Abhinav Shashank is the cofounder and CEO at Innovaccer Inc. Abhinav has led the San Francisco-based healthcare data activation platform company since its inception in 2014. Under his supervision, Innovaccer developed its proprietary healthcare data activation platform.
We dream of a healthcare system that encircles all citizens and connects them to the common thread of care, which is built on the foundation of the quadruple aim. With frequent policy changes and new mandates, the care ecosystem in the US is poised for a major transformation in years to come.
The lawmakers and governing bodies are coming up with new ways to defeat the beast in healthcare that has created so many problems. But how successful have they been? How many changes are going to be needed? What direction do we need to take before we start thinking of newer and better ways? Progressing from price to value, here are some updates in healthcare this year that merit a special focus:
1. Most Recent Updates In Medicare Advantage And Part D
What Is The Current Status?
To maximize coverage and competition, the Centers for Medicare and Medicaid Services (CMS) has proposed changes in the Medicare Advantage (MA) and Part D plans with expansion in plan choices and benefits. Keeping up with the opioid epidemic, the proposals also address significant actions to combat it.
What Can We Expect?
- Once accepted, there will be extended opportunities for senior citizens to choose MA Plans providing new supplemental benefits in 2019. Also, certain enrollees will gain access to various benefits and services.
- Speculated for the 2020 plan and beyond, MA Plans will have greater flexibility to offer chronically ill patients with a wide range of additional benefits. These include a home-delivered meal or transportation for perfectly tailored non-medical needs.
- With CMS encouragement, Part D plans might provide lower cost-sharing for opioid-reversal agents.
- Patients with chronic pain or who are undergoing addiction treatment can expect targeted benefits as CMS has encouraged MA Plans to take advantage of new flexibilities and bring about cost-sharing reductions.
Buzzing Speculations on the Policies
MA Plans being a popular choice among beneficiaries continues to yield high satisfaction ratings. Touching the lowest average premiums in three years, MA Plans and Medicare Part D are ready to soar with better and increased plan choices.
What Do The Authorities Have To Say?
“CMS is committed to modernizing Medicare and our top priority is to ensure that seniors have more choices and affordable options in receiving their Medicare benefits,” CMS Administrator Seema Verma said. “[MA] enrollment is at an all-time high as more and more seniors are choosing to enroll in private Medicare health and drug plans, and we need to maximize competition by providing plans the flexibility to meet patients’ needs.”
2. New Proposed Rule For Alternative Payment Model For Chronic Kidney Care
Where Are We Today?
The current Medicare payment system for chronic kidney disease treatment encourages in-center hemodialysis as the default treatment for patients starting dialysis.
CMS has recently proposed one mandatory and four new voluntary alternative payment models (APM) for Medicare beneficiaries who receive treatment for chronic kidney disease and end-stage renal disease (ESRD).
What Will Change Here On?
- The proposed ESRD Treatment Choices (ETC) Model will provide beneficiaries the choice of ESRD treatment, including home dialysis and kidney transplant. This will not just support quality care, but prevent disease progression for the patients.
- The new mandatory model will adjust Medicare reimbursements to ESRD facilities and providers managing ESRD Medicare beneficiaries, through upward or downward payment adjustments, based on their home and transplant rates. This model is all set to protect ESRD facilities and providers who treat patients by risk-adjusting home dialysis and transplant rates, according to CMS.
- The four proposed voluntary payment models would use fixed payment mechanisms to encourage greater use of at-home dialysis and kidney transplants for patients suffering from late-stage chronic kidney disease and ESRD.
With these models, kidney contracting entities will have accountability for the total cost and quality of care for their patients. In exchange, the providers will receive a portion of the Medicare savings they achieve.
What Do The Authorities Have To Say?
A statement by HHS Secretary Alex Azar noted that “decades of paying for sickness and procedures in kidney care, rather than paying for health and outcomes, has produced less-than-satisfactory outcomes at tremendous cost. Through new payment models and many other actions under this initiative, the Trump Administration will transform this situation and deliver Americans better kidney health, more kidney treatment options and more transplants.”
“The way we currently pay for chronic kidney disease and kidney failure isn’t working well for patients,” CMS Administrator Seema Verma said in a statement. “Under President Trump’s leadership, we are focused on strengthening Medicare and protecting the program for the individuals it was intended to serve. These historic initiatives aim to improve the quality of life for kidney disease patients by preventing disease progression, encouraging transplants over dialysis, and if dialysis is needed, more convenient home-based dialysis to improve health outcomes.”
3. Advancing American Kidney Health
HHS recently launched Advancing American Kidney Health, a bold new initiative to improve the lives of Americans suffering from kidney disease, expand options for American patients and reduce healthcare costs. The initiative lists targeted solutions to cater for three main purposes: fewer patients developing kidney failure, fewer Americans receiving dialysis in dialysis centers and more kidneys available for transplant.
4. Formation of the Quality Summit
In July 2019, HHS also announced the formation of the Quality Summit (QS), which aims to bring together major stakeholders and government leaders to deliberate on the evaluation and adaptation of the current quality programs. Streamlining all initiatives for value-based care, all organizations are striving to improve the health outcomes for American patients.
5. Primary Care First Path
HHS in 2019 has announced five new voluntary payment models, divided into two paths. Primary Care First (PCF) Path includes two voluntary, five-year payment models that are specially designed for primary care practices. The payment models will be launched in 26 regions throughout the United States beginning in 2020.
- PCF General: It is designed for primary care practices prepared to assume substantial financial risk in exchange for reduced administrative burden and performance-based payments.
- PCF-HNP: PCF High Need Populations is designed to encourage advanced primary care practices, including Medicare and hospice or palliative care services, to assume accountability for highly needy, seriously ill beneficiaries who lack a primary care practitioner or effective care coordination.
What Will Change Here On?
Practices participating under any of the two PCF payment models will receive a simplified, total monthly payment that will allow clinicians to focus on patient care instead of erratic revenue. These practices will receive payment based on how they perform on certain clinical quality measures listed by the CMS. Specialized practices in complex, chronic or severe-conditions care will receive higher monthly payments.
6. 2020 Physician Fee Schedule Proposed Rule
The physician fee schedule (PFS) proposed rule includes potentially misvalued codes, adds services to the telehealth list and other policies affecting the calculation of payment rates. 2019's proposed PFS rule included a number of new proposals, including a proposal to change documentation, coding and payment to reduce administrative burden and improve payment accuracy for office/outpatient Evaluation and Management visits, and a proposal to pay separately for two newly defined physicians’ services provided using communication technology.
7. Improving Outcomes in Child Welfare
The 2020 Budget brief supports implementation of the Family First Prevention Services Act of 2018 and includes policies to further improve child welfare outcomes and prevent child maltreatment. The Budget also aims to expand the Regional Partnership Grants program, which addresses the considerable impact of substance abuse, including opioid abuse, on child welfare.
The Road Ahead
The future of healthcare holds spurring growth for value-based initiatives. Patient health accountability is increasingly observing a considerable share at the hands of providers and networks. Healthcare on the wheels of value initiatives and innovation is set to cover miles of efficient care and clinical outcomes.
As much excitement as it brings to the table, the care ecosystem is set to welcome reforms that promote a balance of accountability and value in care approaches for a robust healthcare system!