Health Care Cost

This week, the top managed care stories included encouraging results from the Next Generation Accountable Care Organization model; concerns that CMS' new billing rules will hurt the sickest patients; a study confirms the value of daily aspirin for patients with diabetes.

The proposed Medicare Shared Savings Program rule has many sweeping changes that present a number new opportunities, but also challenges. In addition, the National Association of ACOs highlighted its concerns that the changes will decrease the number of ACOs and may discourage new entrants.

Robert A. Gabbay, MD, PhD, FACP, chief medical officer and senior vice president at Joslin Diabetes Center, said health systems need people with the skill sets that diabetes educators possess to make the transition to a reimbursement system based on quality, prevention, and eliminating costs.

A new rule in the Medicare Access and CHIP Reauthorization Act’s 2019 Quality Payment Program and the proposed 2019 Medicare Physician Fee Schedule could negatively affect the quality of cancer care for Medicare beneficiaries, according to the American Society of Clinical Oncology.

A new study found hospital participation in 5 common medical bundles under the Bundled Payments for Care Improvement initiative was not associated with significant changes in Medicare payments, clinical complexity, length of stay, emergency department use, hospital readmission, or mortality.

Health plans continue to show interest in expanding outcomes-based contracts, according to an Avalere Health study that also found cardiovascular diseases, infectious diseases, and oncology represent the most common therapeutic areas to have these contracts.

Adam Boehler, director of the Center for Medicare & Medicaid Innovation, is taking on an additional role as the senior advisor for value-based transformation and innovation. He represents the last departmental appointment as part of HHS Secretary Alex Azar's 4 priority areas.

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

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.

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.

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

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.

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.

Integrated care teams will create more value for the patient, but there are multiple challenges in the creation of these teams, said Mark Soberman, MD, MBA, FACS, former president of the Association of Community Cancer Centers.

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.

Practice reorganization can worsen clinician burnout, explained Mark Friedberg, MD, MPP, senior natural scientist and director of the Boston office at RAND Corporation, who also discussed his solutions for addressing burnout in the practice.

"If clinicians are burning out, it is unlikely that participation in new payment models will be sustainable," explained Mark Friedberg, MD, MPP, senior natural scientist and director of the Boston office at RAND Corporation.

The third annual population health survey from Numerof & Associates found that healthcare organizations have not made as much progress to transition to risk-based agreements as they predicted they would 2 years ago.

Getting to value in healthcare has proven to be difficult, but succesful programs have certain characteristics, said David Blumenthal, MD, MPP, president of The Commonwealth Fund.

Shantanu Agrawal, MD, MPhil, CEO and president of National Quality Forum, recognizes the importance of diminishing health disparities.

In a commentary for New England Journal of Medicine, Karen E. Joynt Maddox, MD, MPH, of Washington University School of Medicine, outlines key principles for designing alternative payment models (APMs) to avoid harming vulnerable populations and penalizing the providers who care for them.

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 changes to the Next Generation ACO Model caused 7 accountable care organizations to leave the model; a report highlights how quickly hospital acqusition of physician practices is occurring; CMS finalizes coverage for Next-Generation Sequencing tests.

Results from the ODYSSEY Outcomes trial for the PCSK9 inhibitor alirocumab were the top news at the meeting.

Overview of alternative payment models and how leading national organizations are involved with linking quality improvement initiatives and payment reform.