Focusing on Physician Based APMS with Main Street Medical

Taking a closer look at Physician Focused APMs in MACRA

One major concern, as we make the shift over to value based care and the new Alternative Payment Models (APMs) under MACRA, is that the current seven payment models aren’t enough to cover all of the different situations that individual private practices and hospital managed practices face.  CMS has heard this concern and considered it valid, creating a vehicle for practices to submit their own customized APMs for approval.  

APMs for Physicians, By Physicians

To see why physician created APMs are so important, let’s take a quick look at the current or existing Alternative Payment Models.  Below you’ll find the seven current models listed.  While they cover a wide range of situations, they fail to cover the complex landscape of modern medicine completely.


Current APMs

  1. Payment for a High Value Service
  2. Warrantied Payment for Physician Services
  3. Multi-physician Bundled Payment
  4. Physician-Facility Procedure Bundle
  5. Condition Based Payment for Physician’s Services
  6. Episode Payment for a Procedure
  7. Condition Based Payment for all services related to a condition


As of September 19th, CMS has received 16 full proposals and 17 letters of intent from physicians and physician lead organizations who are submitting their physician based APMs for consideration and approval.  Many doctors associated with these groups have stated that the current initiatives, which are centered around team based penalties, won’t work.  This is because, during one patient care episode, many different people and/or teams of people are involved, which can lead to one aspect of a very multifaceted situation penalizing everyone involved despite quality and cost improvements being met.


How do you form a Physician Focused APM?

The following is a simplified description of the process.  For more detailed information on the process and the details outlined in each of the various phases, please click here.

Step 1: Formal Letter of Intent:

Stakeholders for the Physician Focused APM should write and submit a brief formal letter of intent to the Physician-Focused Payment Model Technical Advisory Committee (PTAC). This letter should describe the nature of the proposed plan. It should also include the expected date that the plan will be submitted.  The letter should be sent at least 30 days before the plan is to be submitted.  

The letter should also include the expected participants, and the intended goals for the plan, as well as an overview of the model, an implementation strategy and timeline.

Step 2: Payment Model Proposal

Now that the PTAC has formed the guidelines for the Physician Based Alternative Payment Models, and issued a request for proposals, physician groups may now submit formal proposals. You can review the guidelines and requirements for proposal submissions here.


Step 3: PTAC Reviews Proposals

Upon receipt of the proposal, a  subgroup from the PTAC will read through and review the proposal in its entirety and then submit change requests to the group of physicians submitting the proposal to ensure that it meets the standards and guidelines put forth by the PTAC.  This group will be formed within one week of the receipt of the proposal, ensuring that there is no member of this group with conflicting interests.


After the subgroup of PTAC members reviews the proposal, receives answers to their questions, runs a financial analysis and seeks any professional guidance necessary, the full committee will review the proposal.  This review will take place in the form of a public meeting.  The meeting will start with a check to identify any conflicts of interest, move on to the report from the subgroup who initially reviewed the proposal, open the proposal up for discussion and then deliver their decision.


Step 4: Submit Ruling to the Secretary of Health and Human Services

Upon the culmination of the full PTAC committee’s deliberation, the members will submit their comments and/or recommendation to the office of the Secretary of Health and Human Services. If the committee supports proposal, it will be posted within two weeks, otherwise, decisions will be posted within 30 days of their full review.   Proposals not recommended by the committee will be able to re-submit their request.  


Contact Main Street Medical Consulting to speak to one of our experts to get a more in-depth idea of today’s healthcare industry and how your practice can better navigate it and prosper.