Steven Lash shared PPT on how a Peak Into the Future Healthcare Systems & Hospitals. He shows different-2 health plans for your coming years. Watch and share the info if you think this help for you and others as well.
3. Consolidation of Health Plans
5 major plans down to 3
Regional consolidations
Health Systems starting their own plans
Moving the financing “upstream”
Federal and State Governments
MACRA legislation
Bundling of major surgical services
Presidential & Congressional election
Physician Practice Arrangements
Currently more than 200,000 employed
Accenture projects 67% will be employed within 3 years
4. The Big 5 become the Big 3
Aetna (acquiring Humana)
Anthem (acquiring CIGNA)
United
131 Million covered lives
Reasons for mergers
Scale Economics
Negotiating leverage with hospitals & physicians
Diversification (more MA plans)
The consequence for Hospitals & Systems
Anthem has access to national Blues rates; typically lower
Anthem converts all CIGNA agreements to BCBS rates
Margins drop for hospitals
5. Declining Hospital I/P margins
Increasing complexity of patient population
Medical inflation (CMS projects 4.9% - next 3 years)
Niche players taking profitable lines
Increasing regulatory developments & scrutiny
Health Plan negotiating leverage dropping
New payment models
Bundled payments – CMS
Ortho & Cardiac
Commercial payers to follow
Advanced Alternative Payment Models
NextGen ACOs
6. MACRA replaces The Sustainable Growth Rate (SGR)
Will impose 4-9% reimbursement reductions on physicians who do not
move to value based payment methodology
Annual reimbursement increases are prescribed
MACRA charts the path for physician compensation for the
next 10 years in 2 separate tracks
Merit Based Incentive Payments (MIPs)
Alternative Payment Models (APMs)
Physicians will wonder the following:
“How can I avoid the 4-9% cuts in reimbursement under MIPs?”
“How can I get exempted from MIPs and lock in the annual bonus
payment of 5% under the APM track
“How do I join an APM?”
7. 2026 and beyond
0.25% annual updates 0.75 annual updates
2019-2025
4-9% penalties/bonuses* 5% lump sum bonus
2015-2018
0.5% annual updates
Merit-based Incentive
Payments (MIPs)
Alternative Payment Models
(APMs)
*Bonuses may be higher
Physicians will Follow the Money
9. 20192017 2018
MIPS Performance Period
All MIPS performance categories are aligned to a
performance period of one full calendar year
2017 performance measurement period
2019 1st payment year
2024 20252020 2021 I
I
I
2023
25%
2022
50% 75%
10. Requires Participants (physicians & hospitals) to use certified
EHR technology
Bases payment on Quality measures comparable to MIPS
quality performance category
The APM either:
Requires APM entities (hospitals and physicians) to bear more than
nominal risk for monetary losses
Is a Medical Home Model expanded under CMMI
What are the current APMs under MACRA
MSSP (Track 2 and 3)
NextGen ACO
ESRD
CPC+
OCM (2 sided risk beginning in 2018)
11. Newest of ACO models; went live in July 2016 with 21
organizations participating
This is the 3rd version of ACOs
Pioneer (2012- part of ACA)
32 participants; 9 left
Burdensome reporting, limited upside, difficult quality measures
Medicare Shared Savings Program (MSSP)
404 participants; most successful
Fixed some flaws of Pioneer model
2 tracks for cost management; 1/3 received any bonus payments
NGACO
Financial risk of care coupled with quality measures
2 tracks – 80% of savings or losses of 100%
2nd year move to capitation aka a Medicare Advantage Plan
13. Financial performance
Improve eroding I/P margins through efficiency & supply chain productivity
Add new services that are higher in margin
Improve cash flow through enhanced contracting and denials recovery
Effective Population Health Management including risk stratification
Compete on the basis of “Demonstrated Value”
Best customer experience
Best price
Best service
Documented best outcomes
Failure to build a robust & viable physician organization
Ensures the ability to compete in new payment models
Counterbalance to commercial payors contracting leverage
Locks in referrals to hospitals
By sharing risk and quality profitability improves
For the most part, Physicians are seeking the comfort of the hospital