In these Alternative Payment Models, participating entities are accountable for quality and total cost of care for a broad population of patients
Feb. 7, 2025 (ACP) -- The American College of Physicians recently offered guidance to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) as it reviews Population-Based Total Cost of Care (PB-TCOC) models and drafts recommendations to the Secretary of Health and Human Services (HHS).
PB-TCOC models are Alternative Payment Models (APMs) in which participating entities assume accountability for quality and TCOC and receive payments for all covered health care costs for a defined population, according to Dejaih Johnson, ACP manager of regulatory affairs. “Strengthening PB-TCOC models provides an important opportunity to improve clinical quality and reduce health inequities while controlling rising costs,” she said.
The PTAC, she explained, is an independent federal advisory committee that makes recommendations to the Secretary of HHS on physician-focused payment models and related topics. “It is intended to play an essential role in advancing value-based care,” she said.
The Center for Medicare and Medicaid Innovation has set the goal of having every Medicare fee-for-service beneficiary with Parts A and B in a care relationship with accountability for quality and TCOC by 2030.
In response to a Request for Information from PTAC, Dr. Leslie F. Algase, chair of the ACP Medical Practice and Quality Committee, notes APMs that are “designed with physicians at the core have proven critical in transitioning toward value-based care. However, progress has been hindered by fragmented implementation across regions and payers, as well as an enduring reliance on fee-for-service structures that often undermine efforts to reward value and efficiency.”
Successful PB-TCOC models must prioritize comprehensive and coordinated care, meet the needs of patients with chronic conditions, reduce disparities in care and fully integrate specialty care into accountable care frameworks, Algase writes in the Dec. 20, 2024, letter. “Additionally, scalability and flexibility are essential to accommodate the diversity of practice types, geographic locations and resource availability, particularly for rural and small practices,” she states.
In response to a question from the committee about necessary components of PB-TCOC models, Algase states, “To address challenges related to downside risk, ACP recommends designing arrangements with risk corridors, stop-loss provisions and phased-in requirements to protect physicians from financial harm caused by factors beyond their control, such as patient noncompliance and social drivers of health.”
Algase adds in the letter: “Thoughtful risk adjustment and aligned incentives will ensure that PB-TCOC models can alleviate financial concerns and promote wider participation from physicians.”
She pointed to a 2020 ACP letter regarding physician-focused payment models and urged the committee to “prioritize models that 1) fill the current void of models for specialty care internal medicine physicians, particularly those that are scalable across a range of specialties; 2) encompass a significant portion of payments and/or patients; 3) improve continuity of care across settings; and 4) offer predictable, fixed payments.”
Moving forward, ACP offered guidance about improving the current portfolio of value-based payment models to address “significant gaps.”
“Specialty care clinicians are often underrepresented, resulting in fragmented care and missed opportunities for comprehensive management of complex conditions,” Algase writes. “Furthermore, many models lack the scalability and resources necessary to support small and rural practices, discouraging their participation in value-based care initiatives.”
In addition, “the lack of real-time, interoperable data sharing across practices and care settings also creates barriers to effective care coordination and performance measurement,” she writes.
In the letter, ACP calls for more on-ramps for model participation, especially for small and rural practices, and flexible payment structures that account for the unique challenges of small and rural practices.
“Future models should prioritize expanding multispecialty and multipayer approaches to streamline participation and align incentives,” Algase adds in the letter.
PTAC “makes comments and recommendations to the Secretary of HHS on the extent to which proposed models meet criteria established by HHS for physician-focused payment models, focusing on aspects such as payment incentives, costs, care delivery and quality, beneficiary choice and information availability,” Johnson explained. “The secretary reviews these comments and recommendations and includes them in a detailed report to the agency to inform decision-making.”
Johnson added: “ACP has long envisioned a health care system where value-based payment programs incentivize collaboration among clinical care team members and put the patient at the center of care. ACP strongly believes that a health system that puts patients' needs first and supports physicians and their care teams is best situated to deliver high-value patient- and family-centered care.”
Back to the February 7, 2025 issue of ACP Advocate