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Value-based programs may hurt providers that serve a lot of poor people


A new JAMA report that reviewed the first year of the Medicare Physician Value-Based Payment Modifier (PVBM) Program  found that providers who served “more socially high-risk patients {who are mostly lower socio-economic class} had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs.” This led to fewer bonuses and more penalties for high-risk practices.

The authors said  that value-based payment programs may financially harm practices that “disproportionately serve high-risk patients.”

CMS created the PVBM to measure the quality and cost of care provided to Medicare beneficiaries. Payments are based on providers’ performance on quality and cost measures.

Healthcare Dive commented:

“The JAMA study’s finding that more medically high-risk patients had lower quality and higher costs is eye-opening. Those patients are usually the most costly and payment models will need to figure out ways to reduce those costs while not penalizing physicians if value-based programs are successful. A payment model that only lowers costs and improves care to healthy people won’t move the needle.

“Even worse, if physicians are penalized, what incentive do doctors have to care for the sickest Medicare patients?

“The JAMA report will likely not quell physician fears about how value-based programs may lead to lower Medicare payments. It also won’t satisfy individuals concerned that changes to the healthcare system may harm the most vulnerable, which is always a worry when there are major healthcare changes.”

“One key finding about value-based care so far has been that experience in the model plays an important role in whether a provider has success. Organizations with the most success under value-based programs have often spent years creating clinically integrated networks, James Landman, director of healthcare finance policy at the Healthcare Financial Management Association, recently told Healthcare Dive.

“If you look at the data for the Medicare Shared Savings Program, which is the biggest of the ACO {Accountable Care Organization} programs under CMS, there is a correlation between time spent in the program and the ability to generate savings,” Landman said.”

To read the JAMA report, please hit this link.

To read the Healthcare Dive analysis, please hit this link.

Medicare ACOs seen gaining this year


Avalere Health, the  consulting firm, sees financial-risk-bearing Accountable Care Organizations gaining more traction and popularity this year. It says that “providers will feel increasingly comfortable with assuming financial risk in exchange for larger incentives” as more than 9 million Medicare beneficiaries are covered by a total of 480  (ACOs), including 99 new participants, in the Medicare Shared Savings Program (MSSP).

The number of ACOs participating in the Next Generation ACO Model launched by the CMS Innovation Center has more than doubled to 45 this year, from 17 in 2016..

Of the 525 ACOs serving Medicare beneficiaries, 87 are in risk-sharing arrangements that include bearing financial losses if certain cost targets aren’t reached.

Healthcare Dive noted: “Expansion of MSSP and growth in the number of risk-sharing ACOs is due in large part to the passage of MACRA, which is accelerating the trend toward value-based initiatives through the Quality Payment Program. So far, it seems that MSSP has been successful saving a total of $466 million in 2015 and more than $1.29 billion total since 2012.”

“As Congress considers health reform, there is some doubt surrounding the future of value-based initiatives like MSSP, which was established by the ACA. One reform floated by Republican leadership could be detrimental to progress made toward value-based care.”

“This approach would cause Medicare to function more like traditional markets, which would increase financial responsibility borne by beneficiaries and leave improvements to market forces rather than government regulators.”

To read the Avalere report, please hit this link.

To read the Healthcare Dive analysis, please hit this link.



Looking at the future evolution of the MSSP


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.

CMS releases stronger incentives to join ACOs

CMS has released final regulatory revisions  to strengthen incentives for Accountable Care Organizations in the Medicare Shared Savings Program.

CMS Acting Administrator Andy Slavitt said the changes  will “encourage more physicians to improve patient care by joining ACOs, while also refining how the program measures success, so that current participants are better rewarded for quality.”

Mr. Slavitt said the changes will also help physicians prepare for the new Quality Payment Program That program will hold providers to unprecedented accountability not just for reporting, but also, among large physician groups, for performance on a broad range of behaviors.

Here, according to Becker’s Hospital Review, are five takeaways from the MSSP ACO final rule.

1. “CMS modified the process for resetting benchmarks used to determine ACO performance.”

2. “CMS removed the adjustment that explicitly accounts for savings generated under an ACO’s prior agreement period.”

3. “The rule includes a phased-in approach to implementation.”

4. “CMS finalized an additional option for ACOs participating under Track 1 to apply to renew for a second agreement period under a two-sided model.”

5. “The rule establishes timeframes and criteria for ACOs to appeal CMS’ calculation of bonuses and penalties.”


A look at MSSP quality measures



This HealthAffairs article “dives into the pool of ACO quality measures,” and and looks at Medicare Shared Savings Program Year 2 performance metrics.

The authors conclude:

“The findings indicate the per-member benchmark is the strongest predictor of receiving savings and the amount of savings. But while success in savings to date is largely influenced by the established per-member benchmark, several quality measures are logically related to the magnitude of savings. Opportunities remain for improving patient outcomes. Additional time and experience in selecting quality metrics may be required to strengthen the relation measures of care quality and cost savings.”


Absorption of PCPs helps R.W. Johnson Health System toward goals


Robert Wood Johnson University Hospital, in New Brunswick, N.J. 

This piece in Hospitals & Health Networks discusses how New Jersey’s Robert Wood Johnson Health System,  “Rather than build a network and set of processes around a particular objective, such as participating in the Medicare Shared Savings Program… set a course to pursue the Triple Aim concept of lowering costs, improving clinical results and improving population health. …Physician alignment necessary to move smoothly into a systemwide set of health care delivery goals was aided by a proliferation of primary care physician employment by RWJ, from zero employed practices in 2012 to 110 today.”

2 big Ohio systems merging their ACOs


Two Ohio health systems will jointly contract for accountable care with health plans under a newly created clinically integrated network with broad geographic reach in the Buckeye State.

Cincinnati-based Mercy Health, formerly Catholic Health Partners, and Akron-based Summa Health said that each system’s Accountable Care Organization would join a new organization, Advanced Health Select — a clinically integrated network.

Other large regional systems, such as, in Michigan, Ascension Health and Trinity Health,  have been working to broaden their contracting in similar ways

The idea in the Ohio case is to build on ACOs’ success in the Medicare Shared Savings Program and the  systems’  total of  $100 million invested in the last four years in data analytics, information technology and care coordination.

N.Y.-Presbyterian creating population-health division


New York-Presbyterian Healthcare System’s Weill Cornell campus, on the East River.

New York-Presbyterian Healthcare System  is creating a population-health division in part to aid the system’s planning for the huge healthcare changes underway and accelerating.

The population-health division will be within the delivery network, with a leadership team of two physicians at the top to “enable its continue success under its new model of integrated care,”  the system said.

New York-Presbyterian, which is linked with the Cornell and Columbia medical schools, has been moving in the population-health direction for some time. Initiatives have included its 13 patient-centered medical homes in its ambulatory-care network and a joint venture with the two medical schools to start a Medicare Shared Savings Program Accountable Care Organization earlier this year.

Now, apparently, the system has reached critical mass to have a  formal population-health unit.

The division will, among other things, boost its ability to analyze claims data and improve care-management skills. Officials are also looking into such things as boosting partnerships with retail health clinics and dramatically increasing the use of telemedicine.

The system thinks that three to five years will be needed to get the new population-health program up to  full speed.


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.


The routes of 2 ACOs to improve care, control costs


Two Accountable Care Organizations (ACOs) discussed strategies to boost engagement with patients  in order to improve healthcare delivery and outcomes while more rigorously controlling costs.

One is Mercy Clinic ACO, in Des Moines, Iowa, which in 2012 became a Medicare Shared Savings Program (MSSP) participant. The ACO has provider participants throughout Iowa and focuses on primary care,  community resources, patient advisers and health coaches, who are registered nurses.

Mercy also uses  patient advisers to find out what it can do to offer better  service to patients and the broader community, as the imperative of improving population health becomes more pressing.

The Triad Healthcare Network, in Greensboro, N.C., is is also an MSSP ACO participant. Its initial patient-engagement efforts focused on care management for high healthcare users.But that only represented  5 percent to 10 percent of its patient population.

So it reached out  via telephone to “under-utilizers” — patients with chronic illness who haven’t had an appointment in  months. The idea, of course, is to more closely monitor their condition and care to prevent their illnesses from becoming more dangerously (and expensively) serious.




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