The initial cohort of the Primary Care First model went live on Jan. 1.  Cohort 1, represented by 822 practices and 14 payer partners, is offered in 26 regions across the country. Over the six-year PCF demonstration period, CMS will test whether advanced primary care practices can improve patient experience and quality, reduce total cost of care and manage risk through performance-based payments, while decreasing the administrative burdens and increasing financial incentives for a primary care practice. PCF puts particular focus on comprehensive care coordination and the doctor-patient relationship. The Center for Medicare and Medicaid Innovation announced several PCF model updates in the last few weeks: The Seriously Ill Patient component of PCF, which would have gone live on April 1, has been postponed until further notice and is currently under review. The SIP component was established for practices that could focus on patients with complex chronic needs and fragmented care patt...

DataGen has completed its analysis of enacted Medicare cuts, the results of which are shared here. Please note that this analysis is intended for advocacy purposes only and should be used as an indication of the extent to which hospital providers nationwide have been impacted by existing Medicare provider payment cuts. These cuts were enacted by Congress to achieve Medicare payment policy and long-term deficit reduction goals. This DataGen impact analysis includes major cuts enacted since 2010. The enacted legislative cuts analyzed consist of: Medicare marketbasket, Medicare Disproportionate Share Hospital and quality adjustments authorized by the Affordable Care Act of 2010; note that for the purposes of 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; inpatient coding adjustment reductions authorized by the American Taxpayer Relief Act of...

It’s been a year: a year since the first lockdowns and a year since the landscape of healthcare in the U.S. changed forever. While we’re still evaluating the impacts of the pandemic on healthcare policy, we now have seen enough data to assess the effect of the past year on alternative payments models and how participants are reacting. It’s been reassuring to see the strength of APMs has broadly held steady, as has the resolve of the participants in those programs, despite the impact of the COVID-19 pandemic. Here’s what we’ve learned this year, along with what (we think) those lessons can teach us about the future. COVID-19 has not stopped the progress of APMs — but it is delaying it. COVID-19 has extended the period of some programs, like the Comprehensive Care for Joint Replacement and Oncology Care Model, and delayed the start of others, like Kidney Care First and the Radiation Oncology Model. This is, in part, a function of an overwhelmed system. As policymakers and healthcare org...

On Jan. 19, the Office of Management and Budget requested public comment on recommendations for changes to OMB’s metropolitan and micropolitan statistical area standards. The recommendations, made by the Metropolitan and Micropolitan Statistical Area Standards Review Committee, included increasing the minimum urban area population to qualify a metropolitan statistical area from 50,000 to 100,000. The analysis assumes that Core-based Statistical Area lines, state rural floors and rural wage indexes remain the same as they were with the federal fiscal year or calendar year 2021 final rules. It does not include any recalculation of wage indexes by CBSA or adjustments to the rural floor, which we recognize would directly impact all providers. An estimated impact on hospitals moving from urban to rural within the 144 effected CBSAs in the U.S. shows some states gaining, while others lose funds. If adopted, this would likely start in FFY 2025. The recommendations are published in the Federa...

Background:  After months of anticipation, CMS is planning to go forward with the mandatory Radiation Oncology Model. This bundled payment model, which was first announced in a proposed rule on July 10, 2019, with an anticipated start in January or April 2020, is notable for being one of the first mandatory models the industry has seen from CMS in years. While the model has been delayed, in part due to the complications presented by the COVID-19 public health emergency, CMS finally broke its silence on the future of the model in September with the publication of the RO model final rule. A revised start date was announced in the OPPS final rule in December: the RO model is anticipated to begin on July 1, 2021 and will run through 2025. Key facts: RO participants include freestanding radiation therapy centers, hospital outpatient departments and physician group practices with radiation oncologists that furnish radiation therapy services. The model is mandatory for selected participan...

The COVID-19 pandemic has impacted every aspect of our healthcare system. That’s true for participants in the Oncology Care Model and Bundled Payments for Care Improvement Advanced programs. Organizations in these programs had to make important decisions regarding the overlap of their program performance periods with the COVID-19 public health emergency. Several trends have begun to emerge from these choices. Here’s what DataGen’s analysts have seen from the data: BPCIA For performance periods that overlapped with the PHE, BPCIA participants had to decide if they would remove all upside and downside risk, or just remove COVID-19 patients from their reconciliation. From our analysis, it appears that decisions were balanced between these two options. We are not aware of any episode initiators who chose to continue their reconciliations as usual with no exclusions at all. Here’s what we believe drove those decisions: Opting out of the performance period reconciliation entirely by removing...

What can you do while CMS decides how to handle the mandatory program? As the healthcare community continues its march away from fee-for-service models, bundled payment initiatives have risen in popularity—thanks in no small part to their ability to fuel cost savings and significantly improve care outcomes. The Centers for Medicare and Medicaid Services (CMS) issued an interim final rule in March that delays implementation of the new bundled payment model for heart attack and cardiac bypass surgery services; expansion of the existing Comprehensive Care for Joint Replacement bundling model; and implementation of a new cardiac rehabilitation incentive payment model, from July 1 to October 1, 2017. Prior to the interim rule, CMS’ push forward on bundled payments focused the industry on episodic efficiency. The delay has pushed these initiatives back three months and, as DataGen’s Vice President, Kelly Price recently explained, is causing confusion and worry among participants.