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A TURNING POINT FOR MEDICARE PAYMENTS

In an exciting move, the Centers for Medicare and Medicaid Services (CMS) and the Innovation Center announced five new payment models collectively titled the “CMS Primary Cares Initiative.” We see these as a strong improvement to the variety of organizations which can participate in value-based payment models for Medicare. “We recognize that the road to value must have as many lanes as possible,” said CMS Administrator Seema Verma, and these new options clearly reflect the center’s commitment to offering a wide variety of payment models.

These new models add variety to the menu of existing payment arrangements such as Bundled Payments for Care Improvement Advanced (BPCIA) and Medicare Shared Savings Program (MSSP) ACOs. Now organizations of all sizes and provider types will be able to find the best fit for their unique situation. Healthcare leaders are asking themselves many questions when evaluating these new options.

  • Which model will ensure continued sustainability?

  • Which model best suits business needs and imperatives from governance?

  • Which model will best meet the needs of Medicare beneficiaries by improving their health outcomes and providing better access to care at the right place and time?

Carinal Consulting Group has decades of experience with payer strategy, including evaluating various options for contracting with Medicare. Our team works closely with healthcare leaders, offering expert counsel to choose the best-fit option. We understand the pressures facing providers of all kinds: from solo independent practices to regional integrated delivery systems. And it’s our job to cut through the complexity with clear, data-driven recommendations that fit our clients needs and help them meet their strategic, financial and quality goals.

To get started, our team wrote out some key considerations for different healthcare organizations. Check out the sections below and don’t hesitate to reach out to discuss your organization.

This initiative will radically elevate the importance of primary care in American medicine
— Alex Azar, U.S. Health and Human Services Secretary

ABOUT US

The team at Cardinal Consulting Group has decades of experience solving complex business problems across the healthcare industry. We take pride in our highly tailored methodology, which starts with fully understanding the business realities and real-world obstacles facing today’s healthcare leaders. Click below to learn more about our firm.

 

PHYSICIANS AND GROUP PRACTICES

Individual practices and medical groups have new options to engage with Medicare. Primary Care First (PCF) is a model which will be offered in 22 regions nationwide. PCF aims to embed the tenets of enhanced primary care into Medicare payments to achieve the Triple Aim of increased quality and patient experience while managing expenditures.

This model might be a fit if you:

  1. Value your independence and delivering high quality primary care

  2. Understand and employ best practices to manage chronic diseases before patients require acute care

  3. Use care management and/or care coordination functions

  4. Experience with population health analytics tools to make informed decisions regarding patient care

  5. Have a focus on primary care, with at least 70% of practice’s billing revenue from primary care services

  6. Want to reduce administrative burden to focus on patient care

Primary Care First - High Needs Population is a model with much in common with PCF but is primarily focused specifically on organizations serving high needs groups. This model fits if you:

  1. Specialize in working with patients with chronic or complex needs

  2. Desire autonomy in determining the best methods to care for your patients

  3. Have experience with population health analytics tools to make informed decisions regarding patient care

  4. Have a focus on primary care, with at least with at least 70% of practice’s billing revenue from primary care services

  5. Emphasize preventative rather than reactive care

HOSPITALS AND HEALTH SYSTEMS

Hospitals and health systems with acute care facilities and physician networks now have more choices for participating meaningfully in value-based payments with Medicare. New options allow for greater organizational flexibility and more freedom for a market curated approach to care.

Introduced along with the PCF models, the Direct Contracting (DC) models launch in 2020-2021 and allows for organizations to assume varying levels of responsibility for both savings and losses. This presents great opportunities for organizations situated to take advantage of these new models. The professional model assigns 50% accountability for savings and losses while the global model allows for 100%.

Direct Contracting can be a viable solution if you:

  1. Have a demonstrated ability to manage costs and promote organizational efficiencies

  2. Have a mature integrated delivery system and experience in other value-based payment models

  3. Want to minimize revenue cycle operations

  4. Effectively manage downside risk through preventative care and interventions to curb unnecessary acute care utilization

  5. Emphasize care quality while maintaining appropriate levels of access for the population you serve

  6. Desire a model influenced by private sector approaches with reduced administrative burden applied to the traditional Medicare landscape

ACCOUNTABLE CARE ORGANIZATIONS

CMS has already made a substantial progress in the development of provider networks nationwide through the Medicare Shared Savings Program (MSSP) ACOs. With the finalization of the Pathways to Success, many of these organizations are facing a choice to remain in the MSSP as a BASIC or ENHANCED network after their agreement term ends.

You might want to consider a program renewal under Pathways to Success if you:

  1. Have achieved shared savings or are projected to achieve shared savings before your current agreement ends

  2. You have developed arrangements with commercial payers and want to continue using/building population health management infrastructure

  3. Have a stable participant list and aligned physicians

  4. Possess a firm understanding of how your costs compare to those of your region

  5. Have favorable financial benchmarks that could benefit from a longer agreement period

 

CONTACT US

Our team would be excited to talk to you about Medicare strategy. Chat with an expert on our team by using the form here, or give us a call at (213) 291-9061.