Cooperating for better care.


Tag Archives

Capitalizing on Medicaid APMs


Deloitte has studied Medicaid alternative-payment models (APMs) to see how payers and others can best capitalize on them. The consulting firm looked at:

  • Patient-centered medical home initiatives.
  • Medicaid Health Homes.
  • Episode of care payments.
  • Accountable Care Organizations.

The firm concluded that:

  • “Many states are taking advantage of Medicaid program flexibility and federal financing to implement APMs in a variety of ways.
  • “Although many state initiatives are underway, relatively few have been evaluated for their impact on total cost of care of health outcomes.
  • “The potential impact of Medicaid alternative payment models on care delivery can depend considerably on how much of a provider’s revenue comes from Medicaid.
  • “Medicaid models may need to evolve to incorporate more financial risk and increase participants’ meaningful use of electronic health records (EHRs) to qualify as advanced APMs under MACRA.’’

“Despite limited evidence, APMs continue to spread, and federal and state policies are increasing pressure on providers and insurers to participate. Aligning Medicaid AMPs’ design, reporting requirements, and financial incentives with other payers could potentially increase their impact and likelihood of success. This could be particularly true for specialists or other providers who treat a low volume of Medicaid patients.’’

To read the report, please hit this link.




The fiscal future of weight management

Douglas W. Rothrock, M.D., the  founder of Prescott Cardiology, in Arizona, looks at the intersection of value-based payments, MACRA and the obesity epidemic in a Physicians Practice piece, at the end of which he comments:

“By offering a weight management protocol that is consistent with evidence-based guidelines, physicians can help patients prevent disease progression, improve standards of quality in obesity management, and comply with an achievable quality measure that can contribute to maximum reimbursement.

“In the future, we may expect to see the astronomical human and fiscal cost of obesity prompts the expansion of quality measures for obese patients, including evidence-based obesity prevention and treatment that includes the behavioral, nutritional intervention, and counseling necessary to lose weight and keep it off. And at the heart of MACRA and other value-based payment systems, that’s what it’s all about.”

To read his essay, please hit this link.

Douglas W. Rothrock, MD is the founder of Prescott Cardiology in Arizona.

Benefits to public are hard to see in the ‘corporate transformation of American medicine’

An article in Health Affairs looks at the MACRA and the “corporate transformation of American medicine.”

Among its observations:

”There is surprisingly little evidence about the performance of different forms of physician practice. Several recent studies suggest that, on average, larger practices and practices owned by hospitals charge higher prices, generate higher total costs of care per patient, and do not provide better quality. However, the available evidence is far from definitive. It is possible that if payment incentives to improve quality and control costs become stronger over time, large organizations will gradually develop superior capabilities to improve the care they provide.”

The article ends with this:

“Meanwhile, the corporate transformation of American medicine proceeds. Once independent practices become owned by a corporation, it is very difficult for them to disengage themselves and re-create a functional practice. Given the limited research to date about higher prices, higher costs, and at best equivalent quality for patients of physicians employed by hospitals, there is an urgent need for more evidence on the impact of different types of provider organization on the quality and cost of care, and on patient, physician, and staff experience.”

2 experts to physicians: Value-based care is her to stay


Ingrid Lund, Ph.D., practice manager for the physician practice roundtable at  The Advisory Board Co.,  and Eric Cragun, senior director for health policy at the Advisory Board, agreed in a Physicians Practice podcast that value-based care is here to stay, as is much of the Affordable Care Act.

Ms. Lund said: “Certainly whatever the GOP does, whatever their next move on healthcare reform is, it will impact providers in some way, but I think we can agree there are some safer bets and ways to move strategy forward even though we’re in this point of uncertainty.”

She also said that the bi-partisan Medicare Access and CHIP Reauthorization Act (MACRA) will stick around and that physicians should continue to adapt to the move toward risk-based contracts.

Another “safe bet,” according to Ms. Lund, is to “double down on your consumerism strategy” thanks to the rise of health savings accounts and high-deductible health plans.

To hear/read more, please this link.

New ACO model for small rural hospitals

CMS has come out with  details of its newest Accountable Care Organization (ACO) offering in the Medicare Shared Savings Program — Track 1+ — intended to push more small physician practices and small rural hospitals to adopt risk-based systems.

Becker’s Hospital Review has come up with five things to know about the Track 1+ Model. Here’s our edited version of the list.

1. “The Track 1+ Model is a hybrid of Tracks 1 and 3 of the MSSP. It lets practices begin to take on some downside risk, but limits exposure. The downside risk in Track 1+ is more limited than that of Tracks 2 or 3. ”

2. “It qualifies as an advanced alternative payment model under the Medicare Access and CHIP Reauthorization Act. Clinicians can enroll in the program to start in 2018. Those who participate may be eligible to earn the lump sum incentive payment for Medicare Part B payments under the advanced APM track beginning in the 2018 performance year. By adding this option as an advanced APM under MACRA, the agency expects an additional 70,000 physicians to qualify for incentive payments in 2018.

3. “The model follows that of MSSP Track 1 with a few key differences. The elements of Track 3 included in the new model are as follows:

  • Prospective beneficiary assignment.
  • Option for symmetrical thresholds for shared savings and losses.
  • Option to use the three-day skilled nursing facility. waiver, allowing ACOs to admit patients to SNFs without a minimum three-day inpatient hospital stay.

4. “The program has a 50 percent maximum shared savings rate. For perspective, Track 2 has a 60 percent MSR and Track 3 has a 75 percent MSR. Track 1+ has a fixed 30 percent loss sharing rate and the maximum level of downside risk will vary. Depending on the ACO composition, the maximum loss limit will be capped at 8 percent of Medicare fee-for-service revenue or 4 percent of the updated historical benchmark. Lower levels of risk may be offered for ACOs with independent physicians or small rural hospitals.”

5. “The application process will follow the same timeline as all other MSSP applications. CMS has not yet finalized application details, but interested ACOs will need to submit a letter of intent in May 2017. New ACOs and Track 1 ACOs will be eligible to apply. In addition to 2018, CMS plans to offer the model in 2019 and 2020.”

To read the whole article on this, please hit this link.

Why direct primary care beats MACRA


John Squire, President and COO of Amazing Charts, writes in Med City News that direct primary care (DPC) has MACRA’s goals but without the complexity. (A reminder: MACRA stands for  Medicare Access and CHIP Reauthorization Act of 2015.)

He writes:

“When I first heard about the federal government’s new value-based Quality Payment Program for physicians, I was struck by the similarities with direct primary care, a grassroots movement that seeks to establish a straight financial relationship between patients and providers, cutting out private insurance carriers and Medicare. The premise of direct primary care is that patients pay providers directly, usually in the form of a low monthly subscription.”

“The ways these goals are achieved by direct care and MACRA/MIPS are incredibly similar. Both approaches focus on: enhanced access to the practice; proactive care for chronic conditions and preventive diseases; patient and caregiver engagement; and coordination of care across the medical neighborhood. But the ways of administering care and measuring results is dramatically different.”

“Direct primary care is growing in popularity, fueled by physician discontent with the traditional fee-for-service model that encourages 15-minutes-or-less exams with an overwhelming number of appointments. Patients typically join a DPC practice as a ‘member’ and pay a flat monthly fee (about $75) for virtually unlimited primary care, including extended in-office visits, as well as non-face-to-face care via email, phone and text. As a result, patients visit DPC doctors more often and develop stronger personal bonds.”

To read the article, please hit this link.

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.

Video: How Mich. hospitals share information


In this video, Doug Dietzman, executive director of Great Lakes Health Connect, Grand Rapids, Mich., describes how this Michigan health-information exchange is connecting 129 hospitals, and many other healthcare settings, using a field-funded model. He also discusses the progress of interoperability and how MACRA fits into all of this.

To see the video, 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.

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.


Page 1 of 212

Contact Info

(617) 230-4965

Wellesley, Mass