The 2022 Primary Care First performance year is underway, does your practice have the necessary steps in place to maximize returns and avoid negative payment adjustments? Participating in the Primary Care First model offers the opportunity to enhance patient care and reimbursement, but it also comes with risk. Practices face negative payment adjustments if they fail to meet certain utilization and quality thresholds. Learn more about the three strategies you can employ for PCF success in our new infographic, and access a checklist of all the steps you can take to enhance outcomes, track requirements, and continuously measure performance.

Kidney Care Choices has begun and participating dialysis facilities, nephrologists and other healthcare providers are on their way to improving care for patients with end-stage renal disease. Does your practice have the necessary steps in place to maximize returns in the Kidney Care Choices Model? Each of the options for KCC participation offers many benefits, but the rules are complex and participating presents financial risks. Learn more about the three strategies you can employ for KCC success in our new infographic, and access a checklist of all the steps you can take to enhance outcomes, track requirements, and continuously measure performance.

There is renewed emphasis on advancing primary care. Primary care serves as the front door to the overall healthcare system, and early and accurate diagnosis can lead to fewer hospital admissions – a metric that has become especially important during the pandemic. With the January 2022 launch of Primary Care First Cohort 2, it is important to review how the program works and what steps healthcare organizations should take to ensure the best outcomes. To be successful, PCF participants must pay special attention to three aspects – tracking beneficiary population, obtaining physician buy-in, and ensuring timely access to performance metrics. Tracking Beneficiary Population Tracking patients participating in the PCF program is necessary to build patient navigation processes and monitor care outcomes. However, this can be challenging for many providers as internal EMR solutions do not provide complete data across the entire continuum of care for all providers that a patient may see. Th...

In this edition of DataGen Insights, we take a deep look at the important role of data analytics in understanding health outcomes. Read more to learn how hospitals are using data to guide their social determinants of health strategies. DataGen's newsletter is designed to provide relevant healthcare insights to providers and associations. Please explore our website to learn more about our products and services .  Download DataGen Insights today .  We hope you enjoy!

Can ACO REACH help CMS and providers achieve the unmet goals of prior alternative payment models? If so, a stronger focus on equity, provider leadership, accountability through risk and evaluation may make the difference. Announced Feb. 24, ACO REACH — Accountable Care Organization Realizing Equity, Access, and Community Health — is CMS' newest voluntary APM. Robust resources and capabilities will be needed to navigate its requirements. As highlighted in a recent CMS webinar , ACO REACH is the first APM to launch following a Strategy Refresh by the Center for Medicare and Medicaid Innovation. ACO REACH aligns with the CMMI objective of driving accountable care to improve cost and quality and will replace the current Global and Professional Direct Contacting program, effective Jan. 1, 2023. CMMI encourages current GPDC participants and new entrants to apply, noting that selection criteria and performance monitoring will be more stringent. This blog highlights key differences bet...

All forward-thinking hospitals understand the role of social risk in providing effective, equitable and efficient care. In many ways, hospital objectives align with those of social risk assessment. Both help to distinguish acute from long-term needs, identify underlying contributors to poor outcomes, and, wherever possible, help minimize or completely prevent more serious interventions. Six social risk factors and their drivers Social risk is a measure of vulnerability as defined by specific social determinants of health. DataGen uses the following six SDOH categories. Social Determinants of Health Category Defined by Individual risk drivers Community risk influencers Digital Access, affordability and literacy Competency Resources Finance Strength, resources and resiliency Financial assets, liabilities and opportunities Income, cost of living and opportun...

CMS has introduced more than 50 innovative care delivery models designed to drive health system transformation over the last decade. Only six of those produced significant savings; of those, only four met the requirements to be expanded. As the second 10-year period of the program gets underway, which includes $10 billion in new funding, CMS’ Center for Medicare and Medicaid Innovation is considering numerous changes to improve the overall success of these programs and, in turn, drive overall gains in care outcomes and health equity. When evaluating what has worked in the past and what changes are needed moving forward, it is important to review what success looks like for Alternative Payment Model programs.  CMMI relies on three benchmarks to measure levels of success: The gold standard: improving quality of care while simultaneously reducing expenditures. Improving quality of care without impacting expenditures. Reducing expenditures without impacting qual...

In the first part of this blog, we discussed the “Discover” phase of working with community-based organizations to address social determinants of health. Next we’ll discuss the other steps in the Discover-Plan-Act cycle. In planning SDOH strategies, hospitals and health systems, guided by their Community Health Needs Assessments, are often best able to identify and convene key partners to address SDOH. The CHNA process brings neighboring healthcare providers and community-based organizations together to: learn from one another; gain commitment; share expertise; understand public policy efforts; and leverage technical and hands-on assistance. But, are these efforts sufficient? The recent HealthLeaders Social Determinants NOW Summit highlighted the conversations needed to identify, solve and scale collaborative SDOH programs with CBOs. The summit showed the importance of identifying, expanding and improving existing CBO wish list programs. In other words: leverage, scale, improve and ...

Partnership has always been essential to achieve healthcare's aims. And where there's a will — and a pandemic — there's a way. To find the way , hospitals and community-based organizations must partner in new ways to incorporate social determinants of health into patient care improvement efforts. Rich new SDOH data sets can supercharge the design, implementation and evaluation of SDOH initiatives as providers are expected to assume more responsibility for outcomes related to non-clinical factors.  The impact of social determinants of health  The pandemic resurrected a statistic that has been around for some time: 80% of health outcomes are based on social determinants, with only 20% dependent on clinical care.  People naturally understand it is harder for someone to manage their diabetes without access to affordable, healthy food. Through the federally-required Community Health Needs Assessment process, hospitals understand local need, but many do not yet know how to shif...

DataGen’s 2022 Enacted Medicare Cuts Analysis shows how hospitals have been impacted by existing Medicare fee-for-service provider payment cuts enacted by Congress to achieve Medicare payment policy and/or long-term deficit reduction goals. This analysis is provided to DataGen clients for advocacy purposes only . The impacts shown in this analysis include the major legislative, regulatory and quality cuts enacted since 2010 and are described below.  Enacted legislative cuts analyzed: Medicare marketbasket, Medicare Disproportionate Share Hospital and quality adjustments authorized by the Affordable Care Act of 2010; note that for this analysis, quality adjustments are broken out into their own category;  the effect of the 2.0% across-the-board sequestration reduction to payments authorized by the Budget Control Act of 2011, and the 4.0% sequestration reduction resulting from the calendar year 2021 triggering of the Statutory Pay-As-You-Go Act of 2010 (PAYGO);  inpatient c...

The Primary Care First Model , an alternative payment model offering an innovative payment structure for the delivery of advanced primary care, welcomed the involvement of Cohort 2 participants on Jan. 1 . This cohort, which was open to all primary care practices that met the eligibility criteria, will participate from 2022 to 2026. Participants in PCF Cohorts 1 and 2 can expect the following benefits: an opportunity to increase revenue with performance-based payments that reward participants for reducing acute hospital utilization; the ability to assess and improve performance through actionable, timely data; less administrative burden so providers can spend more time focusing on patient needs; and potential to become a Qualifying APM Participant , which includes eligibility for a 5% incentive payment and eliminates Merit-based Incentive Payment System reporting requirements. To ensure that new and prior participants succeed in this model, DataGen has compiled and answered some of t...

The 340B Drug Pricing Program allows qualifying hospitals to offer affordable prescription drugs to financially vulnerable and fragile patients by purchasing outpatient drugs from manufacturers at a discounted rate. These hospitals then can reinvest the savings in their services. In 2018, CMS issued a final Outpatient Prospective Payment System rule that reduced by approximately 25% the reimbursement for certain drugs that hospitals acquired through the 340B Program and then continued those cuts in 2019 through 2022. HHS' 340B cuts are currently being challenged through a lawsuit with the U.S. Supreme Court.  This analysis includes the continued 3.19% budget-neutral adjustment and the 340B reduction (Average Sales Price minus 22.5%) that was identified in the Standard Analytic File with the “JG” modifier, resulting in a net impact. DataGen has analyzed the budget neutrality adjustment and 340B cuts utilizing the 2019 Standard Analytic File showing the potential impact to 340B hosp...

Commonly asked questions about the Medicare Radiation Oncology Model billing guidelines What are the billing guidelines for the Radiation Oncology Model? RO Model participants must submit claims under the existing Medicare claims system according to the RO Model billing instructions described in the CMS final rule . In addition, RO participants must submit “no-pay” claims for all radiation therapy services furnished in the episode. What are the approved cancer types? The RO Model covers 15 cancer types. These cancer types are commonly treated with radiation therapy under nationally recognized, evidence-based guidelines and are associated with ICD-10 codes that have demonstrated pricing stability. What are the approved modalities of treatment? Modalities covered under the RO Model include three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, stereotactic radiosurgery, stereotactic body radiotherapy, proton beam therapy and image-guided radiation ...

Check your participation status and build your plan Are you a hospital outpatient department, physician group practice or freestanding clinic providing radiation therapy services? If so, you may be required to adopt the new mandatory Radiation Oncology Model. Mandatory participation is randomized by Core-based Statistical Areas. You can check your organization’s participation status online. CMS released the Final Rule for the RO Model, giving providers 60 days to prepare for program launch on January 1, 2022. If your organization performs radiation therapy in a ZIP code on the list, you will need to begin preparing for the model.

DataGen has just launched a quarterly newsletter designed to provide relevant healthcare insights to healthcare providers and associations. Each edition will feature a case study, recent industry highlights and information about DataGen products and services all designed to help you stay informed and ahead of the curve. Let us know what you think of our first edition. If there are any topics you would like to see covered in a future newsletter, or if you are interested in learning more about our product suite, please reach out. Download DataGen Insights today . We hope you enjoy!

Key takeaways from five final and two proposed rules from CMS CMS adopted five final Medicare Prospective Payment System rules for FFY 2022 and proposed two rules for calendar year 2022. DataGen has interpreted and analyzed each of the final and proposed rules to help you gauge how these changes may impact your organization.   These rules include regular updates to the wage index and other significant items listed below. The Inpatient PPS final rule includes the following proposals: rebasing and revising the IPPS marketbasket and the Capital Input Price Index from FFY 2014 cost report data to FFY 2018 data; rate increase (+0.5%) for the Medicare Access and CHIP Reauthorization Act of 2015 coding offset adjustment; nonstandard adjustments to hospital wage indexes (for eligible hospitals) including bottom quartile adjustments, a 5% wage index “stop-loss” and the reintroduction of an imputed floor policy as mandated by the Consolidated Appropriations Act of 2021; updates to Medicare...

The new Radiation Oncology alternative payment model will start Jan. 1, 2022, after the proposal is finalized in the calendar year 2022 Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System final rule, scheduled for early November. This rule will require prospective hospital outpatient departments, physician practices and freestanding clinics providing radiation therapy services to adopt a prospective bundled payment model with new clinical and quality measure reporting requirements. The model is mandatory for participants selected by CMS. The new RO model includes several notable changes that must be addressed for successful participation: Disease sites update The criteria for cancer types have been clarified. Cancer types must be: commonly treated with radiation therapy according to nationally recognized evidence-based guidelines; associated with ICD-10 codes that demonstrate pricing stability; and not determined to be unsuitable for inclusion by the H...

Alternative payment programs are critical to payment and care delivery transformation. CMS is introducing new alternative payment models that provide opportunities to deliver better value of care and support healthcare innovation in the years to come. Rising healthcare trends should be taken into consideration when evaluating new APMs. Yet, keeping ahead of which programs offer you the greatest opportunity can be a major challenge. DataGen put together Navigating Alternative Payment Models: A User's Guide , offering insights on the participation categories—and detail on programs within each category—this resource can help you determine the best course for your organization’s future. Download our user's guide to learn about new APMs, implications for providers and data-driven strategies for successful pro gram execution.

As we emerge from a global pandemic, accountable care organizations must address key new trends now to maintain progress toward value-based care and mitigate financial risk.  Analytics are key to helping ACOs gain a better understanding of trends so they can identify opportunities to drive quality improvement. These trends include: gaps in access to clinical care;  shifts in patient volume; increased demand for virtual care; and  social determinants of health challenges.  To better understand rising trends and actions providers should take, we will reach out to hospital and health system leaders to discuss how recent trends influenced their decision to adopt value-based contracts. Then, during our July 28 webinar, we will release a comprehensive market report on these trends and implications for the future. Preventing gaps in access to clinical care Advanced payment models incentivize ACOs to deliver high-quality care and close gaps in care for patients, thereby earn...

Redesigned MSSP program The Medicare Shared Savings Program, one of Medicare’s largest alternative payment models, allows providers and suppliers the opportunity to form an Accountable Care Organization. It was redesigned in 2018, establishing “Pathways to Success” as a way to restructure participation and encourage ACOs to transition to two-sided risk models.  As part of this rule, a BASIC track was established for ACOs to begin participation under an upside-only risk model and to incrementally phase into a two-sided risk model through a glide path. The glide path is composed of Levels A through E, in which there is progressively greater financial risk and potential opportunity for savings.  It is critically important for ACOs to understand how their level of participation in MSSP will change in the coming years. COVID-19 impact on MSSP advancement The COVID-19 public health emergency has disrupted efforts to improve population health and care coordination, and has resulted i...