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
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
As we know, the move away from fee for service reimbursement models is not only intended to reduce costs by no longer paying providers based on the volume of services performed, but is also intended to improve the overall value in healthcare delivery by improving quality, outcomes, collaboration across the continuum of care, patient engagement, and, of course, patient safety. Clinical care delivery has undergone substantial transformation over the last several years prompted by the value based reimbursement movement. We have seen a substantial uptick in telemedicine, an explosion of apps and wearables, as well as initiatives designed to support patients who wish to remain in their homes. Technology of course plays a key role in the transformation of healthcare.
The DOJ’s recent announcement of a settlement with eClinicalWorks (“eCW”) generated a lot of interest insofar as it addressed False Claims Act allegations against a vendor of electronic health records that caused providers to submit false claims for incentive payments as a result of
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