Physicians did their job: submit alternative Medicare payment model (APM) ideas for a government-appointed committee to consider. The committee did its job: evaluate those models and recommend viable ones for use or testing.
But three years and more than a dozen recommendations later, the U.S. Secretary of Health and Human Services (HHS) has moved forward on exactly zero of those committee suggestions.
In November 2019, three members of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), including one physician, quit. Two of those members publicly expressed frustration with HHS’ inactivity on the committee’s work, leaving behind uncertainty about the future of physician-driven payment models in Medicare’s Quality Payment Program (QPP) as it moves through its fourth year.
Tyler anesthesiologist Asa Lockhart, MD, who took a crack at proposing his own payment model, says the resignations cast doubt on whether it’s worth it to spend “human and financial capital” on the PTAC process.
“If those people who are in the midst of it have lost faith in the process, you can only imagine … people that are probably struggling to just understand it at a very elemental level have got to find that discouraging,” Dr. Lockhart said.
HHS responded to Texas Medicine with a statement saying, “PTAC’s in-depth deliberations and recommendations are invaluable to HHS and CMS in crafting physician models.”
But Angelica Ybarra, TMA’s director of clinical advocacy, notes that April 2020 will mark five years since the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) and still very few APMs are available to a wide swath of physicians in the QPP. Doctors who don’t participate in the program through an advanced APM must do so through the Merit-Based Incentive Payment System (MIPS).
“These problems with PTAC are very concerning to TMA,” Ms. Ybarra said. “HHS, the Centers for Medicare & Medicaid Services (CMS), and its Center for Medicare & Medicaid Innovation (CMMI) appear to be undermining MACRA, stymying innovation in health care delivery, and hindering the transition to APMs … leaving physicians with no option but to remain in the highly flawed MIPS track.”
PTAC began accepting proposals for physician-focused payment models on Dec. 1, 2016. (See “Build Your Own Payment Model,” July 2017 Texas Medicine, pages 53-58, www.texmed.org/ownpaymentmodel.) PTAC evaluates the ideas – which can be submitted by individuals (including physicians) or entities – and makes recommendations to HHS, which reviews them and ultimately decides whether to test or implement them.
As of late January, the HHS website had posted more than 30 proposed physician-focused payment models submitted to PTAC (tma
.tips/ptacproposals). MACRA mandates that the committee contain 11 members, including physicians and nonphysicians. As of this writing, the three resignations left PTAC with just seven physicians and one nonphysician.
Harold Miller, PhD, president of the Center for Healthcare Quality & Payment Reform, and Len Nichols, PhD, director of the Center for Health Policy Research and Ethics at George Mason University, announced their resignations from the committee one day apart last November. Ten days later, PTAC announced the resignation of Seattle-area physician Rhonda Medows, MD, president of population health management for Providence St. Joseph Health. Through Providence St. Joseph, Dr. Medows declined an interview request.
In detailed resignation letters, Drs. Miller and Nichols took issue with the way HHS, CMS, and CMMI had handled PTAC’s work. They cited as their main grievance the fact that HHS hasn’t acted on any of the committee’s recommendations thus far and, according to them, doesn’t plan to.
“It also seems clear that future recommendations will meet the same fate; the former director of CMMI told us there was ‘no circumstance’ in which CMMI would ever directly implement a payment model submitted through the PTAC process,” Dr. Miller wrote in a Nov. 19, 2019, letter. “We have been told that at most, CMMI would consider how to incorporate ‘concepts’ from the models that PTAC recommended into the payment models that CMMI itself develops. In my view, this is completely inconsistent with the spirit of MACRA; Congress clearly envisioned that at least some of the good payment models developed by physicians would be implemented if they were recommended by PTAC.”
In an interview with Texas Medicine, Dr. Miller said PTAC successfully received payment-model ideas from the physician community and went on to recommend several.
“The problem was that CMS wouldn’t implement any of them,” he said. “It was difficult initially to know, was that just a difference of opinion about a small number of models? But it became increasingly clear that they did not intend to implement any of them.”
Dr. Miller also called the process “misleading” to physicians.
The biggest factor in his resignation was that “CMS started to say that the models that they were implementing were based on the proposals and the recommendations from PTAC – which was simply not true. They were essentially trying to use us, without our consent, as an endorser of the models that CMS was issuing,” he told Texas Medicine.
Dr. Nichols expressed similar concerns in his resignation letter.
The fact that “HHS/CMS/CMMI has rejected all” of the proposed models over a three-year period “leads me to the conclusion that they are not pursuing congressional intent, and our work has been fruitless,” he wrote. “Furthermore, continuing the PTAC process as if nothing is wrong risks deceiving the healing professions that ideas approved by PTAC have a decent chance of being implemented. … Under current modus operandi, they manifestly do not. This is a deception I no longer wish to be a part of.”
HHS’ statement went on to thank Drs. Miller and Nichols for their work and said, “HHS and CMS are committed to value-based care, working with stakeholders, and using the extensive work of PTAC to inform physician models implemented through the CMS Innovation Center.”
“Ominous sign” for physician APMs
Dr. Lockhart called the departures of such high-level subject matter experts as Drs. Miller and Nichols, whom he met, an “ominous sign.” He also questions why the government wouldn’t allow what he describes as “the incubators” of physician-focused payment models to mature.
Dr. Lockhart’s own payment model idea aimed to create a “low barrier to entry” that would allow physicians to get acclimated slowly to participating in the QPP. “If they would keep it simple, it has a chance of success. I think the more complex they make it, while intuitively you would think that would heighten the success, it scares people off,” he said.
With physician-focused payment models meeting a dead end with HHS thus far, he adds, “The complexity of [submitting a proposal], coupled with a vague hope of both acceptance and success, does not really motivate anyone to spend a lot of time and capital to try to participate. Those are the concerns I have.”
Ms. Ybarra said TMA will continue to monitor closely PTAC activity and the implementation of the QPP in general. The association, she added, will continue to “advocate for more APMs that are applicable to all physician practices and specialties who wish to participate in the APM track, including models with lower financial risk requirements.”
Dr. Miller noted one major positive of the PTAC process.
“I do think that PTAC and the submissions that came in were not completely in vain, in the sense that neither Congress nor anyone else ever knew whether physicians would in fact develop payment models if they were ever given the opportunity to. So the fact that they did, and that they developed good models in multiple specialties, shows that there is … the desire for a different approach to payment,” he said.
Tex Med. 2020;116(4):36-38
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