ARTICLE IN BRIEF
The AAN is proposing two new payment models for epilepsy and migraine care as part of an effort to better position neurologists for value-based care.
How do physicians incorporate value-based care at a time when the fee-for-service reimbursement models are being replaced by other options? And what can be done to help neurologists, specifically, drive the process so that they can better manage and become accountable — not only for the quality of the care they provide — but for their costs and reimbursement for those services?
The AAN is hoping to help neurologists with the process by taking the lead in developing two new proposed payment models — for headache and epilepsy care.
Now in draft form, the models are designed to position neurologists to participate in the Alternative Payment Models (APM) option when the Centers for Medicare & Medicaid Service (CMS) implements Medicare payment reform for physicians. (For more on the APM options, see the sidebar, “The MACRA Mandate.”)
The AAN Payment Alternatives Team, chaired by Joel M. Kaufman, MD, FAAN, is seeking feedback from neurologists on the models, with the goal of fine-tuning them before presenting them to payers.
The new models are designed to give physicians more flexibility in how they interact with their patients — and more accountability for their performance.
“You, as a neurologist, say ‘I am taking responsibility to make the right diagnostic and treatment decisions for my patient and here are the resources that I need to do that,” Dr. Kaufman said. “How I use these resources is in my control. The bottom line of the APM is responsibility.”
MODELS UNDER DEVELOPMENT
The Payment Alternatives Team was convened a few years ago to stay abreast of the emerging value-based payment movement. Tasked with making strategic recommendations to the AAN Medical Economics and Management Committee, the Government Relations Committee, and AAN leadership, the team has been monitoring the landscape and educating neurologists about what it finds.
“We have been examining what neurologists are doing and what opportunities are out there and sharing stories from those who are doing bundled payments or are part of accountable care organizations,” said Amanda Becker, the AAN's senior director of policy and practice innovation.
Team members considered all the common neurologic conditions before choosing to focus on epilepsy and headache because they met certain criteria. Among them, the conditions often account for a significant portion of a neurologist's practice, and neurologists have a central role throughout the trajectory of patient care. Stroke was not chosen, Dr. Kaufman said, because ongoing care is often handled by an internist or family practitioner.
Among other criteria, the cost of treatment for these conditions varied considerably. “The variability would indicate that there's an ability to make a significant improvement,” James Goldenberg, MD, a member of AAN's Payment Alternatives Team, said. “We wouldn't want to take something that's running fairly efficiently as our first model. We want to show that we can decrease that variability.”
The team worked with Harold Miller, president and chief executive officer of the Center for Healthcare Quality and Payment Reform, to create the new models.
“People seem to have this impression that physicians are fighting all of this, and they have to be forced into it or be given incentives,” Miller said. “But everything I've seen shows that (physicians) are devoting a lot of their personal time to it and recognize the need to do it.”
He applauds the AAN for having the Payment Alternatives Team in place long before legislation mandated a new physician payment system.
By putting forth its own payment models, the AAN is seizing the opportunity to influence the way neurologists are paid for high-value work, Dr. Goldenberg said.
“It is an opportunity for physicians to help develop a fair and efficient payment model, rather than having one created for us,” he said.
HEADACHE CARE PAYMENT
To receive these alternative payments, physicians would have to meet minimum quality standards set by the Academy (and, in the case of headache care, the International Headache Society and the American Headache Society). Physicians would be accountable for their performance on measures of service utilization, spending, care quality, patient outcomes, and patient experience specific to a particular phase of care. Payment amounts would be adjusted up or down based on their performance on the measures.
Three categories of headache-care payments would correspond to the different types of care during diagnosis versus treatment and variation in how effectively treatments control headaches: diagnosis and initial treatment for patients with poorly controlled headaches; continued care for patients with difficult-to-control headaches; and continued care for patients with well-controlled headaches.
For the first two categories, headache care payment would replace current Evaluation & Management (E&M) payments, giving physicians flexibility to deliver the services their patients need. In these categories, payment amounts would be stratified based on specific patient characteristics such as headache diagnosis, frequency and severity of headaches, and other comorbidities.
For the third category — patients with well-controlled headaches — physicians would receive E&M payments plus a supplemental payment to deliver services other than face-to-face visits and to support coordination between the patient's various physicians.
SEIZURE CARE PAYMENT
Nine categories of epilepsy care payments reflect the different types of care patients need during various phases of the diagnosis and treatment process:
- Diagnosis of a new patient with possible epilepsy
- Initial treatment for epilepsy following diagnosis
- Continued treatment for a patient who has well-controlled seizures
- Supervised withdrawal from epilepsy drugs
- Changes in treatment regimens for well-controlled patients
- Management of pregnancy and epilepsy
- Treatment planning for refractory epilepsy
- Non-surgical treatment for refractory epilepsy
- Surgery for epilepsy
- Within each category, payment amounts would be stratified to reflect specific patient characteristics such as age, comorbidities, and ability to access appropriate treatments.
WHERE WE ARE HEADED
The two condition-specific payment models should be considered “detailed concepts” rather than final proposals, Miller said.
“We really view these as fluid,” Becker added. “If a payer says, ‘This is too complicated, we couldn't implement it,’ then we can work on ways to simplify them. Or if they do not meet the requirements that come up from CMS, we will alter them so that they do.”
The first stakeholders who need to vet the draft concepts are neurologists, Miller said. Payers will only be interested in a new payment model if a significant number of physicians want to participate in it. Thus, any payment concept that becomes an actual proposal from the AAN will require broad support from neurologists working in a variety of practice settings.
AAN leaders are already meeting with national insurers to get their initial feedback on the concepts, Becker said. And they will meet with CMS or the Center for Medicare & Medicaid Innovation Center later this year.
“We want to make sure that they know we are working on this and if they are working on a pay model for neurology, we don't want them to work in a vacuum separate from us,” she said.
Meanwhile, the payment concepts need to be fleshed out with data analysis. Currently, none of the payment categories — for example, treatment planning for refractory epilepsy — have payment amounts attached to them because the amount of time and effort required to do that work has not been analyzed. Indeed, in many cases, the data needed to understand the level of work associated with a payment category is not currently being collected. So the initial analysis of what each payment category entails will be tentative, Miller said.
“What's really going to be needed is a partnership with one or more payers and practices to put the payment model in place to be able to figure out what works and doesn't work about it,” he said.
The draft payment concepts will be challenging for some physicians, Dr. Kaufman said. He encourages them to remember that fee-for-service systems are rapidly being replaced by value-based reimbursement models, and any new payment system is going to require changes in the way physicians manage care.
“My colleagues are going to go, ‘You've got to be kidding. I'm not going to do this. It's too complicated,’” he said. “But we hope when they look at our models, they will see the framework to organize their practice to be successful in new payment models. We think they reflect what neurologists actually do now.”
THE MACRA MANDATE
The Medicare Access and CHIP Reauthorization Act (MACRA) passed by Congress last year, requires physicians to choose one of two payment systems: The Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM).
The MIPS will pay a physician based on his or her composite score in four performance categories: quality, resource use, clinical practice improvement activities, and meaningful use of electronic health record technology.
Beginning in 2019, a physician's Medicare pay will be adjusted upward or down by up to 4 percent to reflect his or her performance in 2017. The maximum pay adjustments will increase incrementally to 9 percent in 2022 and beyond.
Physicians who participate in a qualified APM for a minimum percentage of their Medicare revenues (initially 25 percent of their Medicare or total revenues and increasing over time) will avoid the MIPS system. They will receive 5 percent lump sum bonus payments in the years 2019-2024 and a higher fee schedule update beginning in 2026.
What constitutes an advanced APM has not yet been finalized; Congress required that physicians participating in this pay model bear “more than nominal” financial risk for the care of their patients, but the Centers for Medicare & Medicaid Services (CMS) has not yet finalized the regulations that define “risk” and “more than nominal.”
Initially, most physicians will have no choice but to participate in MIPS because, for many specialists, APMs are not yet available. But participating in an APM will be a financially better choice for physicians in the long run, Dr. Kaufman said, because MIPS must be budget-neutral.
“MIPS is a fixed pool (of money) so, in order for you to get a reward, someone else has to do poorly,” he said. “But in the APMs, you get the automatic 5 percent increases as long as you comply with all of the requirements.”
James Goldenberg, MD, a member of AAN's Payment Alternatives Team, said the transition will be challenging but participating in an APM is the right thing for two reasons: By design, APMs will improve the value of care, which benefits patients and society at large — and APMs allow value-oriented physicians to be rewarded for their work.
He encourages physicians to see the APM option as an opportunity to succeed financially.
“We're not going back to the table where there's no money left,” said Dr. Goldenberg, a neurologist at Medical Specialists of the Palm Beaches in Atlantis, FL. “We're going to go to the new table and saying, ‘We provide a valuable service, our patients do extremely well, and here's how we think we should get paid.’”