Sept. 8, 2016
AGA met with CMS officials to highlight the importance of including GI specialty alternative payment models under MACRA.
AGA leaders Larry Kosinski, MD, MBA, AGAF, clinical councillor, AGA Institute, and Joel V. Brill, MD, AGAF, AGA CPT advisor, met with high ranking officials from CMS and the Center for Medicare and Medicaid Innovation to advocate for the inclusion of specialty alternative payment models (APMs) in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). AGA asked CMS that GI payment models that demonstrate positive clinical and fiscal results, such as Project Sonar, be recognized as a Clinical Practice Improvement Activity (CPIA) and represent a path to qualify as an APM in 2018.
CMS issued a proposed rule on MACRA in April 2016 and we anticipate the final rule being issued sometime this fall. However, in the proposed rule, the criteria for qualifying as an advanced APM was extremely limited and would not allow most specialty models to qualify as currently written, which is not consistent with congressional intent.
Dr. Brill provided an overview of AGA’s bundle and episode payment models for gastroenterological issues, including colonoscopy screening and surveillance, gastroesophageal reflux disease, viral hepatitis, and obesity, to help gastroenterologists prepare for success in the new value-driven reimbursement environment. These APMs reward providers for identifying efficiency gains, effectively coordinating care and improving quality. Dr. Brill stressed to CMS officials that gastroenterologists who participate in these risk-bearing models covering at least 50 percent of Medicare beneficiaries should be eligible as a qualified APM under MACRA.
Dr. Kosinski highlighted the importance of population health, value-based payments and patient engagement under APMs. Project Sonar, founded by Dr. Kosinski and built on AGA IBD quality measures, is an intensive medical home developed in conjunction with Blue Cross and Blue Shield of Illinois, which demonstrated that use of patient engagement tools can result in significant reduction in unnecessary emergency department visits, inpatient hospitalizations and costs of care, while improving medication adherence and health outcomes for patients with Crohn’s disease.
Drs. Brill and Kosinski stressed that Project Sonar has components similar to the CMS Oncology Care Model, including care pathways for proactive management of the patient, medication reconciliation and appropriate use, a monthly management fee tied to results, and downside risk. Given these similarities, Project Sonar and other GI payment models that demonstrate these results should be recognized as a CPIA and represent a path to qualify as an alternative payment model in 2018.
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AGA continues to advocate on behalf of gastroenterologists to policy makers and provide the tools and payment options necessary to be prepared for the implementation of MACRA and help maximize earning potential under this new payment system.