The Centers for Medicare & Medicaid Services (CMS) continues to face a string of challenges in trying to attract more fee-for-service medical practices to Medicare’s accountable care organizations (ACOs) and other value-based purchasing arrangements.

“Value-based purchasing programs link provider payments to improved performance by healthcare providers. This form of Payment holds healthcare providers accountable for both the cost and quality of care they provide,” CMS said last week in a press release touting the success of its most popular ACO, the Medicare Shared Savings Program. ACOs are groups of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated care to Medicare patients, and CMS has set a goal of getting 100% of traditional Medicare beneficiaries to be part of an ACO or other accountable care relationship by 2030.

To move more providers in this direction, the agency has developed a variety of what it calls “alternative payment models” (APMs), including ACOs, episode of care-based payments, and bundled payment arrangements like the comprehensive joint replacement Model.

Primary Care-Focused Models

A recent survey by the Medical Group Management Association (MGMA), which represents medical practices, found that 79% of respondents said that Medicare does not offer a clinically relevant advanced APM for their specialty, despite most expressing interest in one. The survey, which drew 208 responses out of about 3,500 MGMA members who sign up to receive survey questions, isn’t a scientific one, said Anders Gilberg, MGA, the association’s Senior Vice President for government affairs. (Disclosure: Gilberg is a member of the MedPage Today editorial board.) However, he added, “this response is not inconsistent with other surveys we’ve done on the same topic … We do a regulatory burden survey every year and I think we’ve asked similar questions,” and gotten similar responses.

So why aren’t more groups signing up? Specialty groups say one reason is that the payment models that CMS has developed so far are focused mainly on primary care.

“Since the inception of Medicare value-based care programs more than a decade ago, there is still a paucity of alternative payment models available for specialty physicians, including neurosurgeons,” Katie Orrico, senior vice president for health policy and advocacy at the American Association of Neurological Surgeons/ Congress of Neurological Surgeons, said in an email. “Year after year, our professional associations have urged CMS to collaborate with the physician community to develop specialty APMs, to no avail. Instead, the agency is doubling down on a one-size-fits-all approach to value-based care, focusing on primary care, chronic care management, and large ACOs.”

Problems With PTAC

Another issue revolves around the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Created by Congress in 2015, PTAC’s mission was to hear proposals from physician groups for APMs and decide which ones to recommend to HHS and CMS for possible adoption. However, although the PTAC has considered more than three dozen models and recommended several, not one has been adopted by HHS.

“Unfortunately, it will likely take another act of Congress to make the PTAC relevant,” Orrico said. “It is mystifying why CMS has ignored the work of the PTAC, which has vetted and sent several potentially viable APMs to CMS for review and implementation. Snubbing these PTAC-blessed models makes a mockery of the countless hours and significant financial resources the medical specialty societies have devoted to developing these APMs and has thwarted progress in moving Medicare to a more value-based care program.”

Gilberg agreed that it was concerning that the models PTAC recommended haven’t been adopted. “If we’re really going to transition away from fee-for-service, we need to have clinically relevant ACOs for practices to transition into,” he said. “What we run into a lot is that the federal government is pushing down solutions that practices aren’t finding work well with existing value-based contracts with commercial payers, and are not available to certain specialties outside primary care.”

The lack of success to date of the PTAC process and adoption of physician-focused APMs is complicated, said Susan Dentzer, MS, president and CEO of America’s Physician Groups, an organization of physician groups committed to value-based care. She noted in a phone interview that congressional supporters of PTAC, and groups whose models were not adopted into the Medicare program, have previously directed their anger at prior HHS secretaries, but now they’re focused more on CMS and on Elizabeth Fowler, PhD, JD, who runs the Center for Medicare & Medicaid Innovation (CMMI).

“Liz, to her great credit, has taken a lot of opportunities to meet with PTAC and the people who are proposing physician-focused models, and listen to them,” Dentzer said. “But she, CMS, and HHS are still subject to those criteria that HHS devised for when a model has enough evidence that it should be incorporated into Medicare or tested further by CMMI … and basically none of these physician-focused payment models have really cleared the criteria.”

In contrast, CMMI has created APMs for some specialties and procedures — oncology, kidney care, and joint replacement, for example, she added. “And now CMMI and CMS have put out an RFI [request for information] about creating new payment episodes and bundles. Should they be mandatory or voluntary? Should the agency create medical or surgical bundles or both? They’re trying to get feedback from the broader community over what to do.”

The American Medical Association said it is pleased that CMMI is trying to create more of these types of APMs. “It is encouraging … that CMMI is planning to develop and implement new episode-based payment models,” wrote James Madara, MD, the AMA’s executive vice president and CEO, in an August 16 letter to CMS. “However, we urge CMMI to be more transparent about the models it is developing than in the past, and to provide ample opportunities for involvement by practicing physicians during both the design and implementation phases.”

Taking Time to Get It Right

PTAC’s role should probably shift away from recommending specific models, said Aisha Pittman, MHP, senior vice president of government affairs at the National Association of ACOs (NAACOS), in a phone interview. “We know that approach doesn’t work,” she said. “I do think it is useful to leverage the PTAC as a stakeholder group where CMS can potentially take ideas that they have heard and are thinking about models [for] and use the PTAC to get more input on them.”

PTAC also could address some difficult challenges with the existing models, like, “how do we bring specialists into ‘total cost of care’ arrangements?” she said. “I think that’s the right role for them — let’s pick off a few different issues and have some multi-stakeholder input on how we can resolve these issues rather than defining new models.”

Pittman added that when the Medicare Access and CHIP Reauthorization Act went into place in 2018, “they put [financial] incentives for adoption of value-based care into the statute, but those only lasted 6 years because the thought was that at the end of those 6 years, we’ll be at 60% adoption of APMs. But we’re not there yet. I think the important lesson is, it’s a lot harder to do than we once thought. It’s harder on so many levels. It’s harder to design the models right, so that there’s an opportunity for clinicians to be successful while also remaining adequately paid. It’s also harder for clinicians to implement the models … that just takes time.”

CMS could not respond by press time to a request for comment on its efforts to attract more physicians to APMs.