November 6, 2019
The common refrain within the 2475-page Medicare Final Rule for the Physician Fee Schedule and Updates for the Quality Payment Program (QPP) is “we are finalizing our policy as proposed.” This Rule follows the formula CMS adopted in its “Pathways to Success” ACO Rule: Propose a shake-up, reply to concerned commenters, and finalize policy without significant changes. CMS’s desire to move providers into Alternate Payment Models (APMs) comes through loud and clear, both in terms of its vision for MIPS 2.0 and in its more stringent scoring policies. As it stands now, MIPS has not evolved into the program CMS envisioned…Read More
October 30, 2019
Is Patient Lock-In the Next Step in Value-Based Care?
Hoping to safeguard survival under financial risk, health care providers are courting a contentious issue: how patients select primary providers. During the HMO heyday , health care risk economics depended on patient selection of primary providers as part of coverage selection that “locked” them into those PCPs and their referral networks. PCPs operated as gatekeepers to the rest of the health care system, authorizing services (or not) for specialists and other care. It’s well known that the HMO’s Primary Care gatekeeper model generated a backlash among private sector consumers. In fact, the gatekeeper was so unpopular with patients that it…Read More
October 23, 2019
Roji News Roundup: Fall 2019 Edition
In a range of recent industry publications, Roji Health Intelligence CEO Terry Hush shares her insights on the latest moves by CMS and health care trends: Are Value-Based Models Helping or Hindering Care Delivery for Primary Care Providers AJMC Managed Markets Network, October 10, 2019 This article by Jaime Rosenberg summarizes Terry’s presentation at the National Managed Care Physicians 2019 Fall Managed Care Forum in Las Vegas. Value-based models continue to enter the health care system, affecting a variety of fields, including primary care. And while success stories have been shared by payers and CMS touts these models as a…Read More
October 16, 2019
The Hedge Bet for Risk is Patient Experience
Creating a good Patient Experience in health care has gained little traction, despite being touted as one of the Triple Aim’s key goals in Value-Based Health Care. Health systems have been more focused on how to increase patients via health plan negotiations and consolidating regional providers, rather than focusing on the slower paced process of improving customer appeal. But now Patient Experience appears to be gaining some attention, and some forward-thinking providers are innovating to be more attractive to patients. Why? Because in the fiscal landscape of Risk, growing patient volume is essential. Providers are beginning to realize that there…Read More
October 9, 2019
How Physicians Can Navigate to Get Better Value from Specialty Services
In recent articles, we’ve discussed how Value-Based Health Care must help consumers make good decisions. Equally as important, CMS is now emphasizing how physicians should serve as navigators for their patients, providing information and guidance. Let’s take a closer look at how the triad of primary care physician, specialist consultant, and patient can effectively engage in a process that improves Value through better outcomes and lower cost. To focus on the shifting role of primary care physicians (PCPs), we use “physician navigation” to describe PCP actions to coordinate care for their patients. To emphasize continuity of care at stake for…Read More
October 2, 2019
How Consumers Can Choose Quality in Value-Based Health Care
In our last article on how Quality should be reflected in Value-Based Health Care, we looked at the problematic route of quality measurement and reporting. The intent to develop payment for quality has resulted in a complex measurement system that produced provider-specific performance scores across hundreds of measures, yet has failed to advance achievement of better health care outcomes. The system creates flexibility for providers by allowing choice of measures, which eliminates consumers’ ability to see differences among providers. The quality agenda needs to mature. In its developmental period, there was a need to achieve consensus on the standard of…Read More
September 25, 2019
Emergency Rooms Cannot Be the Only Option for “Regular Sick” People in Value-Based Care
I don’t normally write articles on health care based on personal experience. Fortunately, my health is good and my non-routine health care mostly involves orthopedic injuries. Those injuries have taken me more than once to hospital emergency rooms, where I usually am able to leave afterwards and not, instead, have surgery. No chronic illnesses and no prescription meds. I realize that I am a rarity. In the context of Value-Based Health Care (VBHC), most administrators assess emergency department use as optional. As if, except for traumatic injuries, orthopedic injuries, and heart attacks, doctor-office visits are an available alternative to going…Read More
September 19, 2019
Are Patients at Risk when Quality Measures Scale Back?
CMS is now poised to roll back quality reporting requirements in 2021, vastly altering the direction of quality measurement. Simultaneously, CMS will reduce the weight in Value formulas dedicated to quality, transferring the balance to Cost over the next five years. As providers face risk-based reimbursement, what protections are needed to ensure that patients get the right care? Does streamlining the program give providers a pass on quality? And, how do patients choose providers when there is no standardized measurement? In this second in our series on whether Value-Based Health Care is on track to meet its mission, we take…Read More
September 4, 2019
Will “Value” Help Consumers Choose?
In the emerging days of Value-Based Health Care (VBHC), “value” was defined by quality, cost, and experience of health care for patients—the “Triple Aim.” The movement’s initial defining goal: patients should be able to access high value health care services that improved outcomes, to get value for their dollars. Likewise, employers and other purchasers deserved similar value for their share of investment in health care benefit plans. Because incentives inherent in insurance and Fee-for-Service (FFS) payment systems reward volume over value, however, VBHC has also had a subagenda to make value pay for providers. But to reward better value instead,…Read More
August 28, 2019
How Should Primary Care-Centric Physician Practices Choose A Path to Risk?
It’s an urgent question for most practices: How should physicians participate in value-based reimbursement? Traditional Medicare is moving assertively to physician payment models that include capitation and ceilings on spending, with revenue risk tied to patient care costs. Without a doubt, primary care practices are bearing the brunt of risk-based reimbursement. With the exception of specialty-aimed Bundled Payments, most payment models are primary care-centric. Patient costs are grouped and then attributed to their primary care physicians—regardless of whether the services were provided by those physicians or by specialists and hospitals—and those PCPs are then rewarded or penalized under various risk…Read More