During the past year, the pandemic strained the entire health care system. Many health care providers experienced significant disruptions with reductions in use and lower revenue. Some providers were able to weather the crisis by relying on the organizational competencies they had built for value-based payment models. Providers in more advanced payment models had more…
Two influential advisory groups sent recommendations to Congress calling for a revamp of how health plans are paid in the lucrative Medicare Advantage program, culling how many models CMS tests and curbing high-cost drug approvals. By many measures, the MA program has been thriving. Enrollment and participation has continued to grow, and in 2021, MA…
To reduce redundancies and confusion in the Medicare system, health care policymakers should consider implementing “a smaller, more harmonized” portfolio of alternative payment models (APMs). That’s according to the Medicare Payment Advisory Commission (MedPAC), which released its regular June report to Congress on Tuesday. “In many cases, providers participate in multiple [alternative payment models] simultaneously,…
The Centers of Medicare and Medicaid Services (CMS) recently announced a directive to relax the requirement that surgeries for Medicare beneficiaries be performed only on an inpatient basis to qualify for reimbursement. Starting January 1, 2022, more than 250 musculoskeletal surgeries will be eliminated from the “inpatient-only list,” with an additional 1,500 surgeries eliminated in…
Industry expert David Smith, Founder and CEO of Third Horizon Strategies, provides an overview of CMS’s value-based initiatives with specific perspectives on the new administration’s Medicare/Medicaid philosophy, the rise of complex care management, and Medicaid Advanced Payment Models. He also shares an update on the core CMS payment models including MIPS, ACOs, and BPCI, as…
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…
The Global and Professional Direct Contracting Model — a Center for Medicare & Medicaid Innovation (CMMI) creation — has been put on pause. The holdup is just another example of CMMI pumping the brakes on an alternative payment model in the days since the Biden administration took over the executive branch. Broadly, the Global and…
The goal of the value movement is to incentivize providers to move away from the traditional fee-for-service model and provide coordinated care for patients with an eye toward improving quality and reducing cost. One key mechanism to achieve this goal is accountable care organization (ACO) models that—because they are offered along a continuum of varying…
Medicare Direct Contracting program is a unique opportunity for existing Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs), NextGen ACOs, organizations that have experience serving Medicare fee-for-service (FFS) patients, and even organizations with limited Medicare FFS experience that wish to grow their market share. The primary goals of Medicare Direct Contracting include: Transform to…
Medicare has clarified that providers cannot participate in both accountable care organizations (ACOs) and coming direct-contracting arrangements after 2020. The clarification — and others — came amid early provider feedback on the model, which is slated to start this spring. Providers sought a range of clarifications on the Direct Contracting model from staff of the Centers for…