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Trump’s CMS pushes back against bundled payments

knee

The CMS has delayed the expansion of a major bundled- payment pilot, Comprehensive Care for Joint Replacement, and implementation of its bundled-payment initiatives for cardiac care to Oct. 1, 2017, from July 1, according to an interim final rule posted to the Federal Register. It also again delayed the effective date of a final rule detailing the  implementation process  for CJR and other bundled-payment programs, to May 20, 2017 from March 21.

The agency is considering delaying  implementation of all bundled-payment initiatives even further, until 2018.

Modern Healthcare speculated that the Trump administration’s “move to delay these initiatives raises questions about the future of government initiatives to usher healthcare out of fee-for-service operations and into a new age of value-based payment.”

The new secretary of health and human services is Tom Price, M.D., who had a very lucrative career as an orthopedic surgeon and has been a major investor in some medical companies. CMS ultimately reports to him and President Trump.

To read more, please hit this link.


Providers complain about lack of guidance on ‘observation’ status

 

Modern Healthcare reports that  providers say that the lack of guidance from CMS about a new rule mandating that hospitals notify Medicare patients why they are receiving “observation” care could cause hospitals to lose billing privileges and patients.
Beneficiaries must spend three consecutive nights as admitted patients in a hospital  for Medicare to cover subsequent skilled-nursing facility costs; observation days don’t count.

The publication reported that  as of March 8 hospitals had to begin “giving out the notices, which alert patients that they received observation care rather than being admitted as an inpatient. CMS estimates as many as 1.4 million beneficiaries will receive the notices every year, and they are meant to cut down on the surprise bills observation patients tend to receive.”

“The CMS requires hospitals to give patients a reason for their observation status, but the CMS has declined repeated requests from hospitals to suggest language that providers should use. Providers are concerned that the vague instructions put them at risk of auditor citations.”

“The stakes are huge in that without guidance from CMS, each auditing organization is left only with their personal interpretation if a hospital is in compliance or not,” Ronald Hirsch, M.D., a vice president at R1 Physician Advisory Services, a consulting firm on billing matters for providers, told Modern Healthcare.

The publication added that a CMS spokesman declined to comment on the issue, but pointed to an FAQ document on the agency’s Web site “that encourages providers to use their clinical judgment when writing the notices and make them ‘reasonably understandable’ to the beneficiary.”

To read more, please hit this link.

 

 


Should standards be lowered for safety-net hospitals?

 

The federal government sometimes withholds money from safety-net hospitals because they fail to meet certain standards.

A piece in governing.com asks whether those standards should, at least in some cases, be lowered.

Penalties “handed down by CMS are part of the Affordable Care Act {and} are meant to motivate hospitals to correct procedures so as to avoid patient safety violations. But the problem with these penalties, some health policy experts say, is that they don’t take into account the particular challenges that individual hospitals face.”

“Most of the penalized hospitals take care of the poorest and sickest,” Ashish Jha,  M.D., a  Harvard professor who focuses on patient safety, told the news service.

“Jha and others argue that CMS should add a risk adjustment factor. Until then, safety-net and academic-centered hospitals {with the most challenging patients} will continue to get slapped with the most penalties.”

“Adding to the hospitals’ exasperation is the fact that there is little information about whether the penalties have actually improved health outcomes.”

To read the piece, please hit this link.

 


Change in CMS primary-care program seen scaring away some providers


Looking at the future evolution of the MSSP

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In HealthcareDIVE,   Farzad Mostashari, M.D., and Travis Broome write about the continuing evolution of the Medicare Shared Savings Program. Dr. Mostashari is founder and CEO of Aledade Inc., where Mr. Broome is the lead policy person. Dr. Mostashari is the former national coordinator for health information technology at the U.S. Department of Health and Human Services.

”{M}ore investment and more fine-tuning will be required if we are to strengthen the MSSP and use it to help power the transformation of Medicare to a value-based system.

”First, CMS needs to tailor the risk for MSSP ACOs so that it is enough to motivate, but not sink a small practice. It’s critical that the risk small practices take on bears some relationship to the financial resources of the ACO and its members. If it’s too much so that a bad year that happens because of an external event – such as an epidemic or disaster – can sink even the most well-intentioned practice, then no one will enter into an ACO arrangement.”

“”Second, we need an accurate way to measure whether or not an MSSP ACO creates value. The best way to do that is through a difference-in-difference approach. In this, the key question asked is: Did a Medicare beneficiary get better care at lower cost in the ACO than if that same Medicare beneficiary had not been in the ACO? To get closer to this difference-in-difference approach, CMS needs to move away from national inflation updates and artificial risk-scoring methodologies to regional inflation updates and direct risk scoring.”

”Third, CMS should continue to seek to simplify the program. For example, while we appreciate the work that was done in Track 1+, it is quite possible all of the same benefits could have been accomplished by adding just a few lines of changes to Track 2 without the need to create a whole new track. This would have been both simpler and created a better business case for physicians to move towards risk.”

To read more, please hit this link.


The future of CMS payment models

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Print (c. 1902) by Albert Robida showing air travel over Paris in the year 2000 as people leave the opera.

The trouble with the future is that it’s so much less knowable than the past.”

 John Lewis Gaddis, ”The Landscape of History”

The authors of an article in Health Affairs look at future CMS payment models based in part on recent payment evolution. Among the predictions:

Population-based models and disease-specific models will continue to develop.

”As ACOs mature and stabilize, opportunities exist to expand them to cover more lives and allow more providers, payers, and organizations to participate in accountable care. More established ACOs will need to expand the spectrum of healthcare providers they work with including behavioral- health, post-acute care and pharmacy providers, and will need to consider the socioeconomic needs—like transportation, housing, and education—of their patient populations.”

”CMS has relatively few disease-specific models, which offers an opportunity to take knowledge gained from current programs and expand to other diseases and co-morbidities through either specialty ACOs or bundled payment programs. The Oncology Care Model and the Comprehensive End-Stage Renal Disease (ESRD) Care Model are two examples of disease-specific models. The ACO movement has focused around primary and general care, but ACOs are most successful when they include providers that are involved at all levels of patient care, including specialists.”

More efforts to show bigger cost-savings

As the healthcare culture shifts to adopting value-based care, ”opportunities exist for more payment models and models that involve higher levels of risk, although mandatory demonstration models are unlikely to continue” if, as expected, Tom Price, M.D, becomes health and human services secretary.

”As ACOs demonstrate success and more physicians have confidence in accountable care, ACOs can move from shared savings-only to taking on more risk.”

Efforts to encourage growth of multi-payer, state and wider- region initiatives

”Multi-payer initiatives spread cost among different payers—for example, commercial and Medicaid—and provide a shared incentive to improve quality and care. When multiple stakeholders work together toward a common goal, collaboration is rewarded and patients benefit. State and regional initiatives also allow states greater flexibility in implementing programs that work best for their populations.”

”Maryland, Vermont and Colorado serve as examples of state multi-payer initiatives. Each of these state’s programs are designed to improve primary care through promoting care coordination, health management, patient-centered care, and disease prevention.”

Concurrent models will be developed

”For some physicians, particularly specialists, aligning different payment models might make more sense than being restricted to a single model. For example, participating in different bundled-payment programs could benefit a specialist who has less influence than a primary-care physician over a patient’s overall health management. CMS has an opportunity to provide clarity and guidance to physicians on which models work best together for different types of physicians or practices.”

To read more, please hit this link.


10 things about CMS bundled-payment rule

 

Becker’s Hospital Review has done a handy 10 things to know about CMS’s final rule on a mandatory bundled-payment program for coronary-artery-bypass surgery and its expansion of the existing Comprehensive Care for Joint Replacement program. To read whole article, please hit this link.

Here they are, stripped down:

1. “Under the final rule, acute care hospitals in certain markets will be accountable for the cost and quality of care provided to heart attack, coronary bypass and surgical hip and femur fracture patients beginning with hospitalization and extending 90 days after discharge.”

2. “The rule expands the existing CJR model to include additional surgical treatments for hip and femur fractures….”

3. “Hospitals will receive retrospective episode-based payments under the new bundles. Hospitals that spend less than the target price for the episode of care while meeting or exceeding quality standards keep the savings achieved. A hospital is required to repay Medicare if the costs exceed the target price.”

4. “The final rule includes a cardiac rehabilitation payment model, which will test whether a payment incentive can increase the utilization of cardiac rehabilitative services….”

5. ”The heart attack and coronary bypass bundled payment model will be mandatory for hospitals in 98 metropolitan statistical areas….”

6. ”About 860 hospitals will participate in the hip- and femur- fracture bundles, which will be tested in the 67 MSAs already selected for the CJR model.”

7. ”The cardiac rehabilitation payment model will be implemented in 90 MSAs, 45 of which were not selected for the heart attack and coronary bypass models….”

8. ”The cardiac bundles and the expanded CJR model qualify as Advanced Alternative Payment Models under the Medicare Access and CHIP Reauthorization Act and the Quality Payment Program.”

9. ”The American Hospital Association said it was pleased with some parts of the final rule, including the flexibility the rule provides regarding MACRA participation. However, the AHA expressed concern about the pace of change. ‘The bundled payment model for cardiac care is the second mandatory demonstration project the agency has finalized in just the past 15 months,’ said the AHA. ‘This is too much, too soon.”‘

10. The bundles will begin July 1, 2017.


HHS nominee seen favoring fellow physicians’ interests

banknotes

When Medscape reported on the nomination of Tom Price, M.D., to be secretary of health and human services, an internist commenting on the story wrote, “FINALLY.”

Many physicians expect that Congressman Tom Price, M.D., a former orthopedic surgeon and longtime promoter of the economic and other interests of physicians, will, in the words of Medscape,  “rescue them from the burdens of Medicare reporting programs, the swift transition to value-based payments, and doctors’ growing inability” to make more money.

American physicians are by far the highest paid in the world.

In fact, Dr. Price is probably in the best position to make these changes and may eventually succeed, says Joe Antos, PhD, a health-policy expert at the American Enterprise Institute, a conservative think tank. But he adds that making such changes would be very challenging and could well take years to accomplish.

As HHS secretary and a physician, Dr. Price could take “a more active role” in the Centers for Medicare & Medicaid Services (CMS), which reports to HHS and creates many of the policies that concern physicians,  Joe Antos, a health-policy analyst at the conservative American Enterprise Institute,  says.

“Previous HHS secretaries often didn’t have the experience to interpret the complexities of CMS policies and regulations,” Mr. Santos told Medscape. “Price is a clear exception.”

Patrice A. Harris, M.D., chairwoman of the American Medical Association (AMA), is a psychiatrist from Dr. Price’s home state of Georgia and has known him  for 15 years. “Dr Price has always been willing to listen and to hear both sides of an informed debate,” she told Medscape.

Several commentators have predicted that Dr. Price would stop CMS’s move toward value-based payments, which reward quality and outcomes, and return to fee-for-service payments, which comprise the most lucrative system for physicians.

To read the Medscape piece, please hit this link.


Berwick: Push for the Triple Aim will continue under Trump

 

Ilene MacDonald, of FierceHealthcare, writes about the views of former CMS Administrator Don Berwick, M.D., on health policy under the Trump administration.

She writes:

“Trump’s pre-election healthcare platform called for complete price transparency, and elements of the Affordable Care Act also call for transparency to help make the healthcare system easier to understand, creating a more competitive market. That meant CMS had more authority and responsibility to make data more available to the public. That was a difficult journey, Berwick says, because historically CMS kept the data guarded and tightly controlled for research. Over time data has become more available but he’s unsure what the future holds with the new administration.”

Tom Price, M.D. [Trump’s pick for the new head of the Department of Health and Human Services] is a fan of doctors and doctor practices. And doctors are uncomfortable with transparency so I’m not sure which way he will call this,’ Berwick says.”

“Although Berwick isn’t sure what will happen to the star ratings system under the new administration, he says he is certain quality improvement in healthcare and the goal of the Triple Aim to improve individual care, boost the health of patient populations and reduce overall costs, will continue.”

To read all of Ms. MacDonald’s piece, please hit this link.


Insurers, physicans ask rejection of site-neutral provision

A coalition of physician advocacy groups and insurers that includes the Blue Cross and Blue Shield Association and insurance industry lobbying group America’s Health Insurance Plans is asking Congress to reject a provision in the 21st Century Cures Act that lets some lets some hospital-owned outpatient facilities avoid some site-neutral payment rules.

The Alliance for Site Neutral Payment Reform called on House Energy and Commerce committees leaders to oppose exempting cancer hospitals and other outpatient departments under development before Nov. 2, 2015, from the payment policies passed as part of the Bipartisan Budget Act of 2015 and finalized by the CMS earlier this month.

Modern Healthcare reported: “The alliance said the 21st Century Cures provisions would continue to drive up costs for Medicare and patients and would encourage hospitals to swallow up independent physician practices, thereby reducing patient choice.”

The group’s letter to Congress said: “Preserving an outdated reimbursement policy that continues to drive up healthcare spending in the outpatient space is counter to Congress’s goal of modernizing the Medicare system and providing patients with healthcare choices at less cost.”
Modern Healthcare reported that “Insurers want to limit the exceptions to the site-neutral payment rates because those exempted outpatient facilities will ultimately be paid more and insurers want to keep Medicare reimbursement low. Moreover, prices tend to float up when providers consolidate, so insurers end up paying more.”

The publication noted: “Medicare pays a higher rate for services provided in a hospital’s off-site facility rather than a physician’s office. The CMS and the Alliance for Site Neutral Payment Reform said this difference has led to hospitals buying up physician offices to receive higher rates, increasing costs for both Medicare and patients.”

To read the Modern Healthcare piece, please hit this link.


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