Alternative Payment Models (APMs)

Asthma

Patient-Centered Asthma Care Payment (PCACP)

The Patient-Centered Asthma Care Payment (PCACP) model was developed by the American College of Allergy, Asthma & Immunology (ACAAI). It is designed to give asthma specialists and primary care providers the resources and flexibility they need to more accurately diagnose, treat, and manage patients with asthma and asthma-like symptoms.

The PCACP model would create two new flexible monthly payments for asthma specialists:

• a monthly Payment for Diagnosis and Initial Treatment that is designed to support evaluation, testing, diagnosis, treatment planning, and initial treatment for up to 3 months for a new patient with asthma-like symptoms, and
• a monthly Payment for Continued Care for Patients With Difficult-to-Control Asthma that is designed to support ongoing care for patients for whom asthma has not been successfully controlled after an initial period of treatment, or whose treatment regimens require close monitoring and management.

Both of these new payments would replace standard evaluation and management (E/M) payments during the months the patients are receiving the services.

In addition, for patients who have achieved control of their asthma following an initial period of treatment, both asthma specialists and primary care providers would be able to bill and be paid for non-face-to-face visits in addition to traditional E/M services in order to support continued successful care of the patients’ asthma.

More information about the APM:

• Patient-Centered Asthma Care Payment Design
• AMA Support Letter for PCACP
• CHQPR Support Letter for PCACP
• Results of PTAC Review of PCACP

Cancer

Patient-Centered Oncology Payment (PCOP)

Patient-Centered Oncology Payment (PCOP) was developed by the American Society of Clinical Oncology (ASCO). It is designed to enable medical oncology practices to function as a community-based “oncology medical home” that provides high-quality care to patients with most types of cancer.

Under PCOP, oncology practices would receive three types of Care Management Payments (CMP) in addition to current payments for office visits and administration of chemotherapy:

• a New Patient Payment to support diagnosis, treatment planning, and education for patients when they begin cancer care;
• a monthly Cancer Treatment Care Management Payment while the patient is receiving chemotherapy, to help the patient avoid and address complications of treatment, and
• a monthly Active Monitoring CMP to address the patient’s needs after treatment has been completed and during months in which no treatment is being delivered.

More information about the APM:

• Patient-Centered Oncology Payment Design (2015 Version)
• Patient-Centered Oncology Payment Design (2019 Version)
• PCOP Graphic Summary
• A Better Path to Value in Cancer Care
• Updates to the ASCO Patient-Centered Oncology Payment Model
• AMA Support Letter for PCOP

Making Accountable Sustainable Oncology Networks (MASON)

Making Accountable Sustainable Oncology Networks (MASON) was developed by Barbara McAneny, MD and Innovative Oncology Business Solutions, Inc. It is intended to provide oncology practices with adequate, flexible payments needed to support high-quality care for patients with cancer and to control the cost of cancer care.

MASON would create a set of Oncology Payment Categories (OPC), each of which defines a group of patients who have the same type of cancer, similar comorbidities, and similar treatment plans. A “target price” would be established for each OPC based on the expected costs of cancer-related care for patients with those characteristics. The oncology practice would have the flexibility to deliver services that are not adequately supported by fee-for-service payments as long as the total cost of care is within the target price.

In order to ensure the quality of care, the practice would be responsible for following evidence-based clinical pathways in the treatment of the patient.

More information about the APM:

• MASON APM Design
• AMA Support Letter for MASON APM
• PTAC Report on MASON APM

Chronic Conditions

Patient-Centered Payment for Care of Chronic Conditions

The Center for Healthcare Quality and Payment Reform (CHQPR) developed Patient-Centered Payment for Care of Chronic Conditions. It is intended to enable patients who have chronic conditions to receive high-quality care from a specialist when needed in addition to care from their primary care practice. Although every chronic disease is different, physicians face similar barriers in treating most chronic conditions under current payment systems, and these barriers could be resolved using this patient-centered payment approach.

Under Patient-Centered Payment for Care of Chronic Conditions, a specialist physician practice could receive the following payments to support diagnosis, care planning, and/or condition management services for an individual who has the symptoms of a chronic disease or who has been diagnosed with a chronic condition:

• A one-time Diagnosis Payment to support an accurate evaluation of the patient’s symptoms by the specialist. The specialist could also receive a Diagnostic Assistance Payment to help the patient’s primary care physician complete the diagnosis or determine whether a referral to the specialist is needed.
• A one-time Care Planning Payment to support the development of an evidence-based plan for treatment and management of the patient’s chronic condition by the specialist. A Care Planning Assistance Payment would also be available to enable the specialist to assist the patient’s primary care physician in developing a care plan.
• An Initial Condition Management Payment to enable the specialist and practice staff to provide initial treatment and management for the patient’s condition. Monthly Condition Management Payments would also be provided if the patient needs ongoing support from the specialist practice after the initial treatment period.

Each of the payments would be stratified based on the complexity of the patient’s needs, and the specialist would be accountable for delivering evidence-based services to the patient in return for the payments.

More information about the APM:

• Patient Centered Payment for Care of Chronic Conditions
• Executive Summary of Patient Centered Payment for Care of Chronic Conditions

Colonoscopy

Comprehensive Colonoscopy APM

The Comprehensive Colonoscopy APM was developed by the Digestive Health Network. It is intended to provide adequate, flexible payments to support high-quality screening colonoscopies, and to make the cost of colonoscopies more predictable and comparable.

Instead of separate payments for each individual service, a single bundled payment would be paid that covers all of the services required for a colonoscopy, including the physician performing the procedure, the facility where the procedure is performed, anesthesiology, radiology, and pathology. In addition, the payment would also have to cover the cost of any ED visits needed to evaluate complications that occur within 7 days of the colonoscopy.

More information about the APM:

• Comprehensive Colonoscopy APM Design
• Bundled Payment Framework for Colonoscopy

Emergency Medicine

Acute Unscheduled Care Model (AUCM)

The Acute Unscheduled Care Model (AUCM) was developed by the American College of Emergency Physicians (ACEP). It is designed to give emergency physicians the time and resources necessary to enable more patients to be treated and safely discharged to home rather than being admitted to the hospital.

The AUCM APM would be used for patients who come to an Emergency Department (ED) with a condition such as abdominal pain, chest pain, altered mental status, or syncope that often result in unnecessary hospital admissions. Under the APM, emergency physicians could be paid for transitional care management services to a patient prior to and following discharge, and for telehealth visits and home visits with the patient after discharge. The physician would be accountable for reducing the total cost of services delivered to the patients during the 30 days following discharge, including the cost of return ED visits and inpatient admissions.

More information about the APM:

• Acute Unscheduled Care Model Design
• AMA Support Letter for AUCM APM
• PTAC Report on AUCM APM
• Presentation on AUCM APM
• Video on AUCM APM
• Annals of Emergency Medicine Article on AUCM APM

End-Stage Renal Disease

Incident ESRD Clinical Episode Payment Model

The Incident End-Stage Renal Disease (ESRD) APM was developed by the Renal Physicians Association (RPA). It is designed to enable nephrologists to deliver high-quality care to patients who have advanced chronic kidney disease (CKD) and are beginning dialysis therapy. Many patients experience complications during the first few months of dialysis due to failure to prepare adequately for the transition and due to lack of care management support during the transition. The APM is intended to reduce the frequency and severity of these complications by enabling and encouraging improved services.

Under the Incident ESRD APM, a nephrologist would take responsibility for the total cost of services to a CKD patient during the six months following initiation of dialysis. If the nephrologist can reduce this cost through better preparation of the patient for dialysis or better care management during the initial months of dialysis, the nephrologist would receive a share of the savings.

More information about the APM:

• Incident ESRD Payment Model Design
• AMA Support Letter for Incident ESRD APM
• PTAC Report on Incident ESRD APM

Epilepsy

Patient-Centered Epilepsy Care Payment (PCECP)

Patient-Centered Epilepsy Care Payment (PCECP) was developed by the American Academy of Neurology. It is designed to give neurologists and primary care physicians the resources and flexibility they need to make accurate diagnoses and to deliver appropriate, cost-effective treatment for patients with epilepsy.

Patient-Centered Epilepsy Care Payment (PCECP) would replace current evaluation and management (E/M) services payments with flexible monthly payments that could be used to deliver a range of services to patients without the restrictions in the current fee-for-service system. Because epilepsy patients need different types of care during different phases of the diagnosis and treatment process, PCECP payments would be divided into nine categories corresponding to these different phases of care:

• 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 and treatment-resistant epilepsy;
• Non-surgical treatment for refractory/treatment-resistant epilepsy; and
• Surgery for epilepsy.

More information about the APM:

• Patient-Centered Epilepsy Care Payment Design

Headache

Patient-Centered Headache Care Payment (PCHCP)

Patient-Centered Headache Care Payment (PCHCP) was developed by the American Academy of Neurology. It is designed to give neurologists, primary care physicians, and other headache specialists the resources and flexibility they need to make accurate diagnoses and to deliver appropriate, cost-effective treatment for patients with headaches and migraines.

Because different services are needed by patients during different phases of their care, there would be three categories of PCHCP payments:

• Payment for Diagnosis and Initial Treatment for Patients with Symptomatic Headaches: The physician would receive a single, bundled payment to support evaluation, testing, diagnosis, treatment planning, and a 3-month period of initial treatment for a patient who is experiencing headaches and who is not currently receiving effective treatment for those headaches.
• Monthly Payments for Continued Care of Difficult-to-Manage Headaches: For patients with frequent or severe headaches that do not respond well to standard treatments, the physician managing the patient’s care would receive a monthly payment to support a combination of visits and monitoring to allow changes in treatment to be made and evaluated.
• Supplemental Payments for Continued Care for Well-Controlled Headaches: For patients with infrequent, low-severity, non-disabling headaches that are adequately addressed with symptomatic medications, the physician managing the patient’s care could be paid for non-face-to-face visits in addition to traditional E/M services in order to ensure rapid and effective response to patient problems and to enable coordination of headache care with care of the patient’s other conditions.

More information about the APM:

• Patient-Centered Headache Care Payment Design
• AMA Support Letter for Patient-Centered Headache Care APM

Inflammatory Bowel Disease

Project Sonar APM

The Project Sonar APM was developed by Lawrence Kosinski, MD. It is intended to support the delivery of effective care management services to patients with inflammatory bowel disease (IBD) and also to patients with other chronic conditions that have high rates of avoidable hospitalizations.

Under the Project Sonar APM, the physician practice managing the care of a patient with inflammatory bowel disease (or the chronic condition the practice is managing) would receive a monthly payment to support the cost of care management staff and a communications system that proactively contact patients to monitor their symptoms and intervene early to prevent or reduce the severity of disease exacerbations.

More information about the APM:

• Project Sonar APM Design
• AMA Support Letter for Project Sonar APM
• PTAC Report on Project Sonar APM

Ischemic Heart Disease

SMARTCare APM

The SMARTCare APM was developed by the American College of Cardiology and the Center for Healthcare Quality and Payment Reform. It is intended to enable patients with chest pain and other symptoms associated with heart disease to be accurately diagnosed and successfully treated while avoiding unnecessary tests and invasive procedures.

Under the SMARTCare APM, a team of cardiologists and other physicians and providers could receive three new payments for patients with suspected and diagnosed stable ischemic heart disease:

• Payment for Diagnosis, Evaluation, and Treatment of Stable Ischemic Heart Disease: The SMARTCare team would receive a single, bundled payment to support all of the costs associated with evaluation, testing, diagnosis, and treatment planning for patients with suspected stable ischemic heart disease. Higher amounts would be paid for patients with more risk factors and more severe symptoms.
• Payment for Initial Guideline-Directed Medical Therapy for Stable Ischemic Heart Disease: The SMARTCare Team would receive a monthly payment for up to six months to supervise Guideline-Directed Medical Therapy for a patient who has been diagnosed with new or worsened stable ischemic heart disease and who is either not appropriate for revascularization or who has chosen not to pursue revascularization at the current time. The monthly payment would replace evaluation & management (E/M) payments. Higher amounts would be paid for patients with more severe disease or symptoms and/or serious comorbidities.
• Payment for Continued Guideline-Directed Medical Therapy for High-Risk IHD Patients: The SMARTCare Team would receive a monthly payment to supervise continued Guideline-Directed Medical Therapy for patients who are at high risk of a myocardial infarction or who have refractory angina, but who are not candidates for revascularization or choose not to pursue revascularization.

More information about the APM:

• SMARTCare APM Design

Maternity Care

Maternity Care Alternative Payment Model

The Maternity Care APM was developed by the Center for Healthcare Quality and Payment Reform. It is designed to enable more women to deliver babies in birth centers rather than hospitals, reduce the frequency of Cesarean sections in low-risk births, support more extensive prenatal and postpartum care services for higher-risk women, and improve outcomes for both mothers and babies.

Under the APM, a Maternity Care Team would receive five different types of payments during the different phases of perinatal care:

• Monthly bundled payments for all pregnancy-related services needed prior to childbirth;
• A bundled/warrantied payment for labor and delivery services, regardless of whether the delivery occurs in a birth center or a hospital;
• A standby capacity payment for hospitals in the community to support the minimum capacity needed to offer labor and delivery services on a round-the-clock basis, particularly for high-risk pregnancies;
• Monthly bundled payments for all post-partum care services for up to six months; and
• Outlier payments for infrequent events and unusual circumstances that result in the need for more services or more expensive services.

The Maternity Care Team would receive no payment during a month or phase of care if the Team failed to provide all evidence-based care to the woman or if a “never event” occurred (i.e., death of the mother, unexpected death of the infant, or iatrogenic injury to the infant). Payments to the Team would be reduced if desirable outcomes (e.g., physiologic childbirth, successful breastfeeding) were not achieved during a particular phase of care.

More information about the APM:

• Maternity Care APM Design

Palliative Care

Patient and Caregiver Support for Serious Illness (PACSSI) APM

The Patient and Caregiver Support for Serious Illness (PACSSI) payment model was developed by the American Academy of Hospice and Palliative Medicine (AAHPM). It is intended to enable interdisclipinary palliative care teams to deliver community-based palliative care to patients with a serious illness.

Under the PACSSI APM, palliative care teams would receive monthly care management payments instead of payments for evaluation and management (E/M) services. Payments would be higher for patients with more functional limitations.

More information about the APM:

• Patient and Caregiver Support for Serious Illness APM Design
• AMA Support Letter for PACSSI APM
• PTAC Report on PACSSI APM

Primary Care

Patient-Centered Primary Care Payment

Patient-Centered Primary Care Payment is designed to provide adequate, flexible payments to primary care practices to support the three principal types of services they deliver: (1) wellness care, (2) chronic condition management, and (3) non-emergency acute care. Additional payments would be available to support the delivery of integrated behavioral health services.

Patient-Centered Primary Care Payment would have separate payments for each of these types of services in order to ensure that each patient can receive the combination of services they need and want, and also to ensure that primary care practices with different types of patients can be paid adequately for the specific types of services they need to provide:

• Monthly Payments for Wellness Care Management.
• Monthly Payments for Chronic Condition Management. Higher amounts would be paid for patients with a newly diagnosed or treated chronic condition and for patients with a complex condition.
• A Fee for Diagnosis and Treatment of a Non-Emergency Acute Event.
• Monthly Payments for Behavioral Health Services.

The practice would only receive monthly payments for wellness care and chronic condition management for patients who explicitly enroll with the practice to receive those services. The practice would continue to receive standard evaluation and management payments for non-enrolled patients, and it would continue to receive fees for delivering procedures and tests.

More information about the APM:

• Patient-Centered Primary Care Payment Design
• Executive Summary of Patient-Centered Primary Care Payment
• JAMA Article on Patient-Centered Primary Care Payment

Innovative Model for Primary Care Office Payment

This APM was developed by Jean Antonucci, MD, a solo family physician practicing in Farmington, Maine. It is intended to provide adequate, predictable, and flexible payments that support the delivery of high-quality services to patients by small primary care practices.

Under this APM, a primary care practice would receive a monthly payment for each patient that would support all of the primary care services that patient needs. A higher amount would be paid for patients at higher risk of poor outcomes as determined by the patient’s responses to the questions in the “What Matters Index” from the How’s Your Health patient-reported outcomes survey.

More information about the APM:

• Innovative Model for Primary Care Care Office Payment Design
• PTAC Report on Innovative Model for Primary Care Payment APM