PTAC Recommends CMMI Test ‘Medical Neighborhood’ Advanced APM

Sept. 30, 2020
HHS advisory group recommends against implementing a Patient-Centered Oncology Payment Model

At its September 2020 public meeting, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) recommended that the Center for Medicare & Medicaid Innovation test the "Medical Neighborhood" Advanced Alternative Payment Model, but recommended against implementing a Patient-Centered Oncology Payment Model.

The MACRA legislation called for physicians to design their own advanced alternative payment models based on how care is actually delivered. PTAC was set up in 2015 to provide recommendations to the Health and Human Services (HHS) Secretary about proposed alternative payment models.

 PTAC has not had much success, however, in getting the HHS Secretary to heed its recommendations on new APMs. Last year, two members of the committee quit because none of its 16 recommendations had been approved at that point. On Nov. 20, 2019, PTAC member Len Nichols, Ph.D., director of the Center for Health Policy Research and Ethics at the College of Health and Human Services at George Mason University, resigned in frustration. Joining him in quitting PTAC was Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform. 

 Nichols, who was nominated in 2015 and reappointed in 2017, noted that PTAC has reviewed 32 proposals and recommended either testing or implementation for 16 of them. “Every single one of those recommendations has been declined by the Secretary of HHS,” he wrote.

 The Medical Neighborhood Model (MNM) proposal PTAC recommended for testing  was submitted by the American College of Physicians (ACP) and the National Committee for Quality Assurance (NCQA). It is a five-year, multi-payer pilot that builds on CMMI’s Comprehensive Primary Care Plus (CPC+) model and the Primary Care First (PCF) model slated to begin in 2021.

 The model incorporates Patient-Centered Specialty Practices (PCSP) standards and guidelines developed and maintained by NCQA. MNM is designed to address two key problems: a dearth of specialty APMs and poor primary care practice and specialist referral coordination, which is a significant contributor to poor quality care, inefficient resource allocation, and unnecessary costs.

 ACP suggested that MNM be piloted in a subset of CPC+ regions (and PCF regions once initiated) with specialties that have enough high-value electronic clinical quality measures (eCQMs) that can be used to implement and monitor the MNM. ACP proposes cardiology, infectious disease, and neurology as the three initial pilot specialties.

 The MNM proposal aims to improve care for Medicare beneficiaries with multiple chronic conditions through better coordination between specialty and primary care practices (PCPs).

 A PTAC preliminary review team described the MNM as one possible approach to incentivizing better care coordination between primary care providers and specialists – both to potentially avert unnecessary specialty care as well as improve care within and between specialty practices. However, they found that the MNM needs further development on many aspects of both the care model and the payment model, to ensure successful implementation even as a pilot or test model.

But the PTAC decided that the MNM provides a sufficient framework and mechanisms to justify further consideration, with an acknowledgement that a specialist APM may not be able to achieve the threshold of large savings preferred for model development and implementation. If refined and deemed successful through a pilot for the three specialties proposed by the submitter, the model could be considered for expansion to additional specialties.

 PTAC did not recommend implementation of the Patient-Centered Oncology Payment Model (PCOP) submitted by the American Society of Clinical Oncology (ASCO), but it did vote to refer the model to HHS for further consideration with high priority. The PCOP proposal is designed to support community-based Oncology Medical Homes (OMHs), featuring team-based care led by a hematologist/oncologist. The objectives of the five-year, multi-payer model are to transform cancer care delivery and reimbursement while promoting high-quality, well-coordinated, and high-value cancer care.

The proposal calls for the creation of “PCOP Communities,” comprised of multiple providers, payers, and other stakeholders, to facilitate implementation of the model in each geographic area.  Participating practices would be required to comply with 22 PCOP care delivery requirements that are based on OMH standards, with an emphasis on the use of evidence-based treatment pathways. PCOP Communities would be led by an Oncology Steering Committee (OSC).

The payment model includes Care Management Payments (CMPs), Performance Incentive Payments (PIPs), and the ability to receive bundled Consolidated Payments for Oncology Care (CPOC). The performance methodology is based on meeting quality metrics, adhering to clinical pathways, and reducing cost-of-care.

Each PCOP community would need to have an ability to meet requirements related to sharing electronic health data from participating providers via certified electronic health record technologies and other data sharing requirements.

 The PTAC preliminary review summary found that several aspects of the proposed model warrant consideration as other cancer models are developed – such as the need for more local, multi-payer efforts; greater private payer participation; and a more balanced payment methodology that may allow more oncology practices, particularly smaller ones, to participate. However, it noted that “the proposed model does not appear to meaningfully expand the portfolio of APMs available for the hematologist/oncologist. Core aspects of the model are similar to Oncology Care Model (OCM), which is also undergoing potential revisions, and several other oncology-related CMMI models are in development (e.g., Oncology Care First).”

 While the PCOP model has the potential to improve quality and reduce cost, there may not be sufficient reductions in the total cost of care to achieve cost neutrality or net savings, the report said.

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