Hospitals and health systems face ongoing pressure to migrate away from fee-for-service models, reduce costs, and improve quality. From MACRA to commercial risk arrangements to self-insured employer cost containment models, it is important for hospitals and health systems to take a strategic approach to revenue cycle and contract negotiations. The recent press surrounding Anthem’s rollout of its new policy regarding hospital-based imaging, which will redirect a significant portion of imaging away from hospitals to free-standing facilities, highlights the nuanced approaches insurance companies are taking to rein in what they regard as high cost services. Add to that the proliferation of consumer-driven health care models where patients are on the hook for more of the costs of the health care services they consume and thus look for ways to shop for best quality and price. Further, “repricing” companies engage with self-funded employers to redesign their plans to remain out of network for a host of services for which the plan will pay a percentage of Medicare, which for many
Last week, CMS announced in proposed rulemaking its proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model. It also announced plans to revise certain aspects of the Comprehensive Care for Joint Replacement (CCJR) model, such as granting certain hospitals selected for participation in the CCJR model a one-time option to choose whether to continue their participation in the CCJR model, and a change to increase the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model track. CMS noted in the proposed rulemaking that it “continues to believe that cardiac and orthopedic episode models offer opportunities to redesign care processes and improve quality and care coordination across the inpatient and post-acute care spectrum while lowering spending.” CMS qualified that statement, however, by noting “it is appropriate to propose to rescind the EPMs and CR incentive payment model, and reduce the geographic scope of the CJR model” for several reasons, but most notably due to
The Shift to Value Based Reimbursement Needs to Address Behavioral Health Access and Costs
CMS recently announced that the Center for Medicare and Medicaid Innovation (CMMI) is interested in lowering the cost of care for Medicare and Medicaid beneficiaries with behavioral health conditions while improving the quality of care and the overall access to care for those patients, and will convene a public meeting in the fall to discuss ideas to accomplish these goals. Notably, CMMI indicated that such a model may include participation by other payers, qualify as an Advanced Alternative Payment Model, improve health care provider participation in telehealth services, and address the needs of beneficiaries with care deficiencies in certain areas that lead to poor clinical outcomes or potentially avoidable expenditures, such as substance use disorders, mental disorders with comorbidities, Alzheimer’s disease, and/or behavioral health workforce challenges. As we deal with an aging population and continue to confront the reality that clinical interventions account for only a small part of managing
The District of Columbia federal court recently ruled that a proposed $37 billion merger between health insurance giants Aetna and Humana cannot proceed, granting the US Department of Justice’s bid to block the combination on antitrust grounds (United States v. Aetna, Inc., et al., January 23, 2017, Bates, J.). The Aetna/Humana deal is one of two blockbuster health insurance company mergers that have been challenged by Justice, the other being the Anthem/Cigna deal that remains pending before a different judge in the same court.
The proposed merger would create the largest seller of Medicare Advantage plans, and the challenge by the Department of Justice alleged, among other things, that the effect of the transaction may be to substantially lessen competition in the market for individual Medicare Advantage plans in 364 counties across 21 states. The district court ultimately agreed, rejecting the insurers’ efforts to expand the relevant market definition to include both Original Medicare plans, which are offered directly by the government,
Over the last several years we have seen employers, especially those with self-funded health plans, evolve in their approach to wellness programs. Programs have grown from gathering data – e.g., steps on a pedometer, answers to a health risk assessment – to using the information gathered to take a data driven approach to plan design for health plans and their stand alone or integrated wellness programs. We have also seen employers roll out their wellness programs to spouses, which is a positive trend especially given the latest NIH study which suggests a link between parental obesity and developmental delays in children. Low hanging fruit, such as targeting more hands on care management for high risk, high cost participants, identifying and implementing mechanisms to promote step therapy and generic drug spend, and removing barriers to managing chronic conditions such as $0 copays for maintenance prescriptions and lower cost office visits, have all been part of our self-funded employers’ toolkits over these past few years as the
In the wake of the recent flurry of commentary on the answer to the question of “What will happen to the Affordable Care Act?” the Commonwealth Fund released a new survey addressing how high-needs patients experience health care in the United States. The survey underscores what many in the health care sector already know: that a small minority of patients (according to the survey, 10%), account for the majority (according to the survey, 65%), of healthcare spending in the United States. The survey brings to light the ever-elusive question, the answer to which still remains unclear: how do we as a nation lower healthcare costs and improve population health?
The advent of high deductible health plans has helped employers shift some of the cost burden onto their employees in an effort not only to save money, but more importantly, to have their employees understand healthcare costs and encourage them to be better consumers. Unfortunately, there is not only a lack of reliable data regarding
On November 2, 2016, the Centers for Medicare and Medicaid Services (CMS), released the 2017 Medicare Physician Fee Schedule (MPFS) final rule, which finalized a number of new policies designed to improve Medicare payment for services provided by primary care physicians to patients with multiple chronic conditions, behavioral health issues, and cognitive impairment conditions. The final rule also updates quality measures, audit, and reporting under the Medicare Shared Savings Program. It includes revisions to permit eligible professionals in Accountable Care Organizations (ACOs) to report quality separately from the ACO, incorporates updates to align with the Physician Quality Reporting System and the Quality Payment Program, and implements modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for his/her overall care.
The final rule provides new requirements mandating the release of data associated with Medicare Advantage Organizations, in an effort to foster transparency and better educate beneficiaries making enrollment decisions. It also expands the Medicare Diabetes
On the heels of the release of its final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA), the Centers for Medicare and Medicaid Services (CMS) released a list of additional opportunities for joining Advanced Alternative Payment Models (APMs) in 2017 and 2018. APMs are intended to improve care and offer participating providers the opportunity to earn an incentive payment under the Quality Payment Program created through MACRA. The release of the list provides more certainty to clinicians weighing their options for 2017 and beyond.
By way of brief background, the Quality Payment Program rewards clinicians with sufficient participation in Advanced APMs. By giving more clinicians the opportunity to participate in these models that align incentives for the provision of high-quality, patient-centered care, CMS aims to extend the benefits of high-quality, coordinated care to more Medicare beneficiaries. The CMS Innovation Center (CMMI) tests these innovative care models across the country in an effort to develop sustainable models for the future of healthcare reimbursement.
After receiving roughly 4,000 comments to its proposed rule, the Centers for Medicare and Medicaid Services (CMS) on October 14, 2016 released its final rule for implementing the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA replaced the sustainable growth-rate formula for physician reimbursement with a new methodology to transition providers from volume to value-based reimbursement. This new approach to payment – called the Quality Payment Program – is a major departure from traditional fee-for-service reimbursement in that it rewards the delivery of high-quality care through Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for “eligible clinicians” and groups.
MIPS will consolidate components of three existing programs: the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue to focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. The proposed rule generated a multitude of comments and