Alternative Payment Models

This week, the top managed care stories included additional moves by the Trump administration to unravel the Affordable Care Act; Pfizer canceled a round of drug price increases after speaking to the president; advocates for 340B sound the alarm on efforts to reform the program.

While small and rural practices will likely perform better in the Merit-based Incentive Payment System (MIPS) than they have in previous programs, they will still be outpaced by larger practices. Stakeholders also outlined challenges they think will likely continue for these practices under MIPS.

Experts at the National Comprehensive Cancer Network Policy Summit discussed the present challenges of transitioning to alternative payment models at a time when the costs of many cancer therapies are rising.

Experts recently proposed 3 steps to promote targeted cancer drugs that yield clinical benefits while reducing overall price growth.

Every week, The American Journal of Managed Care® recaps the top managed care news of the week, and you can now listen to it on our podcast, Managed Care Cast.

This week, the top managed care stories included a federal judge blocking Kentucky’s Medicaid work requirements; CMS announced it would launch a demonstration to encourage Medicare Advantage providers to take on more risk; and researchers identify racial disparities in HIV incidence and recommended a 5-part plan of action.

In the United States, too many of our mothers are dying during and after childbirth. Costs of childbirth care are high for everyone—for health plans, for taxpayers, and for families. We are moving in the wrong direction, and it is well past time to change course.

Although most practices participating in CMS' Oncology Care Model (OCM) are among the most sophisticated in the country, they've run into challenges and have identified areas for adjustment in the 5-year pilot.

CMS is launching a demonstration of its Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI), which pushes Medicare Advantage (MA) providers into taking on more risk. The demonstration, which has to be approved and adopted, would waive Merit-based Incentive Payment System (MIPS) requirements for doctors opting into the new program.

With the American population aging, the healthcare system will need to undergo a transformation, HHS Secretary Alex Azar said when he spoke before the Health Care Association/National Center for Assisted Living.

From making the Oncology Care Model work to the challenges of paying for CAR T-cell therapy, panelists at the National Comprehensive Cancer Network Policy Summit discussed how the cost of innovation affects decisions.

Oklahoma’s Medicaid program is the first to win approval from CMS to negotiate supplemental rebate agreements involving value-based purchasing (VBP) arrangements with drug manufacturers, with the aim of producing extra rebates for the state if clinical outcomes are not reached. Separately, CMS denied an application from Massachusetts requesting the ability to exclude certain Medicaid-covered outpatient drugs through a closed formulary.

As radiation oncologists met with policy makers in Congress as part of the 15th annual American Society of Radiation Oncology Advocacy Day, the need for a radiation oncology–specific alternative payment model (APM) was one of the key topics of discussion.

A new study from the Healthcare Financial Management Association, Leavitt Partners, and McManis Consulting found that the penetration of value-based payment (VBP) models is not yet enough to generate cost savings and is also not affecting clinical quality outcomes at the market level.

Providing an alternative to inpatient care, hospital-at-home care bundled with a 30-day postacute transitional care episode is associated with improved patient outcomes, such as readmissions and emergency department revisits, and ratings of care compared with inpatient hospitalization.

A national study of 120 payers has found that nearly two-thirds of payments are now based on value, and value-based care is helping stakeholders to achieve the triple aim of lower costs, improved health, and better patient experiences.

At the America’s Health Insurance Plans Institute and Expo, held in San Diego, California, June 20-22, Ezekiel J. Emanuel, MD, of the University of Pennsylvania’s Wharton School and School of Medicine, presented his “prescription for success” for improving healthcare in United States.

Physicians participating in the Oncology Care Model now provider care for approximately 21% of Medicare patients with cancer. An analysis from Avalere Health found that those doctors treat some types of cancers more than others.

At the Accountable Care Delivery Congress, speakers discussed ways to address social determinants of health, use payment mechanisms as levers, and forge connections through technology.

A group of experts identified 6 high-need populations and dimensions of successful care models to improve outcomes and reduce spending for these populations.

This study surveyed 840 clinical and nonclinical staff in 96 medical offices regarding workplace policies and procedures that facilitate a climate for value.

This study demonstrates that variation reduction is an important, but not requisite, component of organizational success under orthopedic bundled payment.

Physician migration from physician-led practices to hospital employment has shifted. While physicians working for a hospital or in a practice with some ownership increased by 32.6% in 2016, independent and physician led group practices reached 72% in 2017, according to a new Black Book report.

Healthcare organizations have sent a letter to HHS, urging it to count physician participation in Medicare Advantage (MA) plans toward participation criteria for the Advanced Alternative Payment Model track of the Quality Payment Program.

A study of baseline characteristics and spending of hospitals participating in Medicare's voluntary and mandatory orthopedic bundled programs found that there were few differences, indicating that mandatory programs could engage more hospitals that otherwise would not have participated in voluntary programs.

Although accountable care organizations cover more than 32 million people in the United States, the financial savings have been limited and the outcomes are unknown. Place-based approaches aimed at integrating care, improving population health, and controlling costs may be beneficial to adopt as the United States moves away from mandatory participation in payment reform.

An analysis of the 4 years of the Comprehensive Primary Care Initiative found slowed growth in emergency department visits, but no significant changes in Medicare spending or claims-based quality of care.

In general, practices and health systems don’t do a good job of integrating technology into practice, partly because most of the technology they use isn’t well suited to their needs, explained Charles Saunders, MD, CEO of Integra Connect.

To ease administrative burden, CMS has facilitated the collection and processing of information through Qualified Clinical Data Registries, which collect data on quality measures from providers and transfer the information to CMS, helping practices to satisfy MIPS requirements for quality and value improvement.

A new rule from CMS for 2019 would allow for more flexibility in benefit design for Medicare Advantage enrollees with specified chronic conditions.