January 24, 2022
Your health care organization may be on the tightrope of still coping with COVID-related illness and delivering essential patient care, amidst staffing and supply shortages. But in 2022, life is not poised to give health care a breather. Likewise, there is no slow-down to the expansion of Value-Based Care and payment models or development of further stages in 2022. This year, providers in traditional Medicare will rack up stiffer penalties if costs are higher than CMS algorithms calculate. More ACO providers will progress along the path to Risk, and more will participate in alternative payment models (APMs). This will be…Read More
January 6, 2022
Five Predictions for the Fate of Value-Based Health Care in 2022
Only a few days into 2022, it seems obvious that many predicted “trends to watch” floated in late 2021 won’t, in fact, be what will matter most in this critical year for health care. Not that these issues aren’t important, but they are not new (if you’ve been paying attention and, hopefully, planning your strategies). The major predictions are underwhelming: Telemedicine and other types of virtual care will continue to advance. Digitization of health care for consumers will disrupt traditional channels of information and engagement. There will be more collaborations and blurred lines between payers and providers, and even more…Read More
April 29, 2021
New ACO Playbook: Can Coordination of Care Save Enough Money to Save ACOs?
Central to the controversy about ACOs’ potential for Value-Based Care is whether they actually save enough money and reduce costs fast enough. Researchers and advocates have produced various independent studies of ACO savings, the most generous estimating $1.8 billion in cumulative savings over the first three years of the program, almost double CMS estimates. Many others, however, dismiss the small proportion of savings—at a few percentage points—relative to total Medicare spending. The previous CMS administration was clearly dubious about the shared savings model. It favored payment models that put providers at financial risk to increase cost reduction incentives, even though…Read More
April 14, 2021
Why ACOs Need a New Playbook
A lot has happened in health care since 2012, when final rules permitted provider-organized ACOs to be the driving force of Value-Based Care under the 2010 Affordable Care Act (ACA). As we pass the ACA’s eleventh anniversary, a dwindling number of Medicare Shared Savings Program (MSSP) ACOs are entering a new phase marked by higher expectations and more difficult economics. To succeed in this challenging environment, ACOs will need different tools going forward than first contemplated, because of competition, both from providers under new value-based payment models and from Medicare Advantage plans. They also face more skepticism. Although rule changes…Read More
April 5, 2021
5 Value-Based Behavioral Health Strategies for ACOs and Medical Group Models
For ACOs and Direct Contracting Medical Groups adopting value-based payment models, behavioral health is often overlooked. But your patients’ unmet behavioral health issues are a big cost driver for emergency care and inpatient admissions, and they compound risk factors in disease. They also influence your patients’ adherence to treatment plans. You may believe this is a problem you can’t resolve because behavioral health is beyond the boundaries of your participating network. Even so, you need to be aware of a significant emerging trend: integrating behavioral health in primary care. The difference between physical medicine’s approach to disease versus behavioral health…Read More
March 18, 2021
With Competing Payment Models on Hold, What’s the Future for ACOs?
When CMS first announced new primary care payment models in April 2019, ACOs understood that their future might be threatened by competition for both physicians and patients. If medical groups could independently contract with Medicare under these models, they would have the advantage of greater control over their physician network, referral arrangements, and clinical decisions. The Value-Based primary care models of Direct Contracting (DC) and Primary Care First (PCF) were presented as a strategy to fortify primary care and independent practitioners. By combining prospective payment, quality monitoring, and incentive pools for lowering admissions and total costs, providers could potentially reap…Read More
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.…Read More
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.…Read More
January 22, 2020
Can Hospitals Still Lead Health Care Under Risk?
As the millennium's third decade begins, Risk has taken hold as THE strategy for tackling health care costs. Virtually overnight (in health care years) the industry has moved—albeit not uniformly—to accept Risk. This transition is already beginning to impact hospitals and hospital-based systems, and raises serious questions about the viability of their role as the primary financial engine bankrolling health care operations, reforms and modernization. Just one year ago, the concept of provider risk in Accountable Care Organizations (ACOs) was anathema to most participants. Despite initial misgivings, however, most ACOs remained in the system after CMS pushed forward with its…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