Are New APMs from CMMI Coming Soon? Industry Stakeholders Forecast Bold Moves from the CMS Innovation Center in 2019 | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Are New APMs from CMMI Coming Soon? Industry Stakeholders Forecast Bold Moves from the CMS Innovation Center in 2019

January 11, 2019
by Heather Landi, Associate Editor
| Reprints
Click To View Gallery

What might be in the works over at the Centers for Medicare and Medicaid Innovation (CMMI)? Are there new pilot models actively in development that will be rolled out this year? Many industry stakeholders, including federal lawmakers, are eager to know what the relatively opaque agency has in store.

Created under the Obama administration, CMMI is charged with piloting, testing and evaluating alternative payment models (APMs)—such as bundled payment models, for example—with the intent of increasing quality and efficiency, while reducing program expenditures under Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).

However, CMMI has been notably quiet in the first two years of the Trump Administration with regards to new payment models. Last January, CMS did launch a new voluntary bundled payment model, Bundled Payments for Care Improvement Advanced, the Administration’s first Advanced APM.

In several speeches to industry groups this past fall, Health and Human Services (HHS) Secretary Alex Azar has indicated that the Trump Administration is exploring new voluntary bundled payments, and even revisiting mandatory bundled payments, which represents a strong about-face in the Trump Administration’s policy about bundled payment initiatives. Azar has even hinted that CMMI will get more involved in addressing social needs, such as food insecurity and housing.

However, the agency has yet to announce any new payment model pilots, leading many healthcare stakeholders to speculate about what’s coming next.

Back in September 2017, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma wrote an op-ed in the Wall Street Journal where she said that the Trump administration would lead CMMI “in a new direction” to give providers more flexibility with new payment models and to increase healthcare competition. Verma said at the time that CMS was analyzing all Innovation Center models “to determine what is working and should continue, and what isn’t and shouldn’t.” The agency also issued an RFI for ideas on how to determine the best path forward for CMMI, to which various healthcare associations responded with comments and suggestions.

Verma has previously voiced skepticism about some CMMI initiatives, including mandatory bundled payment programs.

It was over a year after President Donald Trump took office that Adam Boehler, the former CEO of home-based care startup Landmark Health, was named CMMI Director in April. A month prior, in March, Politico reported that “There’s been a recent exodus of top officials at the CMS Innovation Center, and the installation of a new leader at the office has been on hold because of financial conflicts. The Obamacare-created office, which many Republicans have viewed with suspicion, has so far received minimal attention from administration leaders.”

Republicans lawmakers have had a love-hate relationship with CMMI, insofar as GOP leaders, including former Congressman Tom Price, M.D., who later was appointed HHS Secretary by President Trump, called out CMMI for “overstepping its authority” by proposing mandatory healthcare payment and service delivery models. In September 2017, Republican lawmakers wrote a letter to CMS and were particularly critical of a CMS final rule requiring at least 800 hospitals in 67 geographical regions to participate in a bundled payment model for hip and knee replacements. That model, the Comprehensive Care Joint Replacement (CJR) model, is operated by CMMI. The Trump Administration has since rolled back that model and cancelled a mandatory cardiac bundled payment model, which also would have been operated by CMMI.

However, Azar, who was confirmed as HHS Secretary earlier this year, signaled early on that he diverged from Verma and Price on his views about mandatory bundled payments.

Many healthcare industry stakeholders who support accelerating the transition to value-based care and payment models are eager for CMMI to develop and roll out new voluntary alternative payment models. And others want to see more transparency in the process. Just this week, two Congressional leaders, U.S. Representative Richard Neal (D-MA), chairman of the House Committee on Ways and Means, and Rep. Kevin Brady (R-Texas), ranking member of the committee, sent a letter to Verma calling for greater transparency from CMMI as it develops new delivery and payment models, noting that its process has “historically been opaque to Congress and to stakeholders.”

Further, Reps. Neal and Brady wrote, "Significant policy changes made unilaterally by the executive branch without sufficient transparency could yield unintended negative consequences for beneficiaries and the health care community. We strongly urge the Agency to provide more sunshine in this process."

In a tweet posted Thursday, Anders Gilberg, senior vice president, government affairs for the Medical Group Management Association (MGMA), welcomed the lawmakers’ efforts to encourage more transparency from CMMI and CMS officials. “Medicare payment model development has been both opaque and anemic. Medical practices need new non-mandatory APMS (alternative payment models) in 2019,” Gilberg tweeted.

Many industry stakeholders are anticipating bold moves out of CMMI in the near future. As reported by Healthcare Informatics Editor-in-Chief Mark Hagland, Don Crane, CEO of the Los Angeles-based America’s Physician Groups, recently noted that statements from federal healthcare officials have made it clear that plans are afoot to accelerate the transition from fee-for-service payment to risk-based and value-based reimbursement. Crane, who said he has participated in roundtables with Boehler, further said, “We haven’t seen any pending rules yet, but we need to get ready for some bold moves in Medicare, where they accelerate the movement.”

Last April, CMMI issued an RFI on direct provider contracting (DPC) between payers and primary care or multi-specialty groups to inform potential testing of a DPC model within Medicare fee-for-service and Medicare Advantage programs, and Medicaid. Crane said he anticipated a DPC model coming out of CMMI.

In a keynote speech at the Patient-Centered Primary Care Collaborative Conference this past fall, in early November, Azar indicated that CMS is revisiting mandatory bundled payment models, possibly for radiation oncology and cardiac care. During the speech, he said, “We intend to revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology. We’re also actively looking at ways to build on the lessons and successes of the Comprehensive Care for Joint Replacement model.” He added, “We’re not going to stop there: We will use all avenues available to us—including mandatory and voluntary episode-based payment models.”

Further, Azar said CMMI would launch new primary care payment models before the end of 2018, with the aim of introducing a spectrum of risk for primary care providers, although no new models were announced.

“Before the end of this year, you will see new payment models coming forth from CMMI that will give primary care physicians more flexibility in how they care for their patients, while offering them significant rewards for successfully keeping them healthy and out of the hospital,” he said.

Also, in a speech to the Hatch Foundation for Civility and Solutions later in November, Azar also hinted that CMMI will get more involved in addressing social needs, such as food insecurity and housing.

During the speech, Azar pointed to the Accountable Health Communities model from CMMI, which was announced in 2016 and launched last year. The model incentivizes providers to screen high utilizers for social needs, such as food insecurity or transportation, housing, and utility needs.

“But what if we went beyond connections and referrals? What if we provided solutions for the whole person, including addressing housing, nutrition and other social needs? What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food? If that sounds like an exciting idea . . . I want you to stay tuned to what CMMI is up to," Azar said in that speech.

Beyond payment models, Jeff Smith, vice president of public policy for the Bethesda, Md.-based AMIA (American Medical Informatics Association) notes there is tremendous opportunity for CMMI to expand its focus and provide innovation support, not simply financial support, to transform care delivery. Reiterating comments AMIA submitted to CMMI’s New Direction RFI in September 2017, Smith said CMMI should be focused on testing new ways to leverage health IT in ways that can’t be done, given the current constraints for billing and documentation.

“There’s no reason that CMMI couldn’t decide to test different kinds of NLP (natural language processing) and sensor-based motion detection technology and figure out how to extract information for billing, for example,” Smith says.

“I think CMMI should tackle workforce and education. Right now, we have just fewer than a few dozen ACGME-accredited Clinical Informatics Fellows programs across the country. These programs are producing the Clinical Informatics leaders of the future, but we need more of them and we need better structural funding,” Smith says. “CMMI could establish a model that looks at the care improvement and cost savings of these programs and begin to develop an evidence base for how institutions who employ such Fellows fare vis-à-vis those who don’t.”

 


The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


/article/value-based-care/are-new-apms-cmmi-coming-soon-industry-stakeholders-forecast-bold-moves-cms
/blogs/mark-hagland/value-based-care/should-physicians-and-hit-leaders-worry-about-implications

Should Physicians and HIT Leaders Worry about the Implications of the Walgreens/Microsoft Deal?

| Reprints
As architect Daniel Burnham once said, “Make no little plans”; the leaders of the Walgreens/Microsoft alliance, like so many others, certainly are thinking big these days
architect Daniel Burnham

Nearly every day, it seems, new business combinations are announced that are threatening to alter the landscape of U.S. healthcare forever. CVS’s acquisition of Aetna, completed last November; the announcement a year ago now that the executives of Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. were launching a broad (if not well defined) initiative to improve consumer satisfaction and reduce costs for their employees; Cigna’s acquisition just last month of pharmacy benefit management (PBM) company Express Scripts; and Amazon’s acquisition last summer of online pharmacy company PillPack.

Every one of those business deals represents a disruptive move in U.S. healthcare, with unalike “species” of organizations combining with one another. And now, the retail drugstore giant  Walgreens Boots Alliance Inc. and Microsoft Corp. are coming together in yet another disruptive venture. As Managing Editor Rajiv Leventhal wrote in an article on Tuesday, the corporations “are joining forces on a major seven-year healthcare partnership that will aim to ‘deliver innovative platforms that enable next-generation health networks, integrated digital-physical experiences and care management solutions.’” As he wrote, “The companies announced today that they will combine the power of Microsoft Azure, Microsoft’s cloud and AI (artificial intelligence) platform, healthcare investments, and new retail solutions with WBA’s customer reach, volume of locations, and outpatient healthcare services to accomplish their goals: to make healthcare delivery more personal, affordable and accessible.”

As Leventhal noted in his report, “While innovation in healthcare has occurred in pockets, officials of the two companies believe that ‘there is both a need and an opportunity to fully integrate the system, ultimately making healthcare more convenient to people through data-driven insights.’” Further, he noted, “As part of the strategic partnership, the companies have committed to a multiyear research and development (R&D) investment to build healthcare solutions, improve health outcomes and lower the cost of care. This investment will include funding, subject-matter experts, technology and tools, officials noted in the announcement. The companies will also explore the potential to establish joint innovation centers in key markets. Additionally, this year, WBA will pilot up to 12 store-in-store ‘digital health corners” aimed at the

“This gap creates an opportunity for the pharmacist to help monitor the patients’ health and prompt the patient to receive preventative care in the retail clinic or through a virtual care visit. Using an enterprise health cloud, like Azure, you create a more connected ecosystem so that we can share that data with the patient’s additional providers, track outcomes, and intervene earlier when an issue arises,” Microsoft CEO Satya Nadella said in a statement Tuesday.

And, Leventhal wrote, “Notably, the companies will also work on building an ecosystem of participating organizations to better connect consumers, providers—including Walgreens and Boots pharmacists—so that major healthcare delivery network participation will provide the opportunity for people to seamlessly engage in WBA healthcare solutions and acute care providers all within a single platform.”

Speaking to the difference between retail pharmacies and traditional care providers, Forrester analyst Arielle Trzcinski said in a statement emailed to the press that “[R]etail pharmacies offer an opportunity to engage with the patient much more frequently than at an office visit, giving an example of how chronic care patients see their pharmacist frequently, while some figures indicate that the average diabetic patient sees his or her provider once every six months.”

The implications of all of this are, of course, huge. For one thing, if one were to ask the average patient/healthcare consumer with whom they interacted more, doubtless, the vast majority would cite their retail pharmacists, rather than their primary care physicians. What’s more, what happens if Walgreens is able to follow through, as CVS also intends to do, in creating minute clinics in retail pharmacy locations? The impact could be revolutionary.

Indeed, it’s no secret that many patients are dissatisfied with the cumbersome, challenging processes around accessing primary and specialty care in the U.S. healthcare system. Simply accessing a timely appointment often proves to be a major hassle; and encounters around needed follow-ups and around questions to doctors and nurses often turn out to be such a hassle that many patients simply give up, with the result of medication non-compliance and other issues.

So what will happen if Walgreens, like CVS, manages to achieve success with one or more elements of this initiative? Those could include enhanced continuum of care for patients, especially those with chronic diseases; improved communication among all care delivery stakeholders; and enhanced patient/consumer satisfaction.

A few stakeholder groups should be paying particular attention here, including practicing physicians and healthcare IT leaders. For practicing physicians, could anyone deny that this business initiative, along with the others mentioned above, should be disconcerting at the very least? Already, patients needing relatively immediate medical attention, are turning en masse to urgent care centers, as both health systems and health insurers are working to cut down on the volume of emergency department visits, which are tremendously expensive, and which burden the healthcare delivery system in ways that are not sustainable. But now, with both Walgreens/Microsoft and CVS/Aetna, is anyone denying that the era of pretty-close-to-immediate medical attention is on the horizon?

The reality is that, while most patients like their primary care physicians and are satisfied with their care overall, strong majorities, in polls, continue to complain about poor service, bad communication, and delays accessing care and accessing follow-up support. What happens when most decent-sized Walgreens and CVS drugstores are staffed up with PCPs or advanced practice nurses, to handle the colds, coughs, flus, strep throats, and minor skin and digestive issues that could easily be handled by such service offerings?

One of the core policy issues here is that the U.S. healthcare payment system remains largely predicated on primary care physicians physically touching patients in order to get paid. Yes, telehealth services are expanding daily; but in most situations, patients still need to go through the awkward, inconvenient, sometimes even-arduous process of scheduling an appointment, using some form of transportation to get to that appointment, and waiting in a crowded physician office, in order to access primary care.  But in 2019, when GrubHub can deliver one’s banh mi Vietnamese sandwich to one’s home, and Amazon is sending everything from books to clothing to furniture to God-knows what, directly to people’s doors, how much longer will healthcare consumers continue to be patient with the glacial pace of care delivery change in U.S. healthcare?

Meanwhile, healthcare IT leaders will inevitably find themselves somewhat behind a proverbial eight-ball on all this, caught between the intensifying demands on the part of practicing physicians, especially primary care physicians, for full clinical IT support for their practices, and constant business changes, including merger-and-acquisition activity in their own organizations that is continuously scrambling their long-term planning.

So we’re seeing both business and technology changing, and changing quickly, with numerous examples already of industry-disruptive business combinations, and technology advancing to the point where previously unimagined breakthroughs are now imaginable. For example, Walgreens and Microsoft noted that, “Through this agreement, Microsoft becomes WBA’s strategic cloud provider, and WBA plans to migrate the majority of the company’s IT infrastructure onto Microsoft Azure,” as corporate officials put it. And “Microsoft also plans to roll out Microsoft 365 to more than 380,000 Walgreens employees and stores globally.” And, to make things just that more intriguing, the announcement quoted Stefano Pessina, executive vice chairman and CEO of the Walgreens corporation, as stating that “WBA will work with Microsoft to harness the information that exists between payors and healthcare providers to leverage, in the interest of patients and with their consent, our extraordinary network of accessible and convenient locations to deliver new innovations, greater value and better health outcomes in health care systems across the world.”

As renowned Chicago architect Daniel Burnham so famously said, “Make no little plans; they have no magic to stir men's blood and probably themselves will not be realized.” There’s no question that the senior leaders of all of these business alliances, combinations, and initiatives are going to be “no little plans.” It would behoove clinicians, clinician leaders, healthcare IT leaders, and all c-suite leaders in provider organizations to think Burnham-sized thoughts; these businesspeople from outside traditional healthcare delivery are certainly doing so.

 

 

 

 

 

More From Healthcare Informatics

/news-item/value-based-care/blue-cross-nc-five-health-systems-announce-major-shift-value-based-care

Blue Cross NC, Five Health Systems Announce Major Shift to Value-Based Care

January 16, 2019
by Heather Landi, Associate Editor
| Reprints
The insurer aims to have half of its 3.89M customers covered by VBC contracts by next year; all customers in VBC arrangements in five years
Click To View Gallery

Blue Cross and Blue Shield of North Carolina (Blue Cross NC), one of the state’s largest insurers, and five of the state’s major health systems in North Carolina have announced a new value-based care program that encompasses hundreds of thousands of healthcare customers throughout the state.

The five health systems—Cone Health, Duke University Health System, UNC Health Care, Wake Forest Baptist Health and WakeMed Health 7 Hospitals—and their accountable care organizations (ACOs) have committed to participating in Blue Premier, a new value-based model of care in which Blue Cross NC and the health systems will be jointly responsible for better health outcomes, exceptional patient experience and lower costs, according to a Blue Cross NC press release.

“With agreements from five of the state’s major health systems and their ACOs, Blue Premier is one of the most rapid and comprehensive shifts to value-based payments in the nation,” Blue Cross NC officials stated. Patrick Conway, M.D., serves as president and CEO of the Durham-based health insurer and previously served as the Chief Medical Officer, Deputy Administrator, and Director of the Center for Medicare and Medicaid Innovation (CMMI), a division of the Centers for Medicare and Medicaid Services (CMS).

Within five years, Blue Cross NC has committed to having all 3.89 million customers covered under Blue Premier’s value-based care contracts. By early 2020, fifty percent or more of all Blue Cross NC members will have a provider who is jointly responsible for the quality and total cost of their care, the health insurer stated.

“As a practicing physician, I have experienced first-hand the challenges plaguing our health care system,” Conway said in a statement. “Historically, our health care system pays for services that may or may not improve a patient’s health, and our customers simply cannot afford this approach. Moving forward, insurers, doctors and hospitals must work together, and hold each other accountable for improving care and reducing costs. We applaud the leadership and commitment of these five leaders in health care to help transform health care delivery in North Carolina.”

During the HLTH Conference, held at the Aria Resort in Las Vegas last May, Conway discussed the payer-provided landscape in North Carolina and alluded to opportunities accelerate the move to value-based care and payment models, according to reporting from Editor-in-Chief Mark Hagland. “We’re looking at a new model, where patient care organizations can partner more fully with Blue Cross North Carolina,” Conway said, per Hagland’s report. And Conway continued, “We’re saying, you can take this alternative pathway with us. And we’ll jointly be accountable for the total quality and cost of care. And we want you to go into two-sided risk. And we’re wondering, should we turn off all prior authorization? And documentation other than for risk coding and STARS measures, we won’t worry about how you document. And for people in the audience, those kinds of partnerships are very exciting, because you’ve now got a provider and payer that are no longer locked into rigid rules, but where you can innovate on quality and customer experience.”

According to the insurer, Blue Premier ties payments to doctors and hospitals over time to the value of services that improve patient health. This means that total payments to the health systems under Blue Premier will be based on the health systems’ ability to manage the total cost of care and their overall performance, measured by industry quality standards. Through a “shared risk” financial model, the health systems will share in cost savings if they meet industry-standard goals to improve the health of patients – and share in the losses if they fall short. “The unprecedented commitment from these five large health systems makes Blue Premier one of the most advanced and comprehensive value-based care programs in North Carolina and the nation,” Blue Cross NC officials stated.

“This unprecedented step by Blue Cross NC and many of the state’s leading health care organizations will make a big difference in advancing high-quality, innovative care in North Carolina,” Mark McClellan, M.D., Ph.D., director of the Duke-Margolis Center for Health Policy said in a statement in the press release. “At Duke-Margolis, we remain committed to supporting state government and private-sector initiatives to reform payment and improve care – providing needed examples for the nation.” 

In a statement, Donald Gintzig, president and CEO, WakeMed Health & Hospitals, said, “This collaboration represents an important step forward in our efforts to provide patients in our area and across the state with high quality, coordinated services for the best value. Our health systems are bringing together valuable resources in a more integrated way that will ultimately lead to better health and more affordable health care.”

The news of the value-based care collaboration comes a month after the health insurer announced a partnership with Aledade, a Bethesda, Md.-based company focused on physician-led ACO development, to launch a value-based care initiative to support primary care physicians across the state. Through the initiative, the two companies will support physician-led ACOs tailored specifically for primary care physicians and the communities they serve. Through these ACO arrangements, Blue Cross NC will collaborate with Aledade to provide physicians with technology and data analytics tools to better manage patient care and costs. After joining these ACOs, practices gain a more comprehensive view of their patients’ total cost of care, gaps in quality of care, and experiences throughout the entire health care system, the companies said.

 

Related Insights For: Value-Based Care

/news-item/value-based-care/kaiser-health-news-report-clinics-treating-immigrants-find-themselves

Kaiser Health News Report: Clinics Treating Immigrants Find Themselves in Limbo Around Notification

January 15, 2019
by Mark Hagland, Editor-in-Chief
| Reprints
The clinicians and leaders of U.S. patient care organizations continue to find themselves in a policy limbo around the information they share with federal and state authorities around their care for undocumented immigrants

The clinicians and leaders of U.S. patient care organizations continue to find themselves in a kind of policy limbo around the data and information they share with federal and state authorities around their medical care for undocumented immigrants, a new report in Kaiser Health News finds.

As Ana B. Ibarra wrote in a new report in Tuesday’s Kaiser Health News, “While the Trump administration decides whether to adopt a controversial policy that could jeopardize the legal status of immigrants who use public programs such as Medicaid, doctors and clinics are torn between informing patients about the potential risks and unnecessarily scaring them into dropping their coverage or avoiding care.” In her story, Ibarra quoted Tara McCollum Plese, chief external affairs officer at the Arizona Alliance for Community Health Centers, which represents 176 clinics, as saying, “We are walking a fine line. Until there is confirmation this indeed is going to be the policy, we don’t want to add to the angst and the concern.” However, if immigrants do come to a clinic wondering whether using Medicaid can affect their legal status, trained staff members will answer their questions, Plese told Ibarra.

Patient care organization leaders are working to figure out how to handle the situation, with some providers deciding to prepare their patients for the potential enactment of the proposal. At Asian Health Services, a clinic group that serves Alameda County, Calif., staff members pass out fact sheets about the proposed changes, provide updates via their patient newsletter and host workshops where patients can speak to legal experts in several Asian languages. “We can’t just sit back and watch,” CEO Sherry Hirota told Ibarra. “We allocate resources to this because that’s part of our job as a community health center — to be there not only when they’re covered, but to be there always,” even when that coverage is in jeopardy, she said.

The proposed “public charge” rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants’ use of an expanded list of public benefit programs including Medicaid, CalFresh and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people. Currently, people are considered public charges if they rely on cash assistance (Temporary Assistance for Needy Families or Supplemental Security Income) or need federal help paying for long-term care.

 

 

See more on Value-Based Care

agario agario---betebet sohbet hattı betebet bahis siteleringsbahis