Tag Archives: Laurie Lingefelt

ACOs have more flexibility to establish beneficiary incentives under Pathways to Success

In August, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that will significantly change the Medicare Shared Savings Program (MSSP) if enacted. The proposed rule, known as “Pathways to Success,” provides new flexibilities for accountable care organizations (ACOs) to offer monetary beneficiary incentive programs. Beginning as early as July 2019, CMS proposes to allow certain MSSP ACOs to provide general monetary incentive payments to beneficiaries who receive primary care services in order to foster greater patient engagement.

In this paper, Milliman’s Carol Bazell, Susan Philip, and Laurie Lingefelt discuss key elements related to beneficiary incentives proposed under Pathways to Success. This paper is the fifth in a series of Milliman papers on the proposed rule.

Two proposed rules open up opportunities for care coordination through telehealth

Over the summer, the Centers for Medicare and Medicaid Services (CMS) issued two proposed rules that will create mechanisms for some providers to receive payment for telehealth as well as other non-face-to-face and care coordination services using telecommunications technologies. Together, the changes proposed in the calendar year 2019 Medicare Physician Fee Schedule (PFS) and the Medicare Shared Savings Program (MSSP) proposed rules have the potential to enable new interactions that strengthen care access and coordination for a much broader set of patients.

The term “telehealth” is often used to broadly refer to the use of telecommunication technologies to furnish healthcare services. However, Medicare telehealth services specifically refer to a set of Part B-covered services specified under section 1834(m) of the Social Security Act. By law, Medicare fee-for-service (FFS) telehealth services under the PFS are currently subject to the following conditions:

• Provided using real-time, interactive audio and video
• Geographic restrictions on originating site (beneficiary location)
• Setting restrictions on distant site (provider location)
• Provider restrictions (and possibly further limitations due to state licensure laws)
• Limitations on type of visits

Waivers of Medicare telehealth rules are currently available under specific CMS Center for Medicare and Medicaid Innovation models. For example, under the existing Next Generation ACO Model, CMS has waived the geographic and originating site requirements for Medicare telehealth services. In addition, beginning in 2018, the Next Generation ACO Telehealth Waiver was expanded to include asynchronous telehealth services for teledermatology and teleophthalmology, which provides physician payment for the receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation.

MSSP accountable care organizations (ACOs) do not currently have such flexibility because no telehealth waivers are available to them. However, under the MSSP proposed rule, for 2020, CMS has proposed changes for telehealth services provided by ACOs that take on two-sided risk. Specifically, CMS proposes to expand the use of telehealth by ACOs by removing the geographic and originating site restrictions on these services. This means that ACOs will be able to provide telehealth services to beneficiaries in their homes as well as for beneficiaries obtaining care in metropolitan statistical areas (MSAs).

In addition, under the PFS proposed rule, CMS proposes to provide separate payment for new non-face-to-face services, virtual check-in visits, chronic care remote physiologic monitoring, interprofessional consultation, and remote professional evaluation of patient-transmitted information.

In this paper, Milliman’s Susan Philip, Carol Bazell, and Laurie Lingefelt describe these changes in greater detail and also discuss the possible implications for providers and MSSP ACOs in particular.

CMS final rule for skilled nursing facilities and value-based care: Is your organization ready?

On July 31, 2018, the Centers for Medicare and Medicaid Services (CMS) released a final rule that outlined the 2019 fiscal year payment updates and quality program changes for skilled nursing facilities (SNFs). This rule continues the drive for change from fee-for-service to value-based reimbursement and reduces the burden on providers consistent with the Patients Over Paperwork and Meaningful Measures initiatives. Below are the three changes introduced by the final rule and how each change affects SNFs. CMS estimates that the new rule will result in an additional $820 million in Medicare reimbursements to SNFs for the 2019 fiscal year due to the 2.4% increase in payment rates.

Changes to the case-mix classification system

The final rule creates a new Patient-Driven Payment Model (PDPM) for reimbursement that will replace the Resource Utilization Group, Version IV case-mix reimbursement model. This new model focuses on treatment of the whole patient rather than on volume of services. This will decrease paperwork and reduce the overall complexity compared to the old model.

The new PDPM goes into effect for fiscal year 2020, which begins on October 1, 2019, and focuses on clinically relevant factors to determine payment using diagnosis codes. The new model will encourage more contact between healthcare professionals and patients.

PDPM decreases the number of payment group combinations by 80%. It essentially focuses on payments based on the complexity of the patient needs and condition, instead of the volume of hours needed to provide care. Finally, CMS suggests that the new model will reduce the amount of documentation for patient assessments and significantly reduce reporting burdens, saving providers approximately $2 billion over 10 years.

To succeed with this new reimbursement model, SNFs will have to assess the types of patients they treat and may have to adjust treatment plans, including the level of care during stays, and realign their operations accordingly. SNFs will also have to assess their documentation procedures and ensure that patient characteristics and needs are accurately captured.

SNF Quality Reporting Program (QRP)

Also in the final rule, CMS removed measures that were not consistent with the Meaningful Measures initiative. The updated measure set focuses on making care safer, strengthening personal and family engagement, promoting coordination of care, promoting effective prevention and treatment, and making care affordable. There were no new measures suggested or initiated.

SNFs can also educate and engage healthcare professionals and review the new documentation formats for each quality measure. The success in meeting a measure is dependent on the engagement of staff and providers, so that the appropriate coding and documentation meet the quality measure specifications. SNFs can also begin looking at appropriate analytical data, which can help with specific performance needs.

SNF Value-Based Purchasing (VBP) program

The SNF VBP program will begin on October 1, 2018, and will add a positive or negative incentive payment for services rendered by facilities based on the result of their readmission measures. This final rule will reward providers that takes steps to limit 30-day readmissions of their patients to hospitals. SNFs can begin preparations for the VBP program by reviewing their financial, operational, and clinical policies and procedures.


There are several steps that SNFs need to begin to implement now to be ready for the October 1, 2018, implementation of the Value-Based Purchasing program. SNFs are an important part of many Value-Based Purchasing programs and are now being incentivized to provide quality of care to patients. They will be rewarded for looking at the needs of the patient instead of how much time a therapist or caregiver spends with a patient. This new program will allow patients and caregivers to pick facilities that cater to their personal needs for care or rehabilitation.

Maximizing value-based care program performance

Over the past few years, there has been a proliferation of value-based care programs offered by health plans and government payers. These programs, including accountable care organizations, bundled payment programs, and quality incentive programs, often include a multitude of measures related to costs, quality, patient experience, and outcomes, along with various methodologies to determine success.

As the use of value-based reimbursement programs and the associated financial impact increases, it is important for providers to learn the program’s intricacies as well as the analytical, operational, and clinical requirements to ensure its success. In this paper, Milliman consultants Rod Martin and Laurie Lingefelt discuss how success with these programs is possible.