Healthcare

With mandatory programs on the horizon, the voluntary Bundled Payments for Care Improvement Advanced (BPCI-A) program offers early access to data and valuable experience in redesigning patient care. But with applications closing June 24, 2019, healthcare organizations will need to make some quick decisions about participating in this voluntary Medicare bundled payment program.

“We want to pay for outcomes, not process ... We need results, American patients need change, and when we need mandatory models to deliver it, mandatory models are going to see a comeback.”

The final phase of CMS’ voluntary Bundled Payments for Care Improvement Advanced (BPCI-A) application process is finally here. Whether your hospital or physician practice intends to participate in the model beginning October 1 (or in a future year) or you are a healthcare attorney advising an organization that intends to participate, CMS’ recent announcements regarding the model are noteworthy.

As value-based payment models gain traction, healthcare organizations are feeling pressure to control costs and improve the quality of patient care, all at a time when the supply of physicians is falling short of demand.

Competition for physicians is already heated. It’s about to get scorching. Demand is on a trajectory to drastically outpace supply, with a projected shortage of up to 120,000 physicians by 2030, according to the Association of American Medical Colleges.

Congress should repeal MIPS and replace it with a new Voluntary Value Program (VVP), according to a report released recently by the Medicare Payment Advisory Commission (MedPAC), the independent advisory agency tasked with making recommendations on Medicare policy.

The Bipartisan Budget Act of 2018 (BBA18), signed by President Trump on February 9, includes several provisions that will affect healthcare providers’ Medicare reimbursement—in both positive and negative ways.

The month of December saw additional and important communications from two watchdog groups on the subject of the Medicare and CHIP Reinvestment Act (MACRA) of 2015.

The previous installment of this blog series described the CMS Innovation Center and its mission to test innovative payment and delivery models and to implement the MACRA Quality Payment Program (QPP).

The QPP is designed to help achieve HHS’ goal of tying half of Medicare fee-for-service payments to quality or value through Advanced Payment Models (APMs) by 2018. Advanced APMs, one of the two tracks of MACRA, allows physician practices to earn more by assuming some financial risk related to patients’ outcomes. Certain Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP), including the new MSSP Track 1+ ACO, qualify as Advanced APMs.

The Affordable Care Act created the CMS Innovation Center to allow Medicare and Medicaid programs to test innovative payment and delivery models that improve patient care and lower healthcare costs.

As discussed frequently in compliance and health care conferences and forums and on this page, fair market value (FMV) of payments to referring physicians is an essential compliance requirement of the Stark law and federal anti-kickback statute. Physician compensation in excess of FMV is at the crux of much health care enforcement activity. As noted by Richard Kusserow, former Inspector General, “Arrangements with physicians are the highest compliance risk area in 2017” (“Kickback Cases Remain Top DOJ and OIG Priority in 2017,” Strategic Management Services, LLC; Jan. 2017). Mr. Kusserow further explained that whistleblowers are a significant source of enforcement activity.

The most astute executives in health systems are rightfully concerned about compliance risks in physician contracting. Among these risks are that a transaction or an arrangement between a hospital and a physician are consistent with fair market value (FMV) and are commercially reasonable (CR) as those terms are defined in the healthcare regulatory context.

Like it or not, MACRA is here. MACRA created the new Quality Payment Program (QPP), comprised of two pathways to higher quality: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). MACRA changed the rules, leaving many to face an uncertain future. Amid the uncertainty, however, one thing is sure: passivity will be costly. Indecision will not prevent or delay physician’s placement into the quality and efficiency compensation measurements of MIPS.