Roji Intel Blog

Theresa Hush 0
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Consumers & PatientsFuture of Health CareMedical Decision-MakingValue-Based Health Care
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…
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Theresa Hush 0
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Consumers & PatientsFuture of Health CareValue-Based Health Care
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…
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Theresa Hush 0
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Future of Health CareMerit-Based Incentive Payment System (MIPS)Quality Payment ProgramValue-Based Health Care
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…
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Theresa Hush 0
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ACOsFuture of Health CarePrimary Care PracticesValue-Based Health Care
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,…
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Theresa Hush 0
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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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ACOsFuture of Health CarePrimary Care PracticesQuality Payment ProgramValue-Based Health Care
August 14, 2019

Five Actions ACOs Should Take Now: Takeaways from Proposed CMS Rulemaking

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…
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Theresa Hush 0
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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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Dave Halpert 0
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Alternative Payment Models (APM)Merit-Based Incentive Payment System (MIPS)Quality Payment ProgramRisk
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…
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Theresa Hush 0
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ACOsFuture of Health CarePrimary Care PracticesValue-Based Health Care
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.…
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Theresa Hush 0
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ACOsFuture of Health CarePrimary Care PracticesValue-Based Health Care
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…
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