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

Risk Management

House Reps Want to Extend MSSP Track 1 ACO Participation

May 22, 2018 - Seven House Representatives are calling on CMS to allow successful accountable care organizations (ACOs) in the Medicare Shared Savings Program’s (MSSP) Track 1 to continue in the upside-only financial risk track for a third agreement period. The MSSP requires Track 1 ACOs to transition to another track that contains downside financial risk after two three-year agreement...


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71% of MSSP ACOs Likely to Quit Rather Than Assume Downside Risk

by Jacqueline LaPointe

The Medicare Shared Savings Program (MSSP) is requiring the 82 accountable care organizations (ACOs) that started in upside-only financial risk tracks in 2012 or 2013 to take on downside financial risk by 2019. However, the majority of thes...“The challenges to assuming risk are not surprising and highlight that CMS needs to face the reality about how the majority of ACOs view risk,” Gaus commented. “ACOs need to gain confidence through successful performance i...

Orgs Not Living Up to Risk-Based Revenue Goals, C-Suite Says

by Jacqueline LaPointe

Provider organizations failed to achieve their risk-based revenue goals in 2017, according to the most recent State of Population Health survey by Numerof & Associates. The survey of healthcare C-suite executives showed that the majorit...Additionally, most executives in the 2015 survey thought that their organizations would be prepared to take on downside financial risk by 2017. Over half (59 percent) expected to be “very prepared” by 2017, but just 21 percent f...Possible threat of financial losses emerged as a top challenge to adopting alternative payment models involving risk-based revenue. About one-quarter of executives cited this as their number one obstacle. Researchers noted that executives i...Despite a lack of progress and several challenges, healthcare executives still felt the transition to population health management and risk-based revenue was worthwhile. Almost all respondents (95) percent rated population health a “m...Risk-based revenue from capitated contracts should particularly grow, executives noted. Only about one-half of respondents said their organization was in at least one capitated contract in 2017, and just 14 percent of respondents had more t...

How Mercy Improved Care Transitions for Risk-Based Care Success

by Jacqueline LaPointe

For the thousands of patients released from their 23 acute care hospitals a year, Mercy Health ensures that each patient receives the highest value care. But there is only so much providers can do within the walls of their health system to ...

Risk-Averse MSSP ACOs Missed $966M By Not Assuming Downside Risk

by Jacqueline LaPointe

Accountable care organizations (ACOs) in the non-risk bearing track of the Medicare Shared Savings Program (MSSP) could have boosted their bottom lines by an additional $966 million in net payments in 2016 if they had assumed downside risk ...The organizations would have earned a total of $966 million in net payments by participating in Track 1+, which was more than Avalere projected in a 2017 simulation that moved MSSP Track 1 ACOs to Track 2. In the 2016 simulation, the consul...However, nearly three-quarters of the organizations that had to repay their shared losses would have offset their financial setback with the Advanced APM incentive payment. The Advanced APM incentive payment should be an effective tool for ...

ACO, Bundled Payments Alignment Key to Success for Both Models

by Jacqueline LaPointe

CMS should align accountable care organizations (ACOs) and bundled payments by creating a blended accountability structure that allows organizations to participate in both alternative payment models without financial conflicts, industry exp...The advantages of joining a gainsharing model including providers not shouldering financial risk under ACO and bundled payment models alone. The model also promotes provider engagement in risk-based value-based care models. However, industr...

Industry Orgs Urge CMS to Lower Risk for MACRA’s Advanced APMs

by Jacqueline LaPointe

Healthcare stakeholders recently encouraged CMS to reconsider the financial risk requirements for Advanced Alternative Payment Models (Advanced APMs), arguing that the risk criteria limit participation in the models. Industry groups, includ...

Addressing Quadruple Aim, Physician Burnout Key to Risk Success

by Jacqueline LaPointe

From capturing patient risk to meeting quality measures, providers face a daunting list of items needed to achieve the Triple Aim of value-based care. But healthcare organizations will not see lasting cost savings and care quality improveme...Unfortunately, that whole bunch of value-based care capabilities and tasks are still required to achieve the Triple Aim despite physician burnout. Healthcare organizations still need to invest in population health management infrastructure,...

Full Risk Value-Based Care Key to Treating Vulnerable Patients

by Jacqueline LaPointe

Oak Street Health, a 24-primary care network headquartered in Chicago, aims to rebuild healthcare as it should be using value-based care contracts with full financial risk. The health system’s mission is to deliver personal, equi...“This is a population that has not traditionally thrived in a fee-for-service environment,” he said. “Frankly, the healthcare system is not really built to take care of them.” Medicare, Medicaid, and dual eligible po...

ACOs Plan to Move to Downside Financial Risk, Capitation Contracts

by Jacqueline LaPointe

Accountable care organizations (ACOs) are planning to enter downside financial risk arrangements, with 47 percent planning on entering a shared savings and losses contract and 38 percent pursuing capitation, uncovered a recent survey of 240...More advanced care delivery redesigns that are “necessary for ACOs to achieve their stated goals of reducing costs and improving quality” were further down on priority lists or not on the top focus areas at all. These activities...Despite differing financial risk adoption levels, both physician- and hospital-led ACOs plan to expand their risk-based arrangements in the near future. On average, ACOs plan to take on downside financial risk contracts within the 10 months...“The stages of adoption of key population health management activities suggest that ACOs are still largely focusing on the initial steps of care redesign,” wrote researchers. “For example, when tackling unscheduled care, A...• Decreasing healthcare costs • Planning participation in mandatory downside financial risk arrangements • Collaborating with payers and a lack of flexibility on their part • Understanding and complying with government r...Based on the survey’s findings, researchers stated that CMS and other payers can better support ACOs to foster their success with downside financial risk and population health management. “For example, CMS could continue to intr...

Bringing Back House Calls to Cut Spending on High-Risk Patients

by Jacqueline LaPointe

Before the early 1960s, the majority of healthcare visits were performed in patient homes. But as healthcare evolved, providers could no longer fit their tools in a transportable medical bag and the proportion of visits made by house calls ...“The reason for doing house calls is to really focus on these patients who have to call 911 and they land in the emergency room,” the system’s Director of Geriatrics said. “The program is there to really prevent 911 ...

Patient-Reported Data Helps Providers Find High-Cost Patients

by Jacqueline LaPointe

Self-reported patient data on health conditions, status, and utilization may be the key to identifying high-cost patients and guiding them to care management models to reduce their spending, a recent American Journal of Managed Care study i...

Accountable Care Organizations Grow, But Face New Challenges

by Jacqueline LaPointe

Since the Affordable Care Act paved the way for accountable care organizations (ACOs) in 2010, healthcare providers have increasingly turned to the alternative payment model as a way to engage in value-based care across patient populations....David Muhlestein, PhD, JD, Chief Research Officer at Leavitt Partners and co-author of the Health Affairs blogpost, explained that the ACO’s maturity as an alternative payment model is the primary driver for its recent growth. “...Without provider buy-in, ACO success may be in jeopardy, a 2016 American Journal of Managed Care study indicated. The early experience of a non-risk bearing Medicare Shared Savings Program ACO revealed that limited provider engagement acted...The shift to value-based reimbursement is also more of a journey than an overnight achievement, which may cause providers to pause before backing care transformations in favor of just the new model. “Fee-for-service has been really go...He also stated that ACOs may be risk-adverse or still experimenting with financial risk because they have not been in operation long enough to confidently put ACO revenue on the line in the face of shaky population health management strateg...Incorporating health IT use in provider workflows has helped mature ACOs get the right data to the right people at the right time. “They have figured out things that work for their own organization to get the data that their providers...“One thing that they can do is try to align their contracts to the point that they are not just administratively being swamped,” he explained. “A big part of this is quality metrics.” For example, assessing A1C level...

MSSP ACOs Missed $886M in Potential Revenue By Avoiding Risk

by Jacqueline LaPointe

Accountable care organizations (ACOs) in Track 1 of the Medicare Shared Savings Program (MSSP) could have received an additional $886 million in net payments in 2015 if the organizations took on downside financial risk and earned the 5 perc...The organizations also would have seen a $1.1 billion boost in payments from the 5 percent Advanced Alternative Payment Model bonus if the incentive reimbursement was offered at that time. Despite some ACOs having to refund CMS a portion of...With the bonus payment, nine more ACOs would have earned shared savings under the regional benchmarking system. “On balance, the 2016 changes to the payment methodology will support efficient ACOs,” stated John Feore, a director...

10 Orgs Call for Medicare Advantage APMs to Qualify for MACRA

by Jacqueline LaPointe

A coalition of ten healthcare industry groups recently urged HHS Secretary Tom Price to weigh risk-based Medicare Advantage alternative payment models the same as Advanced Alternative Payment Models under MACRA. Qualifying participants in M...

Creating Alternative Payment Models to Support Health Centers

by Jacqueline LaPointe

Healthcare stakeholders and lawmakers should encourage community health centers to engage in alternative payment models to financially incentivize providers to improve safety-net care, a recent Journal of the American Medical Association re...

Value-Based Penalties Target Hospitals With High Risk Patients

by Jacqueline LaPointe

Hospitals that serve greater volumes of African-American patients and those with more severe conditions are more likely to receive a value-based penalty under the Medicare Hospital Readmissions Reduction Program (HRRP), a new JAMA Cardiolog...

Did Risk-Based APMs Propel Greater Provider Consolidation?

by Jacqueline LaPointe

A recent Health Affairs study revealed that risk-based alternative payment models, such as accountable care organizations (ACOs), have not spurred greater provider consolidation in the post-Affordable Care Act healthcare environment. Medica...Provider consolidation growth occurred in high and low ACO participation areas, indicating that alternative payment model participation did not drive the increases, researchers contended. “[W]e also found that, compared to markets wit...Even within the same Metropolitan Statistical Area, provider consolidation trends did not suggest that alternative payment model participation spurred more healthcare mergers and acquisitions activity. Only physician group size significantl...Researchers argued that since most alternative payment models, ACOs included, rely on strong, coordinated primary care for value-based reimbursement success, provider consolidation for the sake of alternative payment model participation wou...

NAACOS Reveals 2017 Accountable Care Organization Priorities

by Jacqueline LaPointe

As part of its 2017 advocacy agenda, the National Association of Accountable Care Organizations (NAACOS) released policy recommendations for ACO improvement. The recommendations included Medicare Shared Savings Program (MSSP) changes, one-s...

61% of ACO Contracts Only Include Upside Financial Risk

by Jacqueline LaPointe

A recent Leavitt Partners study showed that 61 percent of accountable care organization (ACO) contracts are upside risk-only, indicating that ACOs may be risk-adverse or are still in the experimental stage with financial risk. Even though A...

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