DMGS Health Care Policy Update

Medicare Trying to Avoid Confusion From Multiple Payment Models

The Medicare agency is working to end the confusion that can result when providers participate in more than one payment test model from its innovation center, a top CMS official said. “These models can and should work together,” Patrick Conway, the CMS’s deputy administrator for innovation and quality, said. The Centers for Medicare & Medicaid Services is trying to align model results so that a doctor participating in both an accountable care organization and a bundled payment model, for example, will know how to attribute savings from each, he said.

The CMS realizes there have been growing overlap problems as more models are introduced, Patrick Conway, who is also the CMS’s acting principal deputy administrator and chief medical officer, told a gathering of health plan officials Oct. 25 at America’s Health Insurance Plans’ Medicare conference. The agency’s Center for Medicare and Medicaid Innovation is testing ways to align the payment models so that a clinician who is part of multiple models knows where to attribute patients and the savings that spring from each, he said. The number of models has proliferated as the CMS works to get doctors out of fee-for-service Medicare and into alternative reimbursement methods that emphasize quality of care and payment risk.

HHS: Nearly 25 Percent of Health Payments Now Based on Care Coordination, Quality

The health care industry is making progress toward paying providers based on new quality-based alternative payment models, according to a report released Oct. 25. Nearly 25 percent of Medicare Advantage, Medicaid and commercial payments are now being made through alternative models, according to the report released at a conference held by the Health Care Payment Learning & Action Network, a public-private partnership sponsored by the Centers for Medicare & Medicaid Services. The Obama administration’s goal for alternative payment models in Medicare is 30 percent in 2016 and 50 percent by the end of 2018.

Moving away from fee-for-service, which health-care experts say rewards volume instead of value of health services, has been a chief goal for the HHS and for health plans in the quest to reduce runaway U.S. health-care costs. The federal government and health insurers are trying to move providers to alternative payment models that are intended to reward better coordinated, more cost-effective care. Health and Human Services Secretary Sylvia Mathews Burwell spoke at the summit, announcing the CMS will re-open two alternative payment models for Medicare providers in 2018, the Next Generation ACO and Comprehensive Primary Care Plus. This will allow medical practices to earn more for taking some risk for patient outcomes. In addition, the CMS’s Oncology Care Model will qualify as an advanced alternative payment model in 2017, the CMS said.

Expanding alternative payment models “means that by 2018, clinicians will have a total of 10 models from the innovation center to choose from as they transition to the quality payment program,” Burwell said, referring to the Center for Medicare and Medicaid Innovation. Starting in 2019, clinicians participating in the quality payment program will also be rewarded for participating in advanced alternative payment models in Medicaid and with commercial payers, she said. Insurers and states representing nearly 200 million patients voluntarily reported their progress moving to alternative payment models, Burwell said. Twenty-three percent of all their health-care spending in 2015 was through alternative payment models, she said.

House Obamacare Dispute Wrongly Decided, HHS Says

A political dispute between two branches of government didn’t belong in a federal court and should have been dismissed before trial, an Oct. 24 administration brief told an appeals court (U.S. House of Representatives v. Burwell, D.C. Cir., No. 16-5202, brief filed 10/24/16). The Obama administration is trying to overturn a decision holding that the Health and Human Services Department and the Treasury Department unlawfully paid insurers cost-sharing subsidies under the Affordable Care Act (25 HLR 717, 5/19/16).

The subsidies were intended to compensate insurers for reducing amounts low-income insured individuals normally would pay, like copays and coinsurance, so the plans would be more affordable. If upheld, the lower court’s decision would prevent insurers’ receipt of billions in federal money. Such a ruling, in the House of Representatives’ favor, could lead to more insurer failures and premium increases. Litigation, however, is a lengthy process, and political realities could ultimately turn the case around.

CMS Halts Automatic Enrollments for New Medicare Advantage Members

Medicare has temporarily stopped granting new approvals to managed care plans that want to automatically enroll their commercial and Medicaid plan members into Medicare Advantage when they become Medicare eligible, the CMS said in an Oct. 21 memo. The Centers for Medicare & Medicaid Services already allows 29 companies to automatically shift these members into Medicare Advantage plans. The companies include UnitedHealth Group, Health First, Anthem and Blue Cross Blue Shield of Michigan. The temporary suspension comes after recent inquiries about protections for enrollees who have been shifted, Michael Crochunis, acting director of the CMS’s Medicare Enrollment & Appeals Group, said in the memo.

Open enrollment for MA and Part D plans in 2017 began Oct. 17 and will end on Dec. 7. The agency said it is reviewing its policies and will issue additional instructions for insurers already allowed to engage in “seamless enrollment” to clarify its stance on beneficiary protections and other requirements. As part of the review, the agency will try to ensure that “enrollment into the MA plan is line with the beneficiary’s wishes and is not the result of a lack of understanding on the part of the beneficiary of the need to deliberately decline the MA enrollment if it is not desired,” a CMS spokesman said.


John Zang Contributed to this Report

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