Healthcare

The introduction of the dual track Quality Payment Program within the MACRA proposed rule has many healthcare systems considering their options. My most recent blog focused on the MIPS track of QPP, so today I will focus on an overview of Advanced Alternative Payment Models. 

The healthcare industry is in a state of constant change, and with change comes opportunity. With the passage of the ACA and MACRA, healthcare providers are, or will be, paid differently for their services. No longer can they rely upon the volume of services rendered to generate sustained income. With the transition from volume-based payments to value-based payments, many health systems are investing in data analytics platforms to help expose cost savings, as well as uncover hidden revenue. But is investing in data analytics worth the cost?

Are you wondering about the status of your Medicare Disproportionate Share Hospital (DSH) payments in light of the recent Allina DSH court ruling? You’re not alone.  An April 2014 ruling from a U.S. Court of Appeals for the District of Columbia Circuit upheld a previous ruling that a Health and Human Services (HHS) rule change in 2004 (codified in 2007) was procedurally defective. The lawsuit had to do with a rule change the HHS made to determine DSH payments in 2007. The hospitals claimed there was not proper notification. Although the court ruled favorably for the hospitals, what happens next is still unknown. 

The appeals court included instructions in the ruling that gave the HHS room to reach the same policy decision through administrative adjudication. The bad news for providers is that adjudicatory findings can be applied retroactively. The Centers for Medicare and Medicaid Services (CMS) has not yet issued a definitive guideline on how to retrofit the reimbursement fractions for the years in question. 

There have been serious, but somewhat quiet experiments going on for years around using bundled care to improve patient outcomes and cut costs. Prepare for some noise as states like Arkansas start figuring out the formula for making it work. The spotlight on bundled care as a potential successor to the Fee-for-Service (FFS) model is getting brighter driven by the Affordable Care Act (ACA) and the search for new payment models that can support the high costs of offering health care benefits to an expanding (and aging) population.