Health care industry warming to role of keeping you healthy

Kaiser Health News reports from the Associated Press, that big players in the health industry are seeing the cost benefits of nabbing problems before they start.  That hot lunch delivered to your door? Your health insurer might pick up the tab. The cleaning crew that fixed up your apartment while you recovered from a stroke? The hospital staff helped set that up.

Some insurers are paying for rides to fitness centers and checking in with customers to help ward off loneliness. Hospital networks are hiring more workers to visit people at home and learn about their lives, not just their illnesses.

The health care system is becoming more focused on keeping patients healthy instead of waiting to treat them once they become sick or wind up in the hospital. This isn’t a new concept, but it’s growing. Insurers are expanding what they pay for to confront rising costs, realizing that a person’s health depends mostly on what happens outside a doctor’s visit.

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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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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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Additional participants in CMS bundled payments pilot

The Centers for Medicare & Medicaid Service (CMS) announced that over 2,100 acute care hospitals, skilled nursing facilities, physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies transitioned to a risk-bearing implementation period in which they assumed financial risk for episodes of care.

Participants include 360 organizations that have entered into agreements with CMS to participate in the Bundled Payments for Care Improvement initiative and an additional 1,755 providers who have partnered with those organizations. CMS defines an episode of care as the set of services provided to treat a clinical condition or procedure, such as a heart bypass surgery or a hip replacement.

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CMS sends cost and quality reports to physicians

The Centers for Medicare and Medicaid Services sent out twenty thousand “Resource Reports” to physicians in the midwest, which show the amount their patients cost on average as well as the quality of the care they provided, according to an article by Kaiser Health News and the Washington Post.
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