PODCAST: Hospital “Out-Patient” Department Pricing Explained

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Hospitals Are Paid More for SAME SERVICE in Outpatient Department Than Doctors Are Paid in Office.

For Example, the SAME Echocardiogram Costs $600 in a Hospital Outpatient Department and $250 in a Doctor’s Office.

By Dr. Eric Bricker MD

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PODCAST: Medicare Payment Bureaucracy Uncertainty

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Dr. Eric Bricker Explains How Medicare Can Take Money Back from Hospitals if it Wants. If the Hospital Thinks Medicare is Being Unfair, the Appeals Process Takes 3 Years!

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BY ERIC BRICKER MD

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Related: On Medicare Bureaucratization

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PODCAST: Medicare Re-Admission Penalty Explained

As part of the Affordable Care Act of 2010

CMS changed its hospital readmission penalty methodology

BY ERIC BRICKER MD

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PODCAST: Medicare Provider Payment Changes

By Eric Bricker MD

The Centers for Medicare and Medicaid Services (CMS) Announce Changes to Doctor and Healthcare Provider Payments

CITE: https://www.r2library.com/Resource/Title/082610254

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PODCAST Related Medical Payments: https://medicalexecutivepost.com/2021/10/01/podcast-on-medicare-payments-to-doctors/

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CMS: MSSP ACO Growth 2012-2022

By Staff Reporters

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DEFINITION: An accountable care organization is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation.

CITE: https://www.r2library.com/Resource/Title/0826102549

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See the source image

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CMS MSSP ACO Growth 2012-2022

Performance YearACOsAssigned Beneficiaries
202248311.0 million
202147710.7 million
202051711.2 million
201948710.4 million
201856110.5 million
20174809.0 million
20164337.7 million
20154047.3 million
20143384.9 million
2012+20132203.2 million

Source: CMS 2022 Shared Savings Program Fast Facts – As of January 1, 202

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Supreme Court Hears Oral Arguments on 340B Drug Pricing Cuts

BY HEALTH CAPITAL CONSULTANTS, LLC

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Supreme Court Hears Oral Arguments on 340B Cuts

On November 30, 2021, the U.S. Supreme Court heard oral arguments regarding the challenges arising from the cuts made by the Centers of Medicare & Medicaid Services (CMS) to the 340B Drug Pricing Program.

The 340B Drug Pricing Program allows hospitals and clinics that treat low-income, medically underserved patients to purchase certain “specified covered outpatient drugs” at discounted prices (applying a ceiling to what drug manufacturers may charge certain healthcare facilities) – 25% to 50% of what providers would typically pay – and then receive reimbursement pursuant to the rates set forth in the Outpatient Prospective Payment System (OPPS) at the same rate as all other providers. (Read more…)

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HEALTH ECONOMICS CITE: https://www.r2library.com/Resource/Title/0826102549

PODCAST: https://medicalexecutivepost.com/2021/08/27/podcast-hospital-340-b-drug-programs/

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TELE-MEDICINE Fraud, Abuse and New Barriers!

Telemedicine: Fraud and Abuse During the COVID Pandemic

By Susan Walberg

The COVID-19 pandemic has brought with it huge challenges for people all over the world; not only the obvious health-related concerns but also shutdowns, unemployment, financial difficulties, and a variety of lifestyle changes as a result.

When the COVID pandemic struck, CMS quickly recognized that access to care would be an issue, with healthcare resources strained and many providers or suppliers shutting down their offices or drastically limiting availability. Patients who needed routine care or follow-up visits were at risk for not receiving services during a time when healthcare providers were scrambling to enhance infection control measures and implement other new safety standards to protect patients and healthcare workers.

The Centers for Medicare and Medicaid Services (CMS) has responded by easing restrictions and regulatory burdens in order to allow patients to receive the healthcare services they need without undue access challenges. One key area that has changed is the restrictions related to telehealth services, which were previously only paid by Medicare under certain circumstances, such as patients living in remote areas.

Among the changes and waivers CMS has offered, telemedicine reimbursement is among the more significant. Telemedicine services, which includes office visits and ‘check ins’ are now allowed and reimbursed by Medicare. In addition to reimbursement changes, CMS has also relaxed the HIPAA privacy and information security enforcement standards, paving the way for providers to adopt a new model of providing services electronically.

TELE-HEALTH BARRIERS: https://www.statnews.com/2021/07/13/telehealth-provisions-emergency-patients/

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MORE:  https://medicalexecutivepost.com/2021/05/18/fraud-schemes-of-few-medical-providers/

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New Study Compares Medicare-Commercial Payment Gaps by Specialty

New Study Compares Medicare-Commercial Payment Gaps by Specialty

BY HEALTH CAPITAL CONSULTANTS


Utilizing data from FAIR Health, the Urban Institute conducted an October 2021 study which reviewed commercial insurance claims across the U.S. (for approximately 60 insurers and third-party administrators covering over 150 million Americans under age 65) from March 2019 through February 2020.

CITE: https://www.r2library.com/Resource/Title/0826102549

This study assessed the gap between commercial insurance payments and Medicare payments for professional physician services to determine whether the payment gap between Medicare and commercial insurance differs by specialty. (Read more…)

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CMS Innovation Center Launches “Bold New” Strategy

BY HEALTH CAPITAL CONSULTANTS, LLC

CMS Innovation Center Launches “Bold New” Strategy


When President Joe Biden was elected in 2020, there was much anticipation and speculation regarding what his election would mean for the U.S. healthcare industry in the coming years.

CITE: https://www.r2library.com/Resource/Title/0826102549

Thriving in a value-based health care model - Biotricity

As an ardent supporter of the Patient Protection and Affordable Care Act (ACA) who campaigned on offering a public insurance option similar to Medicare, many in the healthcare industry assumed that the Biden Administration would be a strong proponent of continuing the shift to value-based care, which shift was largely spurred by his predecessor and former boss, Barack Obama, with the passage of the ACA. (Read more…)

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PODCAST: Medicare Hospital Re-Admission Penalties

EXPLAINED!

BY ERIC BRICKER MD

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CITE: https://www.r2library.com/Resource/Title/0826102549

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COVID-19 UPDATE: Vaccine Booster Shots

BY MEDICARE TEAM

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Important update on COVID-19 vaccine booster shots
If you previously got 2 doses of the Pfizer-BioNTech COVID-19 vaccine, you can get a booster shot of the Pfizer-BioNTech COVID-19 vaccine if you fall into one of these groups:

You’re 65 and older,You’re 18+ and have certain underlying medical conditions, or
You’re 18+ and work or live in a high-risk setting.

You can get your booster shot at least 6 months after you complete your second dose of the Pfizer vaccine.
The booster shot can help strengthen and prolong your protection against COVID-19.

Learn More: Visit CDC.gov for more information on other groups already vaccinated with the Pfizer vaccine that may be eligible for a booster shot.

Remember: Medicare covers a Pfizer vaccine booster shot at no cost to you.

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Oregon says it's ready to provide COVID-19 booster shots to those eligible,  but asks for patience - KTVZ

Sincerely,
The Medicare Team
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PODCAST: APPEALS of Medicare Advantage [Part C] Plans

BY CMS

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PODCAST: Medicare Financial Matters

WHAT COUNTS AS INCOME SOURCES?

BY CMS

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CITE: https://www.r2library.com/Resource/Title/0826102549

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors : Best Practices from Leading Consultants and Certified Medical Planners™ book cover

RISK MANAGEMENT: https://www.routledge.com/Risk-Management-Liability-Insurance-and-Asset-Protection-Strategies-for/Marcinko-Hetico/p/book/9781498725989

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

FINANCIAL PLANNING: https://www.routledge.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

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PODCAST: Why Insurance Carriers Want MEDICARE-FOR-ALL

WHY M-4-A?

BY ERIC BRICKER MD

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CITE: https://www.r2library.com/Resource/Title/0826102549

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CMS Releases 2022 Physician Fee Schedule Proposed Rule

CMS RELEASES CY 2022 Physician Fee Schedule Proposed Rule


On July 13, 2021, the Centers for Medicare & Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2022.

CITE: https://www.r2library.com/Resource/Title/0826102549

In addition to numerous payment updates in the MPFS, such as significant updates to the Merit-based Incentive Payment System (MIPS), new policies may preserve expanded telemedicine services through 2023 and clinicians may incur more difficulty earning bonuses under the Quality Payment Program (QPP) eligibility threshold. CMS also includes in the proposed rule a request for information to address COVID-19 vaccine reimbursement proposals. (Read more...)

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CMS Includes Changes in CY 2022 OPPS Proposed Rule

BY HEALTH CAPITAL CONSULTANTS, LLC

CMS Includes Several Changes in CY 2022 OPPS Proposed Rule


On July 19, 2021, CMS released the proposed rule for the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Centers (ASCs) for calendar year (CY) 2022. The proposed rule builds on President Joe Biden’s July 9, 2021 executive order on “Promoting Competition in the American Economy,” as it relates to increasing access and price transparency in the healthcare industry.

Outpatient Prospective Payment System (OPPS) Project. Understanding  Ambulatory Payment Classification (APC) - PDF Free Download

CITE: https://www.r2library.com/Resource/Title/0826102549

In a press release regarding the proposed rule, CMS stated their commitment to addressing the persistent health inequities in the U.S. and finding opportunities to improve data collection that will lead to policy changes to help meet the health needs of patients. (Read more…)

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CMS: Open Payment Data

OPEN PAYMENTS DATA SEARCH TOOL

By Dr. David Edward Marcinko MBA

The Open Payments Search Tool is used to search payments made by drug and medical device companies to physicians and teaching hospitals.

CMS releases star ratings; nearly 10% of hospitals earn ...

WEBSITE: https://openpaymentsdata.cms.gov/

INVITE DR. MARCINKO: https://medicalexecutivepost.com/dr-david-marcinkos-

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The Integrated Patient-Centered Medical Home Model

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Tools for Transforming Our Healthcare

By Matias A. Klein

[VP, General Manager, Clinical Quality and Collaboration, Portico Systems]

The patient-centered medical home (PCMH) continues to attract increasing attention from many industry stakeholders. The PCMH model has the potential to enhance the US healthcare system by rejuvenating primary care in a way that improves clinical outcomes, lowers costs, promotes wellness, and increases patient and physician satisfaction.

PCMH Pilot Programs

PCMH pilots are currently being tested in almost all states, including a 3-year Medicare medical home demonstration project overseen by the Centers for Medicare & Medicaid Services. However, few organizations have scaled the PCMH across their entire healthcare network, and the existing implementations appear to remain focused on care management at the expense of patient wellness. The value of focusing equally on promoting wellness (although an underappreciated nuance in the implementation of a PCMH) is a critical factor in effectively leveraging the PCMH model to improve clinical outcomes and the US healthcare system.

Centered on the Patient

The PCMH model, as its name suggests, is centered on the patient. The underlying thought is that if a comprehensive, longitudinal view of a patient is taken throughout a patient’s lifespan, the patient’s health could be better “managed” and better aligned with best medical practices. It is well documented that physicians do not consistently or frequently apply evidence based, recommended care to patients. Therefore, a major goal of the PCMH model is to improve the consistent application of evidence-based guidelines and best practices, by making longitudinal information about the patient available to providers and to patients – including any risks and recommended “intervention opportunities.” And although adherence to best practices in disease management is crucial, the PCMH model also focuses on preventing costly episodes by promoting and incentivizing wellness.

PCPs = Medical Homes

To effectively manage a patient’s health and promote wellness, primary care physicians – designated as medical homes – need to act as health “quarterbacks” or “coaches.” In such a role, these physicians will assist in aggregating a patient’s health information, making best practices transparent, offering health education and counseling, as well as coordinating the provisioning of any healthcare services the patient may need. With physicians spending significant time coaching and making critical clinical decisions, these services will be delivered with the support of care management nurses, who will handle the majority of the information processing and operational activity.

An Innovation in Care

The PCMH model is an important innovation in care delivery and has the potential to reduce medical and administrative costs, while improving the quality of care. However, how to implement the PCMH model within a care-delivery system remains unclear. Providers need the requisite infrastructure and capabilities at their locations to meaningfully participate in a PCMH. Patients must be engaged over long periods of time in proactively managing and improving their health. Outcomes and quality must be objectively measured to optimize the delivery of best possible patient care.

Potential Value

To realize the potential value of the PCMH, three distinct stakeholders – patients, providers, and health plans – must work in a collaborative way. Getting these stakeholders synchronized (i.e., aligned in their goals, using interoperable tools, and collaborating on an operational level) is no small feat but can be accomplished with the smart application of technology. Bringing these three stakeholder groups together on a common, collaborative technology platform results in what some are beginning to call the integrated PCMH. The integrated approach to the PCMH can best ensure that implementing a PCMH model does not create additional administrative burdens to health plans or provider organizations.

An integrated PCMH provides a framework for stakeholders to collaborate in a transparent fashion, and where quality, best practices, and outcomes are incentivized. The integrated PCMH also provides a pathway being awarded a medical home designation.

Vertical Integration Deployment

The key to deploying an integrated PCMH is an end-to-end vertical integration of the care-delivery process – that is, a process in which the provider network management, automation, information exchange, and analytics solutions are tightly integrated with patient and provider information. With so much complexity and so many “moving parts” in the delivery of the PCMH model, this end-to-end vertical integration is a practical solution that enables effective coordination of care and accurate measurement of quality: with such system integration, the provider network (e.g., the health plan) can bring economies of scale to even the smallest provider offices to optimize the quality of care delivery.

The 5 Keys

The five key components for such an integrated PCMH are:

  1. A source-of-truth for mapping medical home – designated providers, patients, as well as  the associated relationships with health plans and other medical professionals; a central medical home fact checking is critical for effectively identifying, managing, and communicating with medical home and their networks.
  2. A set of collaborative workflows that align stakeholders with best practices, incentives, and quality measures reporting; these collaborative workflows help each stakeholder understand where a given patient is in the care-delivery process, potential intervention opportunities, why certain interventions are being emphasized, and what incentives are available for executing specific interventions.
  3. An infrastructure for clinical integration and distribution of intervention opportunities, clinical reference content, education, alerts, and reminders. This infrastructure allows all stakeholders to have access to up-to-date, accurate patient information; it aligns stakeholders and helps reduce or eliminate duplication of procedures and tests.
  4. Interoperable clinical applications and collaboration tools to enable patients and physicians to engage in medical home processes; these tools – which include electronic medical records, e-prescribing, e-labs, secure e-mail, personal health records, and document management and exchange technology – can help manage health information, assist with decision-making, and improve communication between patients, providers, and health plans.
  5. Incentive management and analytics tools for modeling, setting, measuring, and rewarding incentives based on quality measures and outcomes; these tools must span the entire PCMH delivery process and are required for objectively evaluating and optimizing the performance of a medical home.

When considering the multiplicity of stakeholders, information, software systems, and knowledge that has to be coordinated in the context of a PCMH model, implementing a medical home pilot and scaling it to a full-blown network may seem a daunting task. The integrated PCMH offers a real-world solution for deploying a scalable and flexible infrastructure for the management of this emerging care-delivery model.

Assessment

Early evaluations of the PCMH model show promising, albeit inconclusive, outcomes. The integrated PCMH model offers a practical road map for deploying a management system that will enable objective measurement of PCMH performance and outcomes.

Conclusion

Although the jury is still out on the ultimate value of the PCMH, deploying an integrated PCMH system can help position PCMH pilots in a way that enhances their flexibility and scalability to support full-scale network transformation.

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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The Medicare Cost Control Paradox

WHAT IS THE “MEDICARE COST CONTROL EFFICIENCY” PARADOX?

The 800 Pound Gorilla in the Medical Treatment Room

Blogger Ezra Klein opined more than a decade ago that one of the dirty little secrets of the health-care system is that Medicare has done a much better job controlling costs than private health insurers. It is a paradox!

DEFINITION: A paradox is a seemingly absurd or self-contradictory statement or proposition that when investigated may prove to be well founded or true.

QUERY: But, what about Medicare, cost control efficiency, today?

Medicare Will Not Cover These 6 Medical Costs

LINK: https://www.msn.com/en-us/money/insurance/medicare-will-not-cover-these-6-medical-costs/vi-BB1g6Oes

Your thoughts are appreciated.

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***

CMS Reimbursement Reductions

CMS Reimbursement Reductions 2021

By staff reporters

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 MORE:

Anesthesiology, -21 percent
Physician assistant, -21 percent
General surgery, -20 percent
Cardiology, -19 percent

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Value Based Insurance Design?

VBID – Epic Fail

By Staff reporters***

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2021 Prescription Drug Payment Model from HHS

Administration Announces Prescription Drug Payment Model
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By staff reporters
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HHS Secretary Alex Azar has announced a drug payment model through the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services that will lower Medicare Part B payments for certain drugs to the lowest price for similar countries and save American taxpayers and beneficiaries more than $85 billion over seven years.
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Starting in January, the model, known as the Most Favored Nation (MFN) Model, will test an innovative way for Medicare to pay no more for high cost, physician-administered Medicare Part B drugs than the lowest price charged in other similar countries.
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Following the President’s recent Executive Orders to lower drug prices and improve access to life-saving medications, the MFN Model will protect current beneficiary access to Medicare Part B drugs, make them more affordable, and address the disparity of drug costs between the U.S. and other countries.
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Source: CMS [11/20/20]

Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC)

CMS Includes Several Changes in OPPS Proposed Rule

By Health Capital Consultants, LLC

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On August 4, 2020, CMS released the latest in a series of recently-published proposed rules, the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule for fiscal year (FY) 2021.

This proposed rule builds upon executive orders such as “Protecting and Improving Medicare for Our Nation’s Seniors,” signed by President Trump in October 2019 and Trump Administration initiatives such as “Patients Over Paperwork.” In a press release, CMS highlighted the proposed rule’s focus on increasing competition among providers to give patients more choice, lowering out-of-pocket surgery costs, increasing provider flexibility, and allowing patients to make more informed decisions about their care. (Read more…) 

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2021 Physician Fee Schedule

2021 Physician Fee Schedule & Quality Payment Program Proposed Rules Released

[By Health Capital Consultants]

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On August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) released two proposed payment rules for calendar year (CY) 2021: the Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP). CMS included in the MPFS proposed rule adjustments to physician payment rates and an expansion of telemedicine services.

The proposed QPP rule, meanwhile, takes into account adjustments made for the COVID-19 public health emergency (PHE) and seeks to reduce unnecessary regulatory burden on providers by eliminating some requirements. These rules, which have garnered mixed reactions from stakeholders, are both open for comment until October 5, 2020. (Read more…)

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CMS Value Based Purchasing for Drugs

CMS Proposed Rule Supports Value-Based Purchasing for Drugs

Courtesy: www.CertifiedMedicalPlanner.org

On June 19, 2020 the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule regarding Medicaid Drug Rebate Program (MDRP) regulations, with the aim of lowering drug prices, increasing patient access, and encouraging innovation in the insurance and pharmaceutical industries.

This proposal is consistent with the Trump Administration’s Blueprint to Lower Drug Prices (Blueprint) released in May 2018, in which the administration highlighted its goal to “avoid excessive pricing by relying more on value-based pricing by expanding outcome-based payments in Medicare and Medicaid” and to “speed access to and lower the cost of new drugs by clarifying policies for sharing information between insurers and drug makers.”

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The proposed rule seeks to accomplish the Blueprint’s goals by reducing regulatory barriers that have previously prevented commercial plans and states from entering into value-based purchasing (VBP) arrangements with drug manufacturers.

Colleagues from Health Capital Consultants, LLC; explain.

ESSAY: DRUGS

Assessment: Your thoughts and comments are appreciated.

BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:

1 – https://lnkd.in/ebWtzGg

2 – https://lnkd.in/ezkQMfR

3 – https://lnkd.in/ewJPTJs

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Centers for Medicare & Medicaid Services (CMS) finalized the calendar year (CY) 2019 Medicare Physician Fee Schedule (MPFS), the Hospital Outpatient Prospective Payment System (OPPS), and the Ambulatory Surgical Center (ASC) Payment System

CMS Finalizes 2019 Physician & Outpatient Fee Schedules

By TODD A. ZIGRANG

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In the course of twenty-four hours, the Centers for Medicare & Medicaid Services (CMS) finalized the calendar year (CY) 2019 Medicare Physician Fee Schedule (MPFS), the Hospital Outpatient Prospective Payment System (OPPS), and the Ambulatory Surgical Center (ASC) Payment System. The finalized rules generally remained unchanged from their proposed versions, with a couple of exceptions. Each finalized rule is reviewed briefly in this special edition of the Health Capital Topics e-journal. (Read more…) 

https://www.healthcapital.com/hcc/newsletter/11.2.18_Alert/HTML/CMS/convert_hc_topics_alert_mpfs_opps_11.2.18.php

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Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

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Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

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Product DetailsProduct Details

On Hospital Price Growth

Explosion in Spending – Inflation Since 1960

By CMS

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[Click to Enlarge]

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The greatest wealth transfer in American history has been from the working/middle class to a wasteful healthcare system.

Sadly, once-mission-based hospitals lost their way failing to address healthcare caused 20 yr long economic depression for working/middle class. Employers spending far more on employees than 20 years ago but all of it has gone to healthcare with no demonstrable outcomes improvement

-Dave Chase [Creator HealthRosetta]

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Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements.

Book Marcinko: https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Subscribe: MEDICAL EXECUTIVE POST for curated news, essays, opinions and analysis from the public health, economics, finance, marketing, IT, business and policy management ecosystem.

DOCTORS:

“Insurance & Risk Management Strategies for Doctors” https://tinyurl.com/ydx9kd93

“Fiduciary Financial Planning for Physicians” https://tinyurl.com/y7f5pnox

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

HOSPITALS:

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

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Product DetailsProduct Details

CMS Seeks Comments on Medicare “DPC Model”

CMS Seeks Comments on Medicare “DPC Model”

“The Direct Primary Care (DPC) model is burgeoning as patients yearn for quality time with their doctor at an affordable price,” writes Marilyn Singleton, MD, JD in a recent oped.

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https://mailchi.mp/aapsonline/cms-dpc-model

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. https://medicalexecutivepost.com/dr-david-marcinkos-bookings/

Contact: MarcinkoAdvisors@msn.com

Product DetailsProduct Details

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A MIPS: Quality Payment Program Report

Percentage Clinicians Might Lose for Failure to Report

By CMS

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Conclusion

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States with the Worst Medicare Waste?

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By http://www.MCOL.com

The Federal Government

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graphoid020117

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Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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A Small Step Forward on Surprise Medical Care “Balance-Billing”

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By @nicholas_bagley

The ME-P Back Story about a Decade Ago:

Link: https://medicalexecutivepost.com/2008/09/17/balance-billing-conundrum/

More on out of network Balance Billing a year ago and … today?

Per a rule released last year, CMS will now require qualified health plans to count the cost sharing paid by the enrollee for an essential health benefit. But, what about today?

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 A small step forward on surprise billing

Assessment

We’ve written about this problem before on the ME-P; and we now appreciate this guest ME-P update.

More: Balance-Billing Conundrum

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Tom Price for HHS Secretary & Seema Verma for CMMS

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Obamacare critic for HHS 

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112_price_ga06

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Trump nominates Rep. Tom Price for HHS secretary

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th

Trump picks Seema Verma to head Centers for Medicare and Medicaid Services

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Product DetailsProduct Details

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A MACRA Info-Graphic by CMS

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By CMS

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macra

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6 Key Takeaways from MACRA Final Rule

  1. Flexibilities provided in the first transition year may continue in 2018.
  2. During the first year of MIPS, providers will not be evaluated on cost or resource use.
  3. Despite flexibilities allowed under the final rule, it is in providers’ best interest to participate as much as possible during the transition year — and not just for the practice.
  4. Quality measure benchmarks will be published this year.
  5. Vendors need to prepare, too.
  6. Small group providers and solo physicians could get squeezed out.

Source: Becker’s Hospital Review

Conclusion

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Find Your Doctor’s Payments

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FBF300BA-321A-49FD-9289-0DE0AD63DCE5

 CMS’ Open Payments Program Posts 2015 Financial Data

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 The Centers for Medicare & Medicaid Services (CMS) has published the 2015 Open Payments (sometimes called the “Sunshine Act”) data, along with newly submitted and updated payment records for 2013 and 2014, at https://openpaymentsdata.cms.gov.
The Open Payments program requires that transfers of value by drug, device, biological, and medical supply manufacturers to physicians and teaching hospitals be published on a public website.
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physician investors

Portrait of two surgeons in a operating room viewing paper charts.

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Assessment
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In program year 2015, healthcare industry manufacturers reported $7.52 billion in payments and ownership and investment interests to physicians and teaching hospitals. This amount is comprised of 11.90 million total records attributable to 618,931 physicians and 1,116 teaching hospitals. To find out what any doctor received in 2015, click here.
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Conclusion
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CMS Announces New Random Payment Generator

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Center for Medicare & Medicaid Innovation

By CMS and CMMI

CMS JUST ANNOUNCED a new Innovation Model from the Center for Medicare & Medicaid Innovation, the Random Payment Generator, which will launch as a demonstration in January 2017.

“We’re pleased to add an eighth category of Innovation Models to our innovation portfolio,”

says CMMI spokesperson Dr. Emmett Brown.

“We felt that with the wide range of models developed to date, we needed to develop a ‘placebo’ initiative that could be measured against the various concepts we have been testing. We’ll be able to better determine if simply taking random actions while facing the formidable challenges in purchasing and coordinating healthcare services yields any different results than the complex models we have undertaken.”

The Random Payment Generator will simply randomize payment amounts to be paid for billed services, based on an algorithm that has programmed into repurposed surplus portable equipment being distributed to Medicare Administrative Contractors. Doctor Brown explained that the older equipment has no Internet connectivity and thus is not susceptible to breaches from outside hackers.

CMS is seeking hospital and medical group applicants to participate in the one-year Medicare trial in which they may render services and submit billings without being subject to most provider program requirements, but will accept whatever payment amount is assigned by the Random Payment Generator as payment in full.

“A number of provider participants in our other models have complained that they can’t understand or find any logic in how they are getting paid, and the basis for payment under this new model will certainly be easier to communicate and understand,”

Doctor Brown continued.

***

ImageProxy

[A Random Payment Generator being shipped to Medicare Administrative Contractors]

Conclusion

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EHR Meaningful Use Rules Finalized

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The CMS Modifications

[By staff reporters]

Source: Joseph Goedert, Health Data Management [10/7/15]
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Centers for Medicare and Medicaid Services
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The Centers for Medicare and Medicaid Services has issued a 752-page final rule covering three components of the electronic health records meaningful use program. The rule finalizes modifications to Stages 1 and 2; the 2015 edition of electronic health records certification criteria; and Stage 3 of meaningful use.
Modifications
Under the modifications to Stages 1 and 2, eligible professionals have 10 meaningful use objectives, down from 18 previously. In Stage 3, there are 8 objectives for eligible professionals and hospitals, and more than 60 percent of measures require interoperability.
Assessment
The entire rule is available here.
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MD with eHR
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Conclusion
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Medical Provider Billing Facts for 2014

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A Look at Medicare Spending

By http://www.MCOL.com

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billing

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Conclusion

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[HOSPITAL OPERATIONS, ORGANIZATIONAL BEHAVIOR AND FINANCIAL MANAGEMENT COMPANION TEXTBOOK SET]

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***

Understanding “Meaningful Use” Attestation Numbers for 2014

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Providers versus Hospitals

By CMS

ME121014_PAGE_16

Assessment

So, what do the hospitals know –  that the doctors do not?

Channel Surfing the ME-P

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Conclusion

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On Hospital 30 Day Re-Admission Rates

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And … Problems Paying Medical Bills for 2011

By http://www.MOCL.com

ImageProxy

Conclusion

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National Health Expenditure Growth

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A Report from the Office of the Actuary

Source: Centers for Medicare & Medicaid Services

According to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary, overall national health expenditures grew at an annual rate of 3.7 percent in 2012, marking the fourth consecutive year of low growth. Health spending as a share of gross domestic product fell slightly from 17.3 percent in 2011 to 17.2 percent in 2012.

Private Insurance

Private health insurance spending growth remained low. Private health insurance spending continued to grow at a low rate, increasing 3.2 percent in 2012 compared to 3.4 percent growth in 2011. Medicare spending growth continued to be low. Despite a large uptick in Medicare enrollment, Medicare spending growth slowed slightly in 2012, increasing by 4.8 percent compared to 5.0 percent growth in 2011.

The Totals for MC/MD

Total Medicare spending per enrollee grew by only 0.7 percent in 2012. Medicaid spending continued to grow at a historically low rate. Total Medicaid spending grew 3.3 percent in 2012. While an increase over 2011, this increase still represents historically low overall growth rates tied to improved economic conditions, as well as efforts by states to control costs.

Rx Drugs

Prescription drug spending growth was low. Retail prescription drug spending slowed in 2012, growing only 0.4 percent as the result of numerous drugs losing their patent protection, leading to increased sales of lower-cost generics. Nursing home spending growth slowed.

Pharma

Assessment

Spending for freestanding nursing care facilities and continuing care retirement communities increased by only 1.6 percent in 2012, down from 4.3 percent growth in 2011, due to a one-time Medicare rate adjustment for skilled nursing facilities.

Conclusion

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Hospital Information Systems and the PP-ACA

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Extension of Hospital Information Systems Beyond the Hospital

By Brent A. Metfessel MD

Dr. MetfesselThe Patient Protection and Affordable Care Act (ACA), affirmed after the November 7th 2012 presidential election, includes a number of policies and potential projects with the aim of improving quality of care while reducing costs – or at least greatly slowing increases in health care costs from year to year.

Included in this effort are CMS payment incentives for providers that can show care patterns that meet the goals of high quality, cost-efficient care.

HHS and ACOs 

On March 31, 2011, the Department of Health and Human Services (HHS) released a set of proposed new rules to aid clinicians, hospitals, and other health facilities and providers to improve coordination of care for Medicare patients using a model known as Accountable Care Organizations (ACOs). ACOs that are shown to lower health care cost growth while meeting CMS quality benchmarks, including measures of patient/caregiver experience of care, care coordination, patient safety, preventive health, and health of high-risk populations, will receive incentive payments as part of the Medicare Shared Savings Program.

But, in some proposed models ACOs may also be held accountable for shared losses.

Care Co-ordination

Coordination of care means that hospitals, physician offices, and other providers have a complete record of patients’ episodes of care, including diagnostic tests, procedures, and medication information.  This potentially would decrease extra costs from unnecessary duplication of services as well as reducing medical errors from incomplete understanding of the patients’ illness histories and medical care provided.

It is also believed that better coordination of care may prevent 30-day hospital readmissions (which occur for nearly one in five Medicare discharges), since needed post-discharge care would be more readily obtainable with more aggressive care coordination.

Medicare patients in ACOs, however, would still be allowed to see providers outside of the ACO, and proposals exist to prevent physicians in ACOs from being penalized for patients with a greater illness severity or complexity.

According to a CMS analysis, ACOs may result in Medicare savings of up to $960 million over three years.  Although the Affordable Care Act’s ACO provisions primarily target Medicare beneficiaries, private insurers are also beginning to create care models based on the accountable care paradigm.  Insurers could offer similar incentives to the ACO model described above, and which might include features such as performance based contracting or tiered benefit models that favor physicians who score highly on care quality and cost-efficiency measures.

Balance

Only the Beginning

ACOs and other implementations of the accountable care paradigm, however, are in their beginning stages, with a number of pilots around the country currently being conducted to more fully evaluate the concept, and there still is some controversy over the best way to achieve these goals. It is a continuing balancing act.

The critical point here is that in all likelihood, with the advent of the ACA and other initiatives, stemming the upward tide of medical cost increases becomes an even higher priority, and no matter what the final models will look like, the success of any of the models requires a high level of care coordination – requiring information systems that are fully compatible and allow seamless and errorless transmission of information between sites of service and the various providers that can be involved in patient care.

More:

  1. Ground Breaking Book Explains Why Accountable Care Organizations May Be the Answer the Health Care Industry Has Been Seeking!
  2. Evaluating ACOs at Mid-Launch
  3. How Using a ‘Scorecard’ Can Smooth Your Hospital’s Transition to a Population Health-Based Reimbursement Model
  4. Doubting the Accountable Care Organization B-Model

Assessment

Thus, wherever a patient goes for care, all the information needed to provide high-quality and cost-efficient care is immediately available.

References

Feds Take Critical Look at Meaningful Use Payments”, InformationWeek Healthcare, October 24, 2012.  http://www.informationweek.com/healthcare/policy/feds-take-critical-look-at-meaningful-us/240009661 [Accessed on November 2, 2012].

Conclusion

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Doubting the Accountable Care Organization B-Model

New Healthcare Business Model or Edsel Model?

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By David Edward Marcinko MBA http://www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Dr. Marcinko with ME-P FansDefined by Professor Michael Porter at Harvard Business School, value is defined as a function of outcomes and costs. Therefore to achieve high value we must deliver the best possible outcomes in the most efficient way, outcomes which matter from the perspective of the individual receiving healthcare and not provider process measures or targets.

Sir Muir Gray expanded on the idea of technical value (outcomes/costs) to specifically describe ‘personal value’ and ‘allocative value’, encouraging us to focus also on shared decision making, individual preferences for care and ensuring that resources are allocated for maximum value.

Healthcare Value and ACOs

According to our Medical Executive-Post Health Dictionary Series of administrative terms http://www.HealthDictionarySeries.org  and health economist and colleague Robert James Cimasi MHA, ASA, AVA CMP™ of www.HealthCapital.com; an ACO is a healthcare organization in which a set of providers, usually large physician groups and hospitals, are held accountable for the cost and quality of care delivered to a specific local population.

ACOs aim to affect provider’s patient expenditures and outcomes by integrating clinical and administrative departments to coordinate care and share financial risk.

ACO Launch

Since their four-page introduction in the PP-ACA of 2010, ACOs have been implemented in both the Federal and commercial healthcare markets, with 32 Pioneer ACOs selected (on December 19, 2011), 116 Federal applications accepted (on April 10, 2012 and July 9, 2012), and at least 160 or more Commercial ACOs in existence today.

Federal Contracts

Federal ACO contracts are established between an ACO and CMS, and are regulated under the CMS Medicare Shared Savings Program (MSSP) Final Rule, published November 2, 2011.  ACOs participating in the MSSP are accountable for the health outcomes, represented by 33 quality metrics, and Medicare beneficiary expenditures of a prospectively assigned population of Medicare beneficiaries.

If a Federal ACO achieves Medicare beneficiary expenditures below a CMS established benchmark (and meets quality targets), they are eligible to receive a portion of the achieved Medicare beneficiary expenditure savings, in the form of a shared savings payment.

Commercial Contracts

Commercial ACO contracts are not limited by any specific legislation, only by the contract between the ACO and a commercial payor.

In addition to shared savings models, Commercial ACOs may incentivize lower costs and improved patient outcomes through reimbursement models that share risk between the payor and the providers, i.e., pay for performance compensation arrangements and/or partial to full capitation.

Although commercial ACOs experience a greater degree of flexibility in their structure and reimbursement, the principals for success for both Federal ACOs and Commercial ACOs are similar.

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Eidsel

Dr. David E. Marcinko with 1960 Ford Edsel

[© iMBA, Inc. All rights reserved, USA.]

[The Edsel was an automobile marque that was planned, developed, and manufactured by the Ford Motor Company during the 1958, 1959, and 1960 model years. With the Edsel, Ford had expected to make significant inroads into the market share of both General Motors and Chrysler and close the gap between itself and GM in the domestic American automotive market. But, contrary to Ford’s internal plans and projections, the Edsel never gained popularity with contemporary American car buyers and sold poorly. The Ford Motor Company lost millions of dollars on the Edsel’s development, manufacturing and marketing].

More:

 

Update

Junking the Merit-Based Incentive Payment System (MIPS) would undoubtedly let the proverbial air out of the MACRA balloon, dealing a significant blow to the value-based reimbursement shift; right?

Assessment

Although nearly any healthcare enterprise can integrate and become an ACO, larger enterprises, may be best suited for ACO status.

Larger organizations are more able to accommodate the significant capital requirements of ACO development, implementation, and operation (e.g., healthcare information technology), and sustain the sufficient number of beneficiaries to have a significant impact on quality and cost metrics.

Conclusion

But, will this new B-Model work? Isn’t leading doctors in a shared collaborative effort a bit like herding cats? And, what about patients, HIEs, outcomes management, data analytics and … Population Health via our colleague David B. Nash MD MBA of Thomas Jefferson University, often considered the “father” of Pop Health?

OR, what about the developing IRS scandal and full PP-ACA launch in 2014? Will it affect federal funding, full roll-out, or even repeal of the entire Act?

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A Financial eMR “Got-Ya” from Uncle Sam?

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CMS and the Feds Want to Verify Docs eMR Info Before Meaningful Use Payment

By ME-P Staff Reporters

The conversion to electronic medical records [eMRs] is “vulnerable” to fraud and abuse because of the failure of Medicare and CMS officials to develop appropriate safeguards, according to a sharply critical report just issued by federal investigators.

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[mobile eMR in clincal use]

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Full Report: https://oig.hhs.gov/oei/reports/oei-05-11-00250.pdf

Assessment

Requiring an audit before paying hospitals and doctors could  significantly delay payments to providers.

Ya think!

Conclusion

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What Does a PQRS Really Measure?

And, What Does a PQRSMeasure Group Look Like?

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[By Staff Reporters]

At a basic level, a Physician Quality Reporting System [PQRS] is a program that pays medical providers for reporting outcomes on quality outcomes metrics for Medicare Part B patients.

Primary care and specialty care providers of all kinds can participate by selecting outcomes measures that are pertinent to their fields. There is something for most every specialty, even pathology and radiology.

For example, you may choose from a menu of outcome measures and pick those measures you want, or you can report on a predetermined group of measures that focus on a specific condition or situation, such as diabetes or perioperative care.

The CMS Document

According to the 655 page 2012 Physician Quality Reporting System Measure Specifications Manual for Claims and Registry Reporting of Individual Measures produced by CMS, here are some high-level descriptions of individual measures.

Assessment

Conclusion

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More on “Meaningful Use” Requirements

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And  …  Its’ Impact on eHRs

Carol Miller RN MBA millerconsultgroup@gmail.com

The American Recovery and Reinvestment Act of 2009introduced the “Meaningful Use” requirement for EHR systems with three main components:

The Components

1) The use of a certified EHR in a meaningful manner, such as e-prescribing, 2) The use of a certified EHR technology for electronic exchange of health information to improve quality of health care, and 3) The use of a certified EHR technology to submit clinical quality and other measures.

Meaningful Use refers to a set of 15 criteria that medical providers must meet in order to prove that they are using their EHRs as an effective tool in their practice.  There are also 10 additional criteria that are considered a la carte from which only 5 need to be demonstrated by the medical provider.

In total, 20 Meaningful Use criteria must be used within the EHR to qualify for stimulus payments during Stage One of the EHR incentive program.   Each of the criteria were developed and further reviewed by the Office of the National Coordinator [ONC] with public input.

A Five Year TimeLine

Meaningful use will be measured in stages over five years.  Each stage represents a level of adoption.  Many certified EHRS will allow providers to complete all Meaningful Use criteria, whereas others will only certify what is required in the early stages and modify at a later date with any new criteria.

The three stages are:

Stage One:  Essentially, Stage One is using the major functionality of a certified EHR.  This includes documenting set percentages of your visits, diagnoses, prescriptions, immunizations and other relevant health information electronically; using the clinical support tools (warnings and reminders that will be included in a certified EHR); and sharing patient information.  Providers and hospitals must report quality measures and public health information. For providers they must report on 6 clinical quality measures – 3 required core measures and 3 additional measures selected from a set of 38 clinical quality measures.  Eligible hospitals and Critical Care Hospitals (CAHs) must report on all 15 of the clinical quality measures.  Stage One is required in years 2011 and 2012.

Stage Two:  In addition to continuing to use all functionality from Stage One, physicians will be required to use EHRs to send and receive information such as lab orders and results.   Other criteria may be added.  Stage Two is expected to be implemented in 2013.

Stage Three:  This stage will continue fulfilling the criteria from Stages One and Two and will include clinical decisions support for national high priority conditions; emailing patients in a Personal Health Record (PHR); accessing comprehensive patient data; and improving population health.  Stage Three criteria have not been developed to date and the implementation is not expected until 2015.

Assessment

CMS payment penalties for non-compliance to the meaningful use regulations will begin in 2016 with an initial 1% penalty which could escalate to 5% five years later.  Therefore, with these criteria in place, we are likely to see virtually all hospitals attempt to meet the meaningful use criteria to avoid penalty cost.

Conclusion

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Case Model Illustration of a Six Sigma Healthcare Pioneer

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The Mount Carmel Health System

By Mark Matthews MD

A “Scrubbed” True Illustration

One of the earliest healthcare adopters of Six Sigma was the Mount Carmel Health System in Columbus, Ohio.

The organization was barely breaking even in the summer of 2000 when competition from surrounding providers made things worse. Employee layoffs added fuel to an already all-time low employee morale.

The CEO

Chief Executive Officer Joe Calvaruso was determined to stem the bleeding, break the cycle of poor financial performance and return the hospital system to profitability.  He sought the potential benefits of Six Sigma and began a full deployment of its methodology. The plan was a bold move, as the organization ensured that no one would be terminated as a result of a Six Sigma project having eliminated his or her previous duties. These employees would be offered an alternative position in a different department. Moreover, top personnel were asked to leave their current positions to be trained and work full time as Six Sigma expert practitioners who would oversee project deployment while their positions were backfilled.

Assessment

The Six Sigma deployment was the right decision. More than 50 projects were initiated with significant success. An example of an early Mount Carmel success story is the dramatic improvement in their Medicare + Choice product reimbursements, previously written off as uncollectible accounts. These accounts were often denied by HCFA due to coding of those patients as “working aged.”

Since the treatment process status often changed in these patients, HCFA often rejected claims or lessened reimbursement amounts, effectively making coding a difficult and elusive problem. The employment of the Six Sigma process fixed the problem, resulting in a real gain of $857,000 to the organization. The spillover of this methodology to other coding parameters also has dramatically boosted revenue collection.

A Glimpse of Lean Medical Management Tools and Techniques

Conclusion

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Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Hospitals: http://www.crcpress.com/product/isbn/9781439879900

Physician Advisors: www.CertifiedMedicalPlanner.org

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