Premier Inc. Leaders. They survey the APM scene, in a moment of change


Where is the entire population health department heading/value-based healthcare training? Two CEOs deeply involved in value-based healthcare, in different areas, have some concrete insights. Healthcare innovation Editor in Chief Mark Hagland recently spoke with Melissa Medeiros and Seth Edwards Premier Inc. Based in Charlotte. About a range of issues, challenges and opportunities in those areas. Medeiros is Senior Director of Policy and Government Affairs, and Edwards is Vice President of Population Health and Value-Based Care at Premier. Below are excerpts from their extensive interview.

Melissa, tell me what areas do you cover in politics, in Premier?

Melissa Medeiros: I oversee value-based care, quality metrics, and anything related to Medicare.

What are your main interests now?

One of our top priorities is around the advanced incentive payments that are due to expire at the end of the year, so we’re pushing to extend those policies. cunning [the Medicare Access and CHIP Reauthorization Act of 2015] Includes 5 percent bonuses for those physicians participating in advanced APMs [advanced payment models]. And in 2022, there is a two-year lag in the payment of those bonuses, between the year of payment and the year of performance. These have been very important to our service providers in advanced APMs. There is a great deal of concern about losing incentives for people transitioning to advanced APMs, or those already participating, and continuing to advance.

What are the participating APMs?

The MSSP [Medicare Shared Savings Program] It is the largest, but only certain practices are eligible. Providers involved in ACO REACH . modelCombined payments are also eligible. Certain paths are eligible. Rewards for doctors and other doctors.

Is this your main policy focus now?

It is one of our main areas of focus at the moment. We had a joint briefing with Hill APG [America’s Physician Groups] And the NAACOS [the National Association of ACOs], last week. We share them closely. This brief has focused on value-based care broadly, with a few designated assistant managers spanning.

Seth, what’s the one thing you’re most involved in right now?

Seth Edwards: Much of the work that we’ve been doing has been around helping organizations develop their strategies for population health, and doing that within the environment and the model where organizations see significant cost increases around supply and workforce costs — so what’s the best way for a hospital or ACO to go forward ? If we can avoid readmissions due to heart failure, which is one of the most expensive — and most readmissions are actually low or no profit-margin events — then we can really help those organizations. So, it’s thinking about rationalizing the delivery model to make sure you’re doing the best thing for organizations and the community, but also making sure that you’re doing the best thing for the long-term health of the overall health care system.

Can you talk about the fact that this can be very difficult to jump to value-based contracting, for provider organizations that have been in service so far? As we all know, the pandemic has caused huge financial distress to patient care organizations, especially hospitals and health systems, in terms of revenue, so their margins are much lower than they were two and a half years ago.

I really think this is the optimal time, to take advantage of what we hope will be finalized in the doctor’s fee schedule. It’s a good time to consider the margin challenges they face under Medicare, and to move forward. And according to the Kaufman Hall Quarterly Reports that I cited, if you say, look, we’re losing money on every single Medicare admission, how long will that negative margin last, and how long will recruitment costs continue to increase? Doesn’t that mean moving forward with a value-based contract. If you enter an MSSP and can participate in the savings, this can give you a rolling margin. So it’s a huge time for organizations that are highly focused on hospital care, and can move forward to become integrated health care delivery systems; We call it future audit. I don’t think there will be more money in healthcare. With prices forced downward and reimbursement continuing to fall, it is time to act in new ways to support the delivery of value-based care.

Medeiros: We see CMS developing policies aimed at engaging new service providers in value-based programs. There is a lot of focus now from management on providing the new flexibility. We’ve even seen new opportunities for advanced investment payments for even the smallest providers of value-based care inexperienced. We hope to see some of these policies completed at the beginning of next month, when we expect to see the doctor’s fee schedule finalized.

Edwards: And as CMMI pursues the goals that they set out in the Vision 2030 document that they put forth, if everyone in Medicare is going to be accountable by 2030, organizations really have to move forward; Because if you don’t move forward with an accountable relationship with Medicare, you will be commoditized compared to other organizations. For me, this presents a real opportunity.

Where are your most difficult members?

Edwards: We work with about 70 organizations within our Population Health Collaborative. Some groups are just getting started; Others have been in this field for 20 years. But the most common request across them all is, can we help them develop a strategic roadmap, or a risk maturity model, that helps the organization visualize how quickly they must move to risk in each of the driving sectors? Medicare, Medicare Advantage, Commercial Insurance, Medicaid, and Direct Employer Contracting. So when they look at each of the payer segments, they have to decide how quickly to transition to risk, what capabilities are required, to become successful with each step, and how to take into account market system readiness and drive-readiness to implement the maturity model. So it’s about developing that strategy and planning carefully. Much care management support – population management infrastructure is needed; This includes technology and analytics. We do a lot of work to help organizations understand their data, as well as develop strategies around complete and accurate documentation and coding.

How will things develop in the next five years?

How will things develop forward in the next five years? There will be a number of combinations, depending on the outcome, the physician’s fee schedule, and how the Medicare Advantage market adjusts to emerging from a public health emergency. Depending on how the industry reacts to that as well – because they have some benefit of lower reporting requirements; That could have an impact on future MA payments. Some of our members are likely to go into advanced amounts of risk. In general, the more risk you take, the more opportunities you have to the upside as well. They will think there is a chance there

Providers say they are learning from Medicare and this helps them take risks with both sides of Medicare.

Yes, many of our members learn this way, but many organizations share risks with health plans, through joint ventures, partnerships, or contractual elements that involve shared savings. So I think that’s going to be a trend that we’ll see, groups that are looking to take on more risk, to strengthen their own margin pressures. There are groups that use their expertise in upward risk-taking only to gain experience and integrate with their doctors, to continue to take a two-sided risk. But I think there will be a lot of doubling, because of the possibility of commoditizing it.

One of the tension points between CMS [the Centers for Medicare & Medicaid Services] Providers, under the previous administration, had exceeded standards in the MSSP, which providers felt were too challenging, and whose details NAACOS leaders, for example, felt would lead to many provider organizations leaving the MSSP. Sima Verma was insisting that providers take on two-sided risks faster than many would like to do.

Medeiros: We were all pleasantly surprised by what CMS proposed last year. There was definitely a shift in thinking between departments. There seems to be less emphasis on progression to risk, as happened with Pathways To Success, which is likely to push people into two-sided risks too quickly for them. There seems to be awareness of the concern that if ACOs continue with the program, there may be a race to the bottom, as they compete against their previous success, per criteria. We have made notes on that. They are looking to set a five-year set of management standards; We urged them to work with stakeholders. I love the RFIs from this department. I think they’re listening, and the former doctor’s fee schedule has shown some flexibility.

Accordingly, the proposed regulation was rolled out in July; We expect the final rule to fall around November 1, I think, to take effect in the year 2024. So we should have a better sense of what it’s going to be early next month. But I think some of the requirements may be implemented incrementally. Also, considering past savings, this is a policy that people have been calling for for some time; Which get MSSP Sustainability. There was definitely a shift from management to management.

Edwards: I agree, there is a shift. It appears to be less focused on getting organizations to take risks at a fast pace, and more focused on getting more organizations involved. This will only increase the number of organizations interested in participating, as well as to maintain their current participation.


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