Enacting value-based care payment models has been a priority of payer and provider organizations in recent years, but the implementation has been uneven, with care centers serving underprivileged or vulnerable populations being left in the lurch. Helping close the gap is pivotal to reaching the US Centers for Medicare and Medicaid Services (CMS) goal of transitioning to value-based payment models for the majority of Medicaid and Medicare reimbursements.
A report by PwC projects that healthcare costs will rise by 7% next year. The report was based on interviews with major payer organizations covering over 110 million patients in the US. Estimated increases in costs are attributed to labor shortages, rising drug prices, provider contracts, and more.
Extensive research has explored how Medicaid expansion has impacted health outcomes in 40 US states, generally finding that it improves health outcomes for patients and provides financial benefits for state governments. A new report by the Kaiser Family Foundation reviews the recent literature exploring the impact of Medicaid expansion on reproductive and sexual health, beginning with coverage.
Research shows that new patients have to wait an average of 26 days for an appointment in 15 major US cities. To tackle this problem, the Centers for Medicare and Medicaid Services (CMS) recently proposed a rule entitled the Notice of Proposed Rulemaking Managed Care Access, Finance, and Quality (NPRM). The NPRM would cap appointment wait times for primary care, mental health, and substance use disorder treatment.
Value-based care models have been put forward as a solution for rising Medicare costs, paying providers for the value their care provides patients. New laws are further incentivizing adaptation of these payment models. To jump on board successfully, Edifecs published an article earlier this year covering three strategies to help providers take on value-based care models successfully.
Although Medicare Advantage (MA) has been greatly beneficial for participating payer organizations, the picture is less rosy for providers, according to an analysis from the Kaiser Family Foundation (KFF). Providers must deal with a more complex policy framework when working with MA plans, resulting in an increased administrative burden and higher costs.
As nursing homes increasingly look for ways to incorporate value-based care into their practices, some are moving towards payvider models, wherein they partner with a Medicare Advantage insurer and play the roles of payer and provider together. A panel of experts spoke about this strategy in a recently broadcast webinar by NetSmart Technologies.
In a new Targeted Oncology Case-Based Roundtable, clinicians discussed new real-world data (RWD) supporting the use of durvalumab in unresectable stage III non-small cell lung cancer (NSCLC). The clinicians discussed their use of the immunotherapy, noting that most of them continued the treatment for 12 months, the length of treatment used in the observational study.
A total of 42 states have adopted laws called the Caregiver Advise, Record, and Enable (CARE) Act, which promotes increased clinician communication with patients and caregivers during care delivery and at the point of discharge from care centers. A newly published paper in JAMA Network Open finds that these policies are having positive real-world impacts on patient health outcomes.
Value-based care will be a major theme of discussion at this week’s National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum. In addition, speakers will cover managed care decision-making in a variety of disease contexts, covering how to improve patient outcomes and reduce costs. The final focus is oncology.
To improve patient mental health outcomes and reduce healthcare costs, behavioral health needs to move to a value-based payment model and be better integrated into primary care. However, significant hurdles stand in the way. Payers could play a pivotal role in addressing the problem, but this will require careful cooperation with providers.
Despite significant public and private efforts, healthcare IT systems are usually not interoperable, impacting patient care, reimbursement, and research alike. As a result, real action is needed to turn ongoing discussions about interoperability into action. One way forward may be focusing on application with the people who use the systems most.
The Area Deprivation Index (ADI) is a metric that assesses the socioeconomic conditions of an area to determine if it is deemed disadvantaged. The US Centers for Medicare and Medicaid Services (CMS) uses the ADI in new payment models that reward providers for serving disadvantaged areas to promote health equity efforts. However, many areas have wealthy people living in close proximity to poorer communities, skewing results and precluding many disadvantaged communities from these initiatives.
The US Center for Medicare and Medicaid Services’ (CMS’s) Interoperability and Patient Access Final Rule ensures patient acccess to clinical data, adjucated claims, and other health information. The newly published Advancing Interoperabilty and Improving Prior Authorization Processes Proposed Rule would, if implemented, extend the prior rule with 5 key proposals targetting health data access and prior authorization.
Despite new rules in the US requiring providers to collect and report pricing transparency data, just over three quarters of hospitals are lagging behind. If this data can be accurately collected and analyzed, it could help establish fair value-based pricing models that could benefit both patients and providers. In addition, the law targets payer-related data.
Pharmacies are changing, sending ripples into the managed care landscape. In a new Managed Healthcare Executive article, Joe Johnson, Todd Clark, and Brendan Mitchell of LEK Consulting discuss new disruptive pharmacy models and how they are affecting managed care and other payers. The first such shift is a move towards better patient access to care decided upon by their provider.
The COVID-19 pandemic exposed deep disparities in care health outcomes in marginalized groups. One contributor to this problem are widely-used fee-for-service (FFS) payment models. In a new Forbes article, Rita Numerof argues that moving to a patient-centered value-based care model that accounts for social determinants of health (SDoH) is key to helping providers promote health equity through their care decisions.
The payer giant UnitedHealthcare announced plans to cut down on prior authorizations by introducing a new gold-card program. The gold-card program would be implemented nationwide and would cut the number of prior authorizations by 20%. Once implemented, the program will relieve a significant work burden for the provider groups involved.
NHS England has announced it is developing a new service to help fast-track diagnoses and care for people with a set of rare genetic brain diseases called inherited white matter disorders (IWMDs). Patients will be reviewed by a group of specialists and undergo genetic testing, getting referred to neurologists if an IWMD is expected.
Despite years of concerted efforts by providers and policy makers, patients from marginalized backgrounds still face significant health disparities. In a new Med Page Today article, Maulik S. Joshi, DrPH, lays out three ways that care systems can enact changes to make health inequity a “never event.” It begins with appropriate goal setting and a sea change in how health systems view care.
Almost 30 provider groups have written a letter asking the US Centers for Medicare and Medicaid Services (CMS) to implement a hybrid system that mixes fee-for-service and prospective payments for primary care. According to the letter, doing so would incentivize primary care physicians (PCPs) to serve rural areas. The letter is, in part, in response to a push from the agency to get PCPs in rural and underserved areas to move to value-based care models.
Despite being largely onboard with value-based care models, oncologists speaking at the Association of Community Cancer Centers (ACCC) 2023 meeting were skeptical of the upcoming Enhancing Oncology Model (EOM) developed by the US Centers for Medicare and Medicaid Services (CMS). The EOM replaces the previous Oncology Care Model (OCM).
As the US Congress deliberates over the Biden administration’s recently released budget proposal, uncertainty looms over the future of Medicare funding. President Biden and most Republicans have pledged not to cut funding from the program, but some outliers within the GOP are pushing for cuts. These potential cuts could take one of a three different forms, according to Kaiser Health News correspondent Julie Rovner in a new NPR interview.
New rules proposed by the US Drug Enforcement Agency (DEA) will require patients to have in-person visits when prescribing certain controlled drugs to patients who primarily receive care via telehealth. While many controlled drugs are targeted, the rules are an expansion to access for buprenorphine treatment for patients with opioid use disorder.