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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

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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.


Move to value-based care seen continuing

 

The move to value-based care will continue under the Trump administration, argue Emme L. Deland, New York-Presbyterian Hospital’s  senior vice president and chief strategy officer, and Jonathan Gordon, director of NYP Ventures,  a New York-Presbyterian telemedicine unit, in a post for NEJM Catalyst.

They write:

“At the moment, it seems likely that health care financing will get more attention than health care delivery under the new Administration. Medicaid expansion may be rolled back in some states, and block grants are likely to constrain state Medicaid plans — though a fixed Medicaid budget may drive a more rapid shift toward value-based care in many states. The aspects of the ACA that have attracted the most public attention — the individual and employer mandate, and insurance exchanges and subsidies — are most likely to see significant changes.”

“{W}hile there is a significant chance that the specific mechanics of reform may change, the interest in and demand for value-based care will persist on both sides of the aisle. This can be seen in the 392-37 and 92-8 House and Senate votes that passed MACRA, which established a permanent ‘doc fix’ to Medicare reimbursement rates in exchange for a choice between a complex series of quality and efficiency measures, or participation in risk-bearing value-based payment models.”

“Looking ahead, it is possible that there may be a push for a less-regulated approach toward new models, with state Medicaid plans, private payers, and employers taking more of a lead as a result of a more hands-off CMS and a move toward federal Medicaid block grants. The result could be net positive for innovators in health care, as an even more diverse range of delivery reform approaches is tried — though incumbent providers and payers may be challenged to adapt to yet another changing landscape. Many states and their providers, however, could be financially adversely affected by block grants.”

To read their whole article, please hit this link.


CMS finalizes rates for hospitals’ off-campus sites

 

CMS has finalized the new payment rates for the Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center Payment System (ASC).

Altogether, the changes would boost the OPPS payments  1.7 percent and ASC payments  1.9 percent in 2017.

But hospitals will not win  everywhere.  For example, the new OPPS rules exclude payments of certain outpatient services at inpatient levels at  hospitals’ off-site facilities.

CMS said: “This payment differential has provided an incentive for hospitals to acquire physician offices in order to receive the higher rates. This acquisition trend and difference in payment has been highlighted as a long-standing issue of concern by Congress, the Medicare Payment Advisory Commission, and the Department of Health and Human Services Office of Inspector General.”

“We spoke to stakeholders across the outpatient community who care about the quality and value of care that Medicare patients receive,” said Sean Cavanaugh, CMS deputy administrator. “The policies finalized in today’s rule will not only improve the value of care provided to Medicare beneficiaries, but are also responsive to healthcare providers who are crucial to outpatient care.”

Physician groups have mostly supported “site-neutral payments” but many hospital leaders have strenuously opposed them for fear of losing money.   The Bipartisan Budget Act passed by Congress last year essentially eliminated the payment disparities between different sites.

CMS also issued an interim final rule on the Medicare Physician Fee Schedule  to  address other payments received by off-campus hospital providers.

To read a FierceHealthcare article on this, please hit this link.


Conn. hospitals ask for relief from tax

conncap

The Connecticut State Capitol building, in Hartford.

Connecticut hospitals have filed a petition with  the CMS in which they assert that the state is violating the federal Medicaid Act through enforcing a hospital tax and providing inadequate Medicaid reimbursement.

State legislators imposed the hospital tax in 2011 with the goal of increasing federal funding. When states tax hospitals and  then redistribute the funds back to the sector, the Feds  provide matching funds through the Medicaid program. However, since the tax was put into place, the state has reduced the money it redistributes after collecting the tax.

The hospitals say that the  $556 million annual tax puts hospitals in financial peril. The Connecticut Hospital Association asserts that inadequate Medicaid funding and the hospital tax have forced hospitals  to lay off 1,390 employees since 2013. “Hospitals are actively evaluating the elimination of programs and, in many cases, are also assessing their ability to meet bond covenants,” said the CHA.

The hospitals ask the CMS to make the state  amend its Medicaid plan to bring Connecticut’s Medicaid rates and the hospital tax in compliance with the federal Medicaid Act.

The Connecticut Hospital Association and 20 hospitals have also appealed a recent state  decision rejecting their argument that the tax is applied illegally.

To read more, please hit this link.


CMS gives some relief on off-campus reimbursement

CMS, in a final rule that changes how providers with off-campus facilities are reimbursed, has grandfathered in some hospitals that have had to relocate their facilities because of natural disasters.

The final rule  stops paying  for care at hospital off-campus facilities at the same rate as at hospital-based outpatient departments if they started billing Medicare after Nov. 2, 2015.

Modern Healthcare notes:  “The change will make it difficult for health systems to recoup capital or operational costs for off-site facilities, even though they are responsible for continuing to equip and maintain the off-campus offices.”

There has been concern that the draft rule did not protect reimbursements  for work done at recently relocated off-site facilities that had to be moved because of  environmental issues, such as being on an earthquake fault line or a flood plain; having a lease expire, or becoming too small because of population shifts and increased patient loads.

So  CMS is allowing exceptions for extraordinary circumstances while warning that exceptions will be rare.

To learn more, please hit this link.

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