Health Care Cost

Rising consumerism, new competition, and payment models designed to keep patients out of acute care are forcing hospital-centric enterprises to rethink their delivery models. Organizations that excel in building integrated care delivery ecosystems and lasting consumer relationships based on a differentiated brand promise and superior outcomes will be the ones that find success.

The industry is speedily moving and advancing, and the only way for hospitals see continued success is if they stay nimble and capable of adapting to new developments. Looking to the future, healthcare systems should concern themselves less with size and instead shift focus to adopting business and payment models that bring value.

There has always been interest in bundled payments, and now the industry is moving toward implementing more, explained Scott Hewitt, vice president, payment strategy and innovation, UnitedHealthcare.

Although safety net organizations are eligible for some two-thirds of federal payment reform programs, fewer than 20% of these programs directly target the safety net.

Data published in JAMA Internal Medicine are the latest to sound the alarm on the emerging crisis in primary care.

Compared with other payment models, like bundled payments or the Comprehensive Primary Care Program, accountable care organizations (ACOs) have done a better job of saving money, said Rob Mechanic, MBA, senior fellow at the Heller School of Social Policy and Management at Brandeis University and executive director of the Institute for Accountable Care.

All providers, regardless of where they work have a role in the shift to value-based care, but independent physicians need to have a voice in the transition, said Sibel Blau, MD, medical oncologist at Northwest Medical Specialties, PLLC.

One-time curative treatments provide a huge challenge to health systems that were not created with them in mind. Despite having no approved treatments, bluebird bio has proactively released a model to pay for these one-time cures in a way that provides value to patients and the health system.

Hospitals that are participating in Medicare’s mandatory bundled payment model for hip and knee replacements reported a decrease in spending per episode of $812 compared with control hospitals not participating in the Comprehensive Care for Joint Replacement (CJR) program.

While the Oncology Care Model is likely not a sustainable mode for oncology care, it will probably inform what payment structure comes next.

To speak about the success and continued development of Priority Health's payment reform model in cancer care, John Fox, MD, medical director at Priority Health, joined Dennis Zoet, chief business development officer at Cancer and Hematology Centers of Western Michigan, on a panel at the Community Oncology Alliance Payer Exchange Summit.

A report from RAND Corporation and the American Medical Association (AMA) describes how alternative payment models (APMs) are affecting multiple aspects of physician practice and offers guidance for efforts to improve APMs and help practices succeed in them.

The type of cancer a provider treats can determine how well he or she performs under the Oncology Care Model (OCM), according to research from Avalere Health that was presented at the American Society of Clinical Oncology Quality Care Symposium.

The pace of change to value-based payments has been happening quickly, but the real test is whether or not these payments produce higher quality and more affordable care, said Suzanne Delbanco, PhD, MPH, executive director of Catalyst for Payment Reform.

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 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.