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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.

Expanding health systems’ pricing power tied to surging premiums and insurer withdrawals

 

Ashish K. Jha, M.D., of the Harvard T.H. Chan School of Public Health and an internist at the Veterans Affairs Boston Healthcare System, argues in a JAMA piece that the insurer withdrawals and big insurance premium increases this year are to no small degree attributable to the market power being wielded by ever larger hospital chains.

He thinks that the future of the Affordable Care Act may rest on the federal government’s ability to monitor and regulate healthcare-industry consolidation among practices, hospitals and hospital systems.

“If the ACA is to thrive under the next president, he or she must ensure that we have a dynamic healthcare marketplace,”  Dr. Jha wrote. “For that reason alone, the ability of the ACA to fulfill its promise of greater access at an affordable price will depend as much on the effectiveness of the FTC  {Federal Trade Commission} as it will on the effectiveness of the CMS.”

His remarks come as a federal appeals court decided to support the FTC’s challenge of  the proposed merger between Advocate Health Care and NorthShore University HealthSystem, both in Illinois.

The 7th Circuit Court  of Appeals called a lower court’s decision to allow the proposed merger between the two health systems “erroneously flawed.”

FTC has argued that the deal could hurt both patients and insurers and result in higher medical costs because of the new behemoth’s pricing power. The health systems have been battling with the FTC over  how their market share should be defined.

To read Dr. Jha’s JAMA piece, please hit this link.


Vt. will move to voluntary all-payer ACO in Jan.

vermont-quarter

The CMS has announced that in January, Vermont will become the first state  to move to a voluntary all-payer Accountable Care Organization model.

While Vermont’s program is somewhat modeled after a similar one in Maryland,  the Maryland program covers only hospitals while Vermont’s will cover close to all providers. The Vermont ACO will include Medicare, Medicaid and commercial payers, requiring those who participate to pay similar rates for all services.The CMS is giving Vermont $9.5 million in start-up funding to support the transition. The demonstration project is supposed to last  five years.

“This model is historic in terms of its scope, aiming to include almost all providers and people throughout the state in an all-payer ACO model to drive improved quality, better care coordination, healthier people, and smarter spending,”  Patrick Conway, M.D., the CMS’s chief medical officer, said.

“We will become the first state in America to fundamentally transform our entire health care system so it is geared towards keeping people healthy, not making money,” said Vermont Gov. Peter Shumlin, who negotiated a deal with HHS Secretary Sylvia Mathews Burwell.

The state seeks to have 70 percent of its insured residents covered by an ACO by 2022. The model will be considered an advanced Alternative Payment Model under the new Medicare reimbursement program, making participants eligible for a performance bonus.

Vermont will limit  per-capita  annual spending growth for major payers to 3.5 percent and Medicare growth to at least 0.1 to 0.2 percentage points below projected national Medicare growth.  In recognition of the role of behavioral health in other health, state officials also said they will seek to improve access to primary care and treatment for substance abuse, mental health and chronic disease as part of the ACO project.

The Vermont Legislative Joint Fiscal Office said that better care and an improved  state economy might well come out the initiative. However, it also  warned of such risks as uncertainty that the federal funding would cover transition costs and whether all providers will be adequately represented.

To read a Modern Healthcare article on this, please hit this link.

CMS widens options for APMs

CMS  offering additional opportunities for physicians and other clinicians to join advanced Alternative Payment Models beginning in 2017 and 2018.

The advanced Alternative Payment Model is the more lucrative of two options under the Medicare Access and CHIP Reauthorization Act, (MACRA) a payment system for Medicare physician fees that replaces the controversial Sustainable Growth Rate formula.

CMS will offer the Oncology Care Model with two-sided risk as a qualifying advanced APM beginning in 2017 and  will reopen applications for the Comprehensive Primary Care Plus model and the Next Generation ACO model for the 2018 performance year.

Patrick Conway, M.D., deputy CMS Administrator,  said:

“With these new opportunities, CMS expects that by the 2018 performance period, 25 percent of clinicians in the Quality Payment Program will earn incentive payments by being a part of these advanced models. Thanks to MACRA and the Innovation Center, we’re striving to see more Medicare patients benefit from better care when they visit their doctor for a knee replacement, receive cancer treatment or have a coordinated care team manage their complex conditions.”

Physicians who participate in Medicare must submit at least some performance data next year to avoid a penalty under MACRA. These data will determine payment adjustments beginning in 2019. Physicians who qualify as an advanced APM will avoid some reporting requirements and be eligible for a 5 percent lump-sum bonus.

To read a Becker’s Hospital Review article on this, please hit this link.


Feds okay broad Wash. State Medicaid reform

ranier

Mt. Rainier, in Washington State, considered a very dangerous volcano whose eruption could kill many thousands of people.

The CMS has granted Washington State preliminary approval to reform its Medicaid program  aimed at addressing cost and clinical-care challenges associated with the state’s swelling Medicaid population and moving to value-based care from fee for service. An aim is to move  90 percent of Medicaid payments to a value-based model by 2021.
The five-year waiver program will get $1.5 billion in federal funds.

The program calls for   delivery-system reforms and expanding  the range of  long-term services and supports.

Washington’s  Medicaid population has jumped nearly 60 percent since 2013, to 1.7 million,  as spending has risen to $10.4 billion a year from $7.8 billion.

Key to the changes  is creating so-called Accountable Communities of Health.  Each will be charged with crafting delivery-system reforms that consider social conditions that can affect health.

To read a Modern Healthcare article on this, please hit this link.

 


10 things to know about final MACRA rule

 

Becker’s Hospital Review, in another of its “things to know” articles, presents 10 things to know about the final MACRA rule.

Nearly a third of physicians could be exempt from Medicare’s new merit-based incentive payment system under a final rule the CMS issued Friday. The CMS also signaled it would broaden the opportunities for physicians to participate in alternative models.

The news service seeks to answer:

1. Who qualifies for the Quality Payment Program?

2. When does the Quality Payment Program start?

3. What options are there for participation?

4. What is MIPS and how has it changed from the proposed rule?

5. What qualifies as an advanced APM? 

6. How will small practices be able to participate?

7. How is the final rule more streamlined?

9. How are people responding?

10. What’s next?

Meanwhile, an analysis of the rule suggests that almost a third of physicians could be exempt from Medicare’s new merit-based incentive payment system.  And the CMS also indicated it would make it easier for physicians to participate in alternative models.

To read the whole Becker’s article, please hit this link.

 


Many physicians still worried about MACRA

 

Despite soothing words from CMS, and some adjustments based on criticisms from providers, many physicians remain worried that the  final rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA) is still too narrow and complex to reach its  goal of creating a mostly value-based payment system.

Many fear that the final rule will hurt small and rural medical practices and set primary-care doctors against specialists.

Under MACRA, better-performing doctors will get bonuses and under-performers will face financial punishments based on a variety of metrics of cost and quality of care.

To read a MedPage Today article on this, please hit this link.

 


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