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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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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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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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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42 percent of Medicare payments tied to value in 2013

According to Catalyst for Payment Reform, a coalition of large employers and health care insurance purchasers, approximately 42 percent of the $360 billion in Medicare fee-for-service payments to providers in 2013 were tied to boost the value of care that patients receive.  CPR defines value in payment methods as those that either improve the quality or improve efficiency and reduce unnecessary spending.

In the report, one-third of Medicare payments were related to pay-for-performance programs, 12 percent to shared savings programs and 2 percent to shared-risk programs.  For calendar year 2013, the CPR report noted there were six Medicare programs that met that definition:

  1. The Hospital Value-Based Purchasing Program;
  2. End Stage Renal Disease Quality Incentive Program;
  3. Medicare Shared Savings Program for accountable care organizations;
  4. Medicare Pioneer ACO Program;
  5. Electronic Health Record Incentive Program for eligible hospitals; and

 In addition, in January the Department of Health and Human Services announced goals to tie 30% of Medicare FFS payments to alternative payment models and 85% to quality or value by 2016.  DHHS plans to achieve this goal through investment in alternative payment models such as Accountable Care Organizations (ACOs), advanced primary care medical home models, new models of bundling payments for episodes of care, and integrated care demonstrations for beneficiaries that are Medicare-Medicaid enrollees. Overall, HHS seeks to have 85 percent of Medicare fee-for-service payments in value-based purchasing categories 2 through 4 by 2016 and 90 percent by 2018.

Medicare begins to penalize hospitals for readmissions beginning in October

Over 2000 hospitals across the country stand to lose approximately $280 million in Medicare reimbursement dollars beginning in October 2012, as Medicare begins to penalize hospitals for readmissions within 30 days of hospital discharge, according to an analysis by Kaiser Health News.
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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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CMS physician quality reporting and eRx incentive payments have increased since 2009

The Centers for Medicare & Medicaid Services results for the 2010 Physician Quality Reporting System and the 2010 Electronic Prescribing (eRx) Incentive Program show significant increases in participation and incentives paid to eligible health care professionals since 2009, according to a press release.
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