WASHINGTON -- Providers could soon have new options for caring for some of their sickest patients if the Centers for Medicare & Medicaid Services (CMS) agrees to them.
The Physician-focused Payment Model Technical Advisory Committee (PTAC), on Monday decided to recommend three new models to the Secretary of Health and Human Services.
The PTAC voted 8-2 in favor of the proposal from the American Academy of Hospice and Palliative Medicine (AAHPM).
The PACSSI model provides tiered monthly care management payments to support interdisciplinary palliative care teams delivering community-based palliative care to eligible patients who have a diagnosis of a serious illness or multiple chronic conditions, functional limitations, and high healthcare utilization. PACSSI care management payments would replace payment for evaluation and management services.
The supporting PTAC votes included seven members seeking limited-scale testing, and one member urging full-scale implementation.
Several members pointed out that the quality measures for the PACSSI still need to be developed, and that benchmarks and risk adjustment also needed work.
The committee also voted 10-0 in favor of the from the Coalition to Transform Advanced Care (C-TAC). Votes on this model were split 5-5 in favor of recommending full implementation versus limited-scale testing.
"The ACM delivers comprehensive, person-centered care management; multidisciplinary team-based care; concurrent curative and palliative treatment; care coordination across all care providers and settings; comprehensive advance care planning; shared decision-making with patient, family, and providers; and 24/7 access to clinical support. ACM services end when the beneficiary enrolls in hospice or dies," according to the .
PACSSI Concerns
The PACSSI model would offer a 5-year demonstration payment to bring palliative care services to patients with serious, potentially life-limiting diseases (metastatic cancer, advanced pulmonary disease) or multiple chronic conditions.
The model involves a system of two tiers of monthly payments based on complexity: tier 1 includes a $400 per beneficiary per month (PBPM) payment, while tier 2 is for more complex patients and offers $650 PBPM.
The model also includes two distinct financial incentive pathways: The first pathway would award positive and negative payment incentives of up to 4% based on performance on quality standards. The second track -- available in the third year -- would involve a shared risk and savings model based on total cost of care.
Robert Berenson, MD, an institute fellow at the Urban Institute, said he worried about offering financial rewards for reducing costs when caring for patients at the end of their lives. "I think this is a dangerous payment model, and that's why I voted against it," he stated. "We have this tendency to think this payment model is going to be used by good guys ... This can't be restricted to just the people we would hand-select for it."
However, he noted after the vote that limited-scale testing of the model would not be unreasonable, and he stressed the model could still work if the payment track that involved measuring total cost of care was eliminated.
Phillip Rodgers, MD, AAHPM chair, said he recognized Berenson's concerns, but emphasized that "when we do palliative care right, it does save money." When patients are engaged in shared-decision making, they opt out of many low-value, high-cost services, Rodgers explained.
C-TAC Model
This model focuses on payment for palliative care services to Medicare beneficiaries in the last 12 months of life. Screening for the model relies on meeting specific criteria related to acute care utilization, functional decline, nutritional decline, and performance on certain tests, such as the Karnofsky Performance Scale.
Payment would involve a wage-adjusted $400 per member per month payment of "indefinite duration" as well as a bonus payment to reflect the total cost of care in the last 12 months of life.
The care team would be evaluated on 13 measures in areas such as access and timeliness of care and communication and overall satisfaction with care; evaluation would occur 1 month following admission, and after the episode of care is over.
Joining Forces?
The committee deliberated for a long time on whether to recommend the C-TAC proposal for limited-scale or full implementation, with several members commenting that the C-TAC model was "closer to being ready to go." Ultimately, PTAC agreed to send one letter to the Secretary of Health and Human Services recommending both models.
Grace Terrell, MD, CEO of Envision Genomics in Huntsville, Ala., said that it would be "irrational" to execute one model and not the other.
Some committee members suggested combining the two models into a "hybrid," which Tom Koutsoumpas, co-chair of C-TAC board of directors, said was a "tremendous idea."
Home Hospitalization Model
The committee also assessed and recommended a third model on Monday by a vote of 11-0. , submitted by Personalized Recovery Care, is a partnership between Marshfield Clinic Health System and Contessa Health.
The model targets patients that would be eligible for a hospitalization but who submitters feel could safely be treated in the home, and who agree to such an option. An admitting physician would have at least one daily telehealth visit and a nurse would monitor care twice daily. The patient would also have 24/7 access to an on-call physician.
The model consists of a bundled payment proportional to 70% of the payment a hospital would have received for a particular diagnosis-related group (DRG). That bundle would reimburse services including home visits and telehealth, which are normally unreimbursed under Medicare, committee members noted. (See the proposal for a .)
The committee's preliminary review team for the model determined that it met all for a physician-focused model, with the exception of patient safety.
Rhonda Medows, MD, executive vice president of population health at Providence Health & Services, expressed concern over the broad range of conditions included in the model -- a total of 151 DRGs. She worried that the range of services exceeded what has typically been included in a hospital-at-home model.
"If there's evidence to support it, I would agree with you [that it should be tested, but] ... if there's not evidence to support it, I don't think this is the place to take that risk," Medows said.
Disclosures
Harold Miller assisted the American Academy of Hospice and Palliative Medicine with developing "an alternative payment model for palliative care that would address patients and care needs that are similar, but not identical, to the CTAC proposal." He recused himself from voting on both the CTAC proposal and the AAHPM proposal.
Bailet disclosed being a speaker at a C-TAC summit, and that Blue Cross Blue Shield partnered with C-TAC for 4 years but did not renew its membership for 2018..
Bailet noted that a survey of C-TAC members was used to provide input into the APM proposal over a year ago with an endorsement of support on the concept of an APM for palliative care at that time.
"Leadership confirmed that if the APM aligned with our current plan to roll out our APM, we'd be in support of a Medicare APM. There was no formal commitment made to C-TAC nor did I participate in the survey or communicate with C-TAC staff in any capacity," Bailet said.
Bailet also served on the Wisconsin Chamber of Commerce Board with Dr. Susan Turney, CEO of the Marshfield Clinic and was on the Board of the Wisconsin Medical Society during her tenure as CEO.
Bailet met Narayana Murali, MD, executive director of the Marshfield Clinic during a visit there. He was also "familiar with the Marshfield Clinic" while leading the Aurora Medical Group but has not had any involvement in the Development of the Personalized Recovery Care, LLC, Home Hospitalization: An Alternative Model for Delivering Acute Care in the Home.
Ferris disclosed that he oversees palliative care at as senior vice president for Population Health Management at Partners HealthCare.
Ferris disclosed being a presenter at a C-TAC conference, and overseeing palliative care at as senior vice president for Population Health Management at Partners HealthCare.