CMS Overhauls ACO Programs Towards Quicker “Pathways to Success”


As 2018 came to a close, the Centers for Medicare & Medicaid Services (CMS) released substantial adjustments to the Medicare Shared Savings Program (MSSP), most of which are arguably the most impactful since its inception. “Medicare can no longer afford to support programs with weak incentives that do not deliver value,” CMS Administrator Seema Verma emphasizes. The final rule particularly targets MSSP Track One ACOs, the vast majority in the market, as data on their ACO cost performance ‘does not move the dial’ as substantial as ACO participants who took performance-based financial risk.

To further encourage risk, CMS reduced the shared savings rate to 40% for those ACOs that do not assume risk, previously known as Track One MSSP ACOs. All other ACOs that acquire financial risk will keep the 50% shared savings rate.

The bold “Pathways to Success” initiative will implement the most substantial adjustments representing CMS’ lessons learned these past six years:

Timeline Within the new program, new “low-revenue” ACOs will have only three years to remain in a one-sided risk model whereas existing one-sided ACOs will only have a single year to take on additional risk.  All other new ACOs will have two years to take on risk.  Those ACOs strategically avoiding MIPS and/or those ACOs who did not emphasize the seriousness of their commitment to the program will no longer have a free pass.

Quality: Pathways to Success increases accessibility to telehealth services to boost convenience for patients and providers, including services delivered at a patient’s residence, as difficult as that may prove to be.  Many Telehealth enthusiasts appreciate another incremental step towards broadly supported Telehealth services even if the reimbursement expansions may only be available to ACO participants who take significant financial risk.

Beneficiary Engagement: To further drive improved health outcomes, Pathways to Success allows ACOs to offer new incentive payments for beneficiaries who participate in their care by obtaining primary care services and adhering to necessary follow-up care plans.  With care coordination resources provided by most ACO’s, the theory of ‘getting them in the door’ and thus having actionable data, will permeate the necessary communication and care most go without today.

Though CMS themselves predicts 109 ACOs will leave the program due to these changes by 2028, the estimated savings is estimated at $2.24 billion over the next decade.  Most ACOs and provider organizations are rightfully scrutinizing the details of this verbose rule, despite the short deadline for a July 1, 2019 start date, with applications due by February 19, 2019.  With 3-Day SNF waivers, gift cards available for patient reward, and telehealth reimbursement carrots dangled to provider organizations by CMS, it’s a quick turn likely to push more entrants into the MIPS program.  However, the savviest of groups may recognize the potential advantageous economics of the SNF Waiver that eases and expedites the referral process to a nursing home without the currently required three-day inpatient stay.  Only ACOs participating in MSSP performance-based risk tracks are eligible to obtain these waivers that very well can directly impact your daily census.  Though CMS limits waiver use to patients prospectively attributed to the ACO, the minimal reduction in red tape is enticing depending on your unique patient population and market needs.  Many particulars of the Final Rule will continue to further split providers into financial risk takers, taking the form of ACO members and MIPS-Composite score focused MIPS participants, while continuing to complicate and catalyze healthcare payment reform in 2019.

Meanwhile, the message is clearer now than ever before.  Get on the Fee For Value train before your wallet and patients are left at the station…

FHIR Finally Breathing Interoperability

With 82% of hospitals and 64% of Merit-Based Incentive Payment System (MIPS) Eligible Clinicians using EHR technology supported by Fast Healthcare Interoperability Resources (FHIR®), it might be time for patients, providers, and health systems to finally expect complete and centralized personal health records. FHIR is a pivotal turn for Health Level Seven (HL7®) to essentially turn your EHR into an application platform allowing immediate access to secure data sources, like your iphone, android, or smart TV centralizes banking information, mobile health information, and an endless supply of capabilities competing for screen time. FHIR provides a secure transformation of health information across disparate data sources, this ultimately can lead to reduced administrative quality reporting burdens, more timely transfers of personal health records (PHRs) across EHRs, even reliable biometric data monitoring within PHRs, and much more.


This swift technological advancement breaks down data exchange barriers, largely in pursuit of population health capabilities encouraged by HL7s Argonaut Project which health information technology juggernauts such as Epic, Cerner, AthenaHealth, and provider organizations like Intermountain Health and Mayo Clinic. To a layperson, these organizations are using FHIR to essentially share meaningful clinical data on secure internet-based platforms (Think of an https:// address) called resources, that allow other entities to build off of this flexible set of data, including imaging results, lab tests, longitudinal care plans, etc.

This industry sweeping capability raises the temperature for data blocking, recently referred to as ‘patient profiteering’ by CMS administrator Seema Verma who points out the financial incentives for health systems, vendors, or payors that purposefully contort patient data to maintain market share. The Office of the National Coordinator for Health Information Technology (ONC) will soon propose further teeth in the 21st Century Cures Law by defining data blocking instances to penalize with fines and decertification.  This proposal is expected in December, which will then lead to a period of public comment. Congress has specifically focused on defining and regulating application programming interface (API) capabilities that halt data-sharing by intentionally forming proprietary data agreements to gain competitive market advancement.

So, what’s the point? Interoperability may not be a day-to-day must-have for most providers and administrators in 2019, however it could finally connect disparate sources of health information in a clinically and practically relevant fashion in the very near future.  Real-world clinical practice scenarios will drastically transform if FHIR continues to gain traction as the world’s brightest technology innovators compete for providing the most clinically relevant information sharing, within your existent EHR platforms.

Can Existing Technology Really Save Rural Hospitals?

Between 2013 and 2017, nearly twice as many rural hospitals (64) closed their doors than the previous 5-year period; predominately located in the south, according to a recent publication by the U.S. Government Accountability Office.  Through shrinking commercial reimbursement rates, increasing dual-eligible Medicaid-Medicare beneficiary populations, competition with alternative care settings (Urgent care, Minute Clinics, etc.), transitioning payment models and the usual complex nature of rural healthcare finances, rural hospitals find few opportunities for new revenue sources.  Considering the often-devastating impact of losing our rural caretakers within our communities, let’s take a quick pulse of the technology 2018 brought, that could potentially boost 2019’s income statement, if implemented wisely.

  1. Telehealth: Telehealth services bring obvious and immediate communication convenience to patients and staff alike. Instituting e-health billable services and billable chronic care management or transitional care programs, can be a bit of a challenge at first; though they routinely lead to recurrent revenue strategies for America’s rural hospitals. On top of that, virtual visits and remote monitoring bring a complicated logistical, scheduling, and reimbursement opportunity as well as an increased expectation of availability. The lesser understood benefit here, however, is the ability to institute upfront payment for such convenient services. As patient liability continues to rise to roughly 20% of outstanding allowables, the uniquely “brand-spanking new” nature of telehealth services allows an opportunity to collect patient portions immediately. Consumer-minded patients seek convenience; thusly, the question to ‘Press 1 to pay now’ is much more palatable while waiting for a convenient e-visit. Instituting recurrent revenue streams by introducing telehealth services throughout the daily workflow, can turn “Found Time” to “Billable Time.”

  2. Routine Follow-Up Care: Define it as telehealth, EHR utilization, population health or simply patient outreach – Every health system or physician practice can re-evaluate how efficiently we utilize technology to contact our patients. Providing routinely effective follow-up care is the starting point for not only the best possible clinical outcomes, but also maintaining patient loyalty, reducing readmissions and unnecessary ED utilization, and providing a top-notch patient experience. While hospitals handle telephone encounters and routine follow-up care differently, most often utilizing technological strategies instituted several years ago, it is always worth re-evaluating your outreach and use of business intelligence to monitor your success rates. This does not imply purchasing anything new, but often implies restructuring familiar and deeply ingrained workflows and internal skill sets.

  3. Partnerships with Data: Whether you’re providing teleradiology reading services, sharing in population health initiatives, Health Information Exchanges, or partnering with cloud-based HIT providers, the enormous influx and importance of data-driven decision-making continues to rise. Data accuracy, integrity, and reliability all continue to grow in variance from the high-end partnerships with continuously reputable results down to incomplete and incoherent data-sourced partnerships. When considered a priority, rural hospitals with keen eyes for technological solutions, often can find applicable alternatives via partnerships, without major disruptions in workflow or collections. Routinely reviewing current contracted claim payments, understanding the timing of patient liability payments, and reviewing the continuity of care services are the mere tip of the analytical iceberg rural hospitals must be successful in doing on a routine bases. Navigating the relative impact of which data-driven partnerships to pursue will continue to keep our rural hospitals afloat and thriving as our industry continues evolving.

To quote Charles Darwin….”It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”

CBO: 6 Million More People Will Be Insured Through an Association Health Plan or Short-Term Plan in 5 Years

Over the next five years, association health plans and short-term plans will gain about 6 million additional enrollees according to a new estimate by the Congressional Budget Office and Joint Committee on Taxation.


When association health plans and short-term plans federal rules are fully phased in, about 4 million people will choose an association health plan and another 2 are predicted to be in a short-term plan of 12-months duration. With an association health plan, employers could band together to jointly offer coverage that does not meet minimum standards for benefits that "insurers small group or non-group markets must provide."

Healthcare Finance predicted that since younger, healthier individuals would probably join the short-term plans and depart the small group and non-group markets.  This may result in premium hikes for those left in those plans by 2 to 3 percent, CBO estimates. 

Premiums for benchmark plans are expected to increase about 15% by next year and 7% per year between 2019 and 2028. According to healthcare finance, Federal subsidies for those who are insured will total $685 billion this year and will reach $1.2 trillion in 2028. Medicaid and CHIP will account for 40% of the total as well subsides from tax benefits. 

The CBO also estimated that administration's budget will reduce mandatory federal spending for health care by $1.3 trillion, or 8% every year for the next ten years. In addition, the budget would repeal the ACA expansion of Medicaid coverage, cap Medicaid spending on a per-enrollee basis, cap damages in medical liability system, and require Medicare Part D beneficiaries to pay higher out-of-pocket expenses for some prescription drugs. 


Providers Overpaid: Medicare's Multimillion-dollar Mistake

The Centers for Medicare and Medcaid Services told Georgia Health News last Wednesday that the agency is seeking to recoup nearly $55 million from hospitals and other medical providers in Georgia and other surrounding states, citing contractor errors. The agency found nearly 268,000 claims from hospitals, rural health clinics, and other providers that mistakenly paid though the traditional fee-for-service Medicare program. The agency also sated that "the patients served in these instances were members of a Medicare Advantage program and they were run by private insurers, and that hospitals should have been paid by those health plans instead". 

The states affected are Georgia (owes $19.1 million), Tennessee ($15.4 million) and Alabama ($11.9 million), and another $8.3 million from other states. 


Among rural providers, Upson Regional Medical Center in Thomaston, GA owes the feds $254,000. The recoupment involves more than 1,400 claims from May 2014 to May 2018. The hospital executive, Sallie Barker, stated "Hospitals are being Penalized for someone else's mistake" and that she had asked questions but wasn't getting any answers. HomeTown Health, an association of rural hosptials in Georgia says their repayments from its members could range from $3,000 to $254,000.

For hospitals struggling with cash flow, a takeback can create a big problem. When you’re given a mandate, you’ve got to figure out how to pay it.
— Jimmy Lewis, CEO, HomeTown Health

The medical providers had until a tight deadline of July 1st for repayment but CMS announced that it extended the planned repayment by two weeks to "allow providers time to research the issue and provide documentaion showing they do not owe the funds". 

CMS to Increase Oversight of Medicaid Enrollment and Managed Care Plans

According to Modern Healthcare, CMS announced Last Tuesday that will be heightening audits to "confirm that Medicaid beneficiaries are correctly identified as expansion or pre-expansion enrollees". States receive higher federal match rates of around 90% for expansion enrollees, while the match rate can be as low as 50% for pre-expansion enrollees.


This imbalance in the federal matching rate creates financial risks for taxpayers by incentivizing states to shift cost to the federal government.
— Seema Verma, CMS Administrator

CMS will also audit states that are at high risk for enrolling ineligible people in Medicaid. In the past, states like California, Kentucky, and New York have been cited by the OIG for doing so.

This strategy is a multi-faceted plan to reduce improper payments within the Medicaid program. That includes fraudulent claims, payments distributed to the wrong recipient or for the wrong amount, payments with insufficient documentation and cases when recipient uses the funds improperly. Matt Salo, Executive Director of the National Association of Medicaid Directors stated he doesn't have a reason to believe there is any more fraud, waste, and abuse than there was 20 years ago but it is important to be 'constantly vigilant'.

CMS also intends to take a closer look at Medicaid managed care plans to ensure they are complying with medical loss ratio standards. The agency set a rule in 2016 that sets the medical loss ratio at 85%, meaning all insurers must spend at least 85% of their Medicaid revenue on medical care and other activities that will improve quality. The remaining 15% can be spent on salaries, marketing, profits, or other administrative tasks. If plans do not meet the 85% standard, they will have their state rates lowered in the future. 

CMS to Test Offering Medicare Advantage as Another Track Under QPP

According to Modern Healthcare, CMS wants to lunch "an experiment that allows doctors in Medicare Advantage plans to qualify as participating in an alternative payment model (APM). 


For a brief reminder of the Quality Payment Program, clinicians have two tracks to choose from: MIPS, which requires clinicians to report and meet quality goals and APM, which require clinicians to take on financial risk as part of their efforts to improve care and lower costs. They clinicians meet the goals under an APM, they are eligible for bonuses. 

Clinicians in Medicare Advantage plans have urged CMS to consider those plans as APMs since some are offering risk-based contracts. When clinicians participate in an APM, they must receive a certain amount of Medicare fee-for-service revenue, but for some providers who primarily see Medicare Advantage patients, that threshold may be too high. 

Previously, CMS would have launched a five-year demonstration year. They would have asked providers about the payment arrangements they had with Medicare Advantage plans and the number of patients covered under those arrangements. That information will determine whether the payment arrangement will meet the risk standards to count as an APM. 

However, Seema Verma announced late today that they would offer another choice, Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI). MAQI comes as an option as CMS stated there are not enough alternative payment model (APM) options to avoid MIPS requirements. 

MA enrollment is projected to grow to 9% in 2018, which will bring total enrollment to 20.4 million lives. CMS estimated that more than one-thirds of all Medicare enrollees will be in a Medicare Advantage plan in 2018. 

American Cancer Society Recommends Colon Screenings Should Start at 45, not 50

New guidelines released recommend that Colon cancer screenings should start at age 45, instead of the previously recommended age of 50 for U.S. adults. American Cancer Society's advice came after a study published last year found a rising rates of color cancer and deaths in people younger than 50. Experts aren't sure why there is a 50% increase in cases since 1994. The advice also puts American Cancer Society out of sync with guidelines from an influential government advisory group, which kept the screening age at 50 since it was updated 2 years ago. 

The guidelines are for men and women ages 45 to 75 of average risk for colon cancer; recommendations are different for people with certain conditions, like Crohn’s disease, or a family history of colon cancer. The group endorses six kinds of screening exams, from inexpensive take-home stool tests performed every year to colonoscopies done every 10.
— Associated Press

Most colon cancer occurs in adults 55 or older, but the rate of cases and deaths have thankfully been falling for decades. Colon cancer, combined with rectal cancer, is the second leading cause of cancer death in the U.S., falling in line after Lung cancer. This year alone, more than 140,000 Americans are expected to be diagnosed with it and about 50,000 will die from it. 

Doctors may have to look into specialty medical societies to sort out the different guidelines, as experts are worried about pre-50 colon cancer in some racial and ethnic groups. On the other side, people have argued that instead of lowering the age to 45, more effort could be put into getting more people tested, since only two-thirds of the population have been following screening guidelines. Dr. Andrew Wolf, lead author of the new guidelines, suggested that they should be able to do both - lower the age and get more of the population to follow screening guidelines. 


FCC Chairman calls for Increase in Rural Health Care Program Funding


Federal Communications Commission Chairman Ajit Pai drafted an order to his colleagues to increase the annual funding cap by nearly 43%, from $400 million to $571 million for the Rural Health Care Program. The program provides telecommunications and broadband services to rural communities that support telemedicine. If approved, the $171 million increase would take effect immediately to address funding shortfalls and improve telemedicine care in rural areas. 


This money will help healthcare providers get the connectivity they need to better serve patients throughout rural America. Demand for funding has been outpacing the program’s funding cap, so I also believe that the increased cap should apply to the current funding year so that rural healthcare providers can be fully reimbursed.
— Ajit Pai

In 1996, Congress mandated that the FCC use Universal Service Fund to support telecommunications and information services to eligible providers in rural communities to enable telemedicine, transmit health records, and conduct telehealth activities. However, the cap for the Rural health Care Program was never inflated since it was set in 1997, causing the funding to outpace the budget. 

According to Health Data Management, 31 senators warned Pai that unless the spending cap is raised appropriately to current and future needs, the providers may experience severe rate increases for their services, making it harder for rural practitioners to engage in life-saving telemedicine. On the other hand, American Hospital Association concurs that the Rural Health Care Program needs to be updated and the funding is critical to improve lives of rural Americans. Pai is hoping his colleagues will support the funding increase and prevent delay. 

Piedmont Health Becomes Out-of-Network with BCBS


As of April 1st, Piedmont Health became out-of-network with the largest insurance company in the state of Georgia, Blue Cross Blue Shield (BCBS). The two organizations were unable to reach an agreement on a new contract, therefore causing the current contract to lapse. Piedmont Health is a rapidly expanding healthcare system based out of Atlanta; who currently have 11 hospitals across the state.

Who is Affected?
Since an agreement was not reached, any individual carrying BCBS plans cannot visit Piedmont Health facilities without going out-of-network. The affects not only the public, but also the over 550,000 State of Georgia, and University System employees. For the patients that have BCBS they can still have many options for receiving care. They can go to another in-network doctor, or if they need emergency care they can still go to a Piedmont Health Hospital. Emergency care is always covered benefit, regardless of the network status of a hospital.

What Patients Can Do for Care
Emergency care is not the only remaining coverage between BCBS, and Piedmont Health. The dissolution of these two companies does not affect all plans. Any patient that has a Blue Cross Blue Shield MA plan can still have continuation of coverage. BCBS A state law protects patient that have a chronic or terminal illness continuous care for 60 days after the termination of an agreement. Also pregnant women can continue to see their physician throughout the entire length of their pregnancy, and six weeks after childbirth.

Will it be fixed?
With Piedmont Health, and Blue Cross Blue Shield temporarily dissolving their relationship. This leaves many across the state with less options when it comes to seeking care. However, now that the contract has passed its termination date it puts more pressure on both Blue Cross Blue Shield and Piedmont Health to pass a new agreement.

To learn more about this topic see below.

Source: Out of Time and Our of Network: Piedmont, Blue Cross fail to reach deal by Andy Miller, Georgia Health News. Posted April, 1st 2018

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