adjustments for Program Year 1 (paid in PY2) for CPC+ practices based on the quality and utilization data available to CMMI and pay 50% in advance in PY1, truing up in PY2.”

Story Highlights

The letter also urged adjustments to PCF’s flat visit fee and population-based payment rate to account for Medicare’s recent payment increase for office/outpatient evaluation and management services.

“While CMMI indicated it planned to re-evaluate the flat visit fee and population-based payment to reflect this increase, the updated rates have not been integrated into the model,” the Academy and the ACP wrote. The FVF and the PBP should therefore be increased, they added.

The May 3 letter also asked CMMI to consider the impact of the COVID-19 pandemic when setting PCF quality and utilization benchmarks, and to exclude new-patient telehealth visits (especially annual wellness visits) from PCF attribution methodology.

A May 14 letter to Fowler, coordinated by the AAFP and the ACP and signed by 167 health care practices successfully participating in CPC+, echoed the need for swift action to ensure stable transitions to other APMs.

“When the CPC+ model sunsets, there is no clear mechanism for our practices to sustain our current practice model. We are calling on CMMI to develop solutions to help CPC+ practices successfully transition into other alternative payment models,” the letter said.

“We ask that you recognize our commitment to advancing Medicare’s transition to value-based care by creating a bridge for practices transitioning from CPC+ to their next model of choice.” the groups wrote. “A bridge will provide us the flexibility and financial security we need to ensure the gains made over the last five to 10 years are not lost by backsliding into fee-for-service and will allow us to continue to provide enhanced primary care services to our patients and communities without disruption.”

Toward Better APMs

The need for value-based care models designed with physician input was the message of a May 25 letter to Fowler signed by the Academy with 21 other medical and specialty groups, including the AMA, the American Osteopathic Association and the American Society of Anesthesiologists.

“The physician community has devoted significant effort to develop well-designed APM proposals that can help transform Medicare’s payment system, consistent with the goals of the Medicare and CHIP Reauthorization Act of 2015,” the groups wrote. “Many front-line physicians who have experienced the barriers to value-based care in their practices have put in years of work to develop patient-centered APMs that could offer meaningful benefits to patients and savings for the Medicare program if implemented by CMMI.

“Unfortunately, six years after passage of MACRA, most physicians do not have the opportunity to participate in an APM designed for the kinds of patients they treat or the level of risk they are equipped to take on. Existing models are also often geographically limited, excluding physicians in other areas who are interested and well-equipped to participate.”

The latter is true for PCF, which is limited to practices in certain regions. To compensate for this lag and attract more physicians to APMs, the letter’s co-signatories called on CMMI to

be more transparent about the models it is developing;
provide “ample opportunities for stakeholder involvement during both the design and implementation phases;”
provide adequate resources to help practices achieve better health outcomes for high-risk patient populations;
ensure that APM payment methodologies and performance measures “support and encourage practices to address patients’ social needs, including by providing care management services and coordinating services across interprofessional teams;”
support legislation to extend advanced APM-qualified participant payments and maintain the current qualified participant threshold through 2030;
coordinate and increase model options across Medicare and Medicaid “to remove the barriers that prevent participation in Medicare Advantage and Medicaid APMs from helping physicians meet the QP threshold;”
provide startup funding to APM participants so they can invest in data analytic capabilities, care managers, training and other practice changes needed to improve care delivery and facilitate successful APM participation; and
design APMs “with ‘on-ramps’ that give participants time as well as resources to transform their practices before being expected to take on downside risk.”