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   RE: opportunity for imps Please respond?
 From: Peter Liepmann
 To: Member Forum
 Posted: 05-30-2017 21:41
 Message: Hi Jean,

Let me repeat, this is a terrific idea.  How far have you gotten on writing it up?  I can help on that...
I suggest you/we borrow liberally from the AAFP APM.   I emailed them about this, and they said there was no problem--

"Dear Dr. Liepmann,
I am responding to your email, below, in which you asked if the AAFP proposal to PTAC could be quoted with attribution. I apologize for the delay in my reply.
The AAFP proposal to PTAC is on the PTAC web site. As such, it is a publicly available document at this point. You and others are free to quote it with attribution, just like any other document that is readily available to the public.
I hope that this answer is helpful, despite the delay in my response. Please let me know if you have other questions or if I may be of further assistance. We appreciate your membership in the AAFP!
Kent J. Moore | Senior Strategist for Physician Payment
American Academy of Family Physicians"

FWIW, the AAFP APM puts the primary care capitation at 12% of the expected MCR total, (About $9000 PMPY, so primary care capitation would be ~$90 PMPM)  risk adjusted similar to the CPC+ (though CPC+ payments are much lower. )AAFP used MIPS to quality adjust some part.   You could substitute HYH- (more later.)
They also address issues like attribution, etc., etc.
(Your 'back-of-the-envelope' calculations putting reasonable payments at $1/day put you in competition with professional actuaries who can predict expenses much better than we can.  Current MCR pays something like 4% ($33pmpm) to 6% ($55pmpm.) We should rely on the AAFP expertise regarding a fair payment for primary care.)

You mentioned somewhere "finding 5000 patients"- there's no need for that, and I think you should open it up to any primary care doc with more than ~30 MCR patients- that's about the number needed to manage the risks of adverse selection (especially considering you're going to get paid about 3X what Medicare pays now.)
So-since AAFP did the homework and made a terrific proposal, take advantage of it.  We can make a new APM submission that exactly duplicates the AAFP APM, and just change a few parts.

Those should be-
  • Pay monthly capitation at 4.8% of average total cost for all patients, plus 7.2% of HCC risk adjusted expected total cost, recalculated on a continuous monthly basis as claims (and new diagnoses) are received.
  • Use HYH for all quality measurement- there needs to be some explanation of how HYH numbers (eg, for cholesterol, HBA1c, etc.,) match very closely w the lab, other measures assess accessibility and communication, and patient confidence is a very good predictor of a number of important outcomes, so essentially, it includes an outcome measure.  (There's justification for using HYH under Comparable Quality Measures in the Final Rule II (F) 4 (b) 2.)  It's been submitted to NQF and won honorable mention.  (Having IMP  'approve' HYH as a quality measure might help too.)
  • Make an additional payment of $2 pmpm conditional on reporting HYH data and being at least one SD above the mean of historical comparison (baseline) clinic practices.  Paid concurrently, and reduced for the next year if quality not acceptable.
  • For practices with over 100 Medicare patients, compare total spending of the population vs. a CMS projection of expected cost for those members.  
  • Make an additional payment of $3 pmpm conditional on achieving savings vs. projected costs. Paid concurrently, and reduced for the next year if total costs not acceptable.  Amount increasing to $4 in 2019, and $5 in 2020 and later, per final rule.
  • Use the same list of "primary care services" as HHS uses in the CPC+ program.
  • Other services paid FFS.
  • Optionally, include outpatient behavioral health services in office, for additional $5 pmpm.
  • Each 'APM Entity' is an Advanced APM.  There is no need to combine multiple practices.
  • Empanel patients as in CPC+ or via a specific non-billed code on a claim. This could be combined with billed codes. Diagnoses for risk calculation would be taken from the empaneling claim.  If there were too many diagnoses to fit on one claim, diagnoses from multiple claims could be combined, as well as billed codes from all providers. E.g., patient has admission for CHF, not with primary doctor- CHF would be added to the patient's diagnoses used for risk calculation. 

Other comments, documentation:

If  you're doing FULL capitation on a free-ranging MCR population, 5000 is certainly enough to smooth out variations, but you'd still need risk limitation for the very rare, very very high cost patient.
I strongly suggest primary care stay away from full capitation-it means we have to ACTIVELY manage other spending, which is a big logistical task.

Primary care costs don't vary as much as total cost, according to NIHCM (see slide 4)
By that measure, the variability of Office-based care is about 60% the variability of the total cost
                        Top 1%        Top 10%   ratio
Total                   $98k           $28 k        3.5
Office-based       $10,700     $5,000      2.15   (about 60%, thus the 7.2 and 4.8% numbers above.)

HHS (in the MACRA rules) didn't specifically mention primary care capitation (blind spot,)   BUT the implication was that just being at risk for supplying all PRIMARY care would not be enough.
An APM would be more acceptable to HHS if primary care had money 'at risk' for both quality and total cost.  The AAFP APM proposal strongly shied away from total cost risk, but my reading of the final rule is that the APM either has to be an expansion of a PCMH from a section 1115 demonstration, OR put money at risk.  It may be that PTAC considers all APM models going through them to be 'Medical Home models expanded under Section 1115A(c)', and if so, it would not be required to put money at risk.  Note however, the way I've written it; this is extra money, ....

In the final MACRA rules, They specify what they require for a "Medical Home Model."  There is a LOT of dancing around what the various laws require, but I think I've found the relevant sections:

"An Advanced APM must, by statute, meet certain requirements, and we are finalizing policies for these requirements within this section. First, the broad category of APMs is defined at section 1833(z)(3)(C) of the Act, which states that an APM is any of the following:
(i) A model under section 1115A (other than a health care innovation award);
(ii) the Shared Savings Program under section 1899;
(iii) a demonstration under section 1866C; or
(iv) a demonstration required by federal law."

(To make a very long story shorter, the broadest umbrella is the "demonstration required by Federal law")
I found such under the Medicare Modernization Act (MMA)  specifically,
Section 646 -- Medicare Health Care Quality Demonstration Program =CMS023618
Section 648(a) -- Demonstration Project for Consumer-Directed Chronic Outpatient Services. =CMS1198948  which has no end date.  Both say "the Secretary must..."            Otherwise you need to be in an ACO ("SharedSavings")--blech. Unless CMS considers all the models under PTAC to be under section 1115A(c).

"We are finalizing our proposal that an APM that is considered a demonstration required by Federal law is one that meets the following 3 criteria:
(1) The demonstration must be compulsory under the statute, not just a provision of statute that gives the agency authority, but one that requires the agency to undertake a demonstration;
(2) there must be some "demonstration" thesis that is being evaluated; and
(3) the demonstration must require that there are entities participating in the demonstration under an agreement with CMS or under a statute or regulation.

Second, to be considered an Advanced APM, an APM must meet all three of the following criteria, as required under section 1833(z)(3)(D) of the Act. The criteria are:

  • The APM must require participants to use CEHRT;
  • The APM must provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS;
  • The APM must either require that participating APM Entities bear risk for monetary losses of a more than nominal amount under the APM, or be a Medical Home Model expanded under section 1115A(c) of the Act. For a discussion of Medical Home Models under this criterion, see section II.F.4.b.(6) of this final rule with comment period."


2) Comparable Quality Measures  II (F) 4 (b) 2

The second criterion for an APM to be an Advanced APM is that it provides for payment for covered professional services based on quality measures comparable to measures under the performance category described in section 1848(q)(2)(B)(i) of the Act, which is the MIPS quality performance category. We interpret this criterion to require the APM to incorporate quality measure results as a factor when determining payment to participants under the terms of the APM....

The statute also established priorities for both the quality domains of measures to be developed and the types of measures to be prioritized in the measure development plan, which are located, respectively, at sections 1848(s)(1)(B) and (D) of the Act. The priority measure types include outcome, patient experience, care coordination, and measures of appropriate use of services such as measures of overuse.

We wanted to ensure that APMs have the latitude to base payment on quality measures that meet the goals of the APM and assess the quality of care provided to the population of patients that the APM participants are serving. It is important to note that many APMs include some common measures that are proposed for inclusion in MIPS. For example, many of the quality measures used in the Shared Savings Program and the Next Generation ACO Model are also proposed for inclusion in MIPS.

However, APMs that focus on patients with specific clinical conditions such as end-stage renal disease (ESRD), or on patients undergoing specific surgical procedures, would have valid reasons for including different quality measures than those that target more general populations. Similarly, some APMs may focus on specialist eligible clinicians for whom there may be only a small number of valid and relevant quality measures. Lastly, we cannot predict the specific care goals and payment designs of future PFPMs and other APMs. Consequently, we did not want to impose measure requirements that would prevent us from including quality measures that may be better suited to the specific aims of new innovative APMs.

We proposed that the quality measures on which the Advanced APM bases payment must include at least one of the following types of measures provided that they have an evidence-based focus, and are reliable, and are valid:

(1) Any of the quality measures included on the proposed annual list of MIPS quality measures;

(2) Quality measures that are endorsed by a consensus-based entity;

(3) Quality measures developed under section 1848(s) of the Act;

(4) Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act; or

(5) Any other quality measures that CMS determines to have an evidence-based focus and be reliable and valid.

We believe that quality measures that are endorsed by the National Quality Forum (NQF) would meet these criteria. Because each APM Entity is different, there needs to be the flexibility to determine which measures are most appropriate for use in their respective APM for the purpose of linking those measures to payment under the APM. Measures that could be used in both MIPS and APMs are beneficial to eligible clinicians who may switch from one program to the other, but we also do not want to restrict APMs from including new innovative measures that may not be included in MIPS initially, or until later years of the program."

"(5) Measures for Inclusion

Under section 1848(q)(2)(D)(v) of the Act, the final annual list of quality measures must include, as applicable, measures from under section 1848(k), (m), and (p)(2) of the Act, including quality measures among:
(1) Measures endorsed by a consensus-based entity;
(2) measures developed under section 1848(s) of the Act; and
(3) measures submitted in response to the "Call for Quality Measures" required under section 1848(q)(2)(D)(ii) of the Act.
Any measure selected for inclusion that is not endorsed by a consensus-based entity must have an evidence-based focus. Further, under section 1848(q)(2)(D)(ix), the process under section 1890A of the Act is considered optional."

Peter Liepmann MD FAAFP MBA
My mission is to fix US health care
Bakersfield CA
Original Message:
Sent: 05-17-2017 09:59
From: Michael Safran
Subject: opportunity for imps Please respond?

It might be easier to put in proposal what IS included in Capitation, as opposed to what is not.  So less need (incentive) to use all the codes many of us have become adept at using to make a living.
In addition, there is now some incentive to primary care doctors to offer even more comprehensive care and provide some of the services that patients are referred to Urgent Care, Specialists, etc.

E/M:  99201-99205,  99211-99215
Preventative codes:  99381-99387,  99391-99397
Weight loss management,
depression screen
AWV  /  Welcome to medicare:
Hospital transition:
Home Health Care orders:
Waived labs:
Immunization admin
(I am sure there are other codes I have overlooked that are appropriately apart of capitation and some may disagree with.    Others may want to make additions to this list and add the actual codes.)

Anything / everything else is still FFS.  ie: 
GYN / Pap  - this is a difficult one.   Politically probably still better to reimburse for this.
laceration repair
minor fracture codes
I and D
meds, injectables
? All other CPT codes that do not start with 9****

NO copay / deductible at primary care.   Incentivizes  patients to start with primary care.   That should save CMS lots of money.


Michael S. MD
Original Message:
Sent: 05-17-2017 08:44
From: Kathy Saradarian
Subject: opportunity for imps Please respond?

I still think you should ask for more.?? Even so, it will be a cost savings for Medicare by a lot.?? But if they approve less you will never get more.
--  Kathy Saradarian, MD Solo since 2003 Always Private, Small Group since 1990 Practice Partner since 2003 Branchville, NJ

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