To Cut is to Cure: The Surgeon's Role in Improving Value (original) (raw)

The ACS-Brandeis Advanced Alternative Payment Model (A-APM) is a new approach to physician-focused payment for Medicare and other payers. This model is designed to make sense to clinicians. It provides for specific and meaningful clinical contexts (episodes) that are needed to make inferences about quality and cost. Clinicians' involvement in care for each patient is identified and acknowledged in a structure of shared accountability for quality and cost outcomes. This level of precision is applied to a large majority of Medicare spending, which means that most clinicians in most specialties could practice as Qualified Participants (QPs) in an advanced APM environment. ACS-Brandeis APM P a g e | 6 program, assignment of quality tiers will be determined by performance using a composite score of the applicable quality measures. Exhibit 2: Quality Requirements by Category for Procedural Episodes in Surgery During Transitional Phase of the Program *(Measures reported on 50% of all patients involved in APM Episodes including at least 1 outcome measure) B. Cost 1) Leveraging the Episode Grouper for Medicare (EGM) The model is designed to deploy the CMS Episode Grouper for Medicare (EGM) within a single or multi-payer environment in order to create an efficient array of procedural and condition episodes. These episodes define the resource use of numerous clinical providers within teambased care systems for a given period of time, and can be used in payment models by applying two-sided (upside/downside) risk payments, consistent with MACRA regulations. The episode grouper calculates risk-adjusted cost targets or expected resource use for each patient in each episode. These cost targets are then compared to actual resources used at the point Quality Tier All-Patient Based Quality Category (MIPS Measures) Episode-Based Quality Category (Surgical Phases of Care) Unacceptable Failure to meet minimum reporting threshold* Failure to meet minimum reporting threshold* Acceptable Meets minimum reporting threshold* + Reports at least 2 MIPS measures including 1 outcome measure Meets minimum reporting threshold* + Reports measures for at least two surgical phases of care, including at least one outcome measure + Demonstrates ability to collect PROMs in at least one episode for 10% of patients Good Meets minimum reporting threshold* + Reports at least 6 MIPS Measures or a Specialty Measure Set Acceptable + Demonstrates ability to collect PROMs in at least one episode for 50% of APM patients Excellent NA Good + Scores in the top decile of performance for at least one measure ACS-Brandeis APM P a g e | 7 ACS-Brandeis APM P a g e | 10 Other clinicians might provide supporting and ancillary roles such as consultations and tests. In time, the patient might experience an AMI (acute exacerbation) or undergo a revascularization procedure, which would trigger their own (nested) episodes with the requisite team-based care. Responsibility for appropriate care for such a family of episodes or a "line of service," is the proper domain of the CAG, which in this example would include PCPs, cardiologists, radiologists, surgeons and surgical teams affiliated with an entity participating in the ACS-Brandeis model.