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Looking for payment models for community health


Because Cambridge Management Group has done considerable work in community/population health, including in addressing the social determinants of health, especially in the Pacific Northwest, this article in The New England Journal of Medicine caught our eyes.

The authors  of the article, headlined “Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid,” write:

“As health systems are increasingly being held accountable for health outcomes and reducing the cost of care, they need tools and interventions that address patient and community factors contributing to excess utilization. Effective partnerships among medical care, social services, public health, and community-based organizations could improve population health outcomes, but developing sustainable payment models to support such partnerships has proved challenging.

“Some encouraging innovations have emerged. Catalyzed in part by statewide all-payer delivery-system reform and the growth of value-based or shared-risk payment models, some purchasers and providers of medical care have found innovative ways to support high-value community-focused interventions. For example, Hennepin Health, a county-based Medicaid managed-care organization in Minnesota, has reduced emergency department visits by 9% by using housing and community service specialists who are part of a tightly integrated medical and social service system.”

“To accelerate the development of a scalable delivery model for addressing upstream determinants of health for Medicare and Medicaid beneficiaries, CMS recently announced a 5-year, $157 million program to test a model called Accountable Health Communities (AHC). …{T}he test will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.”

“The AHC model reflects a growing emphasis on population health in CMS payment policy, which aims to support a transition from a health care delivery system to a true health system. The AHC test will improve our understanding of whether savings can materialize when upstream factors are addressed through collaboration among stakeholders who are accountable for the health and health care of their community.”

MU hardship exemption soothes providers and CMS



Herewith a look at how letting eligible hospitals and  other providers participating in CMS’s Meaningful Use  electronic health record apply for a blanket hardship exemption to avoid reimbursement penalties will  help CMS as well as the providers.

Congress  recently passed bill S. 2425, which lets any eligible hospital or  clinician to apply for an exemption for 2017 from MU penalties. Previously, hospitals and professionals had to meet certain criteria  to apply for the exemption.

As Becker’s Hospital Review noted, the hardship exemption “offers an obvious respite {to providers} in their journey to Meaningful Use attestation. Not only does it stave off penalties, but it softens the burden of meeting the newly released stage 3 requirements….”

The news service added: “What’s more, CMS eases the burden on itself with this blanket exception. Since the agency no longer has to review hardship exemptions on a case-by-case basis, that eliminates thousands of applications it needed to individually review….”


Plan to discourage routine prostate-cancer screenings fought


There has been a lot of pushback to a proposed plan by the Centers for Medicare & Medicaid Services to penalize doctors who order routine prostate-cancer screening tests. It’s part of a federal effort to define and reward quality in health-care services and to advance evidence-based medicine.

The Wall Street Journal reports that some complain that the measure “would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.”

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” David Penson,  M.D., chairman of public policy and practice support for the American Urological Association,  told the WSJ. The association urged  the CMS not to implement the proposal.

The U.S. Preventive Services Task Force  opposes routine screening for prostate cancer for men of any age because, it says,  the benefits don’t outweigh the harms.




CMS has been underpaying duel-eligible health plans


Responding to complaints from health plans questioning the accuracy of the CMS template for predicting costs, the agency has disclosed that it has been underpaying health plans that enroll many people  dually eligible for Medicare and Medicaid. CMS says it will modify its  risk-adjustment model to make up for the underpayment.

The CMS has been using a  model (called the CMS-HCC) to calculate risk scores, using health status in a base year to predict costs in the next one. Modern Healthcare reports that “scores drive adjustments to capitated payments made for elderly and disabled beneficiaries enrolled in Medicare Advantage (MA) plans and certain demonstration programs. ”

CMS bundled-payment plan seen driving up costs


An X-ray showing a right hip (left of image) has been replaced, with the ball of this ball-and-socket joint replaced by a metal head set in the femur and the socket replaced by a white plastic cup.

He writes that as “now designed, the mandatory ‘comprehensive care for joint replacement’ payment model could encourage many of the program’s 800 hospitals (and their affiliated orthopedic surgeons) in 75 metro areas to perform more of the pricey procedures on arthritic seniors, not less. If that happens, it will be a perverse twist on the old saying: What the CMS makes on each bundle will be lost on volume.”

“In fact, {the CMS plan} would provide a powerful incentive for hospitals and surgeons who make money on the bundle to do as many as possible. No wonder consultants, physician management firms and medical suppliers are touting their ability to show hospitals how to make money under the bundled-payment program. Many are even willing to share the risk.

“There is an alternative. Hospital systems could offer the ‘watchful waiting’ strategy if the CMS would give them a comprehensive payment to cover the patient’s condition—in this case, severe arthritis of the knee or hip.”

How ACO ‘triple whammy’ undermines Triple Aim


This HealthAffairs posting describes how a “triple whammy” undermined the Triple Aim. It looks at the experience of Dartmouth-Hitchcock Health, the pre-eminent academic health system in northern New England, which recently decided to bail out of  being a Pioneer Medicare Accountable Care Organization.

The “Triple Whammy” discussed in the piece include:

A Flawed Risk-Adjustment Methodology

A Moving And Flawed Target

Identical Incentives Regardless Of Baseline Performance

The authors concluded:

“DH {Dartmouth-Hitchcock} did not make the decision to leave the Pioneer program lightly. A leader in the adoption and application of ACO principles, DH is committed to pursuing high-value population-based care through continuous quality improvement and a relentless focus on cutting waste from health care delivery by engaging providers and payers, waste that is perhaps more difficult to identify and reduce from within a very low-cost environment.”

“To meet its ambitious goals, CMS must provide fair incentives that are large enough to encourage more healthcare systems to enter new reimbursement models and attract and retain providers in both high- and low-cost settings; otherwise, unrestrained fee-for-service cost growth will continue and the full promise of “accountable care” will remain unrealized.

“CMS must rectify the flaws in the Pioneer model so that high-cost ACOs are rewarded for meaningful improvement, and low-cost ACOs—that have already benefited CMS and Medicare beneficiaries by applying ACO principals over the long term and whose ability to generate cost savings is likely to be modest—are rewarded and not punished while demonstrating improvement.”




Fee-for-value leader Dr. Beauregard joins CMG


George Beauregard, D.O., has joined Cambridge Management Group (CMG) as a senior adviser. Dr. Beauregard has been a leader in moving hospitals and physicians into the new world of fee-for-value care.

He has 20 years of experience in private practice in internal medicine and vast experience with pay for performance; performance- and risk-based contracts involving commercial and Medicare payers; EMR/HIT implementation, and Accountable Care Organization and Bundled Payment development.

In his recent role as senior vice president and chief clinical officer for the PinnacleHealth System, based in Harrisburg, Pa., he worked closely with the clinical and administrative leadership to help PinnacleHealth achieve enterprise- wide success in successful CMS Accountable Care and Bundled Payment initiatives; quality and performance improvement; clinical integration, and HIT optimization. This helped lead CMS to welcome RiverHealth ACO, of which PinnacleHealth is a founding member, into the 2014 Medicare Shared Savings Program.

Prior to joining PinnacleHealth, in September 2012, Dr. Beauregard was president and chief medical officer of Southcoast Physicians Network, in Massachusetts.  His leadership helped gain Southcoast admission into the 2013 Medicare Shared Savings Program.

Before that, he was co-founder, in 1996, of Primary Care LLC, the largest independent community-based primary-care-physician network in eastern Massachusetts. Dr. Beauregard guided a merger of that entity with Tufts Medical Center in 2005 to form the New England Quality Care Alliance (NEQCA), where he then served as chairman of the board for four years. He also was trustee of Tufts Medical Center Physicians Organization Inc.

George Beauregard is a graduate of the University of New England College of Osteopathic Medicine. He has been awarded Diplomate Certificates by the American Board of Internal Medicine and the National Board of Osteopathic Medical Examiners.


Glitch in the way of pay for performance


In an  unintended consequence of federal law, some of the highest-performing Medicare Advantage (MA) plans aren’t getting the incentive payments they earned, this HealthAffairs piece reports. These plans stand to lose nearly half a billion dollars in quality incentive payments because of a cap on MA plan benchmarks.

The piece says: “The Center for Medicare and Medicaid Services (CMS) has used quality measurements to adjust its payments to Medicare Advantage plans since 2012. The program, known as the Star Rating System, is intended to provide bonus payments to high quality plans. These bonuses allow plans to provide additional benefits that then attract more enrollees, increasing market penetration for those high performing plans. The impact is clear:

  • “Since Congress attached star ratings to payment, the average rating per contract has increased by almost 1.5 stars — from 2.56 in 2012 to 3.92 in 2015.
  • “Today, 60 percent of Medicare Advantage beneficiaries are enrolled in a 4+ star plan.
  • “Among first-time enrollees, there is a 5 percent increase in likelihood to enroll per 1 star increase in plan rating.”

“However, under a cap that is also part of the law, benchmarks cannot exceed the amount that would have been calculated under the previous methodology. CMS has interpreted this cap to include cuts to quality incentive payments despite clear congressional intent to establish a quality structure that rewards rather than penalizes high performing MA plans.”

The Centers for Medicare & Medicaid Services is being pressed to fix this glitch.




Income implications of new ICD-10 and HCCs

This Medscape piece by Greg A. Hood, M.D., looks at the need for providers to better understand the income implications of the new ICD-10 codes as they relate to hierarchical condition categories (HCCs).

Dr. Hood notes:

“HCC codes have been affecting insurance products and physician reimbursements for years, though most clinicians have under-appreciated them at best or more plainly ignored them. They’ve been a cornerstone of` reimbursement for Medicare Advantage plans for over a decade.

“Because HCCs, which are gathered from encounter claims data, are used to estimate predicted costs for plan members in the year to come, they’re integral in calculating benchmarks for (ACOs) as well as for the hospital value-based purchasing program.”

He goes on:

“CMS and other insurers that incorporate HCC methodology into reimbursement will probably exclude codes that lack the relative degree of specificity achievable with many ICD-10 codes. This means that providers will probably be unable to avoid coding in extreme … detail. It’s important to note that the ICD-10 codes that do venture into highly detailed specificity do not necessarily connote a meaningful HCC score. In other words, it’s not the degree of detail that predicts expenses, but rather the severity of the condition represented by the diagnosis code.”


Big mental-health-reform bill is filed

Senators Bill Cassidy (R.-La.) and Chris Murphy (D.-Conn.) have proposed a bipartisan mental-health reform bill with an eight-point agenda intended to shore up the U.S.  mental-health system ( Among other measures, the bill proposes to designate an Assistant Secretary for Mental Health and Substance Use in the U.S. Department of Health and Human Services, require audits on mental- and physical-health-parity law implementation, and establish new grants for early mental-health intervention.

Of course, given the close connections among behavioral health, mental heath and “physical health” (as if the brain isn’t an organ!) such a bill, if it becomes law, could have a huge impact across the healthcare system.

Senator Murphy’s office sent us this summary of the bill:

The Cassidy-Murphy Mental Health Reform Act will do the following:

Integrate Physical and Mental Health

  • Encourages states to break down walls between physical and mental health care systems by requiring states to identify barriers to integration. States would be eligible for grants of up to $2 million for five years, prioritizing those states that have already taken action. States taking part are eligible with additional federal funds to treat low-income individuals who have chronic conditions or serious and persistent mental illness. 

Designate an Assistant Secretary for Mental Health and Substance Use

  • Elevates the issue of mental health by establishing an Assistant Secretary for Mental Health and Substance Use Disorder within the U.S. Department of Health and Human Services who will be responsible for overseeing grants and promoting best practices in early diagnosis, treatment, and rehabilitation. The Assistant Secretary will work with other federal agencies and key stakeholders to coordinate mental health services across the federal system and help them to identify and implement effective and promising models of care.

Establish New Grant Programs for Early Intervention

  • Establishes a grant program focused on intensive early intervention for children as young as 3 years of age who demonstrate significant risk factors recognized as related to mental illness in adolescence and adulthood. A second grant program supports pediatrician consultation with mental health teams, which has seen great success in states like Massachusetts and Connecticut.

Establish Interagency Serious Mental Illness Coordinating Committee

  • Establishes a Serious Mental Illness (SMI) Coordination Committee under the Assistant Secretary to ensure documentation and promotion of research and treatment related to SMI and evaluate efficiency of government programs for individuals.

Establish New National Mental Health Policy Laboratory

  • New entity will fund innovation grants that identify new and effective models of care and demonstration grants to bring effective models to scale for adults and children.

Reauthorize Successful Research & Grant Programs

  • Reauthorizes key programs like the Community Mental Health Block Grants and state-based data collection. The bill also increases funding for critical biomedical research on mental health.

Strengthen Transparency and Enforcement of Mental Health Parity

  • Requires the U.S. Department of Labor, the U.S. Department of Health and Human Services, and the U.S. Department of the Treasury to conduct audits on Mental Health Parity implementation and issue guidance on how determinations are made regarding comparability mental health services and physical health services.

Improve Mental Health Services within Medicare/Medicaid

  • Makes critical reforms to allow for patients to use mental health services and primary care services at the same location, on the same day. Repeals the current Medicaid exclusion on inpatient care for individuals between the ages of 22 and 64 if the CMS actuary certifies that it would not lead to a net increase of federal spending.


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