What is the purpose of the Physician-Focused Payment Model Technical Advisory Committee (PTAC)?
In 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) authorized new ways for the federal Medicare program to pay physicians for the care they provide to Medicare beneficiaries. These new ways include the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MACRA also created incentives for physicians to participate in APMs, and it specifically encouraged the development of certain types of APMs referred to as physician-focused payment models (PFPMs).
To encourage stakeholders to engage in the development of PFPMs, Congress also enacted section 101(e)(1) of MACRA, which created the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The statutory mission of PTAC is to make comments and recommendations to the Secretary of the Department of Health and Human Services (HHS) on proposals for PFPMs submitted to PTAC by individuals and stakeholder entities. The Secretary is required by MACRA to review PTAC’s comments and recommendations on submitted proposals and post a detailed response on the Centers for Medicare & Medicaid Services (CMS) website.
What are APMs and PFPMs?
After the passage of MACRA, APMs were defined in federal regulations at 42 CFR § 414.1305 as any of the following:
- A payment model under section 1115A of the Social Security Act (other than a health care innovation award).
- The shared savings program under section 1899 of the Social Security Act.
- A demonstration under section 1866C of the Social Security Act.
- A demonstration required by federal law.
PFPMs also were defined in federal regulations at 42 CFR § 414.1465 as an Alternative Payment Model:
- In which Medicare is a payer;
- In which eligible clinicians that are eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act are participants and play a core role in implementing the APM's payment methodology; and
- Which targets the quality and costs of services that eligible professionals participating in the Alternative Payment Model provide, order, or can significantly influence.
Federal regulations at 42 CFR § 414.1305 define “eligible clinicians” as an “eligible professional” as defined in section 1848(k)(3) of the Social Security Act, as “identified by a unique TIN and NPI combination and, includes any of the following:
- A physician.
- A practitioner described in section 1842(b)(18)(C) of the Act.
- A physical or occupational therapist or a qualified speech-language pathologist.
- A qualified audiologist (as defined in section 1861(ll)(3)(B) of the Act).”
Section 1848(k)(3) of the Social Security Act defines “eligible professional” as any of the following:
- A physician.
- A practitioner described in section 1842(b)(18)(C). [(C) A practitioner described in this subparagraph is any of the following:
- A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)).
- A certified registered nurse anesthetist (as defined in section 1861(bb)(2)).
- A certified nurse-midwife (as defined in section 1861(gg)(2)).
- A clinical social worker (as defined in section 1861(hh)(1)).
- A clinical psychologist (as defined by the Secretary for purposes of section 1861(ii)).
- A registered dietitian or nutrition professional.]
- A physical or occupational therapist or a qualified speech-language pathologist.
- Beginning with 2009, a qualified audiologist (as defined in section 1861(ll)(3)(B)).
Who are the members of PTAC?
MACRA required that PTAC be composed of 11 members appointed by the Comptroller General of the United States and that these members include individuals with national recognition for their expertise in PFPMs and related delivery of care. The individual members of the PTAC, their expertise, and terms of appointment are listed on the Members tab of ASPE’s PTAC website. The Chair and Vice Chair of PTAC are appointed by HHS.
How does PTAC conduct its work?
In addition to being governed by its authorizing statute (MACRA), PTAC is governed by the Federal Advisory Committee Act (FACA) and FACA regulations which require PTAC to conduct all of its deliberations in public meetings, to provide advance notice of its meetings to the public at least 15 days prior to the meeting, and to meet other FACA requirements for “openness” and transparency.
In accord with these governing rules, PTAC has created policies and procedures to solicit, review, and make comments and recommendations on submitted proposals to the Secretary of HHS. They address how individuals and stakeholders can submit proposals for review by PTAC, and how PTAC will review proposals and make recommendation to the Secretary. These policies and procedures are contained in:
In implementing these policies and procedures, PTAC is supported by staff from the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in HHS. MACRA requires ASPE to provide technical and operational support to PTAC and requires the Office of the Actuary of the Centers for Medicare & Medicaid Services to provide actuarial assistance to PTAC as needed. Members of the public can communicate with PTAC through ASPE’s PTAC email address: PTAC@hhs.gov.
When does the Committee meet?
Public meetings are typically held quarterly, although the timing of meetings may be modified based on the volume and nature of the proposals received and to ensure efficient and effective proposal review. Advance notice of all public meetings is published in the Federal Register. Additionally, announcements about public meetings are made through the PTAC listserv. Materials for upcoming meetings can be found on the PTAC website.
Where will these meetings be held, and may the public attend?
Meetings are generally held in the Washington, D.C. metro area in or near the HHS Humphrey Building, 200 Independence Avenue S.W., Washington, D.C., 20201.
All meetings are open to the public. Registration is encouraged as space is limited and to allow ASPE staff to best plan for meeting logistics. Meeting registration information is available through the Federal Register notice and on the PTAC website. Questions about PTAC meeting registration can be submitted by email to PTAC@hhs.gov.
Additionally, the Committee meets non-publicly for administrative and planning purposes. These administrative sessions are used to prepare for public meetings and to make decisions about the operations and processes of the Committee. These meetings are not and will not be used to discuss proposals or to make decisions regarding recommendations on proposals submitted to the Committee.
How may the public receive information about upcoming PTAC meetings and activities?
The public can receive communications and news about PTAC by signing up for the PTAC listserv.
Is there a process for members of the public to make comments during a public PTAC meeting?
Members of the public may indicate during the meeting registration process if they would like to sign up to make a public comment. Public comments can be made in person, on the phone, or sent by email after the meeting to PTAC. Instructions will be provided before each meeting.
Where can the public find information about past meeting materials and presentations?
Meeting materials for all past meetings are posted on the PTAC website.
What is the role of non-physician stakeholders in the PTAC process?
Although it is likely that the majority of models submitted will come from physician groups, PTAC invites the submission of payment models from all eligible professionals. PTAC also believes that non-physicians (e.g., beneficiaries, consumer advocates, and other health professionals) can contribute very useful insights on all submitted models. PTAC also welcomes multi-stakeholder input and invites public comment on all of its processes. PTAC values the knowledge of all individuals invested in the health care system as it works to evaluate and recommend PFPMs.
Where can the public find resources for the development of payment model proposals?
PTAC recognizes that individuals and stakeholders may benefit from support in the proposal development process. The Resources tab of the PTAC website includes a number of documents intended to provide guidance to those submitting payment model proposals. PTAC also recommends that interested parties subscribe to the PTAC listserv so that they may be informed about PTAC webinars, data sources or other resources as they are made available.
Who may submit a payment model?
PTAC welcomes the submission of proposals for PFPMs from a variety of stakeholder groups. Any individual or organization may submit a proposal, and there is no limit on the number of proposals stakeholders may submit.
When can stakeholders submit payment model proposals to the Committee?
Proposed payment models submitted to PTAC must be preceded by a Letter of Intent (LOI). PTAC receives LOIs on an ongoing, 24/7 basis. LOIs are non-binding and must be received at least 30 days prior to the submission of the full model proposal. LOIs expire after six months.
What information must be included in an LOI?
A template LOI is available on the PTAC website along with instructions for uploading a LOI on to the PTAC submission site (See the Guide for Uploading LOIs and Proposals to PTAC’s Submission System).
Where can submitters obtain instructions on how to submit proposals?
PTAC’s Proposal Submission Instructions are available here. For instructions on uploading proposals to the PTAC submission site, review the Guide for Uploading LOIs and Proposals to PTAC’s Submission System. These documents are the official instructions for the development and submission of proposals.
Is there an opportunity to ask questions/clarification on the instructions prior to proposal submission?
Members of the public are welcome to submit questions regarding the submission of proposals to PTAC@hhs.gov. PTAC also has provided instructions and clarifications on submitting proposals in two webinars which can still be viewed by the public:
- A webinar, “How to Submit to the Physician- Focused Payment Model Technical Advisory Committee” took place on Wednesday, November 16, 2016 and was hosted by PTAC Members Dr. Kavita Patel and Harold Miller. This webinar described how to submit a proposal to PTAC, the information requested in a proposal submission, and the estimated timeline of PTAC’s review process. Click here to view an archived recording of this webinar.
- A second webinar, “How to Submit a Proposal to PTAC: Clarifications and Tips for Submitters” took place on February 27, 2017 and was hosted by PTAC Members Harold Miller and Robert Berenson, MD. This webinar reviewed the proposal submission process, addressed common questions that individuals have asked regarding proposals, and highlighted the characteristics of strong proposals. Click here to view an archived recording of this webinar.
Any future webinars (and how to register for them) will be communicated to the public through the PTAC listserv and website. Registrants will receive a link to a recording of each webinar following completion of the event.
What do stakeholders need to know about proprietary or confidential information when submitting a model to PTAC for a Physician-Focused Payment Model?
Proprietary information is information that has been created by or is in the possession of an organization or entity and is kept internal to that organization/entity (i.e., not generally shared with external parties) because the organization/entity believes it must keep the information confidential to safeguard its competitive advantage in the marketplace. Proprietary data or information may be protected under copyright, patent, or trade secret laws.
Confidential information is information that an organization or entity has agreed not to disclose to other parties except under specific circumstances. This can include protected health information or data that has been obtained under a data use agreement that limits the ways in which it can be used.
Sometimes proprietary or confidential data is shared with another party under a legal agreement wherein the party who receives the proprietary or confidential data agrees to use it to the mutual benefit of both parties and to not further disclose it to a third party.
PTAC believes that proposals for PFPMs that are submitted to PTAC should not (and do not need to) contain proprietary or confidential data that cannot be shared with the public. The reasons for this are:
The Federal Advisory Committee Act (FACA) requires FACA committees to practice “openness.” PTAC is a FACA committee and is thereby required by law to conduct its business in a manner that is transparent and fosters public access to materials PTAC receives, reviews, develops, or uses in its deliberations. The FACA statute requires that,
Information requested by PTAC as part of a proposal submission for a PFPM does not require the inclusion of confidential information; information that is protected under copyright, patent, or trade secret laws; or information that would threaten the competitive position of a submitting organization.
PTAC seeks to approve models for uptake by multiple parties as opposed to a model for use by only one submitting party. The goal of PTAC’s recommendation of a model to the Secretary is that HHS would test and implement the model across other providers and patients. Indeed, a model, by definition, is a prototype or example for use by others.
“Subject to section 522 of Title 5, United States Code [The Freedom of Information Act] the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or other documents which were made available to or prepared for or by each advisory committee shall be available for public inspection . . . until the advisory committee ceases to exist.”
PTAC adheres to these requirements and seeks to make its work as transparent and open as possible. PTAC does not want to make a recommendation regarding a PFPM based on information that the public is not permitted to see. Further, PTAC believes that the input of all types of stakeholders — consumers and their advocates, clinicians and practitioners, health care organizations, health plans and insurers, and purchasers and regulators — will ensure that the information used by PTAC in making its recommendations is as accurate and complete as possible. Because of this, PTAC intends to post on its website for public comment all PFPM proposals that it receives in order to foster openness and transparency, and effective, balanced reviews of submitted proposals.
PTAC’s Proposal Submission Instructions identify the types of information that PTAC requests in order to evaluate the merits of a proposed PFPM. In all circumstance the information requested is aggregate information; i.e., information about a patient or provider population. No practitioner or patient-level data is requested; this protects the confidentiality of both.
In order for HHS to test (and PTAC to recommend) a model, PTAC and HHS will need to know information that is salient to the workings of the model. Similarly, other health care providers who seek to participate in a test of the model will need to understand the features of the model that affect its workings and effectiveness. Withholding salient information from participants testing the model would undermine the effectiveness of the testing, if not make a test of the model impossible. Because of this, submitters need to be prepared to share with PTAC, HHS, and other health care providers the relevant information on how the model works and any essential data and information needed to understand the working and effects of the model.
Questions about this PTAC policy can be directed to PTAC@hhs.gov.
How will the Committee determine whether to recommend a payment model proposal?
As directed by MACRA, PTAC reviews proposed models and prepares comments and recommendations to the Secretary of HHS using criteria for PFPMs established by the Secretary. These criteria were established in federal regulations (at 42 CFR 414.1465) and are as follows:
• Value over volume: Provide incentives to practitioners to deliver high-quality health care.
• Flexibility: Provide the flexibility needed for practitioners to deliver high quality healthcare.
• Quality and Cost: PFPMs are anticipated to improve health care quality at no additional cost, maintain health care quality while decreasing cost, or both improve health care quality and decrease cost.
• Payment methodology: Pay APM Entities with a payment methodology designed to achieve the goals of the PFPM criteria. Addresses in detail through this methodology how Medicare and other payers, if applicable, pay APM Entities, how the payment methodology differs from current payment methodologies, and why the Physician-Focused Payment Model cannot be tested under current payment methodologies.
• Scope: Aim to either directly address an issue in payment policy that broadens and expands the CMS APM portfolio or include APM Entities whose opportunities to participate in APMs have been limited.
• Ability to be evaluated: Have evaluable goals for quality of care, cost, and any other goals of the PFPM.
• Integration and Care Coordination: Encourage greater integration and care coordination among practitioners and across settings where multiple practitioners or settings are relevant to delivering care to the population treated under the PFPM.
• Patient Choice: Encourage greater attention to the health of the population served while also supporting the unique needs and preferences of individual patients.
• Patient Safety: Aim to maintain or improve standards of patient safety.
• Health Information Technology: Encourage use of health information technology to inform care
PTAC begins this review by using subcommittees called Preliminary Review Teams (PRTs). PRTs are typically composed of three PTAC members̶, at least one of whom is a physician. All PRT members must provide written declarations that they have no conflicts of interest with respect to the proposal under review and that they possess no other threats to their impartiality.
It is the job of PRTs to bring before the full PTAC a preliminary analysis of the proposal under review and any additional information that the full PTAC may need to evaluate the proposal. Frequently, PRTs send written questions to the submitter of a proposal to ensure that the PTAC is able to fully understand the proposal under review. PRTs also hold follow-up conversations with submitters as needed to obtain any further needed clarifications. PRTs also may:
• Commission quantitative analyses of Medicare data to understand the targeted patient population(s), clinical condition(s), providers and / or expected impact of the proposed models;
• Commission qualitative analyses of certain aspects of a model (such as a proposed intervention to improve care) that may be a part of a proposed model;
• Obtain consultation from clinical experts on the condition(s) that a proposed model is aiming to address;
• Obtain information on aspects of current Medicare programs that intersect with the proposal under review; and
• Obtain actuarial consultation on the implications of a proposed model.
PRTs also review any comments on the proposal submitted by the public. They are assisted in their analyses by ASPE staff.
Once PRTs have gathered all needed information, they write a report to the full PTAC on the PRT’s assessment of the extent to which the proposal meets the above criteria promulgated by the Secretary in regulations at 42 CFR § 414.1465. While the PRT’s report is very helpful to the PTAC’s review and deliberations, it is important to note that:
• The PRT report is a preliminary report from three PTAC members to the full PTAC. The PRT report does not represent the consensus or position of the full PTAC.
• The PRT report is not binding on the full Committee. PTAC may reach different conclusions from those contained in the PRT report.
• The PRT report is not a report to the Secretary. PTAC will write a new report that reflects the deliberations and decisions of the full PTAC. This new PTAC report will be sent to the Secretary.
PRTs may also provide initial feedback to the submitter in advance of sending a report to the full PTAC on the extent to which the proposal meets the Secretary’s criteria. However, PRTs are not permitted to provide technical assistance to submitters on how to improve their models.
Once the full PTAC receives the PRT’s report and all accessory information gathered by the PRT, the full PTAC conducts its review and deliberations at a public meeting. At the public meeting PTAC evaluates the extent to which proposed models meet these criteria, and PTAC’s conclusions regarding this are the basis of its comments and recommendations to the Secretary. Like the PRT process, all PTAC members must provide written declarations that they have no conflicts of interest with respect to the proposal under review and that they possess no other threats to their impartiality. Any such risks are reviewed by the full PTAC before PTAC deliberations on a proposal, and members may recuse themselves from voting, deliberation, or both as determined by PTAC. PTAC’s bylaws contain extensive provisions detailing how potential conflicts of interest and threats to impartiality are to be addressed.
How long does PTAC’s review process take, and are there opportunities for submitters to respond to reviewer questions/clarifications?
In general, proposals need to be submitted at least 16 weeks in advance of a PTAC public meeting in order for the Committee and its PRTs to complete all of the steps necessary to review and evaluate the proposal at that public at meeting. PTAC will seek to review and act on all proposals as quickly as possible, but the time necessary to evaluate a proposal is affected by the volume of proposals received and the completeness of those proposals.
Upon receipt, proposals are reviewed for completeness and adherence to submission requirements spelled out in PTAC’s Proposal Submission Instructions. Proposals that are incomplete or non‐adherent will be returned to the submitter with an explanation of what is missing or non-adherent and advised of the opportunity to address these issues.
If a proposal is complete, the individual or entity that submitted the proposal may be invited to respond to questions or provide additional information as requested by a PTAC PRT.
If a proposal is not recommended, can the decision be appealed?
PTAC has no appeals process with respect to its recommendations to the Secretary. However, submitters may revise and resubmit their proposals based on initial feedback from PTAC, issues identified by PTAC during its public deliberations on the proposal, or both.
Is there an opportunity for public comments on submitted proposals?
Once a proposal has been received and is found to be complete, it is posted on the PTAC website for public review. Members of the public may file written statements on all such proposals. All such written statements should be sent to the Designated Federal Officer for PTAC at PTAC@HHS.gov. These public comments are available to PTAC members as they review and deliberate on proposals. Comments on proposals also are posted on the PTAC website for viewing by the public.
Members of the public may also publicly comment on proposals at all meetings of PTAC during which PTAC deliberates on proposals. All such meetings and procedures for registering to make public comments are announced in the Federal Register at least 15 days prior to such a meeting.
In general, three weeks are allowed for submission of public comments on a proposal. PTAC does not formally respond to individual public comments, but does consider comments in making its decisions. Written comments that are received after the deadline will be sent to members of the Committee, however, the Committee members are not required to consider them.
How does PTAC review proposals that require specialized expertise in the types of care addressed by a proposal?
If PTAC finds that it needs additional expertise to assist in reviewing a proposal, it may invite one or more outside experts to provide comments on relevant aspects of the proposal. Individuals with conflicts of interest or relationships that could result in a lack of impartiality will not be used as outside experts. If any outside experts provide assistance, they will be publicly acknowledged. The Committee may also identify specific issues regarding a proposal and request input from any interested experts on those issues during the public comment period.
From where does PTAC obtain additional analyses or specialty-specific subject matter experts (SMEs)?
PTAC obtains additional analyses and / or consultation from SMEs on an ad hoc basis as it reviews proposals. Through the Office of the Assistant Secretary for Planning and Evaluation, expertise is available as needed through contractual arrangements. PTAC is able to secure any needed expertise throughout the review process on a timely basis as necessary.
Must the Secretary accept the Committee’s recommendations?
Section 1868(c)(2)(D) of the MACRA requires the Secretary to review PTAC’s comments and recommendations on proposed PFPMs and to post a “detailed response” to those comments and recommendations on the CMS website. The Secretary is not required to accept the Committee’s recommendations.
For further information, please contact: PTAC@hhs.gov
Last updated January 28, 2019.