Entries in Provider Payments (42)

Friday
Nov032017

Three Recent Studies and Three Different Perceptions of Value Based Payments

Three Recent Studies and Three Different Perceptions of Value Based Payments
 

by Clive Riddle, November 3, 2017

 

Three different recently released studies addressing value based payments fuel three different perceptions: (1) value based payments have solid momentum; (2) that hospitals view value based care is growing more slowly than anticipated; and (3) physicians prefer FFS systems to value based care.

 

The Health Care Payment Learning & Action Network has just released a report with survey results indicating “29% of total U.S. health care payments were tied to alternative payment models (APMs) in 2016 compared to 23% in 2015, an increase of six percentage points.” The Network states that “the survey collected data from over 80 participants, accounting for nearly 245.4 million people, or 84%, of the covered U.S. population.”  

 

While 29% of payments were value based and totaling “approximately $354.5 billion dollars nationally” in 2016, the Network determined that 43% of payments were “traditional FFS or other legacy payments not linked to quality” and 28% was “pay-for-performance or care coordination fees.”

 

Deloitte recently released results from their 2017 Survey of US Health System CEOs which includes are chapter on Population health and value-based care that provides these insights:

·         “Survey participants say the transition to value-based care is happening, but at a slower rate than initially anticipated. Still, many of the CEOs report that they are developing and expanding innovative delivery and payment models, and are focusing on MACRA and physician activation.

·         “Many CEOs also are looking into strategies to generate physician buy-in and encourage behavioral change, which will help them be better prepared for the transition to population health and value-based care.”

·         “Many of the surveyed CEOs express concern about operating under two different payment systems—FFS and value-based care—and having misaligned incentives. Moreover, moving towards population health and bearing financial risk likely will require a large patient population.”

·         “Many CEOs who previously had acquired and invested in physician practices report being more engaged and prepared for MACRA implementation than other survey respondents. “

·         “In our survey, some respondents indicate they are using tools including clinical integration, employment contracts with incentives, ACOs and risk-sharing agreements, among others to better activate physicians in care delivery transformation.”

 

Meanwhile, Bain & Company recently released their Front Line of Healthcare Report 2017, in which they surveyed 980 physicians and concluded that “more than 60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape. After years of experimentation, physicians now want evidence that new models for care management, reimbursement, policy and patient engagement will actually improve clinical outcomes. Without it, they see little reason to alter the status quo and move toward widespread adoption.”

 

Specific to physician receptivity toward value based care, Bain found that physicians very much prefer FFS if they had their druthers: “More than 70% of physicians prefer to use a fee-for-service model, citing concerns about the complexity and quality of care associated with value-based payment models. Fifty-three percent of physicians say that capitation reduces the quality of care, and most see little advantage from pay-for-performance models either. Further, many believe their organizations are not sufficiently prepared for the shift to value-based care.”

 
Friday
May052017

Different Approaches in Tackling the Surprise Medical Bill Problem

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By Clive Riddle, May 5, 2017

 

Surprise medical bills – from out of network physicians affiliated with network hospitals, and other similar situations – have been a long standing problem vexing consumers, providers, plans, employers and regulators. This simmering issue began boiling over the past few years as growth in narrow networks and ever increasing retail charges exacerbated the problem.

 

Arizona last week had Senate Bill 1441 signed into law: “The legislation, which takes effect in 2019, will allow a consumer with an out-of-network bill exceeding $1,000 to contact the Arizona Department of Insurance to request the appointment of an arbitrator. The insurer and health-care provider must try to settle the dispute through an informal telephone conference within 30 days of the consumer's arbitration request. The case advances to arbitration if the two sides cannot agree to an amount, with the insurer and health-care provider splitting the cost. Either party would have the right to appeal an arbitrator's decision to the county Superior Court.”

 

Oregon, Texas and Nevada, to name some states, currently have legislative activity of different kinds on this front.

 

Gastroenterology & Endoscopy News ran a nice April 20th 2017 article, Out-of-Network Billing: ‘Surprise Billing’ or ‘Surprise Gaps In Insurance Coverage’? that included a great summary of state level initiatives addressing these surprises.  Included in this discussion was:

·         A number of states are linking reimbursement to rates determined by the independent third-party database.

·         In New York  “Hospitals must disclose which health plans they accept and list standard charges for services. Perhaps most important, they must alert patients that physicians working at an in-network facility may not actually participate in the insurance network and can therefore bill patients directly.”

·         “California recently passed a law that settles out-of-network billing disputes by using one of two benchmarks. Providers will be reimbursed the greater of either 125% of Medicare rates or the insurer’s average contracted rate for the same or similar services in the same geographic region.”…but “not surprisingly, the California law is already being challenged in court.”

·         “Florida’s new law sets reimbursement for out-of-network claims at the lesser of: the provider’s charges; the UCR provider charges for similar services in the community where the services were provided; or the charge mutually agreed to by the insurer and the provider within 60 days of the submittal of the claim. The key in Florida moving forward will be how UCR is defined.”

 

The American Journal of Managed Care  has just issued a release discussing an article in their current issue: Battling the Chargemaster: A Simple Remedy to Balance Billing for Unavoidable Out-of-Network Care, in which “two doctors and two lawyers say they have a solution that doesn’t require legislation: better use of contract law…..Authors Barak D. Richman, JD, PhD; Nick Kitzman, JD; Arnold Milstein, MD, MPH; and Kevin A. Schulman, MD, say the problem starts with the ‘chargemaster,’ a hospital’s master list of prices for billable services. The authors say the defining feature of the chargemaster is that it is ‘devoid of any calculation related to cost,’ and has no relation to local market conditions.”

 

They release continues that “acontract law solution empowers the very parties who currently are being exploited by out-of-network charges,” they write. An emerging consensus, supported by a key court ruling, finds that providers are not entitled to ‘chargemaster’ rates, because neither the patient nor the payer agreed to them. Instead, the authors write, the law “entitles providers to collect no more than the prevailing negotiated market prices” for out-of-network care. In other words, rates already negotiated by hospitals, doctors, and area payers are the norm, not those artificially inflated on the ‘chargemaster.’ This leads to a stark conclusion, the authors find. ‘Providers have no legal authority to collect chargemaster charges that exceed market prices for out-of-network services, nor are payers under any obligation to pay such chargemaster prices.’ The authors make their case in a legal analysis available online.”

 

So while “the authors praise state legislators for trying to end surprise medical bills, they say the courtroom is the proper place for these disputes. Other remedies, like bans on out-of-network bills, don’t encourage cost-saving steps or competition.”

 
Friday
Jan202017

2017 MSSP ACOs By The Numbers

by Clive Riddle

 

CMS has announced their 2017 new and renewing ACOs, so we took a somewhat deeper dive into what comprises this year’s MSSP ACO roster, along with who dropped out. For starters, though, here’s the 2017 totals including the other active ACO types (there are also 9 remaining ACOs in the non-active Pioneer model):

  •          MSSP - 480
  •          Next generation - 45
  •          Comprehensive ESRD (CEC) – 47
  •          Total: 572

 

52 MSSP ACOs participating in 2016 dropped out of the program for 2017. 8 of these started in 2012, 11 in 2013, 22 in 2014, 8 in 2015, 3 in 2016.

 

For the 480 MSSP ACOs participating in 2017, with respect their track:

  •          Track 1 – 438
  •          Track 2 – 6
  •          Track 3 – 36

 

17 of these ACOs remain in the non-active Advance Payment program. 45 of these ACOs are the AIM program, and 25 are in the SNF 3 day waiver program.

 

With respect to geography, when classifying the MSSP ACOs by the primary state they serve (many ACOs serve markets in more than one state), 16 states comprise over two-thirds (68%) of the total:

  •          FL 44 ACOs
  •          TX 44 ACOs
  •          NY 34 ACOs
  •          CA 25 ACOs
  •          MI 20 ACOs
  •          NJ 19 ACOs
  •          NC 18 ACOs
  •          IL 17 ACOs
  •          GA 15 ACOs
  •          IN 15 ACOs
  •          MD 14 ACOs
  •          OH 14 ACOs
  •          KY 13 ACOs
  •          VA 13 ACOs
  •          PA 12 ACOs
  •          MA 11 ACOs

 

With respect to their initial year joining the program, MSSPs break down as follows:

  •          2012: 49 ACOs (14%)
  •          2013: 63 ACOs (13%)
  •          2014: 79 ACOs (16%)
  •          2015: 77 ACOs (16%)
  •          2016: 97 ACOs (20%)
  •          2017: 99 ACOs (21%)
Friday
Dec022016

Focus on Value to Survive, Maybe Flourish, for Next Four Years

by Clive Riddle, December 2, 2016

What shall be the fate of value-based care initiatives in the wake of a new administration’s zeal to slash away at all thing Affordable Care Act? The following article: Focus on Value to Survive, Maybe Flourish, for Next Four Years, recently appeared in the Inaugural issue of Value-Based Payment News, Russell Jackson, editor:

The quadrennial change of who’s who in the nation’s capital generally brings with it a shift in focus at the federal regulatory agencies and a reboot of the dynamic between the White House and the Capitol. But despite the magnitude of change that could reverberate throughout the national-level political apparatus this time around, experts pretty much agree that the value- and quality- and other payment reform-related programs – the Medicare Access and CHIP Reauthorization Act included – will likely continue in much their current form, albeit, in some cases, under different names and with, in all likelihood, different, and surprising, claims of original ownership.

Don’t be surprised, in other words, if a newly named Centers for Medicare and Medicaid Innovation turns out to have been the new president’s idea all along. Here’s a sampling of what the policy experts have been telling the press about value-based healthcare programs for the next four years.

“Premier Senior Vice President Blair Childs says Republicans strongly support Accountable Care Organizations. ‘They first ran the ACO demonstrations under the Bush Administration,’ he said by email. ‘They are envisioned in MACRA, of which the Republicans are strong supporters.’”

== ‘Republicans Expected to Spare ACOs, Other Demos from ACA Repeal;’ http://insidehealthpolicy.com/

“Ian Spatz, a senior advisor at Manatt Health, said there is no reason to think Republicans would reverse the trend toward providers sharing risk. He said ACOs and other demonstrations that move away from the fee-for-service system are not partisan. However, Spatz said it’s likely that Republicans will place restrictions on CMMI, such as prohibiting mandatory demonstrations, and they might change the Centers’ name.”

== same article

Gilberg, senior vice president of government affairs for the Medical Group Management Association, said they are advising members to continue preparation for MACRA. ‘We don’t see that that is going to be repealed. It was bipartisan, nearly a unanimous vote.’”

== ‘MACRA will move forward largely untouched when Trump steps in, experts say;’ http://www.healthcarefinancenews.com/news/macra-will-move-forward-largely-untouched-when-trump-steps-experts-say

 “Christopher Kerns, managing director at The Advisory Board, said, ‘MACRA is not in trouble, but mechanisms by which they control spending could change.’ Kerns said there might be a shift away from ACOs as a principal driver of controlling spending, and more toward bundled payments or price controls, cuts or other forms of utilization control in the form of reduction in reimbursement for different kinds of services.”

== same article

“The American Academy of Family Physicians said [it doesn’t] believe MACRA as a whole is in any real danger of repeal. ‘The election of Mr. Trump will have a limited impact on the MACRA law in the short-term,’ said AAFP President John Meigs Jr. ‘Looking forward, this law was supported by 91% of Congress. Based on the bipartisan support, it is difficult to see how there would be any fundamental changes under the Trump Administration.’”

== same article

“’This is a movement that’s happening independent of the ACA, or parallel to it,’ said David Jones, an assistant professor of health law, policy and management at Boston University’s School of Public Health. ‘It’s very unclear when they say they’re going to repeal ObamaCare whether they’re even thinking about things like CMMI or to shift away from things like fee-for-service.’”

== ‘Will value-based payment initiatives continue under Trump?;’ http://www.modernhealthcare.com/article/20161111/MAGAZINE/161109907

On the other hand …

“House Budget Chair Rep. Tom Price (R-GA) has had CMMI in his sights for a while now, and Sen. Orrin Hatch (R-UT) is no big fan. Both claim the center lacks accountability and hasn’t shown clear results. They may try to eliminate mandatory CMMI payment models and could seek to legally trim its sails.”

== ‘CMS CMMI, ONC and AHRQ preparing to take hits;’ https://www.g2xchange.com/statics/cms-cmmi-onc-and-ahrq-preparing-to-take-hits

 

You can request a sample copy of Value-Based Payment News by going here: http://valuebasedpaymentnews.com/sample.html

Friday
Oct282016

How to Increase Physician Engagement in Value Based Care: Deloitte Survey

By Clive Riddle, October 27, 2016

HHS, commercial health plans, states and health systems continue to advance value based care initiatives at a rapid and accelerating pace. But the question is, as the value based train is leaving the station, are the doctors on board?

Deloitte has released a report: Practicing Value-Based Care, which aims to answer the question “What do doctors need?” based on results from their Deloitte Center for Health Solutions 2016 Survey of U.S. Physicians.

The problem for physicians, Deloitte’s Mitch Morris tells us, is “today there is little incentive for them to change; many are still being paid under fee-for-service models and they're not equipped with tools that could help them deliver high-value care."

The Deloitte physician survey “found that while 3 in 4 physicians have clinical protocols, only 36 percent have access to comprehensive protocols (i.e., for many conditions). Also, only 20 percent of physicians receive data on care costs.”

Additionally, Deloitte findings from the survey indicate financial incentives haven’t changed enough: “Eighty-six percent of physicians reported being compensated under fee-for-service (FFS) or salary arrangements, similar to 2014. Showing no change from 2014, one-half of physicians reported performance bonuses less than or equal to 10 percent of their compensation, and one-third were ineligible for performance bonuses.”

Deloitte advocates that public and private stakeholders should partner with doctors to accomplish three things that would greatly enhance physician engagement:

  1. Tie at least 20% of physician compensation to performance
  2. Equip physicians with the right tools to help them meet performance goals including “clinical protocols, quality measures that align with their specialties and emphasize outcomes rather than processes of care, and detailed data on their own performance and on physicians to whom they refer patients.”
  3. Invest in technology capabilities to connect and integrate the tools