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Features  |   April 2016
Perioperative Care and MACRA-Approved APM
Author Affiliations
  • Mike Schweitzer, M.D., M.B.A.
    Committee on Future Models of Anesthesia Practice
    Chair
Article Information
Practice Management / Quality Improvement / Features
Features   |   April 2016
Perioperative Care and MACRA-Approved APM
ASA Monitor 04 2016, Vol.80, 12-14.
ASA Monitor 04 2016, Vol.80, 12-14.
Mike Schweitzer, M.D., M.B.A., is Principal Population Health Chief Medical Officer for Bundled Payments –Premier Inc., Charlotte, North Carolina.
Mike Schweitzer, M.D., M.B.A., is Principal Population Health Chief Medical Officer for Bundled Payments –Premier Inc., Charlotte, North Carolina.
Mike Schweitzer, M.D., M.B.A., is Principal Population Health Chief Medical Officer for Bundled Payments –Premier Inc., Charlotte, North Carolina.
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Peggy L. Naas M.D., M.B.A., is Chief Medical Officer, Healthcare Performance Improvement, a Press Ganey Solution, Virginia Beach, Virginia. She is a Board-Certified Orthopaedic Surgeon.
Peggy L. Naas M.D., M.B.A., is Chief Medical Officer, Healthcare Performance Improvement, a Press Ganey Solution, Virginia Beach, Virginia. She is a Board-Certified Orthopaedic Surgeon.
Peggy L. Naas M.D., M.B.A., is Chief Medical Officer, Healthcare Performance Improvement, a Press Ganey Solution, Virginia Beach, Virginia. She is a Board-Certified Orthopaedic Surgeon.
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Medicare reform addressed the sustainable growth rate (SGR) formula, which was eliminated with a bipartisan supra-majority of Congress, both House and Senate, in 2015 with the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA created a two-track physician payment incentive program that includes a Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).
In January 2015, Secretary of Health and Human Services (HHS) Sylvia Burwell announced a timeline and measurable goals to shift the Medicare program away from traditional fee-for-service payment structure toward a more outcome-based system based on APMs tied to quality.1  Currently, more than 20 percent of Medicare fee-for-service payments flow through APMs, putting the Administration’s goals of 30 percent by the end of 2016 and 50 percent by 2018 within reach.2  This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare. Through the CMS Innovation Center’s Transforming Clinical Practice Initiative, CMS will invest up to $800 million in providing hands-on support to 150,000 physicians and other clinicians for developing the skills and tools needed to improve care delivery and transition to APMs. Three bundled payment models, Bundled Payments for Care Improvement (BPCI), Comprehensive Care for Joint Replacement (CJR) and the Oncology Care Model (OCM), were developed in the past few years by the Innovation Center.
The voluntary BPCI initiative comprises four broadly defined models of care, which link payments for the multiple services beneficiaries receive during an episode of care. Under the initiative, physicians or health care organizations enter into bundled payment arrangements that include financial and performance accountability for one or more of 48 defined episodes of care. As of October 2015, there were 1,618 participants in BPCI, including physician group practices, hospitals, skilled nursing and inpatient rehabilitation facilities, home health agencies, and awardees.
Table 1.
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Table 1.
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The CJR bundled payment program began April 1, 2016, and has over 750 hospitals that are mandated to participate for five years. The CJR episode of care begins three days prior to admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 (major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (major joint replacement or reattachment of lower extremity without major complications or comorbidities) and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries. These CJR mandated hospitals will be held accountable for both total Medicare spend and for quality of care of these patients.
OCM will begin the spring of 2016. OCM is a voluntary CMS bundled payment program designed for physician practices that administer chemotherapy to fee-for-service (FFS) Medicare beneficiaries.3  OCM will concentrate on the total cost of care for cancer patients undergoing chemotherapy during a six-month episode (episodes begin when a patient receives chemotherapy for cancer and includes almost all care provided during that time) and tie payments to performance based on meeting certain quality metrics and practice transformation requirements. The OCM program had 443 applicants, expects about 125 participating physician practices and will last for five years. Physician payment will be a two-part payment system, first on a monthly per beneficiary per month (PBPM) and second on a performance-based payment, which will incentivize practices to lower the total cost and improve the quality of care for beneficiaries during treatment episodes. OCM is the first to have other payers (including Aetna, Anthem, Blue Cross/Blue Shield, Cigna, Humana, United Healthcare, and others) join CMS by offering a similar payment model, aligning incentives for practices and facilitating improvements in care.
All of these past Medicare Bundled Payment reforms laid the foundation for the recent historic changes in 2015 for the shift from physician fee-for-service payments toward payments as part of a bundle based on an episode of care and meeting certain total spend targets and quality thresholds. For all physicians over the next few years, the challenge will be how to become effective members and/or leaders of a team or team of teams that will meet and/or exceed yet-to-be-determined MIPS metrics or reducing total Medicare spend for an episode of care as an approved APM for MACRA.
Physicians and health care organizations must foster a culture of safety by becoming high-reliability organizations, using error prevention behaviors and through leadership programs such as TeamSTEPPS® or McChrystal’s team of teams concepts.4  TeamSTEPPS® is an evidence-based teamwork system to optimize patient care by improving communication and teamwork skills among health care professionals and frontline staff.5  An organization’s culture is their strategy. In order to really adapt and succeed, we must work differently not “harder.”
The Perioperative Surgical Home (PSH) is a model of care focused on patient-centered, consistent, efficient, safe, high-quality medical care, with timely access and full functional recovery being the ultimate goal. Optimal care is best provided by a coordinated inter-disciplinary team recognizing each member’s expertise. Coordinated surgical care provides the best outcomes, lowers costs and increases patient satisfaction.
The PSH provides a platform for redesigning the delivery of care for an entire episode of care. The physician payments for a PSH episode of care could then be bundled. Working collaboratively with other physician specialties, a proposal to qualify as an APM as defined by MACRA could be presented to CMS. Physician leaders will need to establish a financial accounting methodology to track the contributions to savings and quality improvement in these episodes of care. A fair payment distribution formula or methodology must be created to help assign the payment of incentives to each provider (physicians, facilities and other care providers) for the APM bundled payments. There are many variations of these types of payments to use as a guideline for distribution in a bundle payment that are currently in existence that could be modified or adapted. One of the many approaches to develop this contribution to savings and quality distribution with merit-based contribution payment methodology or formula involves four basic steps6  :
  • 1: Identify the key elements of the multiple value-added care coordination or management initiatives across the entire episode of care. In the PSH model this can be broken down into these four phases – preoperative, intraoperative, postoperative and long-term recovery.
  • 2: Assign the relative percentages of clinical responsibility for each physician specialty in an ideal implementation of care or care coordination/management to realize quality, savings and efficiency.
  • 3: Develop attribution metrics to establish the contribution of each individual physician in that specialty group. This individual composite score may then be multiplied by the number of patients in the episode of care that the individual physician impacted.
  • 4: Analyze outcomes and results – total episode spend as compared to target spend, tier achievement of target quality metrics, and other agreed-upon measures level of achievement.
In This Issue of the Monitor
In this series of articles, David Mackey, M.D., co-authors an article with a surgeon, nurse and hospitalist focused on the importance of interdisciplinary team-based clinical care and front-line decision-making empowerment in the non-linear environment of the PSH and optimized perioperative recovery. Drs. Solomon Aronson and Attarian write about their many surgical home programs, including POET, POSH, PARTNER, CLOT, RECOVER and MAPS. Sonya Pease, M.D., and her co-authors outline one approach for physicians to qualify for these large incentives and avoid onerous penalties. Peter Dunbar, M.B., Ch.B., and Mike Scott, M.B., Ch.B., reflect on the American and British approaches to perioperative care with a population health perspective. These articles highlight approaches to improve quality, patient and provider satisfaction, and are responsive to the call for new models of care and payment. Redesign of the delivery of care to provide higher-quality care with fewer complications and preventable harm will reduce total health care spend.
Optimal dyad leadership involves physician-led, team-based care that includes a multitude of health care providers, including physicians, nurses, technicians and other health care professionals working closely with a facility operations team. The contributions of each group will vary by practice and local environment. A payment model to support the additional work of redesigning the delivery of care is required to sustain this process. Developing and refining this alternative payment model will be a challenge for the future. ASA must also partner with other physician specialties for CMS approval of this APM under the MACRA law.
The opinions expressed here are those of the authors and not those of Press Ganey or Premier, Inc.
References:
Burwell SM . Setting value-based payment goals – HHS efforts to improve U.S. health care. N Engl J Med. 2015;372(10):897–899. [Article] [PubMed]
Press M, Rajkumar R, Conway PH. Medicare’s new bundled payments: design, strategy, and evolution. JAMA. 2016;315(2):131–132. doi:10.1001/jama.2015.18161. [Article] [PubMed]
Oncology care model. CMS Innovation Center website. https://innovation.cms.gov/initiatives/oncology-care/. Accessed January 20, 2016.
McChrystal SA, Collins T, Silverman D, Fussell C . Team of Teams: New Rules of Engagement for a Complex World. New York, New York: Penguin Books; 2015.
TeamSTEPPS®: strategies and tools to enhance performance and patient safety. AHRQ website. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html. Accessed January 30, 2016.
Toward Accountable Care Consortium. Distribution based on contribution: a merit-based shared savings distribution model. TAC Consortium website. http://www.tac-consortium.org/wp-content/uploads/2013/09/Shared-Savings-Guide_091013_revised_reduced-file.pdf. Published 2013. Accessed February 11, 2016.
Mike Schweitzer, M.D., M.B.A., is Principal Population Health Chief Medical Officer for Bundled Payments –Premier Inc., Charlotte, North Carolina.
Mike Schweitzer, M.D., M.B.A., is Principal Population Health Chief Medical Officer for Bundled Payments –Premier Inc., Charlotte, North Carolina.
Mike Schweitzer, M.D., M.B.A., is Principal Population Health Chief Medical Officer for Bundled Payments –Premier Inc., Charlotte, North Carolina.
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Peggy L. Naas M.D., M.B.A., is Chief Medical Officer, Healthcare Performance Improvement, a Press Ganey Solution, Virginia Beach, Virginia. She is a Board-Certified Orthopaedic Surgeon.
Peggy L. Naas M.D., M.B.A., is Chief Medical Officer, Healthcare Performance Improvement, a Press Ganey Solution, Virginia Beach, Virginia. She is a Board-Certified Orthopaedic Surgeon.
Peggy L. Naas M.D., M.B.A., is Chief Medical Officer, Healthcare Performance Improvement, a Press Ganey Solution, Virginia Beach, Virginia. She is a Board-Certified Orthopaedic Surgeon.
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Table 1.
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Table 1.
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