Health Care Cost

The cost of radiation oncology services has typically been a small part of the Medicare and Medicaid budget, but with more patients having complex radiation treatments, it is becoming more important to have alternative payment models in the space, said Shalom Kalnicki, MD, FASTRO, FACRO, professor and chairman, radiation oncology, Montefiore Einstein Center for Cancer Care and Albert Einstein College of Medicine.

Practices should make deliberate choices when choosing to participate in multiple payment reform models and should not just participate in something because it is the newest model, said Travis Broome, vice president of policy at Aledade.

Depending on how ready accountable care organizations (ACOs) are to move to risk probably affects how they view CMS’ decision to transition the Medicare Shared Savings Program (MSSP) to Pathways to Success, said Travis Broome, vice president of policy at Aledade.

The healthcare system has a long way to go to make voluntary payment models more attractive before it can consider making payment models mandatory, said Travis Broome, vice president of policy at Aledade.

Bringing together different stakeholders in healthcare to share the challenges they see and their own understanding of how to fix the problem can help make impossible things happen and bring change to the healthcare system, said Elizabeth Mitchell, president and chief executive officer, Pacific Business Group on Health.

Currently, the number of patients who are actually utilizing precision cancer care treatments is small, but it is growing fast. As that happens, physicians will need to get comfortable with ordering the right tests, explained Clynt Taylor, chief executive officer of Intervention Insights, and Lee Newcomer, MD, formerly of UnitedHealth Group.

Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) cover more than 32 million lives and have been found to save money and improve quality in past research, but a new study in Annals of Internal Medicine is calling their success into question.

The American Journal of Managed Care® sat down with David Smith, the executive director of the Medicaid Transformation Project, to get an update about the integration challenges health systems are facing, including system issues, infrastructure issues, coding and payment issues, and more.

A study of readmission rates by primary care providers (PCPs) finds a lack of variation and calls into question implementing pay-for-performance programs that incentivize or penalize PCPs for readmissions.

Humana has expanded its focus to the social determinants of health because issues like food insecurity and lack of transportation impact outcomes even if patients are getting the best medical care, said Bryan Loy, MD, physician lead, oncology, laboratory, and personalized medicine, Humana.

Even though Northwestern Medicine is projected to sustain a loss in the new Bundled Payments for Care Improvement Advanced, it plans to participate because doing so will position Northwestern Medicine as best possible to manage future challenges in episodes of care.

The advantage of having mandatory models is it enables you to get participation broadly across the community and it allows you to design the bundle in a way that’s not so intent on encouraging participation. If you have voluntary participation you are somewhat limited as to how you could design the bundle, because if you design it too aggressively no one will participate, explained Michael E. Chernew, PhD, the Leonard D. Schaeffer Professor of Health Care Policy; director of the Healthcare Markets and Regulation Lab in the Department of Health Care Policy at Harvard Medical School; and co-editor-in-chief of The American Journal of Managed Care®.

Some of the health policies coming out of Washington, DC, are clever, but there might be too much coming out for practices to keep up with, said Michael Kolodziej, MD, vice president and chief innovation officer at ADVI Health, Inc.

Payers, providers, and other stakeholders have to come together to figure out how to make a better patient member experience for those who are fighting cancer, said Bryan Loy, MD, physician lead, oncology, laboratory, and personalized medicine, Humana.

The new primary care models from HHS will provide greater flexibility to practices that want to participate and deliver care in a different way to reduce hospitalizations, said Travis Broome, vice president of policy at Aledade.

Creating a value-based care system means upending the current one and providing more models to encourage providers to take on risk.

Implementing new payment models is really complicated, and the private sector is not doing as much as the public sector, said Michael Kolodziej, MD, vice president and chief innovation officer at ADVI Health, Inc.

Rising consumerism, new competition, and payment models designed to keep patients out of acute care are forcing hospital-centric enterprises to rethink their delivery models. Organizations that excel in building integrated care delivery ecosystems and lasting consumer relationships based on a differentiated brand promise and superior outcomes will be the ones that find success.

The industry is speedily moving and advancing, and the only way for hospitals see continued success is if they stay nimble and capable of adapting to new developments. Looking to the future, healthcare systems should concern themselves less with size and instead shift focus to adopting business and payment models that bring value.

There has always been interest in bundled payments, and now the industry is moving toward implementing more, explained Scott Hewitt, vice president, payment strategy and innovation, UnitedHealthcare.

Although safety net organizations are eligible for some two-thirds of federal payment reform programs, fewer than 20% of these programs directly target the safety net.

Data published in JAMA Internal Medicine are the latest to sound the alarm on the emerging crisis in primary care.

Compared with other payment models, like bundled payments or the Comprehensive Primary Care Program, accountable care organizations (ACOs) have done a better job of saving money, said Rob Mechanic, MBA, senior fellow at the Heller School of Social Policy and Management at Brandeis University and executive director of the Institute for Accountable Care.

All providers, regardless of where they work have a role in the shift to value-based care, but independent physicians need to have a voice in the transition, said Sibel Blau, MD, medical oncologist at Northwest Medical Specialties, PLLC.