August 14, 2019
Last week CMS released a proposed rule addressing revisions in the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP), along with a few other matters. Of 1,704 pages, only about 20 addressed ACOs issues directly. But ACOs should take a holistic approach to reading this proposed rule, as well as the proposed Outpatient Prospective Payment System (OPPS) rule. Competition Among Risk Models Will Strongly Affect the Course of Change With so many CMS programs and models now in flux, the whole is more than the sum of its parts. It’s worth the effort to pay attention to the…Read More
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…Read More
July 31, 2019
A MIPS Rewrite is Certain: CMS Proposed Rule for the 2020 Quality Payment Program
The CMS Proposed Rule for the 2020 Physician Fee Schedule and changes to the Quality Payment Program picks up where the “Pathways to Success” ACO rule left off. This time, the “Pathways” shake-up is aimed squarely at MIPS, in the form of “MIPS Value Pathways.” We’ve described the growing frustration with MIPS, specifically MedPAC’s report to Congress on its concerns that MIPS is overly burdensome and complex, and doesn’t translate into better care. That theme repeatedly shines through the 1,704 page proposal. CMS is using this rule as an initial salvo indicating that MIPS as we know it is headed…Read More
July 24, 2019
Can ACOs Survive the Complicated New Landscape in Medicare Risk?
What a difference a year makes. In Spring 2018, many Accountable Care Organizations (ACOs) pondered a walkout over Medicare plans that included downside risk in ACO financials. Nonetheless, CMS finalized its plans to make provider risk a reality for all ACOs in its Pathways to Success overhaul of the Medicare Shared Savings Program (MSSP). ACOs’ lukewarm reception to the goal of compelled savings, however, was not forgotten. Fast forward to April 2019, when CMS announced five Primary Care Models to propel physician groups to adopt risk-based reimbursement directly—including capitation. Those models are now under fast-paced implementation, with application deadlines approaching.…Read More
July 10, 2019
Can Medicare Primary Care Risk Models Work in Today’s Practice Environment?
There’s now no doubt that Medicare is eager to move forward with Value-Based Health Care and risk-based reimbursement. CMS has rolled out major changes to make Accountable Care Organizations (ACOs) risk-bearing and add attractive benefits to capitated Medicare Advantage plans. Add to that two new classes of Primary Care Risk Models that introduce risk-based reimbursement into the general provider population, which, CMS says, are designed to stimulate primary care: Primary Care First (PCF) and Direct Contracting (DC). But we also know, from early CMS statements on direct contracting, that it intended to find other mechanisms to move physicians into Value-Based Health…Read More
June 26, 2019
Follow the Pathway to PCP Success In Medicare Direct Contracting
Primary care physicians were sitting on the sidelines as Medicare developed financial risk models in various generations of ACOs. At best, they could only hope to participate in Medicare Advantage and/or join a larger ACO. But potential for financial gain was elusive when the physicians’ success depended on the actions of others to achieve savings. Now Medicare is offering a carrot to large primary care practices with its new Direct Contracting (DC) models, luring them with the possibility of capturing higher and more predictable revenues as well as shared savings. CMS recently announced an initiative to test risk-based reimbursement models…Read More
June 19, 2019
Roji News Roundup: Industry Insights from CEO Theresa Hush
From women’s health care to the future of the Affordable Care Act, Roji Health Intelligence CEO Terry Hush has shared her insights with numerous industry publications in recent months. Here’s a sampling of current articles: Value-based arrangements in ASCs — 3 quotes from an industry CEO Becker’s ASC Review | June 11, 2019 Terry’s predictions, based on 25 years of industry experience, for what to expect for the future of risk-based agreements. Hint: Episodes of care and bundled payments will become increasingly important. The Future of Healthcare: “Make tools available for women so that they can have a real voice…Read More
June 12, 2019
Get the eBook “Not Second Best: Inject Value in Women’s Health Care”
Six months ago, I started writing about women’s health, in response to this simple question: What trends are emerging in health care for 2019? The New Year is filled with predictions about what is coming, and I thought this year’s list from health care leaders was too “last-year.” Artificial intelligence, medical science advancements in biologicals and genetic therapies, and business consolidation are not coming; they are already here and will simply go further. Witnessing the debate about health care rights in the country, and the increasing distrust of health care by consumers, I observed that most of those speaking are…Read More
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…Read More
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…Read More