Alternative Payment Models

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.

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.

As benchmarking is now becoming a part of payment models, practices realize they need comparative data to understand how well they perform relative to their competitors and whether there is room for improvement.

Since the launch of the Blue Distinction Total Care program, it has outperformed 96% of industry quality measures in key healthcare quality and patient health metrics, The Blue Cross Blue Shield Association (BCBSA) announced.

Value-based payment reform provides an opportunity for increased resources and improved short- and long-term health outcomes for children, wrote experts in a JAMA Pediatrics Viewpoint article.

So far, the move to accountable care has been promising, but more needs to be done to encourage providers into risk, said panelists at The American Journal of Managed Care®’s Accountable Care Delivery Congress.

A group of healthcare organizations have come together to advocate for policies that support independent practices moving to risk-based care models.

Employers may be intimidated by the idea of purchasing healthcare, but they are getting more involved in it and they are in a position to transform the market and promote value-based care, said Suzanne Delbanco, PhD, MPH, executive director of Catalyst for Payment Reform, during her keynote at The American Journal of Managed Care®’s Accountable Care Delivery Congress.

Since its inception, the Center for Medicare and Medicaid Innovation (CMMI) has implemented 37 models testing healthcare delivery and payment reform. A new Goverment Accountability Office assessment found that CMMI has partially met goals for performance targets.