Entries in Provider Payments (44)

Thursday
Apr122018

Long Term ACO Impact: Medicare vs. Medicaid vs. Commercial

Long Term ACO Impact: Medicare vs. Medicaid vs. Commercial
 

By Clive Riddle, April 12, 2018

 

Commercial accountable care – value based payment arrangements between purchasers and providers seem to be spreading virally. States Medicaid accountable care initiatives are proliferating.  Will Medicare continue to consumer the greatest share of healthcare stakeholder attributed ACO patients and financial resources?  The April issue of Accountable Care News Thoughtleaders Corner ask a panel this question: “Which type of ACO activity will have more impact on stakeholders in the long term: Medicare, Medicaid  or commercial?”

 

Kirit Pandit, Co-Founder & Chief Technology Officer of VitreosHealth responds that “I think Medicare ACO activity will have the most impact in the long term based on where incentives are maximized. Fully capitated plans such as Medicare Advantage and managed Medicaid plans will have the highest incentive to reduce costs and maintain high quality scores. This is where ACO activity will produce the best outcomes. The per member per month costs are high to make it attractive for providers to participate in these performance-based contracts.  However, compared to Medicare ACOs, Medicaid has higher churn rates. This makes it challenging for the providers to manage these members with a long-term perspective. If the churn rates are high, chronic care management activities will not have enough time to impact patient behavior and outcome. So the Medicare ACO plans that are fully capitated and have minimal member churn will have the highest impact.”

 

 Michael Millenson, President, Health Quality Advisors; adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine and author of the book Demanding Medical Excellence has this to say: “Right now, it’s synergistic. Medicare is by far the nation's largest payer, but joining an ACO is voluntary. However, Medicare’s clout and standardization are critical. On the other hand, Medicaid and private payers can both push their programs on providers (a state or large employers can choose only ACOs) and be much more innovative. Statutorily, CMS could switch all Medicare to ACOs without additional congressional authorization. If that ever happens – with implicit Congressional approval and definitely in the long term – this question will have answered itself.”     

 

William DeMarco, Founder and President, Pendulum HealthCare Development Corporation, which has advised a wide range of ACO clients shares that “We think after all the dust settles, Medicare will offer the biggest impact on stakeholders. This considers total dollars and the fact that 10,000 Baby Boomers turn 65 every day and total cost of care will continue to rise ahead of inflation – so it will always be a big number. Medicaid will continue to be in a constant state of change on a state-by-state basis, but will slowly follow the ACO transition that may very well lead to more Special Needs and Dual-Eligible strategies being promoted by states and offered by insurers, as well as provider-led health plans that see the advantage of receiving a large capitated sum from Medicare and Medicaid for eligible patients. I say this based upon the number of Section 1115 waivers being sought to permit states to offer above and beyond Medicaid benefits through ACOs and CCOs. Commercial will always be in transition, as self-funded and fully insured are finding big deductibles do not work and the fiduciary accountability starts to weigh heavily on many of the purchasers of care. What employers are interested in are ACOs that can manage the active workers and retirees at a predictable cost. Health plans and insurers are seeing their profitability is linked with these ACOs that can take partial or full risk for the medical portion of the premium, and this allows the health plan to improve administrative cost savings – plus predict total cost of care.”

 

So, some collective wisdom seems to point towards Medicare continuing to hold the strongest magnetic force attracting ACO activity.

 
Friday
Jan192018

2018 CMS Medicare Shared Savings Program: 43 Previous ACOs out, 124 New ACOs In

By Clive Riddle, January 19, 2018

CMS recently published 2018 Medicare Shared Savings Program information.  After comparing the listing of 561 2018 MSSP participants to the 480 2017 participants, we found 43 2017 ACOs have exited the program for 2018, and there are 124 new ACOs for 2018.  Caravan Health has sponsored 15 new ACOs, and Community Health Systems is sponsoring 14 of the new ACOs.

Here’s the list for the 43 ACOs exiting the program:

  1. Accountable Care Coalition of Mount Kisco (CT, NY)
  2. Accountable Care Coalition of Western Georgia (AL, GA)
  3. ACO of East Hawaii (HI)
  4. Advanced Premier Physicians ACO (CA)
  5. APCN-ACO (CA)
  6. ApolloMed Accountable Care Organization (CA, FL, HI)
  7. Arkansas High Performance Network ACO of FQHC (AR, KY)
  8. Arkansas HIgh Performance Network ACO (AR)
  9. Bay Area Medical Associates ACO (CA)
  10. Bluegrass Clinical Partners (FL, KY, TN)
  11. Care Covenant (TX)
  12. Catholic Medical Partners-Accountable Care IPA (NY)
  13. CHRISTUS Louisiana ACO (LA)
  14. CHWN ACO (IL)
  15. Collaborative Health ACO (MA)
  16. Community Health Accountable Care (NH, NY, VT)
  17. Connected Care (MI)
  18. Cornerstone Health Enablement Strategic Solutions (NC)
  19. Health Leaders Medicare ACO Network (LA)
  20. Indiana Care Organization (IN)
  21. Kansas Primary Care Alliance (KS, MO)
  22. KCMPA-ACO (KS, MO)
  23. Mary Washington Health Alliance. (VA)
  24. Mercy ACO (AR, MO)
  25. MHT-ACO (GA, MI, OK, SC, TX)
  26. Midwest Quality Care Alliance (KS, MO)
  27. NEQCA Accountable Care, (MA)
  28. North Jersey ACO (NJ, NY)
  29. OneCare Vermont Accountable Care Organization (NH, VT)
  30. Oregon ACO (OR, WA)
  31. Palm Accountable Care Organization (FL)
  32. Physicians Accountable Care Solutions (CA, CO, CT, IL, NY, OH, PA, UT, WV)
  33. Physicians Collaborative Trust ACO (FL)
  34. Primaria ACO (IN)
  35. Primary Care Alliance (FL)
  36. Revere Health (AZ, UT)
  37. Shannon Clinic (TX)
  38. South Shore Physician-Hospital Organization (MA)
  39. SPACO (FL)
  40. Torrance Memorial Integrated Physicians (CA)
  41. UW Health ACO, (WI)
  42. VirtuaCare (NJ)
  43. Western Maryland Physician Network (MD, PA, VA, WV)

And here’s the list of the 124 new ACOs joining the program for 2018:

  1. Accountable Care Coalition of Alabama (AL)
  2. Account. Care Coal. of Community Health Centers (AR, DC, FL, IL, KY, MD, MI, RI)
  3. Accountable Care Coalition of New Jersey (NJ)
  4. Accountable Care of Nevada (NV)
  5. Accountable Care Organization of Aurora (IL, MI, WI)
  6. ACO West Virginia (PA, WV)
  7. Acorn Network (IL, IN, MI)
  8. Adventist Health Accountable Care (CA)
  9. Adventist Health System ACO (FL)
  10. Alabama Physician Network (AL)
  11. Aledade Accountable Care 22 (OH, PA)
  12. Aledade Accountable Care 25 (NJ)
  13. Aledade Accountable Care 35 (LA, MS, TN)
  14. Aledade Accountable Care 37 (MD, TN, VA, WV)
  15. Baptist Health/UAMS Accountable Care Alliance (AR, TX)
  16. Baptist Physician Partners ACO (FL, GA)
  17. Bethesda Health Quality Alliance (FL)
  18. Boulder Valley Care Network (CO)
  19. Bridges Health Partners ACO (PA)
  20. Caravan Health ACO 11 (AL, GA, IL, KY, NM, NV, TX)
  21. Caravan Health ACO 12 (MN, WI)
  22. Caravan Health ACO 13 (MA, NY, VT)
  23. Caravan Health ACO 14 (ID, MN)
  24. Caravan Health ACO 15 (IA, MN, NE, SD)
  25. Caravan Health ACO 16 (AL, TN)
  26. Caravan Health ACO 17 (OR)
  27. Caravan Health ACO 31 (OK)
  28. Caravan Health ACO 32 (OK)
  29. Caravan Health ACO 33 (OK)
  30. Caravan Health ACO 34 (OK)
  31. Carolinas HealthCare System ACO (NC, SC)
  32. Cascadia Care Network (WA)
  33. Centrus Health of Kansas City (KS, MO)
  34. CHSPSC ACO 1 (AL, FL, LA, MS)
  35. CHSPSC ACO 10 (FL)
  36. CHSPSC ACO 12 (GA, NC, SC, VA)
  37. CHSPSC ACO 13 (PA)
  38. CHSPSC ACO 14 (TN, WV)
  39. CHSPSC ACO 15 (KY, TN)
  40. CHSPSC ACO 16 (OK)
  41. CHSPSC ACO 17 (FL)
  42. CHSPSC ACO 2 (IN)
  43. CHSPSC ACO 21 (AL, FL)
  44. CHSPSC ACO 6 (TX)
  45. CHSPSC ACO 7 (AR, LA, MO, OK)
  46. CHSPSC ACO 8 (AK, AZ, NM, NV)
  47. CHSPSC ACO 9 (IN)
  48. Coastal One Health Partners (CA)
  49. ColigoCare (NJ, NY)
  50. Community Health Center Network Of Idaho (ID, OR, WA)
  51. Community Healthcare Partners ACO, (IL, IN)
  52. Connected Care of East Tennessee (AL, GA, TN)
  53. Connected Care of Middle Tennessee (TN)
  54. Connected Care of Mississippi (MS)
  55. Connected Care of West Tennessee (MS, TN)
  56. CPSI ACO 2 (CA, CO, GU, ID, ND, OR, SD, WA)
  57. CPSI ACO 3 (GA, MS, NC)
  58. CPSI ACO 7 (IA, IL, NE, WI, WV)
  59. CPSI ACO 8 (AR, LA, MO, TX)
  60. Crestwood Regional Healthcare Alliance (AL)
  61. CVACC (VA)
  62. DMH Health Network (IL)
  63. DOCACO GULF COAST (FL, SC)
  64. Einstein Care Partners (PA)
  65. Family Choice ACO (CA)
  66. Foothill Accountable Care Medical Group, (CA)
  67. Genesis Physicians Group (TX)
  68. Health Alliance ACO (DC, MD, VA)
  69. Healthcare Quality Partners (NJ, PA)
  70. HealthChoice (AR, MS, TN)
  71. Heritage Valley Healthcare Network ACO (OH, PA, WV)
  72. Holy Name Medical Center ACO (NJ)
  73. HP2 (GA)
  74. Independent Physicians Accountable Care (CA, CT, FL, SC, TX, VA)
  75. Inspire Health Partners (IN)
  76. Intermountain Accountable Care (NV, UT)
  77. Keep Well ACO (IL, KS, MO)
  78. KENNEDY HEALTH ALLIANCE (NJ)
  79. Kootenai Accountable Care (ID, WA)
  80. McFarland Clinic, PC (IA)
  81. McLeod Healthcare Network (NC, SC)
  82. MHC Accountable Care Organization (KY, OH, WV)
  83. MHN ACO (IA, IL, NE, SD)
  84. MSHP ACO (NY)
  85. MultiCare Connected Care (WA)
  86. NCH ACO (FL)
  87. NorthShore Physician Assoc. Value Based Care (IL)
  88. OhioHealth Venture (OH)
  89. Orange Accountable Care Organization (FL, MD, NJ, NM, PA, TX)
  90. Pacific Private Practice Network, Inc (CA, TX)
  91. PathfinderHealth (AZ)
  92. Physician Partners of Western PA (PA)
  93. Physician Performance Network of Arizona (AZ)
  94. Primary Comprehensive Care ACO (IL, NC)
  95. PRIMARY PARTNERS (FL)
  96. PRIME ACCOUNTABLE CARE WEST (AZ, CA, IL, NV)
  97. Privia Quality Network Gulf Coast II (TX)
  98. QHI ACO (CA, CT, IL)
  99. Renaissance Physicians Accountable Care (TX)
  100. Riverside Health Source (VA)
  101. Rush Health ACO (IL)
  102. Saint Francis Hospital Medicare ACO (AR, IL, MI, MS, TN)
  103. Select Physicians Associates (AL, FL)
  104. SIGNATURE NETWORK (VA)
  105. Space Coast Independent Practice Association (FL)
  106. St. Dominic Medical Associates (MS)
  107. St. Luke's ACO (IL, MO)
  108. St. Luke's Medicare ACO (NJ, PA)
  109. St. Tammany Hospital ACO (LA)
  110. Steward National Care Network, (FL, MA, NJ, OH, PA)
  111. The Iowa Clinic, P.C. (IA)
  112. The Ohio State Health ACO (OH)
  113. Treasure Coast Integrated Healthcare (FL)
  114. UC Davis Health ACO (CA)
  115. UC Irvine Health Accountable Care Organization (CA)
  116. UC San Diego Health Accountable Care Network (CA)
  117. UCSF Health ACO (CA)
  118. UMC Accountable Care (NM, TX)
  119. United Physicians ACO (MI)
  120. University Health ACO (TN)
  121. UPQC (NV, UT)
  122. Valley Medical Group-Renton (WA)
  123. VillageMD Chicago ACO (GA, IL, IN, KY, TN)
  124. White River Health System Clinically Int. Network (AR)
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%)