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Study touts Medicare Advantage’s role in moving to value-based care


This Deloitte study says that Medicare Advantage can help engage providers to move more successfully into value-based care by better using technology and data.

One the study’s conclusions:

“Health plan respondents strongly believe that MA  {Medicare Advantage} presents great opportunities for VBC {value-based care} due to high per-member costs, disease burden and defined populations. In fact, health plan leaders expressed during the in-depth interviews that they believe contracting with MA plans is a better way for providers to develop VBC capabilities than starting with CMS. Unfortunately, few health plans are effectively conveying this message to providers. Despite the clinical and demographic similarities between MA and traditional Medicare patients, providers are more cautious about VBC arrangements with MA plans than with CMS. ”

CMS pleased with program to cut admissions


A new report says that a federal initiative to reduce preventable hospital admissions among nursing-home residents has had encouraging early results.

In 2014, the second year of the Centers for Medicare & Medicaid Services initiative, Medicare expenditures fell for all seven demonstration sites and all-cause hospitalizations. Further, potentially avoidable hospitalizations fell across sites.

“As we plan for new Medicare payment incentives to reduce hospital readmissions from skilled nursing facilities, these results provide early indications that when the right strategies are in place, they may effectively reduce hospitalization rates and reduce overall Medicare spending,” said Patrick Conway, M.D., CMS’s principal deputy administrator and chief medical officer.


CMS clarifies rules for troubled CO-OP sector


The federal government has clarified some regulations that govern the startup  nonprofit insurers called Consumer Operated and Oriented Plans (CO-OPs) created under the Affordable Care Act.

More than half of the original 23 of such plans have shut down as they struggled with financial and enrollment issues.

Among the clarifications, reports FierceHealthPayer:

  • “Federal regulations require two-thirds of CO-OPs’ policies in any given state to be qualified health plans in order to ensure the program ‘retains its focus on providing competitive, high-quality health plan choices to American consumers in the individual and small group markets.’ But the rest can be dental or vision plans, Medicare Advantage plans, large-group policies or Medicaid Managed Care products.”
  • “CO-OPs’ two types of federal loans–start-up loans and solvency loans–are treated differently in terms of repayment. Solvency loans are treated as surplus notes, meaning a CO-OP does not have to repay CMS until a state insurance department determines repayment won’t lead to distress or default. While start-up loans were intended as ‘general obligations to be repaid at a specific time,’ CMS agreed in 2015 to allow CO-OPs to convert these loans into surplus notes on a case-by-case basis to ensure financial flexibility for the CO-OPS.”
  • “CMS will evaluate on a case-by-case basis when a CO-OP’s risk-based capital level falls below 500 percent, determining whether it should be placed on a corrective action plan or if it is considered to be in default. This policy allows CO-OPs to more easily manage changes in their business operations….”
  •  CO-OP board members can’t now represent a pre-existing insurer or  a state government, but CMS is exploring ways “to help diversify board membership without losing the member-run nature of the CO-OP program.”

Google as the next CMS?

Becker’s Hospital Review asks, perhaps half-jokingly, whether “CMS is Google’s next takeover target” as Google seeks new ways to make money off its data-collecting and analyzing expertise.

Still, Google faces a challenging quest to become the next CMS: It won’t be easy to get healthcare providers to hand over their data.


Big successes in a Penn. bundled-payment program

Integrated Patient Relationships for Success with Bundled Payments

Clinician-led Design Incorporates Human Needs Across Episodes of Total-Joint Replacement

CMS is pushing providers to fully integrate care to improve patients’ experience and outcomes, which can also decrease the overall cost of care episodes because of faster recoveries and fewer readmissions.

Cambridge Management Group (CMG), working with colleagues at Pyxera, responded to this imperative in a recently completed year of helping PinnacleHealth and other healthcare providers in central Pennsylvania redesign their total-knee-replacement (TKR) episodes.

The work was initiated within PinnacleHealth’s participation in the CMS Bundled Payment for Care Improvement (BPCI) program as well as within a pilot initiative with a large employer involving total knee replacement. The aim of CMS (and other payers) is to achieve better, more integrated health services while saving money – in the case of CMS, the taxpayers’ money.

Among the outcomes:

  • Identifying and developing physician leaders in context of the TKR design team, a process that can serve as at least a partial template for bundled-payment programs in other service lines.
  • Establishing personal/professional links with clinicians across the care episode – essential for care and cost coordination, empathy and higher morale in the working environment.
  • Demonstrating advanced market methods important in attracting a large commercial payer.

The work was suggested by CMG and sponsored by Dr. George Beauregard, chief clinical officer at PinnacleHealth. Dr. Beauregard saw an opportunity to demonstrate a safe, early-learning collaboration with the Orthopedic Institute of Pennsylvania (OIP); Arlington Orthopedics; perioperative orthopedic staff at Pinnacle, and selected post-acute-care providers.

Dr. Beauregard, other Pinnacle leaders, OIP and Arlington saw the potential of redesigning certain aspects of care delivery within the TKR arc of care to improve the patient experience and outcomes, gain additional process efficiencies, improve communication between all stakeholders involved in a TKR episode and reduce costs. The BCPI program was a laboratory for peer-to-peer learning and innovation for use with all TKR payer groups and, eventually, other bundled episodes of health services. (Dr. Beauregard recently became the chief physician executive at St. Luke’s Health Partners in Boise.)

The work was led by Dr. Jack Frankeny, CEO of OIP. Dr. Frankeny saw an opportunity to demonstrate clinician-led design across the episode to re-calibrate the TKR value-proposition (high quality and easy access) to consistently incorporate human-centered features. At the outset, the TKR service was a well-regarded and busy regional service navigated by resourceful patients and families. The objective was to integrate siloed services within the program for a seamless experience preferred by patients, families and providers.

The lens for focusing the work, evidence-based-design (EBD) methods, was provided by Tad Simons, Ph.D., and Don Westwood, founders and partners in Pyxera, in collaboration with CMG. They have nationally recognized expertise in designing systems, bringing evidence-based design to healthcare networks as their staffs learn to manage interactions across newly integrated services. EBD is one pathway to embed skills/values for adaptive, empathetic care coordination — the essential competence to win with bundled payment.

Participants called the experience very successful, and see it as offering guidance for bundled payments in other service lines, such as hip replacements and heart-bypass surgery.

The work first required interviewing clinicians across the continuum of health services to understand the interactions between them. At Pinnacle and most other systems, individual clinicians have tended to have remarkably incomplete knowledge of the identities and work of colleagues in other parts of a patients’ care. The lack of integration has hurt outcomes in some cases, undermined collaboration between clinicians and between clinicians, patients and family caregivers and led to expensive inefficiencies, including duplication of services.

Dr. Simons led interviews of key players across the course of a patient’s care that provided information, insights and, occasionally, inspiration for designing a human-centered experience enhancing the effectiveness, efficiency and low cost already present in the TKR service.

The basic sequence in the project was:

  • Assessing patients’ pre-op readiness for surgery to reduce complications and prepare well ahead of time for the discharge to home.
  • Working with patients and the hospital’s primary-care network to improve patients’ readiness for surgery.
  • Visiting patients’ homes to ascertain social factors, especially the capacity of family caregivers, to help streamline discharge.
  • Preparing patients for productive post-op physical therapy by connecting early to the physical-therapy team.
  • Coordinating in-hospital plans of the surgeon, anesthesiologist and unit staff to enable discharge after 36 hours.
  • Coordinating and enhancing care between multiple providers preceding the first surgical follow-up visit.
  • Coordinating care between multiple providers and improving outcomes during rehabilitative therapy through the end of care.

The project’s leaders are enthusiastic about the experience. Dr. Simons listed the pilot’s key achievements as:

  • “Better coordination and planning with services outside the hospital — for example, physical therapy, occupational therapy and home visits.’’
  • “A deeper recognition of the importance of patient selection and preparation.’’
  • “Spawning excitement among clinical staff about using design thinking for new process development.’’

Dr. Frankeny, the Orthopedic Institute CEO, called the bundling project a “crash course in value-based care for our orthopedic surgeons who were born and raised in the fee-for-service model. They also learned how important collaboration is with all caregivers throughout the health-service episode. It’s the only way to win in the bundled environment.’’

Dr. Frankeny lauded the Pinnacle administration’s transparency about costs, saying that it helped build trust among surgeons and other clinicians.

He noted, as did Dr. Beauregard, the initial strong opposition of some surgeons, who tend to be “Type A individuals who want to win.’’

But, he said, “Confront difficult docs with evidence {about cost and medical outcomes} and they will listen. And they have come to understand they will have to learn to live with a risk-and-value-based system because it will have a direct impact on their income and in how they run their practices. They must do something or something will be done to them. They understand that the data will compel change in any case.’’

And as part of the brave new value-based world, Dr. Frankeny noted, there’s a new imperative to go with the cheapest procedure if there’s no evidence that it produces worse medical outcomes.

Everyone in the project came to understand more than ever before the importance of the interactions between clinicians and other caregivers along all steps of a patient’s care.

Dr. Beauregard, the former Pinnacle chief clinical officer, noted the project’s victory over skepticism and outright opposition. The first reaction of one surgeon leader was “over my dead body,’’ he halfway joked. But physicians changed their minds as Dr. Simons demonstrated the strengths of the design process in improving outcomes, efficiency and collaboration, even as the doctors were reminded of the inevitability that the CMS — armed with more precise medical-outcome and cost data – would make bundled payments mandatory in multiple service lines.

And, in any event, “fixed price points will be beaten down in the commoditization’’ as CMS caps the prices of many procedures.

Dr. Beauregard said of the bundled-payment project: “Change is mandatory. We’re facing reality.’’

If the Pinnacle pilot program is any indication, that reality will be more than tolerable.

To elaborate on the success factors noted at the top of this article:

  • Executive and physician sponsors have used credibility and energy to enlist previously unconnected hospital executives, physicians and other patient-facing staff and a wide-range of other provider-partners.
  • Physician leaders with clinical and organizational gravitas have helped guide busy colleagues (across the episode) as they transform daily work while rebalancing operations and finances.
  • A process (lens) useful now and in the future to enlist and focus the deep and diverse competencies of the full range of providers, patients and families and to inform and inspire the clinician-led design team.


The world after Meaningful Use


While acting CMS head Andy Slavitt said this week  that the Meaningful Use program, at least as it existed, will end,  providers will still be held accountable for using technology in patient care.

The end of Meaningful Use  as we know it means no more incentives  (as opposed to penalties) from Medicare for adopting it,  although Meaningful Use-style incentives  will continue for Medicaid.

Still, an eligible  Medicare provider who fails to attest to Meaningful Use will  face a penalty.

However, Becker’s Hospital Review says that the recently passed blanket “hardship exemption permitting any Meaningful Use participant to apply for an exemption from Meaningful Use penalties in 2017 may bring the reimbursement penalties that year close to zero.”





CMS announces new Medicare ACOs


The Centers for Medicare & Medicaid Services (CMS) has announced 21 new participants in Medicare Accountable Care Organization (ACO) initiatives designed to improve the care patients receive  and lower costs. With this announcement, ACOs now represent 49 states and the District of Columbia.

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.




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