Medicare publishes final rule on the Quality Payment Program

The Department of Health & Human Services (HHS) finalized a new payment system for Medicare clinicians that will continue to reform how the health care system pays for care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program, which replaces the Sustainable Growth Rate (SGR), is designed to consolidate the SGR, Meaningful Use, and the Value Modifier into a single alternative payment system.  According to the HHS press release, the Administration is building a system that delivers better care, one in which clinicians work together and have a full understanding of patients’ needs, Medicare pays for what works and spends taxpayer money more wisely, and patients are in the center of their care, resulting in a healthier country.

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GAO recommends priority setting to reduce quality measurement burden

The US Government Accounting Office said in a report that the Department of Health and Human Services (HHS) should comprehensively plan and set timelines in developing more meaningful quality measures, and prioritize development of electronic quality measures.  The Medicare Access and CHIP Reauthorization Act of 2015 called for GAO to examine the use of quality measures across HHS programs and private payers, with a focus on reducing burden. In the report, HHS concurs with the GAO recommendations.

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Community Health Centers, Medicaid, and payment reform

Payment reform has become a dominant issue in Medicaid policy, reflecting a broader effort among all payers to reduce spending while improving outcomes. But Medicaid faces unique challenges, including a low-income population with disproportionately high health care needs, as well as surging enrollment in states that have implemented the Affordable Care Act’s Medicaid expansion. One of the goals of payment reform in Medicaid therefore is to use payment to stimulate health care innovation for medically underserved populations who depend on safety-net providers. To meet this challenge, several Medicaid expansion states are now beginning to adapt the special federal payment policies that apply to the nation’s nearly 1,400 community health centers. 

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Obama administration issues most sweeping rules in a decade for Medicaid enrollees

The Obama administration tightened rules Monday for private insurance plans that administer most Medicaid benefits for the poor, limiting profits, easing enrollment and requiring minimum levels of participating doctors.

For consumers the most visible change may be quality ratings intended to reflect Medicaid plans’ health results and customer experiences. The administration agreed to move slowly on such a sensitive industry issue, saying it would develop the scores over several years.

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Doctors having hard time engaging with patients on end of life discussions

According to a national poll released Thursday survey by The John A. Hartford Foundation, the California Health Care Foundation and Cambia Health Foundation, doctors are having a difficult time starting end of life discussions and, when they do, aren't sure what to say.

Such discussions are becoming more important as baby boomers reach their golden years. By 2030, an estimated 72 million Americans will be 65 or over, nearly one-fifth of the U.S. population.

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CMS announces new Primary Care delivery model

Public and private payers can apply through June 1 to participate in a new medical home model that will build on the Comprehensive Primary Care model to help practices support patients with serious or chronic diseases, the Centers for Medicare & Medicaid Services announced today. 

Under the CPC+ model, CMS will partner with insurers and Medicaid agencies in up to 20 regions and up to 5,000 practices to provide monthly care management fees based on beneficiary risk tiers.  The model can accommodate up to 5,000 practices, 20,000 doctors and the 25 million people they serve.

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Medicare starts new method to pay for hip, knee replacement surgeries

Medicare on Friday launches an experiment changing how it pays for hip and knee replacements in an effort to raise quality and lower costs.  The idea is to follow patients more closely to smooth their recovery and head off unwanted complications that increase costs.

Hip and knee replacements are the most common inpatient surgery for beneficiaries, and Medicare will be using financial rewards and penalties to foster coordination among hospitals, doctors, and rehab centers. Traditional payment for such surgeries has been by tying payment to the volume of procedures.  Medicare says that Comprehensive Care for Joint Replacement Model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.

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What CMS is trying to accomplish with a new drug pricing model

The Obama administration is trying to duplicate efforts by insurance companies to manage drug prices.  The results could lead to a change in how the Centers for Medicare & Medicaid Services (CMS) spends $20 billion a year for drugs under Part B, which are those given in doctors’ offices and hospital outpatient centers. 

According to Kaiser Health News, CMS is following recent efforts by insurers such as Aetna and Cigna to only pay for drugs that work--in the long run.

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CMS announces final round of application for Next Generation ACO model

The Centers for Medicare & Medicaid Services’ (CMS) Innovation Center is accepting the second and final round of applications for its Next Generation Accountable Care Organization (ACO) model, which will begin its second performance year on Jan. 1, 2017.

The Next Generation ACO Model is an initiative for ACOs that are experienced in coordinating care for populations of patients and allows doctors and hospitals to assume higher levels of financial risk and reward than are available under the current Pioneer Model and Shared Savings Program (MSSP). The goal of the Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.

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CMS proposes alternative payment model for Medicare outpatient drugs

The Centers for Medicare & Medicaid Services (CMS) today released a rule to test models for how Medicare pays for prescription drugs provided in physician offices and hospital outpatient departments. 

Medicare Part B currently pays physicians and HOPDs the average sales price of a drug, plus a 6% add-on. 

CMS issued a factsheet on the proposal.  According to the factsheet, the model would test whether changing the add-on payment to 2.5% plus a flat fee payment of $16.80 per drug per day changes prescribing incentives and leads to improved quality and value.

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AHRQ develops version of evidenced-based improvement program for doctors offices

The Agency for Healthcare Research and Quality (AHRQ) today released TeamSTEPPS for office-based care, a version of the evidence-based program aimed at optimizing the use of evidence, information, people and resources to achieve the best outcomes for patients in settings such as primary, specialty and pediatric care offices, patient-centered medical homes and walk-in clinics. 

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Medicare to pay doctors to provide end of life care

The new rule did not ignite the fierce fight that a similar measure did during the health law debate. Medicare officials also turned down requests from hospitals to change their plans for a controversial rule to determine which patients are considered out-patient status, and the Wall Street Journal examines how the federal government is curbing the auditors who check those hospital decisions.

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Hospital-acquired conditions fall 17% over 3 years

According to the the Agency for Healthcare Research and Quality (AHRQ), hospital-acquired conditions declined by 17% (1.3 million) between 2010 and 2013, saving an estimated 50,000 lives and $12 billion in health care costs.

Adverse drug events fell by 44%, pressure ulcers by 21% and catheter-associated urinary tract infections by 14%, among other reductions.

The findings are based on the AHRQ National Scorecard, which provides summary data on the national HAC rate for measurement activities associated with the Centers for Medicare & Medicaid Services’ Partnership for Patients initiative, which included more than 3,700 acute-care hospitals participating in Hospital Engagement Networks. 

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Commonwealth Fund reports Colorado medical home pilot reduced ED use and costs

According to a Commonwealth Fund study, a multipayer medical home program piloted in Colorado led to a sustained reduction in emergency department use and costs over three years, although there were no overall cost savings for practices or patients. Primary care visits also decreased. The impact on quality was mixed: cervical cancer screening rates improved, yet colon cancer screenings and hemoglobin testing for diabetes patients decreased.

The goal of Patient Centered Medical Homes (PCMH) are to deliver primary care services in a proactive, coordinated manner and improve quality of care, including patient health outcomes– particularly those with multiple or complex care needs.  In addition, the PCMH goal is to lower by reducing the need for expensive hospital stays and emergency department visits.

The Commonwealth Fund research evaluated a pilot program involving 15 PCMH practices in Colorado serving approximately 98,000 patients both prior to the program’s launch and then again at two and three years.

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US spending largely driven by technology and high prices, according to a new Commonwealth Fund report

According to a new report by the Commonwealth Fund, health care spending in the U.S. far exceed that of other high-income countries, although spending growth has slowed in the U.S. and in most other countries in recent years.

The U.S. spends more public dollars on health care than all but two of the other countries.  Americans have relatively few hospital admissions and physician visits, but are greater users of expensive technologies like magnetic resonance imaging (MRI) machines.  Despite its heavy investment in health care, the U.S. sees poorer results on several key health outcome measures such as life expectancy and the prevalence of chronic conditions. Mortality rates from cancer are low and have fallen more quickly in the U.S. than in other countries, but the reverse is true for mortality from ischemic heart disease. 

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CMS announces new ACO dialysis model

CMS announced the participants for the Comprehensive ESRD Care Model, a new accountable care organization model for Medicare patients with end-stage renal disease (ESRD).  The model brings together dialysis facilities, nephrologists and other providers to form ESRD Seamless Care Organizations (ESCOs) to coordinate care for ESRD beneficiaries and reduce costs. The ESCOs will be financially accountable for quality outcomes and Medicare Part A and B spending for ESRD beneficiaries, including all spending for dialysis services.

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CMS reports positive shared savings results for primary care value initiative

According to a blog by Patrick Conway, CMS Deputy Administrator for Innovation and Quality and Chief Medical Officer, CMS is showing promising results for the first shared savings performance year of the Comprehensive Primary Care (CPC) model.  The initiative was launched in October 2012 to advance primary care by paying clinicians to deliver accessible, comprehensive and coordinated care and is part of CMS's broader effort to promote better care, smarter spending, and healthier people.

In performance year 2014, CPC practices showed positive quality results, with hospital readmissions lower than national benchmarks and high performance on patient experience measures, particularly on provider communication with patients and timely access to care. CPC practices that demonstrated high quality care and reduced spending above a threshold shared in savings generated for Medicare.

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GAO finds no evidence to date that VBP program improved care

According to a story released by Kaiser Health News, the Government Accounting Office (GAO) has found that Medicare’s quality incentive program for hospitals, which provides bonuses and penalties based on performance, has not led to demonstrated improvements in its first three years.

GAO's analysis found no apparent shift in existing trends in hospitals' performance on the quality measures included in the HVBP program during the program's initial years. However, shifts in quality trends could emerge in the future as the HVBP program continues to evolve. For example, new quality measures will be added, and the weight placed on clinical process measures—on which hospitals had little room for improvement—will be substantially reduced.

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CMS announces new Medicare Advantage Value-Based Insurance demo

The Centers for Medicare & Medicaid Services last week announced the Medicare Advantage Valued-Based Insurance Design Model, which will test whether encouraging plan enrollees with certain conditions to consume high-value clinical services through reduced cost sharing and other approaches improves quality and reduces costs.

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