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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.


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


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.


HealthInsight gets CMS contract to improve Indian Health Service


The CMS has awarded a contract to  HealthInsight to improve care quality at the Indian Health Service’s hospitals, first by fixing alarming deficiencies there that have attracted federal scrutiny. HealthInsight,  a nonprofit, community-based organization, is charged with “supporting, building and redesigning if needed” the infrastructure of IHS hospitals.

“IHS hospitals—and our staff members across the country—are focused on continuous improvement. (HealthInsight) will provide training for our staff and access to experts to strengthen IHS capacity to deliver quality health care for American Indian and Alaska Native patients,” said Mary L. Smith, IHS’s principal deputy director.

HealthInsight operates in Nevada, New Mexico, Oregon and Utah, which have large populations of Native Americans. It serves as the CMS’s quality-innovation network-quality improvement organization for those states under a five-year contract that began July 2014 .

“HealthInsight works with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm, engage patients and families, and improve clinical care locally and across our region,” the organization’s Web site explains. That involves “transforming physician practices, employing lean methodology, assisting with value-based purchasing programs and developing innovative approaches to quality improvement.”

Although the contract particularly targets  Medicare beneficiaries,  the CMS said that the work involved would “result in systemic change that improves all of the care provided at these facilities.”

To read more, please hit this link.

Providers plead for new-payment-model slowdown


Stressed healthcare providers are pleading with the CMS to slow its flood of new payment models  that the agency is pushing in order to move  healthcare  from fee-for-service to value-based care.

Modern Healthcare reports that “Since the start of the year, the agency has introduced or expanded nine pay models and announced selected markets for another three. In comments on a July proposed rule that would make 98 markets financially accountable for the cost and quality of all care associated with bypass surgery and heart attacks, industry stakeholders ask the agency to step on the brakes.”

The Federation of American Hospitals said its members “have become increasingly concerned about the pace of change proposed by the CMS and the unreasonable expectations and burden that such rapid and multiple changes in the delivery system and related payment structure place on hospitals and their work forces….Simply put, this is too fast and too soon.”

The publication reported that “The trade group said it believes that the CMS first needs to evaluate and learn from hospitals’ Comprehensive Care for Joint Replacement Model, or CJR experience, which is less than 6 months old, and from the results of the Bundled Payments for Care Improvement initiative.”

The American Hospital Association said:  “In failing to take the time to learn from CJR, the agency has missed a critical opportunity to move bundled-payment models forward in a meaningful way. This proposed rule {in July} raises serious concerns about the agency’s pace of change, as well as its ability to accurately track and process the outcomes of its myriad, increasingly complex alternative payment models.”

Hospitals have been  pushing back against the CMS’s proposal to expand the CJR program to include surgical hip and femur fracture treatment episodes, or to make certain CJR hospitals implement the cardiac bundled-payment model. Providers complain that  neither the CMS nor participating hospitals  have had the time or the data to to properly analyze lessons learned from the model as it is.

To read the whole article, please hit this link.



Study: MSSP at ACOs takes a while to succeed


A new report from Aledade, a company that helps physicians form and run Accountable Care Organizations (ACOs), says its ACOs have increased primary-care use (which should help boost prevention and reduce the need for expensive specialty care) and revenue, cut lab and imaging costs, and reduced emergency department and hospital use and readmissions in Medicare’s Shared Savings Program (MSSP) for ACOs.

Importantly, the CMS and Aledade both emphasized that more time in the program tends to result in more savings – e.g., CMS noted that 42 percent of ACOs that entered the program in 2012 generated savings above their minimum savings rate, compared to just 21 percent of those who entered in 2015.

The company cited problems involving benchmarking, hospital coding, risk adjustment and information flows/information blocking from EHR vendors and hospitals. Aledade also noted the importance of importance of scale, and said that that MSSP policies can be improved to shorten ACOs’ timeline to financial success.

To read the Aledade report, please hit this link.



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