Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

Why Recent Attempts at Healthcare Reform Regulation Matter

By Jacqueline DiChiara

- One notable trending topic — value-based care — is buzzing among healthcare organizations in recent weeks, especially with more federal healthcare reform going into effect. And recent developments at The Department of Health and Human Services show that value-based care has a serious role to play in the federal agency’s plans in the years to come.

Most recently, HHS Secretary Sylvia M. Burwell announced the department’s plans to move away from fee-for-service payments, including a timetable and a series of guidelines.

Such news is the very first time HHS has established specific goals for value-based payment and alternative payment models in the entire history of the Medicare program.

Many Medicare fee-for-service payments are already connected to quality rather than quantity. But now within the next three years, HHS has set a goal shifting 50% of fee-for-service payments to value-based payment models.

By the end of 2016, it is anticipated 30 percent of traditional, fee-for-service Medicare payments will transition into value-based payments via alternative payment models, including bundled payment arrangements and accountable care organizations (ACOs.)

READ MORE: Provider Engagement Key to Accountable Care Organization Success

Other HHS goals include a push to shift 85 percent of traditional fee-for-service Medicare payments to quality or value within the next year. Likewise, by 2018, through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs, the shift is proposed to be at least 90 percent.

Making the Affordable Care Act connection

Alternative payment methods play a vital role in the future direction of the health care system and direct implications of the ACA.

“The ACA creates a number of new institutions and payment arrangements intended to drive the health care system in this direction,” Burwell writes in The New England Journal of Medicine. These include alternative payment models such as ACOs, advanced primary care medical-home models, new models of bundling payments for episodes of care, and demonstration projects in integrated care for beneficiaries dually eligible for Medicare and Medicaid.”

The ACA, says Burwell, created the Patient-Centered Outcomes Research Institute (PCORI) which generates information to assist doctors, caregivers, and patients facing weighty clinical assessments.

READ MORE: Importance of Post-Acute Alignment, Integration to Value-Based Care

Future PCORI research findings which were partially gathered via EHRs provide patients with critically needed clinical information from providers. PCORI collaborates with the Agency for Healthcare Research and Quality to distribute these decisions.

HHS also proposes extensive initiative efforts, millions in investments

Returning to Burwell’s comments in NEJM, the HHS Secretary has stressed the outreaching influence such quality metrics bring.

“Through the Transforming Clinical Practice Initiative, we will invest up to $800 million in providing hands-on support to 150,000 physicians and other clinicians for developing the skills and tools needed to improve care delivery and transition to alternative payment models,” she explains.

“Looking ahead, we plan to develop and test new payment models for specialty care, starting with oncology care, and institute payments to providers for care coordination for patients with chronic conditions,” she continues. Three years ago, Medicare made almost no payments through these alternative payment models, but today such payments represent approximately 20% of Medicare payments to providers, and as noted above, we aim to increase this percentage.”

READ MORE: Nearly 71% of Practice Revenue Under Fee-For-Service in 2016

Mixed factors of a mandatory paradigm shift to a fee-for-value model

Some advocate the benefits of expanded cross-disciplinary paradigms as helping management hierarchy and vastly improving the future quality of healthcare.

Alan Gilbert, MPA, FHIMSS, believes the mandatory shift “necessitates the establishment of multi-disciplinary, multi organizational team based care models to actively manage emerging care plans, care delivery, and compliance with evidence-based care practices across a wide-variety of providers and care settings.”

Additionally, Gilbert and others also find that team based care “enables continuity, speeds the healing process, eliminates waste, and provides better information for future care encounters.”

However, others advocate that coordinated care and value-based reimbursement models are detrimental to smaller medical practices, essentially driving people away from independent practices. And, some report that practices in rural areas may especially hurt from the anticipated effects.

HIMSS says “fee for value” is an impetus for transformation in the midst of historic lows in the growth of health care spending.

For HHS and Burwell, the fact that ten percent of hospitalized patients experience adverse events while hospitalized is unacceptable and something capable of being changed.

She backs up her claims with survey data confirming that 70 percent of ACA enrollees say the overall quality of their coverage is excellent or good. A reported 50,000 deaths were averted due to much safer care delivered throughout 2013 in comparison with 2010. In addition, there were 1.3 million fewer reported adverse effects from 2011 to 2013.

Ultimately, the federal agency’s outlook also remains positive.

“We are dedicated to using incentives for higher-value care, fostering greater integration and coordination of care and attention to population health, and providing access to information that can enable clinicians and patients to make better-informed choices,” Burwell maintains.

 

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