WASHINGTON -- An alternative payment model gained endorsement from a body of policy experts tasked with helping the administration identify ways to shift physician payment from volume to value.
With one member absent, the Physician Focused Payment Technical Advisory Committee (P-TAC) voted 7-3 that Project Sonar, an "intensive medical home model" for targeting patients with inflammatory bowel disease (IBD), met the criteria to qualify as an advanced alternative payment model (APM) at a meeting on Monday.
The proposal now awaits a final decision from the U.S. Department of Health and Human Services.
The Project Sonar model reduces costs and improves care for patients with inflammatory bowel disease (IBD), by increasing patient engagement and leveraging evidence-based medicine, Lawrence Kosinski, MD, MBA, managing partner of the Illinois Gastroenterology Group (IGG) and president of SonarMD, in Chicago, told MedPage Today in a phone interview.
"Most of our savings have come from keeping patients out of the hospital. They're not only out of the hospital, they're keeping their colon; they're not having surgeries ... We really have positively affected their quality of life," he said.
New Payment Models
Advanced APMs represent one of two payment pathways for physicians under the Medicare Access and CHIP Reauthorization Act, which replaced the highly unpopular "sustainable growth rate" formula in 2015.
Under the default pathway, called the Merit-based Incentive Program, physicians are fined or given bonuses on top of a fee-for-service (FFS) structure. Physicians who belong to models that qualify as advanced APMs receive a lump sum 5% incentive payment from 2015 to 2019.
Instead of overlaying payments on a FFS framework, advanced APMs fundamentally alter the nature of physician payment, allowing dramatic changes to infrastructure and investment that previously weren't paid for, Harold Miller, P-TAC member and president and CEO of the Center for Healthcare Quality and Payment Reform (CHQPR) in Pittsburgh, told MedPage Today, last year.
Engaging Patients
Kosinski said that the project evolved from a partnership with Blue Cross Blue Shield of Illinois (BCBSIL). The insurer provided 2 years worth of claims data on roughly 21,000 patients. His group noticed that the high rate of hospitalizations was driven by patients who didn't recognize their conditions were worsening, and didn't contact their physicians.
Project Sonar, a web-based platform,"pings" patients the first work day of every month with five questions based on the Crohn's Disease Activity Index, such as "How many bowel movements have you had per day in the last 7 days?" and "Rate your abdominal pain," Kosinski explained.
Patients responses to these questions are coded into a symptom intensity score, or "sonar score." The nurse care manager, who receives the responses, reviews the numbers, then calls the patient if a score is poor. The nurse care manager also plugs information about that patient's status into health records to bring the physician into the conversation when necessary, Kosinski continued.
In an initial pilot study of the model involving 50 patients with Crohn's disease, hospitalizations dropped from 17% to 5%, according to the IGG proposal, which stated that "cost savings is highly correlated to patient engagement." The cost difference between patients who respond to at least half of their monthly surveys -- "pingers" versus "nonpingers" -- showed a cost differential of -18% versus +23%.
Patients who respond to the pings see $6,000 in annual savings for BCBSIL for a disease that averages $24,000 annually, Kosinski noted. Other estimates suggest Crohn's disease costs about $11,000-$19,000 annually.
Gaining Ground
The IGG and SonarMD submitted the Sonar Project to the P-TAC for review in December 2016. The committee initially returned the proposal, citing the limited scope of the project and a lack of adequate quality measures to drive changes in reimbursement.
However, once the group addressed those concerns, the proposed framework was given a green light, pending the HHS's decision.
The model received an approval for "limited implementation." Full implementation would have allowed any doctor in the country to start using the model, said Kosinki, which is not the group's intention at this time. However, criteria for "limited implementation" have not yet been defined, he noted.
About 600 physicians around the country are currently using the Sonar model, said Kosinski.
Physicians Respond
Crohn's disease and ulcerative colitis affect approximately 1.5 million people in the U.S., and IBD-related treatment costs $6.3 billion annually, according to the Digestive Health Physicans Association (DHPA), which endorsed the proposed model.
In a January letter to PTAC, Lawrence Kim, MD, chair of healthy policy for the DHPA, wrote that "[Project Sonar] is a powerful tool in improving our patients' quality of life and decreasing costs by reducing potentially avoidable complications, emergency department visits, and inpatient admissions. It fosters a true partnership between us as clinicians and our patients -- with a documented tripling of patient engagement to 75-80% over a 20-month study period."
The American College of Physicians (ACP) was also pleased by the PTAC's decision to endorse the Sonar model, albeit with limited implementation.
While the Sonar model is currently geared towards patients with GI-related conditions, Kosinski believes the same platform could be implemented in any practice type among primary care physicians or specialists.
Following a request from BCBSIL, his group are exploring a similar project that targets type 2 diabetes patients, with a focus on monitoring high HbA1c levels. The program will be deployed by primary care physicians in Illinois.
ACP members include internal medicine subspecialists in gastroenterology who could benefit from the model if it succeeds, said Shari Erickson, MPH, the ACP's vice president of governmental affairs and medical practice, in an email.
"We are hopeful that the PTAC will continue to review and approve models for use by internal medicine in order for our members to have greater opportunities to participate in advanced Alternative Payment Models under the Quality Payment Program," she wrote.
The committee also recommended the ACS-Brandeis model, an episode payment model from the American College of Surgeons and Brandeis University, to HHS for limited testing and for a set of specific conditions. The COPD and Asthma Monitoring Project (CAMP) was not recommended for testing.