MedicarePrimary Care PracticesValue-Based Health Care
June 5, 2019

Can Small PCPs Succeed in Medicare’s Primary Care First?

Medicare’s announced primary care models will provide an interesting test of whether financially-motivated primary care practices (PCPs) can improve hospital utilization, the key outcome measure that will determine provider revenues under the pilot. While provider risk for costs of patient care is inevitable for most physicians in the future, providers don’t have the same potential for financial success. That is especially true for PCPs, whose volume and roles in health care have been eclipsed by specialists and industry consolidation. Whether Value-Based Health Care can restore primary care to a central role of coordination—with the potential for cost reduction—is at the…
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ACOsBundled PaymentsFuture of Health CareRiskValue-Based Health Care
May 22, 2019

Can Provider Risk Cure High Medical Costs?

Fee-for-Service (FFS) has been on a slow march toward risk-based reimbursement for two decades. But FFS has proven to be remarkably resilient—until now. In the last six months, Medicare has doubled down on creating new provider risk models for ACOs, specialists and primary care physicians. All of them have methods to ensure that providers are held accountable for medical expenditure targets. Wait. Haven’t we been here before? What‘s different between now and the 1980s, when HMOs and provider risk first prevailed in the market—and then were purged as both ineffective and unpopular? Is provider risk a cure for high medical…
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ACOsFuture of Health CareValue-Based Health Care
May 8, 2019

How Will New Primary Care Models Affect Providers in VBHC?

Embraced by some provider groups and disparaged by others, CMS’s five new payment models for practices focused on primary care include much to consider. All reflect a key departure of Medicare’s Value-Based Health Care (VBHC) efforts to date: they are direct efforts by Medicare to transition physician practice revenues to risk without the necessity of ACO participation. The primary care models will affect both providers and patients. In this article, we’ll address the provider issues. How patient choice of care and outcomes for patients and patient populations will be affected deserves dedicated scrutiny in a future post. No Surprise that…
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ACOsAdvanced Alternative Payment ModelsRiskValue-Based Health Care
January 9, 2019

Pathways to Success: How CMS is Encouraging ACO Participation Despite Impending Financial Risk

CMS closed 2018 with a farewell to upside-only ACOs. Perhaps the biggest surprise in the “Pathways to Success” Final ACO Rule is its consistency with the Proposed Rule, which floated the revamped ACO Track back in August. Citing superior performance among two-sided participants, as well as the belief that upside-only tracks reduce patient choice and increase costs, CMS has finalized its proposal to push all ACOs into two-sided arrangements. Not coincidentally, this rule was simultaneously released with NextGen ACO model results, which showed that these 44 downside-risk ACOs saved $164 million. The rule, which will go into effect on July…
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ACOsFuture of Health CareValue-Based Health Care
September 5, 2018

Ready or Not, Providers Will Face Risk Under ACOs or Medicare Advantage

In any other industry, companies work hard to interpret purchasing and regulatory trends, and adapt quickly in times of change. Swift action is a hallmark of competitive business; those that linger risk failure. Examples of business adaptation are everywhere: a move to digital applications that help consumers and other purchasers connect and build loyalty; acquisition or spin-off of business services to enhance growth; immediate response to negative press. But in health care, the pace of change at the industry’s core—healthcare organizations and health systems—is slow and barely responsive to the market. Case in point: while government and private health plans…
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ACOsFuture of Health CareValue-Based Health Care
August 15, 2018

Proposed ACO Final Rule: 10 Essential Takeaways from “Pathways to Success”

The Final Rule for the Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO)  has been released, the first real revision since the program’s inception. Introducing the proposed rule, CMS stated that it is time to put real ‘accountability’ in Accountable Care Organizations, and this means that ACOs need to accept financial risk. The theme behind Pathways to Success is to end the one-sided risk model. ACO Savings Success Was Zero-to-Limited Under the Savings-Only Model Although ACOs were supposed to curb healthcare spending, data released earlier this year showed that CMS actually spent $384 million more, rather than saving $1.7…
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Alternative Payment Models (APM)Merit-Based Incentive Payment System (MIPS)Qualified Clinical Data Registry ReportingValue-Based Health Care
July 25, 2018

The Proposed 2019 Quality Payment Program (QPP) Rule: What You May Have Missed

Whoever said bureaucracy doesn’t foster change did not anticipate CMS’s Proposed Rule for the Quality Payment Program (QPP), 2019 performance year version, released on July 12. While the familiar overarching structure of MIPS remains, there are a number of revisions that activate newly developed policies. These include “Patients Over Paperwork” and “Meaningful Measures” efforts that CMS initiated in 2018 to streamline the requirements-heavy MIPS program. To be honest, there are some rough patches within the wrangling of old and new MIPS provisions in the 1,473 page 2019 Medicare Physician Schedule Proposed Rule, set to be published in the Federal Register…
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ACOsClinical Data RegistryMerit-Based Incentive Payment System (MIPS)Performance ImprovementValue-Based Health Care
July 18, 2018

No More MIPS Cost Score Details? 5 Ways Providers Can Still Take Control of Costs

CMS is urging providers to participate in ACOs with downside risk, but they might be eliminating one of the keys that providers need to prepare. It couldn’t come at a worse time, when providers already stand to lose under risk-based models if they can’t identify where their cost issues lie. That data is only available from claims data made available by payers. Up until now, practices have had access to indispensable data on costs that are attributed to their providers, showing specifics of where they are above the norm. These were previously part of Quality and Resource Use Reports (QRURs)…
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ACOsAdvanced Alternative Payment ModelsAlternative Payment Models (APM)MedicareMerit-Based Incentive Payment System (MIPS)Value-Based Health Care
June 13, 2018

Medicare Paths to Value-Based Health Care: Which Way is Up?

If you’re scratching your head about the direction of Value-Based Health Care (VBHC) in Medicare, you’re not alone. The current mix includes a swirl of separate initiatives, some new and others recently re-labled. As CMS pushes toward VBHC, providers may feel confused and frustrated as concepts emerge that will affect multiple programs. Within the last several months, the Patients Over Paperwork and Meaningful Measures initiatives have shaken up CMS value-based care programs, particularly: Merit-Based Incentive Payment System (MIPS) Medicare Shared Savings Program ACOs (MSSP ACOs) Direct Provider Contracting (DPC) Even more confounding, CMS is taking a non-linear development path for…
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ACOsFuture of Health CareValue-Based Health Care
May 23, 2018

Tipping Point Test for ACOs: Consent to Financial Risk

Last week the conversation about financial risk for providers in ACOs took on a decidedly different and more contentious tone. After months of CMS reports of ACO growth and success, while retreating on MIPS quality reporting requirements as concessions to “provider burden,” CMS signaled that they were finished waiting for providers to accept financial risk under Value-Based Health Care. With a third of Medicare patients served by an ACO and an even higher number of patients receiving health care via private sector ACOs, the industry seems on track to adopt ACOs as the preferred model of health care contracting and…
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