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Academy Working to Develop Alternative Payment Models for Otolaryngology

The world of medical reimbursement is moving away from the traditional fee-for-service model toward other models, such as accountable care organizations (ACOs) and bundles. These new options will be explored today in the Miniseminar “New Payment Models: Effects on Otolaryngology Reimbursement.”

The session will be presented from 1:00 pm-2:00 pm today in Ballroom C4. It will be led by Rob Lorenz, MD, MBA, and Jane T. Dillon, MD, MBA, co-chairs of the AAO-HNSF Physician Payment Policy (3P) Workgroup, and include two additional speakers.

“This is important because the sustainable growth rate (SGR) fix passed on April 14 retires the SGR problem that has been around for decades,” Dr. Lorenz said. “Also written into the law is a five percent bonus for providers who participate in APMs (alternative payment models). This bonus, through CMS, will be available from 2019 to 2024.

“What is an APM? That is still to be determined, but otolaryngology, through the Academy, is working to develop potential models for our members. ACOs, which can be classified as APMs, tend to focus on areas of chronic disease, such as cardiovascular disease, diabetes, COPD, asthma, and obesity, and otolaryngology has struggled to find a place in the ACO structure. Ideally, participation in a clinical data registry would give the provider credit for participating in an APM, but CMS has yet to determine how different that type of participation would be from fulfilling Meaningful Use criteria.”

The AAO-HNSF Ad Hoc Payment Model Workgroup is studying procedure-based models, known as bundles, for otolaryngology. Most existing bundles in the market focus on high-cost procedures, such as joint implants, coronary artery bypass grafts, and spine surgery.

“Those are not as applicable for otolaryngology either,” Dr. Lorenz said. “So the overall concept is to see if the otolaryngologist can leverage his or her expertise around otolaryngology diseases, and then we will have a lot to offer in APMs. These will be disorders such as hoarseness, dizziness, hearing loss, obstructive sleep apnea, allergy, sinusitis, and upper respiratory tract infections.

“We have been in discussions with the Centers for Medicare and Medicaid Services (CMS) and the private-payer community, and we are looking actively at claims data from payers to look for areas of resource utilization that are not in line with our clinical practice guidelines.”

The two speakers in the session will discuss their work in developing bundles. Drew Locandro, MD, an otolaryngologist at Northwest ENT and Allergy Center, Atlanta, GA, has developed an all-inclusive bundle for outpatient surgery. Lance A. Manning, MD, an otolaryngologist in Springdale, AR, has worked on a state-administered retrospective bundle that looks at otolaryngologists’ total cost per tonsillectomy and rewards high-quality, low-cost providers, while penalizing high-cost providers.

A 2015 poll of AAO-HNS Members found that 83 percent of respondents want to learn more about alternate payment models, Dr. Lorenz said. Members were asked to share their experiences with these models earlier this year through ENTConnect.

“We are proposing a model through which otolaryngologists will work with the payer community to look for areas of inappropriate resource use. An example might be automatically imaging patients who present to the emergency department with acute onset vertigo,” he said. “We are proposing a very innovative model and looking for the payer community to see the value otolaryngologists bring to diseases that have large overall spends, but relatively low otolaryngology charges within those diseases.”