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The future of CMS payment models


Print (c. 1902) by Albert Robida showing air travel over Paris in the year 2000 as people leave the opera.

The trouble with the future is that it’s so much less knowable than the past.”

 John Lewis Gaddis, ”The Landscape of History”

The authors of an article in Health Affairs look at future CMS payment models based in part on recent payment evolution. Among the predictions:

Population-based models and disease-specific models will continue to develop.

”As ACOs mature and stabilize, opportunities exist to expand them to cover more lives and allow more providers, payers, and organizations to participate in accountable care. More established ACOs will need to expand the spectrum of healthcare providers they work with including behavioral- health, post-acute care and pharmacy providers, and will need to consider the socioeconomic needs—like transportation, housing, and education—of their patient populations.”

”CMS has relatively few disease-specific models, which offers an opportunity to take knowledge gained from current programs and expand to other diseases and co-morbidities through either specialty ACOs or bundled payment programs. The Oncology Care Model and the Comprehensive End-Stage Renal Disease (ESRD) Care Model are two examples of disease-specific models. The ACO movement has focused around primary and general care, but ACOs are most successful when they include providers that are involved at all levels of patient care, including specialists.”

More efforts to show bigger cost-savings

As the healthcare culture shifts to adopting value-based care, ”opportunities exist for more payment models and models that involve higher levels of risk, although mandatory demonstration models are unlikely to continue” if, as expected, Tom Price, M.D, becomes health and human services secretary.

”As ACOs demonstrate success and more physicians have confidence in accountable care, ACOs can move from shared savings-only to taking on more risk.”

Efforts to encourage growth of multi-payer, state and wider- region initiatives

”Multi-payer initiatives spread cost among different payers—for example, commercial and Medicaid—and provide a shared incentive to improve quality and care. When multiple stakeholders work together toward a common goal, collaboration is rewarded and patients benefit. State and regional initiatives also allow states greater flexibility in implementing programs that work best for their populations.”

”Maryland, Vermont and Colorado serve as examples of state multi-payer initiatives. Each of these state’s programs are designed to improve primary care through promoting care coordination, health management, patient-centered care, and disease prevention.”

Concurrent models will be developed

”For some physicians, particularly specialists, aligning different payment models might make more sense than being restricted to a single model. For example, participating in different bundled-payment programs could benefit a specialist who has less influence than a primary-care physician over a patient’s overall health management. CMS has an opportunity to provide clarity and guidance to physicians on which models work best together for different types of physicians or practices.”

To read more, please hit this link.

HHS picks 196 physician groups, 17 health insurers in coordinated cancer-care project


The U.S. Department of Health and Human Services has selected 196 physician group practices and 17 health-insurance companies to take part in a value-based delivery model that seeks to provide more coordinated cancer care at a lower cost to Medicare.

Under what has been named the Oncology Care Model, CMS will use certain quality measures to track the care that each physician practice provides to Medicare beneficiaries undergoing chemotherapy.

Becker’s Hospital Review reports that practices “will receive performance-based payments for each six-month episode of care based on quality scores and whether they saved money over the episode, compared to historical fee-for-service payments.”

The news service added: “Practices will also receive a $160 monthly care management payment for each beneficiary. Participants will be enrolled in a one-sided risk model for the first two years of the Oncology Care Model and dive into two-sided contracts beginning in 2018.”

To read the Becker’s article on this, please hit this link

New CMS cancer-care program: ‘Specialty-based global payment’


This JAMA piece looks at CMS’s plans to begin a new Medicare contracting model for pay-for-performance cancer care that “might serve as a model for specialty-based global payment.”

The article says:

The model ”allows oncologists to serve as the coordinator of the patient’s care, similar to primary care physicians in ACOs. Oncologists may be particularly well suited to assuming this role, given their longitudinal relationships with patients, continuity of oncologic treatments, and that costly episodes of care are relatively short and well defined.

“The OCM  {Oncology Care Model} may pave the way for a new phase in payment reform centered on specialty-based global budgets. Another example is the Medicare Comprehensive End-Stage Renal Disease (ESRD) Care Model, in which physicians and dialysis organizations assume responsibility for a budget for beneficiaries with ESRD. Although there are potential pitfalls of using smaller budgets, carefully designed incentives appropriately targeted to a specialty may offer a compromise between fee-for-service and wholesale risk contracts.”

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