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Test 4: New Payment Models
New Payment Models
21
Health Care
Graduate
06/19/2017

Additional Health Care Flashcards

 


 

Cards

Term
A New Model of Health Care: Today
Definition
Treating Sickness
Fragmented Care
Specialty/Hospital Driven
Isolated Patient Files
Utilization Mgmt
Fee for Service
Payment for Volume/FFS
TFSIUFP
Term
A New Model of Health Care: Future
Definition
Managing Population
Collaborative Care
Primary Care Driven
EHR/HIE
Evidence-Based Medicine
Shared Risk/Reward
Payment for Value
MCPEESP
Term
Old Payment Methods: Fee-for-Service
Definition
- Provider selects CPT code, itemized charge associated with each code. When send claim to insurance company, CPT code and ICD-10 code on the bill
- Encourages volume – more you do, the more you are paid.
- Chargemaster Charges (Full Charges – Sticker Price) v Amount contracted with insurance companies – will talk in the next few weeks about charge master
Medicare/Medicaid set the amount of charge (what physician will be paid per CPT code)
Term
Old Payment Methods: Capitation
Definition
(per member – per month). Often primary care for HMO. Discourages over-utilization. Transfers risk to providers. Many believe this is end-goal of insurers.
Term
Old Payment Methods: DRGs
Definition
Medicare method to pay for hospitals admissions based on Diagnosis. (Fixed amount for each diagnosis)
Term
New Payment Methods Value-based Approaches
Definition
- Transfer ‘risk’ to provider!
- Not pay for volume
- Payment based on:
+Quality measures
+Patient Satisfaction
+Cost as related to peer charges – if your charges are more than peers for similar diagnosis, you may face a penalty – CALLED MEDICARE Spend Metric – compares me the doctor to colleague doctor (across town or whatever) to see who pays more for tests and who has better outcomes
+Use of HIT to enhance patient engagement
Term
Two ways to participate in MACRA
Definition
1. MIPS (Merit Based Incentive Payment System) – most physician practices
2. Advanced Alternative Payment Models (APM) – contracting for risk
Term
Alternative Payment Models
Definition
- Patient-Centered Medical Homes (PCMH)
+ Often Medicaid, Some Commercial
- Accountable Care Organizations (ACOs)
+ Medicare ACOs, Commercial ACOs
- Bundled Payments
+ Orthopedics and Cardiology, to date
Term
MACRA – MIPS HIT Summary
Definition
1. What it is : Payment Reform for Medicare Part B
2. Who it impacts: Eligible Clinicians subject to the Medicare physician fee schedule
3. IT is involved: continue Certified Electronic Health Record and Meaningful Use for physicians and other EC’s
4. IT involved : support reporting for Quality, Claims and Clinical Improvement
5. IT involved : one of three imperatives for success in Population Health and risk payment methodology
Term
Financial Impact of New Methods - Merit-based Incentive Payment System (MIPS)
Definition
- Can impact Medicare reimbursement by as much as +/- 9% (by 2022)
+ The positive payment adjustments can go even higher, up to a factor of 3X
- Will feature a publically available Composite Performance Score (MIPS Score)
Term
Financial Impact of New Methods - Advanced Alternative Payment Models (APMs)
Definition
- Providers engage in programs that have shared risk
+ E.g.,: ACOs, PCMH, others..
- Qualified participants avoid MIPS reporting and penalties
- Receive a fixed payment increase (5% through 2024) for each year that the provider or group qualifies (automatically receive this 5% for each year qualify)
- Medicare anticipates limited APM enrollment in 2017 (15% of providers or less – most will be in MIPS because APMs have not developed yet)
+ This may rise to 25% in 2018
- All clinicians may wish to consider reporting through MIPS to determine if they qualify for an advanced APM
Term
PCMH
Definition
- The medical home is an approach to primary care that is:
+ Patient-Centered Supports patients in managing decisions and care plans.
- Accessible: Care is delivered with short waiting times, 24/7 access and extended in-person hours.
- Comprehensive: Whole-person care provided by a team
- Coordinated: Care is organized across the ‘medical neighborhood’
- Committed to quality and safety: Maximizes use of health IT, decision support and other tools
Term
PCMH2
Definition
- Navigators, Care coordinators – keep patients from falling in the cracks. Use HIT to coordinate.
- Value/ Outcome Measurement
+ Reporting of Quality, Utilization and Patient Satisfaction Measures
- Value-Based Purchasing
+ Reimbursement Tied to Performance on Value
Term
Accountable Care Organization
Definition
. . . A group of physician and other healthcare providers and suppliers of services (e.g., hospitals) that will work together and are willing to certify a willingness to become accountable for, and report to CMS, the quality and cost and overall care of Medicare Fee-For-Service beneficiaries assigned to the ACO.
Term
Requirements for Medicare ACO
Definition
- Legal Organization – lawyers must get involved
- 3 Year Commitment
- Sufficient primary care providers for minimum 5000 Beneficiaries
- Accountable for Quality & Cost of Care
- Can collect and provide information, report quality measures
- Can provide administration and clinical care
Offers evidence based medicine and coordinated care
- Is patient centered
Term
Shared Savings - two types of savings that ACOs can be a part of
Definition
- Track one “one sided” CMS will share savings with no risk
- Track two “two sided” ACO can achieve greater profit from sharing but must also share risk for loss
- Must be same track for 3 years
Term
CMS’s Rule to Encourage Participation in ACOs
Definition
- Permit current ACOs taking one-sided risk to request a three-year extension before entering two-sided risk, provided that they did not have significant losses in the initial two years.
- ACOs that choose this extension option will receive a smaller bonus (there is currently the potential to achieve up to 50% of the savings).
- After the three-year extension period, all ACOs must enter the two-sided risk track if they wish to remain in the program.
Term
Bundled Payments
Definition
- One payment to hospitals for encounter and for all related services for up to 90 days after discharge
- Hospitals, physician groups, post-acute providers bear financial risk for spending relative to target price based on historical ‘spend’ per episode less 2 -3 % discount. Assessed on annual basis.
- Some believe Bundled methodology is at odds with Accountable Care Approach(see articles)
Term
MIPS will apply to following Clinicians:
Definition
- Physicians, Mid-level practitioners, Chiropractors, CMS will add other professionals in 2021
Term
Clinicians Exempt from MIPS
Definition
- Low Medicare/Medicaid volume physicians (<100 patients or $30K)
- Physicians practicing at Critical Access Hospitals
- MIPS not applicable to RHCs and FQHCs (most of these PCMHs anyways)
- The intention is to exclude small practices; estimated about 50% of physicians will be excluded initially.
- HOWEVER… Medicare encouraging all insurance companies to move to similar methodology
Term
MIPS – Four Determinants of Performance Score (2017)
Definition
1. Quality Reporting (60%)
2. Advancing Care Information (25%) – Replaces Meaningful Use
3. Clinical Practice Improvement Activities (15%)
4. Resource Utilization (0% - increases in coming years with decrease weight on quality)
*Remember - MIPS Is Budget-neutral for CMS
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