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Practice Matters
New Headache Payment Concept Under Review by Government

ARTICLE IN BRIEF

The AAN has proposed a new neurology-oriented alternative payment model for the diagnosis of headache to be submitted to the Centers for Medicare and Medicaid Services.

In a bid to help neurologists who treat headache and their patients, the AAN has proposed a new payment approach for headache diagnosis and treatment.

The Patient-Centered Headache Care Payment (PCHCP) proposal is the first neurology-oriented alternative payment model (APM) to be submitted to the federal government for consideration.

The Centers for Medicare and Medicaid Services (CMS) and several national private insurers are trying to pivot away from fee-for-service payments to value-oriented payment methods. APMs incorporate quality and cost of care into reimbursement rather than a traditional fee-for-service structure.

APMs are a new concept, however, so very few specialists have a way to participate in the APM movement. “The problem is that there are no APMs for neurologists,” said Joel M. Kaufman, MD, FAAN, chair of the AAN Payment Alternatives Team.

His team targeted two neurologic conditions — headache and epilepsy — for APM development because they are treated by neurologists in a wide range of practice settings and, thus, may benefit many AAN members.

The epilepsy APM will be submitted for consideration after Dr. Kaufman's team sees how the headache proposal advances through the approval process.

“That work is on hold until we get initial feedback (on the headache proposal) because the models are similar in the way they are structured,” said Amanda Napoles, MPH, AAN program manager, payment programs. “If we get any feedback on the headache model, we will incorporate that into our initial proposal for the epilepsy model.”

THE FEDERAL RESPONSE

During the Obama Administration, CMS announced a goal to have 50 percent of Medicare payments in APMs by the end of 2018 and charged its Innovation Center with meeting that goal. During his brief tenure as the Secretary of Health & Human Services, Tom Price, MD, was critical of mandatory programs to move physicians to new payment models. The CMS decision to cancel mandatory bundled-payment programs for cardiac procedures and scale back a program for joint replacements prompted speculation that the government's interest in APMs was waning.

But when CMS issued a request-for-information (RFI) seeking feedback on a “new direction” for the Innovation Center, it said: “The Innovation Center is interested in increasing the availability of specialty physician models to improve quality and lower costs and engage specialty physicians in alternative payment models, especially for independent physician practices.”

The Academy responded to the RFI during the comment period, which ended in November, emphasizing the importance of provider choice and patient-centered care in any new models, said Amanda Becker, the AAN senior director for policy and practice innovation.

THE HEADACHE APM IN CONTEXT

Although headache is one of the most common forms of chronic pain, it is often not treated in the most effective or efficient way. The AAN's proposal for the Patient-Centered Headache Care Payment program identifies several red flags of low-value care:

  • Complex headaches are frequently misdiagnosed; in particular, many patients suffer for years before being accurately diagnosed with migraine.
  • Many patients with difficult-to-manage headaches do not receive timely referrals to the appropriate specialist.
  • Poorly controlled headaches lead to urgent care and emergency department visits and inappropriate use of potentially dangerous medications.
  • Patients who could be appropriately treated by primary care providers often seek care from neurologists or headache specialists, contributing to work overload and burnout.
  • Patients who do not receive the right diagnosis and treatment sometimes stop seeking medical care and suffer in silence.

More than 80 percent of headache patients are treated by primary care providers, rather than neurologists. The PCHCP is designed to make it advantageous for primary care providers to care for patients with well-controlled headaches, while other headache patients are referred to specialists. (See sidebar, “Patient-Centered Headache Care Payment.”)

“We want to encourage headaches that are more challenging and more difficult to control to come to neurologists, and be covered under the APM,” Dr. Kaufman said.

WHAT'S NEXT?

As per the government's protocols, the Academy's proposal was made to the Physician-Focused Payment Model Technical Advisory Committee.

A preliminary review team — a subset of the advisory committee members — is currently evaluating the proposal and the public comments made before the comment period closed November 20, said Harold D. Miller, president and chief executive officer of the Center for Healthcare Quality and Payment Reform and an advisory committee member. (Miller worked with the AAN in the early stages of developing the headache proposal and, for that reason, will recuse himself from the committee's decision on the matter.)

Miller expects the full advisory committee will discuss the proposal at its March meeting and make a recommendation as to whether it is a viable APM to the Secretary of Health & Human Services (HHS).

After the advisory committee makes its recommendation, however, there is no firm timetable. The HHS can accept or reject the headache payment recommendation — or make changes to the proposal as it sees fit, Miller said. If the HHS Secretary approves the headache APM, it will be referred to the Center for Medicare & Medicaid Innovation, which will decide how and when to implement the payment model.

WHO CAN USE THE PCHCP?

The APM concept has emerged in conjunction with CMS Quality Payment Program, which is changing the way physicians are paid. The program has two tracks:

  • the Merit-based Incentive Payment System (MIPS), which gives physicians a performance-based payment adjustment — positive or negative to their Medicare payments.
  • the Advanced Alternative Payment Model track, which allows physicians to earn a 5 percent incentive payment on all Medicare reimbursement in the years 2019 to 2024. The full incentive payment is offered only to physicians that receive at least 25 percent of Medicare payments — or see 20 percent of Medicare patients — through an advanced APM. These percentages increase as the program matures.

Dr. Kaufman stressed that he wants CMS to designate the proposal as an advanced APM, so neurologists can participate on the payment program's APM track and be eligible for the 5 percent incentive payment.

While most physicians will participate in MIPS, that track has a significant drawback. MIPS is a zero-sum game, meaning a physician could perform well on quality and cost but still not get a positive payment adjustment because other physicians performed better.

“For someone to do well (financially) in MIPS, it means someone has to do poorly,” Dr. Kaufman said. “But in the APM track, you get your reward based on participation, not based on someone else doing poorly.”

To qualify as an advanced APM, the Patient-Centered Headache Care Payment proposal will have to meet various criteria, one of which is that a physician practice assumes “more than nominal” financial risk for the care delivered to patients. However, the Physician-Focused Payment Model Technical Advisory Committee does evaluate whether an APM meets the “more than nominal” financial risk standards established by CMS. Miller expects some of the APM proposals coming through the approval process may not qualify.

If the Patient-Centered Headache Care Payment does not meet HHS' standards for advanced APM status, it could still be used in ways that are helpful to AAN members.

The government could approve the headache care payment model as an APM but not recognize it as an advanced APM, Napoles said. In that case, neurologists who care for headache patients could be paid using the Patient-Centered Headache Care Payment methodology, but they would not receive the 5 percent incentive payment.

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DR. JOEL M. KAUFMAN said the AAN Payment Alternatives Team targeted two neurologic conditions — headache and epilepsy — for APM development because they are treated by neurologists in a wide range of practice settings and, thus, may benefit many AAN members.

That is likely a good opportunity for neurologists and their patients, Miller said. “From my perspective, an APM that is not ‘advanced’ may still be a good thing for a physician practice to be in if it enables them to deliver better care to their patients at lower cost.”

CMS might allow the headache care payment model to be used as a “MIPS APM,” Miller said. In this case, neurologists who participate in the MIPS track could use it to be paid for treating headache patients, and the PCHCP would be used for the quality measures, cost measures, and quality improvement activities required for MIPS participation, lowering the data submission requirements and administrative burden of reporting for MIPS for those in the APM.

Private insurers might use the PCHCP as a way to support and encourage high-value headache care. Two large national payers — Anthem and Aetna — belong to a payer-provider consortium that has committed to putting 75 percent of their contracts into value-based payment arrangements by January 2020. Many other health care systems have equally aggressive goals for moving away from traditional fee-for-service contracts with physicians.

Improving headache care, courtesy of a new payment model, may be of particular interest to commercial insurers because it is important to the employers who are their customers. That is because headache is a leading cause of diminished work productivity and absenteeism; a study found that lost productivity resulting from headache cost $19.6 billion in 2002.

“We are looking at commercial payers right now to see if they might be interested in pursuing this model for their patient population,” Napoles said.

PATIENT-CENTERED HEADACHE CARE PAYMENT

The Academy's proposal for the Patient-Centered Headache Care Payment (PCHCP) is designed to improve the diagnosis and treatment of headache by paying neurologists, headache specialists, and primary care physicians in a new way.

The alternative payment model (APM) would replace current evaluation and management (E/M) payments with a flexible payment that supports neurologists and headache specialists to use a team-based approach to care.

Under the PCHCP, patients would be managed by a Headache Care Team that includes some or all of the following: a neurologist, headache care specialist, primary care physician, patient care coordinator, nutritionist, physical therapist, mental health provider, and social service providers. This can be a “virtual” team, meaning a referral network rather than staff members hired by a physician practice.

The proposal calls for three categories based on stage and complexity of headache: diagnosis and initial treatment for patients with undiagnosed, difficult to diagnose, or poorly controlled headache disorders; continued care for patients with difficult-to-manage headaches and their associated symptoms; and continued care for patients with well-controlled headaches

In Categories 1 and 2, the PCHCP would replace E/M payments with a fixed payment amount; a neurologist or headache specialist, working with a Headache Care Team, will use that payment to deliver a range of services that are currently not covered and spend more time with high-need patients than the current payment system allows. Patients in Category 3 would be managed by a primary care physician who receives E/M payments.

The PCHCP represents a dramatically different way for physicians to be paid for headache care, but it is better aligned with the way neurologists want to treat their patients, said Joel M. Kaufman, MD, FAAN, chair of the AAN Payment Alternatives Team.

The payment system would require neurologists to take more responsibility for the course of a patient's care, which is a good thing, he said.

“We think that will lead to improvements in patient outcomes and financial measures and quality measures,” he said.