ACOsBundled PaymentsEpisodes of CareRiskSpecialty ServicesValue-Based Health Care
October 22, 2020

Five Ways to Manage Specialty Costs Without Bundled Payments

When health plans and Medicare propose controlling the cost of specialty care, expect that bundled payments will be the next suggested solution. With the introduction of every new specialty-focused payment model, an episode-based bundled payment model is involved. But let's say you’re an ACO with no interest in bundled payments arrangements. You may not even think you can put the topic on the table with specialists. Or, if you are a health system or specialty practice that is trying to control total cost of care for competitive reasons, perhaps you aren't yet willing to accept fixed fees. How can you…
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ACOsEpisodes of CareRiskValue-Based Health Care
August 26, 2020

Straight Talk for Providers Adopting Capitation: Don’t Fly Blind Without the Right Data

Value-Based Reimbursement—once focused on incentives and shared savings—now more often means capitation. Whether adopting Medicare Alternative Payment Models (APMs) or contracting with health plans, physician groups and health systems have signaled greater willingness to adopt these new Risk payment models with their guaranteed payments for attributed patients. But here's the problem: If you don't have good data on your costs, you are flying blind. Let’s look at the myths and realities of what you really need both to measure your success under global capitation and to ensure that your Risk program is on track to be successful. Do You Need…
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Episodes of CareFuture of Health CareRiskValue-Based Health Care
July 20, 2020

Episodes Are More Than Payment Models: They’re Key to Improving Care

For many health systems and groups, episodes are esoteric. Providers often think of them only in context of risk-based payment models like bundled payments and capitation. Navigating Value-Based Health Care contracts, providers analyze and model performance under Fee-for-Service and episode-based payments to decide their course of action. Or, if already in Value-Based reimbursement, they use them as targets for costs to pinpoint physicians who exceed the targets. These strategies are shortsighted and limited. Even at best, they do nothing to address what is actually driving cost of care. By using payer-constructed episode specifications, such strategies potentially obscure valuable clinical and…
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Future of Health CareRiskValue-Based Health Care
March 11, 2020

Value-Based Care Defined: Know the Vocabulary of Health Care Reform

Today, as we confront a viral threat that is challenging our health system, its capacity, and how care is financed, it seems appropriate to review some fundamentals. Health care reform has been speeding down a particular track, changing how health care is covered, paid, delivered, and organized. These reforms may seem to be about health care financing, but will make a future difference in health care access and patient outcomes. Medicare is driving the train with its huge budget and rulemaking capabilities. But insurance companies, in lockstep, are rapidly implementing similar changes. Understanding all those changes is no easy task.…
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ACOsDirect ContractingFuture of Health CareValue-Based Health Care
February 27, 2020

ACO Path to Viability: Direct Contracting May Be the Opportunity

What if your best route to viability was the high-risk path you feared the most, because that failure might destroy you? That's the question Accountable Care Organizations (ACOs) have been asking this week—whether to participate in Medicare's new Direct Contracting (DC) initiative. With a shift in payments from Fee for Service (paid per-provider service), to Global Capitation (paid per-beneficiary), DC completely changes the incentives for the health care system. Whether Direct Contracting is a boon or a bust to ACOs depends on their ability to control the costs of patient care long-term—and whether they have the leverage to do so.…
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Consumers & PatientsFuture of Health CareValue-Based Health Care
December 18, 2019

Bottom Line: Can Consumers Survive Value-Based Health Care?

As 2019 nears its close, health care has reached a crossroads. Value-Based Health Care was intended to clarify consumer choices and motivate providers to offer high value services that improved outcomes, as well as to improve patient access to those services. But has that goal been realized? Has anything really changed? Or are health care consumers even worse off than before? Since September, we've been evaluating the consumer perspective of Value-Based Health Care, examining whether the movement is helping consumers achieve affordability, better choices, and good quality. We’ve focused on two central questions: Is Value on the right track? Has…
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Consumers & PatientsFuture of Health CarePrice Transparency
December 11, 2019

Can Consumers Ever Get the Transparency Needed to Predict Health Care Costs?

If you’re feeling squeezed to control your medical costs and pressured to find the essential information and help you need to do it, there's a good reason. Health care professionals, politicians, and economic experts are calling on consumers to make decisions about what services to get and where to get them. While Value-Based Health Care claims may focus on provider accountability for better and more coordinated, economic care, a secondary theme is to achieve greater accountability and cost sharing by patients. Giving consumers the tools to be accountable underlies the Transparency movement, including the new proposed rule from CMS that…
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ACOsAlternative Payment Models (APM)Merit-Based Incentive Payment System (MIPS)Primary Care PracticesValue-Based Health Care
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…
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ACOsFuture of Health CarePrimary Care PracticesValue-Based Health Care
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…
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Future of Health CareRiskSpecialty Physicians
August 7, 2019

Risk Payment Models Will Fuel Growth of Equity-Backed Physician Practices

Risk payment models present a daunting challenge to the very cultural of medicine—for most physician practices. Physicians identify their practices as clinical enterprises more than businesses, although some have managed to achieve success solely by being excellent clinicians in their fields. Patients, however, are quick to see the flaws along with higher costs—hence complaints about customer service, poor billing practices, and difficulty communicating. But clinical practice success, up until now, has been measured by the yardstick of Fee-for-Service reimbursement: higher incomes through patient volume and services. Hospital purchasers of physician practices adopted the same benchmarks of success. Even as hospital…
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