Health Care Matters | October 18, 2024
The CMS 2030 Accountable Care Goal
In 2021, the Centers for Medicare and Medicaid Services (CMS) set an ambitious goal to have all patients in accountable relationships by 2030. To date, approximately 24% of Medicare beneficiaries are in what could be considered an accountable care arrangement, 22% remain in fee-for-service, and the rest are in Medicare Advantage. While the number of beneficiaries in accountable care is slowly rising, the number of ACOs has remained relatively constant from 2021 to 2024. The momentum behind the value-based care movement has slowed as some lawmakers relay skepticism in part due to a September 2023 Congressional Budget Office (CBO) Report that found that the CMS Innovation Center raised instead of lowered Medicare spending. The article posits that value-based care is at an inflection point. Fifteen years following the passage of the ACA, CMS has learned a lot and must now leverage that knowledge from both failed and successful models to accelerate progress to meet the 2030 goal.
View the article here.
Why It Matters
As the article notes, the value-based care movement is at a critical juncture. Without additional resources or structural change, it is unlikely that enough new and different providers enter alternative payment models. Key to success for CMS in meeting their goals will be strategic adjustments and continued support from key stakeholders, including:
Working with Congress to reform MACRA including incentivizing alternative payment model (APM) participation by either extending the Alternative Payment Model (APM) bonus or other means.
Addressing issues with sustainability and predictability of shared savings for ACOs.
Continuing to refine how the CMS Innovation Center models are evaluated for success, expansion, or integration into permanent programs.
Addressing constraints of budget neutrality to allow for increased investment in primary care and underserved communities.
$2.8 Million Settlement in BCBSA Anti-Trust Case
Blue Cross Blue Shield Association (BCBSA) and its 33 members have agreed to a $2.8 billion settlement to resolve antitrust claims from health care providers. Originally filed in 2012, the lawsuit accused BCBS of dividing the country into exclusive service areas where they did not compete with each other leading to suppressed competition and underpayment to providers. The settlement requires BCBS to lift these contract restrictions, implement new technology, and streamline prior authorization to enhance transparency, efficiency, and accountability. The resolution is expected to benefit over 500 hospitals and numerous health care providers, offering them new opportunities to negotiate contracts and receive fairer reimbursements.
Why It Matters
This landmark decision will have far reaching impacts by addressing anticompetitive practices, improving provider reimbursements, and enhancing the overall efficiency and transparency of the health care system. By requiring BCBS to lift contract restrictions, this settlement may lead to increased competition among health plans which can lower insurance costs for patients. The resolution is also expected to lead to better provider compensation and organizational financial stability as it will open the door for more contracting opportunities. Finally, depending on how the mandated improvements in technology and streamlining of prior authorizations are implemented, this resolution can lead to greater efficiency and transparency for the benefit of both providers and patients. Overall, this settlement sets a future precedent for antitrust cases in the health care sector, potentially influencing future litigation and regulatory actions.
What We Are reading
Does Higher Spending On Primary Care Lead To Lower Total Health Care Spending?
Primary care experts weigh in on the evidence supporting increased investment to improve patient outcomes and experiences and reduce costs.
What We Are Listening To
All About Midwives: Parent Data Podcast
Emily Oster of the Parent Data podcast interviews Ann Ledbetter about midwives and how they differ from Obstetricians.
What We Are Writing
MSSP Final Rule to Address Anomalous Catheter Billing in 2023
Check out our blog with insights from the MSSP final rule to address anomalous catheter billing in 2023. CMS released a final rule to mitigate the impact of suspected catheter-related Durable Medical Equipment (DME) fraud; referred to by CMS as “Significant, Anomalous, and Highly Suspect Billing Activity” or “SAHS” on Medicare Shared Savings Program (MSSP) ACO financial calculations for calendar year 2023 (CY2023).
In this blog, we provide answers to key questions ACOs may want to know about this final rule. While the final rule specifically governs MSSP, CMMI has released guidance that ACO REACH will align its policies with MSSP to address SAHS billing activity in program year (PY) 2023.
Where We Are Going
2024 HCPLAN Summit
The 2024 Health Care Payment Learning & Action Network (HCPLAN) is hosting their fall Summit at the Baltimore Convention Center on November 14, 2024. It’s free to attend and in person and virtual options are available. Register here
HCTTF Webinar: Payer and Provider Health Equity Strategies
The Health Care Transformation Task Force (HCTTF) is hosting a free webinar on key payer and provider strategies for advancing health equity in value-based care models on November 20, 2024 from 3-4 pm ET. Register here.
