ambulatory specialty model

Started by mille125
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mille125

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We talk about a lot of things on this forum some of which is mostly for thrills and reactions like much of the political forums. This ASM situation that is hitting us all in a little over three months in my opinion is one of the most important issues that we will face in the coming years. Anything that has a potential of a negative 12 percent loss of Medicare revenue is important. Even in a small solo practice like mine, a 12 percent loss of Medicare revenue is essentially the salary of an office manager. This should definitely be enough to get our attention.

I am usually one who is up on all of these things but I must admit that I am really at a loss as the what is actually going to be measured. It seems that 50 of 100 points go to quality and 50 of 100 points go to cost. There are negative only points for not communicating with the PCP (up to negative 20 points) and for not using your EMR effectively (up to negative 10 points). The are bonus points for complex patients (up to 10 points), small practices of 2-13 providers (10 points), and solo practices (15 points).

I have a very hard time figuring out what the details are. Quality for low back pain is made up of use of high risk meds, screening and followup plan for depression, BMI screening, and functional status change.

Cost is even less structured. I don't know how this is going to be factored but it would appear to me that if you are an ASC/HOPD doctor or do a lot of stims and minor surgeries that you are screwed here. In other words office only doc who uses only lyrica will have higher rating than office only doctor who does bread and butter procedures who has higher rating than ASC/HOPD doctor or those that do a lot of stims and other minor surgeries. Yet none of this is worked out.

If I have any of this wrong, please let me know. Interested to get thoughts on this really important item that I dont think gets enough discussion even with us being about 90 days away from it.
 
I’m not on the list, it appears will be updated yearly, but as another solo doc I feel your pain. Driving small practices out of biz will only drive up overall costs.

What if you are in a big ortho group and get a lot direct injections? You may be very busy but really doing the non operative management for 10 orthos etc

You are gonna be an outlier but really just efficiency. Should the orthos be injecting every knee or practice at the top of their training and be in the OR?

Every once in a while I consider supporting single payor but this is emblematic of why the govt shouldn’t be in charge. No one can foresee all the consequences of these decisions even if well meaning and the market should sort it out as much as possible.
 
It is pretty rough. Can’t get a epidural unless you get a mri through wiser. Get dinged for ordering a mri due to cost. I do implants for docs who just do trials. Am I expensive or is the doc who started that train the expensive one?
 
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nvrsumr said:
I’m not on the list, it appears will be updated yearly, but as another solo doc I feel your pain. Driving small practices out of biz will only drive up overall costs.

What if you are in a big ortho group and get a lot direct injections? You may be very busy but really doing the non operative management for 10 orthos etc

You are gonna be an outlier but really just efficiency. Should the orthos be injecting every knee or practice at the top of their training and be in the OR?

Every once in a while I consider supporting single payor but this is emblematic of why the govt shouldn’t be in charge. No one can foresee all the consequences of these decisions even if well meaning and the market should sort it out as much as possible.
Click to expand...
I think that they are just tracking episodes associated with LBP. Orthos (or pain docs) doing knee injections shouldn't matter. But yes, your point is well taken about the doc doing injections for a number of ortho/neuro docs.

There is very very little out there on how costs will be allocated. My NPI is listed twice because of my 2/5 HOPD arrangement and 3/5 own office arrangement.
 
BobBarker said:
It is pretty rough. Can’t get a epidural unless you get a mri through wiser. Get dinged for ordering a mri due to cost. I do implants for docs who just do trials. Am I expensive or is the doc who started that train the expensive one?
Click to expand...
Good question. Since it is a zero sum game and we are all measured against each other, I would assume that they would say that you are expensive compared to the trial guy.

You are right on one end they are saying limit MRIs and then on the other end they force your hand to order one.
 
I think accepting the status that we are trying to trim the fat and this is our budget is ludicrous.

The government blows tons of money on things and increases spending everywhere but when it comes to something that actually helps patients they want to cut every area as much as possible.

I am not on this list but we as physicians need to band together to fight back. **** hospitals, **** insurance companies and **** these cuts by the government.
 
mille125 said:
We talk about a lot of things on this forum some of which is mostly for thrills and reactions like much of the political forums. This ASM situation that is hitting us all in a little over three months in my opinion is one of the most important issues that we will face in the coming years. Anything that has a potential of a negative 12 percent loss of Medicare revenue is important. Even in a small solo practice like mine, a 12 percent loss of Medicare revenue is essentially the salary of an office manager. This should definitely be enough to get our attention.

I am usually one who is up on all of these things but I must admit that I am really at a loss as the what is actually going to be measured. It seems that 50 of 100 points go to quality and 50 of 100 points go to cost. There are negative only points for not communicating with the PCP (up to negative 20 points) and for not using your EMR effectively (up to negative 10 points). The are bonus points for complex patients (up to 10 points), small practices of 2-13 providers (10 points), and solo practices (15 points).

I have a very hard time figuring out what the details are. Quality for low back pain is made up of use of high risk meds, screening and followup plan for depression, BMI screening, and functional status change.

Cost is even less structured. I don't know how this is going to be factored but it would appear to me that if you are an ASC/HOPD doctor or do a lot of stims and minor surgeries that you are screwed here. In other words office only doc who uses only lyrica will have higher rating than office only doctor who does bread and butter procedures who has higher rating than ASC/HOPD doctor or those that do a lot of stims and other minor surgeries. Yet none of this is worked out.

If I have any of this wrong, please let me know. Interested to get thoughts on this really important item that I dont think gets enough discussion even with us being about 90 days away from it.
Click to expand...
Mille

Agreed

Where are you getting this info from ?
 
mille125 said:
Good question. Since it is a zero sum game and we are all measured against each other, I would assume that they would say that you are expensive compared to the trial guy.

You are right on one end they are saying limit MRIs and then on the other end they force your hand to order one.
Click to expand...
Worse than zero sum. They pay out in incentives only 85% of what they withhold in penalties.

I’m thankfully not in the first round. I’m unclear on how the cost attribution works but I thought the cost of each “episode” attached to every provider who treats that patient. So HOPD clinics will inherently be penalized. If I’m wrong about that though, the model includes every provider who treats at least 10 back pain episodes - every PCP in the country will be in the model and if cost only attaches to the performing doctor we will always be higher than every one of them.
 
Last edited:
Malayil said:
I think accepting the status that we are trying to trim the fat and this is our budget is ludicrous.

The government blows tons of money on things and increases spending everywhere but when it comes to something that actually helps patients they want to cut every area as much as possible.

I am not on this list but we as physicians need to band together to fight back. **** hospitals, **** insurance companies and **** these cuts by the government.
Click to expand...
Absolutely agree but the system sets us up in a fragmented way. Organized medicine only puts up tepid responses to this kind of stuff. A few of us stepping away doesn't move the needle. We would literally have to say that we are not seeing any medicare patients to move the needle on this.
 
PinchandBurn said:
Mille

Agreed

Where are you getting this info from ?
Click to expand...
Just trying my best to pull info from multiple sources. With that, I can find nothing about how 50% of this is going to be calculated (the whole cost section).

You can argue about the "quality measures". Is my quality better because I screen for and followup of depression and obesity and you dont? Really?
 
callmeanesthesia said:
Worse than zero sum. They pay out in incentives only 85% of what they withhold in penalties.

I’m thankfully not in the first round. I’m unclear on how the cost attribution works but I thought the cost of each “episode” attached to every provider who treats that patient. So HOPD clinics will inherently be penalized. If I’m wrong about that though, the model includes every provider who treats at least 10 back pain episodes - every PCP in the country will be in the model and if cost only attaches to the performing doctor we will always be higher than every one of them.
Click to expand...
I could be wrong but I thought that this only applied to specialists (hence ambulatory specialty model). I think that we are only up against anesthesiologists, orthos, neurosurg, PMR docs, and interventional pain. I don't know if they are comparing different specialties like neuro vs interventional pain. If they did that, you would think that the cost of neurosurgery is always going to be higher than an office based pain doc...but who knows. They wont say.

I do agree that HOPD and even ASC docs (or anyone generating a facility fee) are probably going to get penalized. There really is no way that an HOPD doc can beat an office doc on cost. Just look at an intralaminar ESI. Office is about $225. ASC is about $430. HOPD may be over $1000. The end goal of all of this may be to show that the quality of care between office and HOPD is identical and to then discontinue that site of service. That is likely one of the end games.
 
nvrsumr said:
I’m not on the list, it appears will be updated yearly, but as another solo doc I feel your pain. Driving small practices out of biz will only drive up overall costs.

What if you are in a big ortho group and get a lot direct injections? You may be very busy but really doing the non operative management for 10 orthos etc

You are gonna be an outlier but really just efficiency. Should the orthos be injecting every knee or practice at the top of their training and be in the OR?

Every once in a while I consider supporting single payor but this is emblematic of why the govt shouldn’t be in charge. No one can foresee all the consequences of these decisions even if well meaning and the market should sort it out as much as possible.
Click to expand...
Can someone please explain what this is?
Only some docs on a list ? How were you notified?
Do they penalize you for doing multiple procedures on multiple Medicare patients? So a lazy doctor or half time doctor won’t get dinged?
 
bedrock said:
Can someone please explain what this is?
Only some docs on a list ? How were you notified?
Do they penalize you for doing multiple procedures on multiple Medicare patients? So a lazy doctor or half time doctor won’t get ding
Click to expand...
it starts on 1/1/2027

google ambulatory specialty model...you will go to a page where you can put your name in...if you come up, you are in and its mandatory.

-9 percent to 9 percent from your medicare payments starting in 2029. The difference is that it follows your NPI. so you cannot change practices. It follows you whereever you go including the HOPD.

I cant answer your other questions because they don't say....just that 50 percent of your score is "cost"
 
How does the decrease in reimbursement multiplier work if you are part of a large group billing under the same ID? If we get +9% satisfying MIPs do they then selectively ding just me for treating back pain?

I imagine hospital employed pain doctors would cost the most, but the hospital is the one billing and collecting so it seems like they would be immune?
 
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Malayil said:
I think accepting the status that we are trying to trim the fat and this is our budget is ludicrous.

The government blows tons of money on things and increases spending everywhere but when it comes to something that actually helps patients they want to cut every area as much as possible.

I am not on this list but we as physicians need to band together to fight back. **** hospitals, **** insurance companies and **** these cuts by the government.
Click to expand...
ok but what does fight back mean? sending letters and showing up in DC? where has that gotten us?

the only option is to walk away from medicare. no other self respecting profession would accept what we have collectively accepted as physicians.
 
we had a practice meeting on this recently. we were also told that risk includes medications used and will also include medications that are high risk prescribed by other physicians. so an anxious little old lady getting a benzo from psych and tramadol or norco from PCP getting injections with you probably gets you dinged.

IPSIS was in DC recently pushing for this to be stalled at least until the questions posed above in other posts are resolved.

if I was in private practice and on this list I'd be looking at becoming a cash based doc.
 
Agast said:
How does the decrease in reimbursement multiplier work if you are part of a large group billing under the same ID? If we get +9% satisfying MIPs do they then selectively ding just me for treating back pain?

I imagine hospital employed pain doctors would cost the most, but the hospital is the one billing and collecting so it seems like they would be immune?
Click to expand...
it's all based on your NPI so it's individual.

my HOPD group is 15 (soon to be 16 docs). I think only like 10 of us are on the list. from a comp perspective in this situation I don't see it likely that I'll ever see a bonus for doing all this stuff and can certainly see us all taking a hit as a group.

I do believe the participants were chosen more on geographic region than by board certification now. initially I thought it was only board certified docs being included but I'm not sure that's accurate.
 
Agast said:
How does the decrease in reimbursement multiplier work if you are part of a large group billing under the same ID? If we get +9% satisfying MIPs do they then selectively ding just me for treating back pain?

I imagine hospital employed pain doctors would cost the most, but the hospital is the one billing and collecting so it seems like they would be immune?
Click to expand...
It's individual doctors. That is how this is different. If we are in the same group and you are plus 4 and I am minus 7, those rates are carried over to all of our encounters even if we change groups
 
DOctorJay said:
it's all based on your NPI so it's individual.

my HOPD group is 15 (soon to be 16 docs). I think only like 10 of us are on the list. from a comp perspective in this situation I don't see it likely that I'll ever see a bonus for doing all this stuff and can certainly see us all taking a hit as a group.

I do believe the participants were chosen more on geographic region than by board certification now. initially I thought it was only board certified docs being included but I'm not sure that's accurate.
Click to expand...
It's geographic region from what I can see
 
DOctorJay said:
we had a practice meeting on this recently. we were also told that risk includes medications used and will also include medications that are high risk prescribed by other physicians. so an anxious little old lady getting a benzo from psych and tramadol or norco from PCP getting injections with you probably gets you dinged.

IPSIS was in DC recently pushing for this to be stalled at least until the questions posed above in other posts are resolved.

if I was in private practice and on this list I'd be looking at becoming a cash based doc.
Click to expand...

Good question....what is high risk?

Do you think that people will limit Medicare patients or screen to reject "high risk" ones?
 
mille125 said:
Good question....what is high risk?

Do you think that people will limit Medicare patients or screen to reject "high risk" ones?
Click to expand...
I certainly think that's one way to game the system. you'd have to have someone screening all the medicare referrals coming in and possibly drop some of your existing patients to make that work.
 
My worry also is these Collaborative Care Arrangement. If we are in Private Practice and most PCPs are employed at hospitals. How the heck will that work? Their overlords will never allow us to colloborate with a Private doc...
 
PinchandBurn said:
My worry also is these Collaborative Care Arrangement. If we are in Private Practice and most PCPs are employed at hospitals. How the heck will that work? Their overlords will never allow us to colloborate with a Private doc...
Click to expand...
slide 24 from here

Collaborative Care Arrangement Use and Key Requirements11

This slide is a high-level summary of the ASM requirements for CCAs. Please refer to a list of the full requirements, (42 CFR, part 512, § 512.771) when developing CCAs..•

Broadly, CCA requirements include:
 Formal agreement. Maintain a written, signed, and dated ASM Participation Agreement with a PCP that shares at least one established patient with the ASM participant and is not excluded from Federal health programs.
 Purpose. Must be to advance clinical goals of ASM or further improvement activity performance.
 Relationship between parties. PCP participation must be voluntary without penalty for nonparticipation. Must preserve clinical independence of each party.
 Safeguards. Agreement must not limit medically necessary services or reward unnecessary utilization.
 Financial incentives, if offered under CCA, comply with additional requirements. May opt to offer financialincentives to CCA partners under CMS-sponsored model safe harbor if additional requirements are met, includingcomplying with payment cap and not linking payment to volume / value of referrals.
 
DOctorJay said:
slide 24 from here

Collaborative Care Arrangement Use and Key Requirements11

This slide is a high-level summary of the ASM requirements for CCAs. Please refer to a list of the full requirements, (42 CFR, part 512, § 512.771) when developing CCAs..•

Broadly, CCA requirements include:
 Formal agreement. Maintain a written, signed, and dated ASM Participation Agreement with a PCP that shares at least one established patient with the ASM participant and is not excluded from Federal health programs.
 Purpose. Must be to advance clinical goals of ASM or further improvement activity performance.
 Relationship between parties. PCP participation must be voluntary without penalty for nonparticipation. Must preserve clinical independence of each party.
 Safeguards. Agreement must not limit medically necessary services or reward unnecessary utilization.
 Financial incentives, if offered under CCA, comply with additional requirements. May opt to offer financialincentives to CCA partners under CMS-sponsored model safe harbor if additional requirements are met, includingcomplying with payment cap and not linking payment to volume / value of referrals.
Click to expand...
So what does tht mean? Just need one pcp for the entire practice or for each patient you have and their pcp...
 
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It’s designed to be difficult to navigate.. more penalties =less payouts .. meanwhile government fraud is at an all time high as well as other insurance fraud.. but you’re the bad guy for wanting to do an esi. Rules for thee and not for me..

This is what will push me back to anesthesia full time.. pain is fun when you can diagnose and treat and do what’s best.. but when everything is a struggle no thanks..and they will come for stim and reduce rfa to two mbs.
 
High-risk meds in older adults is based on MIPS Q238. Don't prescribe in 65+:

TCAs
Flexeril, methocarbamol, soma
piroxican, indomethacin, ketorolac

It's based on your prescriptions, not anyone else's.
 
mille125 said:
it starts on 1/1/2027

google ambulatory specialty model...you will go to a page where you can put your name in...if you come up, you are in and its mandatory.

-9 percent to 9 percent from your medicare payments starting in 2029. The difference is that it follows your NPI. so you cannot change practices. It follows you whereever you go including the HOPD.

I cant answer your other questions because they don't say....just that 50 percent of your score is "cost"
Click to expand...
thank you for explaining that
 
4 components to the score:
1. quality
2. cost
3. "improvement activities"
4. "promoting interoperability"

#3 and #4 are some sort of attestation. There isn't data reporting.

For #1 quality, these are the measures Claude pulled up which is consistent with our hospital:
#MeasureCollection type
Q238Use of High-Risk Medications in Older AdultseCQM or MIPS CQM
Q134Preventive Care and Screening: Screening for Depression and Follow-Up PlaneCQM or MIPS CQM
Q128Preventive Care and Screening: BMI Screening and Follow-Up PlaneCQM or MIPS CQM
Q220Functional Status Change for Patients with Low Back ImpairmentsMIPS CQM only
TBDExcess utilization measure, claims-basedto be determined in CY2027 rulemaking 1 Centers for Medicare & Medicaid Services Ambulatory Specialty Model (ASM) +4

Last one will probably be MRI.

For #2 cost, nothing to report. Supposedly there is a way to see how your data stacks now, but not sure how. Agree that I think it includes facility fees so I doubt there is a lot that can be done to adjust this.
 
bubaghanush said:
High-risk meds in older adults is based on MIPS Q238. Don't prescribe in 65+:

TCAs
Flexeril, methocarbamol, soma
piroxican, indomethacin, ketorolac

It's based on your prescriptions, not anyone else's.
Click to expand...
Interesting.

We were told it’s based on the 120 day episode of care and included all meds they are on regardless of who the prescriber is.

Not saying you’re wrong.
 
bubaghanush said:
High-risk meds in older adults is based on MIPS Q238. Don't prescribe in 65+:

TCAs
Flexeril, methocarbamol, soma
piroxican, indomethacin, ketorolac

It's based on your prescriptions, not anyone else's.
Click to expand...
But not hydrocodone....highest risk of them all

I guess my 65 yo PHN patient is no longer getting nortriptyline
 
bubaghanush said:
4 components to the score:
1. quality
2. cost
3. "improvement activities"
4. "promoting interoperability"

#3 and #4 are some sort of attestation. There isn't data reporting.

For #1 quality, these are the measures Claude pulled up which is consistent with our hospital:
#MeasureCollection type
Q238Use of High-Risk Medications in Older AdultseCQM or MIPS CQM
Q134Preventive Care and Screening: Screening for Depression and Follow-Up PlaneCQM or MIPS CQM
Q128Preventive Care and Screening: BMI Screening and Follow-Up PlaneCQM or MIPS CQM
Q220Functional Status Change for Patients with Low Back ImpairmentsMIPS CQM only
TBDExcess utilization measure, claims-basedto be determined in CY2027 rulemaking 1 Centers for Medicare & Medicaid Services Ambulatory Specialty Model (ASM) +4

Last one will probably be MRI.

For #2 cost, nothing to report. Supposedly there is a way to see how your data stacks now, but not sure how. Agree that I think it includes facility fees so I doubt there is a lot that can be done to adjust this.
Click to expand...
Yep..

Facilitiy fees, stims, or any surgeries are going to get you dinged in the cost area.

If the vast majority of dics in your geography are office based, asc/hopd docs are in trouble
 
bubaghanush said:
4 components to the score:
1. quality
2. cost
3. "improvement activities"
4. "promoting interoperability"

#3 and #4 are some sort of attestation. There isn't data reporting.

For #1 quality, these are the measures Claude pulled up which is consistent with our hospital:
#MeasureCollection type
Q238Use of High-Risk Medications in Older AdultseCQM or MIPS CQM
Q134Preventive Care and Screening: Screening for Depression and Follow-Up PlaneCQM or MIPS CQM
Q128Preventive Care and Screening: BMI Screening and Follow-Up PlaneCQM or MIPS CQM
Q220Functional Status Change for Patients with Low Back ImpairmentsMIPS CQM only
TBDExcess utilization measure, claims-basedto be determined in CY2027 rulemaking 1 Centers for Medicare & Medicaid Services Ambulatory Specialty Model (ASM) +4

Last one will probably be MRI.

For #2 cost, nothing to report. Supposedly there is a way to see how your data stacks now, but not sure how. Agree that I think it includes facility fees so I doubt there is a lot that can be done to adjust this.
Click to expand...

#3 is primarily your collaborative agreement with pcp and can get you -20 points.

#4 is primarily emr which most of us are already doing with MIPs
 
Another thing to keep in mind. Solo docs get 15 points and small practices get 10 points.


So the large PE backed or HOPD heavy interventional practices will be behind these practices.
 
bubaghanush said:
High-risk meds in older adults is based on MIPS Q238. Don't prescribe in 65+:

TCAs
Flexeril, methocarbamol, soma
piroxican, indomethacin, ketorolac

It's based on your prescriptions, not anyone else's.
Click to expand...
Methocarbamol is the least sedating muscle relaxant there is. Are we supposed to not give any muscle relaxers ever to a Medicare patient?

Are there any other meds on this list besides what you’ve shared there ?
 
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Agast said:
Sounds like the anesthesiologists are going to be staying anesthesiologists for a while
Click to expand...
I’m so glad I’m retiring in a few years. Ironically, I’m closing a deal tomorrow to do a lot of PI work my last few years. If that does as well as expected, I’ll just drop all federal insurance and only see commercial insurance and PI.

I actually like most of my Medicare patients but I have less and less patience for growing bureaucratic government interference in medical care, particularly when physicians are much smarter than the bureaucrats.

And these same idiot bureaucrats wonder why physicians retire earlier than they used to, leading to more underserved populations?
 
mille125 said:
Another thing to keep in mind. Solo docs get 15 points and small practices get 10 points.


So the large PE backed or HOPD heavy interventional practices will be behind these practices.
Click to expand...
Are more points better? Where did you find this.
 
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