On January 26, 2015, the U.S. Department of Health and Human Services (HHS) announced an initiative to base more Medicare provider payments on the quality of care provided. HHS has set goals for the use of alternative payment models in the next three years.
Medicare payments have traditionally been based on a fee-for-service where providers receive payment for each individual health care service provided. Some feel this method encourages high volume care rather than high value or coordinated care. Conversely, alternative payment models such as accountable care organizations (ACOs), primary care medical homes, or bundled payments for episodes of care endeavor to link provider payments to quality of care and encourage providers to be more cost-efficient.
In the announcement, HHS established goals both for alternative payment models and for tying payments to quality or value generally. HHS’ goal is to 30 percent of fee-for-service Medicare payments to quality or value through alternative payment models by the end of 2016 and to tie 50 percent of fee-for-service payments to alternative payment models by the end of 2018. Generally, the agency aims to tie 85 percent of all traditional Medicare payments to quality or value by 2016 and to tie 90 percent of all Medicare payments to quality or value through programs such as Hospital-Based Purchasing and Hospital Readiness Reduction Program.
Additionally, the agency is creating a Health Care Payment Learning and Action Network to expand the use of alternative payment models beyond Medicare. Through this network HHS will work with private payers, employers, consumers, providers, states, state Medicaid programs and other partners.
The announcement came after a meeting with health care leaders including representatives from health insurance companies, CVS health, and organizations such as the AMA, American Hospital Association, and the National Partnership for Women and Families.
The AMA issued its own press release in support of the initiative. “Patients benefit when physicians have the flexibility and resources to redesign care, and when payers provide new payment models that can support physician efforts to improve patient care and lower health care costs over the long-term” said AMA President Robert M. Wah.
Two current alternative payment models are the Medicare Shared Savings Program and the Bundled Payments for Care Improvement Initiative. Under the Medicare Shared Savings Program, providers participate by joining an ACO. ACOs are generally groups of health care providers that share financial incentives to improve the quality and efficiency of care provided to a population of patients. With Bundled Payments for Care Improvement Initiative, organizations must meet financial and performance goals for episodes of care.
The AMA notes that ACOs incur costs for care management, consultation between different physicians, and other services not reimbursed by Medicare fee-for-service payments. In order to remove these financial barriers, the AMA recommends that CMS provide monthly care management payments; provide partial capitation payments; and establish low-cost or federally guaranteed loan programs.
Physicians considering involvement with and ACO or any other alternative payment model, should consider the investment required to join and the overall financial and organizational risk of the arrangement.