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...

On April 29, CMS issued a final rule to extend the Comprehensive Care for Joint Replacement model by an additional three performance years. A number of modifications effective in the extension period aim to improve the model and reflect Medicare policy changes over the last several years. CMS anticipates that CJR will save the Medicare program an additional $217 million over the extension period. The following summarizes the most notable model changes: Three new performance years have been added: PY 6 will include episodes that end between Oct. 1, 2021 and Dec. 31, 2022; PY 7 will include episodes that end between Jan. 1, 2023 and Dec. 31, 2023; and PY 8 will include episodes that end between Jan. 1, 2024 and Dec. 31, 2024. Episode definitions under the model have been expanded to include total hip arthroplasty and total knee arthroplasty procedures performed in the hospital outpatient setting. The episode categories under the extension are site-neutral and are defined as: MS-DRG 470: ...

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...