WASHINGTON — The Physician-focused Payment Model Technical Advisory Committee (PTAC), the group tasked by Congress with reviewing payment models, voted not to recommend two separate wound care models on Monday.
While these specific models may not be ready for “prime time,” Jeffrey Bailet, MD, PTAC chair, an otolaryngologist and executive vice president of Blue Shield of California, stressed that wound care models are indeed a priority.
“There’s a disconnect today between the way the payment is delivered and the care that’s needed and that’s a barrier to providing the care … So, what we know is there’s more work to do,” he said.
Bailet, and the full committee, urged stakeholders to collaborate on a more robust, comprehensive model for the committee to review.
Therapists’ Role in Wound Care
The “Upstream Model” was one of those panned by the committee in a 9-1 vote, with one abstention.
The core concept of the Upstream Model is to reimburse physical therapists and occupational therapists (PT/OT) in free-standing, private outpatient clinics for effective wound care treatment, which, in part, can help to overcome barriers to access.
David Van Name, CEO of Alabama-based Upstream Rehabilitation where the model originated, noted that the distance between his own clinic and the closest community hospital is 35 miles — quite a distance for Medicare beneficiaries to travel, he said.
“They won’t do it,” Van Name said.
Under the model, primary care physicians would refer patients to the PT/OT, who would be reimbursed standard Medicare payments plus a $250 one-time fee for wound supplies. Participating PT/OTs would have to repay Medicare when patients do not achieve “minimally significant clinical improvement.” On the other hand, PT/OTs could receive performance bonuses for keeping costs per episode below a risk-stratified threshold over the study period. Therapists would be put on probation if they exceed the risk-stratified cap in one quarter period or if patient satisfaction scores dip below 80% over two quarters.
Grace Terrell, MD, vice chair of the PTAC, an internist and CEO of Envision Genomics, said it was difficult for her to vote against the model but did anyway “because I wanted a bigger win.”
If the Center for Medicare and Medicaid Innovation (CMMI) didn’t see the potential in this model, then the concept of a wound care-focused model could “die.”
“This may be the one rare case where the perfect is the friend of the good,” echoed Len Nichols, PhD, director of the Center for Health Policy Research and Ethics at George Mason University.
Nichols told MedPage Today after the meeting that the model he envisions is a “patient-specific episode [model] that’s consistent with the clinical condition of the patient” and in which payment is risk-adjusted accordingly.
“So, you might have a different bundle for each different … classification, but … there’s a risk adjuster to take care of all that or should be theoretically.”
While waiting for “the nirvana of optimal wound care” Nichols also would like to see immediate action in fixing payment codes in the physician fee schedule, he said during the meeting, and an urgent effort to expand access to wound care in rural areas.
“Think about rural tomorrow afternoon,” he told MedPage Today.
Kavita Patel, MD, MPH, a primary care internist at Johns Hopkins Medicine in Baltimore, also highlighted the problem of “undervalued codes” in the fee schedule and their potential to limit access to innovation for beneficiaries.
Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, and the only committee member to vote in favor of the Upstream model, said he was “disappointed” it did not advance.
The model’s flaws could be resolved with simple changes — for example, narrowing the eligibility — and he worried that a risk-adjusted, total-cost-of-care model might not work in areas where access is a problem. A “one-size-fits all” model could take longer and “not achieve quick results,” he said.
Encouraging Outpatient Wound Care
The PTAC also voted 11-0 against recommending the “Seha Model,” from Seha Medical and Wound Care, although one member backed its “referral for attention” to HHS.
The Seha Model involves a flat payment rate per visit of $400 for nearly all services (with exceptions for services such as hyperbaric oxygen therapy and physical therapy) delivered in the outpatient setting.
Physicians would thus be incentivized to provide more treatment in outpatient settings which is more convenient for patients and less costly to the healthcare system and patients.
Ikram Farooqi, MD, who submitted the model, said hospitals typically charge patients a roughly 20% copay for facility fees. Facing these out-of-pocket costs, patients may delay care, with consequences that include infection and hospitalization — “eventually costing both the patient and Medicare many times more,” he wrote in his proposal.
He also underscored problems in the way Medicare pays doctors for outpatient wound care. For example, a physician can only charge for one service during a single visit — such as debridement of a wound or compression therapy, but not both.
The PTAC’s preliminary review team agreed that the issue of site-specific payments for wound care is a problem.
On average, the “Medicare- allowed charge” for an office based visit is $95, while at an outpatient facility payment climbs to $413 between the facility charge and the provider payment, the review noted. The group noted that currently 75% of wound care occurs in the clinical setting, but it was difficult (given the scarcity of data) to see clear differences between the types of care provided in each setting.
Lacking in the proposal, however, was a cap on the number of visits a clinician could accrue (which could lead to an inflated number of visits), or risk adjustments for patients with more severe or complex needs. The reviewers worried that clinicians might “cherry-pick” less expensive patients. Patients in lower-cost settings might not receive the complete care they need, or be referred to a hospital setting when necessary.
The team also mentioned that the proposal was “under-developed” with regard to “quality assurance, coordination of care, evaluation methodology, and health information technology.”
After the negative vote, PTAC members agreed to write a letter to the HHS Secretary highlighting both models and the group’s broader concerns about wound care payment.
CMMI Chief Drops In
In between sessions, CMMI Director Adam Boehler paid the committee a visit. He described a few models recently launched by the center, including one focused on appropriately paying ambulance transport teams, regardless of whether or where they take patients, as well as an updated Medicare Advantage Value-Based Insurance Design Model, and a new Medicare Part D model. He called these models “the opening act” with more to come.
As for the PTAC, “their work has been invaluable in informing us and driving our models,” Boehler said.
PTAC will next meet again in June.