The purpose of this page is to disseminate information related to specialty care payment model development efforts. This includes various aspects of care furnished by specialist practitioners, which external stakeholders have identified as opportunities to achieve better care, better health, and lower costs.
The Centers for Medicare & Medicaid Services (CMS) Innovation Center (Innovation Center) was established by §1115A of the Social Security Act (as enacted by §3021 of the Affordable Care Act) for the purpose of testing "innovative payment and service delivery models to reduce program expenditures...while preserving or enhancing the quality of care" for those individuals who receive Medicare, Medicaid, or Children's Health Insurance Program (CHIP) benefits. The Innovation Center uses this authority to test alternative payment models to incentivize care redesign, to engage and protect beneficiaries, and to learn and diffuse best practices to inform potential changes to the Medicare Fee-for-Service (FFS) program. More information on the Innovation Center is available here.
The Innovation Center launched this initiative to test new models of care that will focus on specific diseases, patient populations, and specialty practitioner care in outpatient or ambulatory care settings. These models would complement CMS' existing portfolio, which already includes models focusing on both primary care and inpatient hospitalizations as well as care in other settings.
CMS has contracted with the MITRE Corporation—operator of the CMS Alliance to Modernize Healthcare (CAMH) Federally Funded Research and Development Center (FFRDC)—to assess specialty payment model opportunities, convene Technical Expert Panels (TEPs), develop and conduct specialty payment model simulations, and provide the necessary technical, subject matter, and program management expertise for supporting the development of alternative payment models. To accomplish this task MITRE has assembled an integrated project team consisting of MITRE, the Brookings Institution, and the RAND Corporation.
The objectives for this task are (1) to perform an assessment of payment and service delivery model opportunities with input from the larger health care community, (2) to design parameters for model opportunities, and (3) to analyze the impact of potential payment model designs on Medicare spending. Simulations of the impact of these models will help identify those that are feasible for implementation and may have the greatest potential for improving health care quality and efficiency.
Technical Expert Panels (TEPs) are comprised of multidisciplinary groups of clinical, content, and methodological experts who provide individual contributions and expertise in defining populations, interventions, comparisons, or outcomes as well as identifying particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. The SPM TEPs offered insights into opportunities and alternative payment models for improved health care quality and the potential for lowering the costs of specialty care. These TEP meetings provided an opportunity for subject matter experts to assess key findings and issues identified through stakeholder interviews and a review of published literature, provide input on the potential impact of models across different settings, and to discuss potential payment and delivery models for further analysis. The TEPs do not provide advice or recommendations. For the SPM Initiative, TEPs were formed for three specialties—oncology, cardiology, and gastroenterology.
TEP stakeholders include representatives from the following arenas:
Oncology
The Brookings Institution convened a TEP meeting for oncology on November 20, 2013. A list of stakeholder participants can be found in Appendix A of the Specialty Payment Model Opportunities Assessment and Design, Summary of the Technical Expert Panel for Oncology, below. Other documents relating to the oncology TEP include the Slide Deck for the Oncology TEP and the Oncology Environmental Scan. The Brookings Institution also developed an analysis of other specialty areas that show promise for model development (see below Other Specialties and Model Opportunities Scan). Documents related to the oncology TEP and other specialties environmental scan are available below for download.
Cardiology
The Brookings Institution convened a TEP meeting for cardiology on April 8, 2014. A list of stakeholder participants can be found in Appendix A of the Specialty Payment Model Opportunities Assessment and Design, Summary of the Technical Expert Panel for Cardiology, below. Other documents relating to the cardiology TEP include the Slide Deck for the Cardiology TEP and the Cardiology Environmental Scan. Documents related to the cardiology TEP are available below for download.
Gastroenterology
The Brookings Institution convened a TEP meeting for gastroenterology on April 28, 2014. A list of stakeholder participants can be found in Appendix A of the Specialty Payment Model Opportunities Assessment and Design, Summary of the Technical Expert Panel for Gastroenterology, below. Other documents relating to the gastroenterology TEP include the Slide Deck for the Gastroenterology TEP and the Gastroenterology Environmental Scan. Documents related to the gastroenterology TEP are available below for download.
Neurology
The Brookings Institution conducted an environmental scan of alternative payment models (APMs) for patients with complex chronic neurological conditions to explore ways APMs might be used to improve the quality of care. While several alternative care models were identified through the literature review and stakeholder interviews, evidence for specific APMs in this area is limited. Therefore, this environmental scan explores existing alternative care models related to complex chronic neurological care and potential APMs that may successfully support them. A TEP was not conducted for this specialty.
Based on evidence from the environmental scans and feedback from the TEPs, the next steps of this initiative include payment model design and analysis of three specialties: oncology, cardiology, and gastroenterology.
Oncology
RAND led the analysis of a potential episode-based oncology payment model that incorporates care within oncology practices. The model is designed for potential testing in the traditional Medicare fee-for-service (FFS) program (Parts A and B). The details of the model have yet to be determined. The analyses in the Oncology Model Design Report are intended to support decision-making related to model design. In particular, this report focuses on analyses of Medicare claims data related to defining the initiation of an episode of chemotherapy, patterns of spending during and surrounding episodes of chemotherapy, and attributing episodes of chemotherapy to physician practices.
Documents related to the model design and analysis are available below for download.
Gastroenterology and Cardiology
RAND led the analysis and research related to the design of payment models for ambulatory gastroenterology and cardiology services for possible testing by the Innovation Center. Based on evidence from the environmental scans of gastroenterology and cardiology and feedback from stakeholder interviews and the TEPs, this report investigates the possible development of episode-based payment models for outpatient gastroenterology and cardiology procedures. The models would be designed for testing in the traditional Medicare fee-for-service (FFS) program (Parts A and B). The details of the models have yet to be determined.
For questions or comments related to any of these documents, please contact specialtycaremodels@cms.hhs.gov.
Upon completion of the model design report, the next step of this initiative included model simulation to estimate the impact of the payment model on treatment patterns, provider margins, and future Medicare expenditures. Model simulation was conducted for oncology.
Oncology
RAND led the development of the oncology simulation. The Oncology Simulation Report describes research related to the simulation of the possible effects of a payment model for specialty oncology services. This report builds on the methods and findings in the Oncology Model Design Report. This payment model is designed for potential testing in the traditional Medicare fee-for-service (FFS) program (Parts A and B).
For information about the CMS Oncology Care Model, please click here.
For questions or comments related to any of these documents, please contact specialtycaremodels@cms.hhs.gov.
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