Tag Archives: Lynn Dong

What should payers and providers understand about joint venture health plans?

Joint venture health plans are still relatively new to providers and payers. It’s important for both sides to engage a skilled actuary who can assess the potential risks and benefits of such a partnership. In this article, Milliman actuary Lynn Dong provides some perspective on the following questions that providers and payers must consider concerning joint venture arrangements.

• How much is the provider system’s volume likely to increase?
• What is the provider’s range of potential outcomes under the rate concession or risk-sharing arrangement? How does this compare with the current contractual reimbursement arrangements?
• What insurance risks are transferred from the payer to the provider, and how will these risks be managed?
• How will the responsibility for care management, ongoing data and financial reporting, and financial settlements be allocated? What additional resources will be needed from the provider and payer to perform these functions?
• What ongoing data and reports will be made available to the provider? What level of detail will be available, and how often will this information be provided?
• What are the key financial, strategic, and business risks for the provider and payer?

MACRA considerations for Medicare Advantage plans

The Medicare Access and CHIP Reauthorization Act (MACRA) makes significant changes to the Medicare payment system by introducing a quality-based payment model. While MACRA primarily affects Part B clinicians, there are numerous implications that Medicare Advantage (MA) plans should consider. A strategic approach can help MA plans understand and respond to the legislation.

In the article “MACRA and Medicare Advantage plans: Synergies and potential opportunities,” Milliman actuaries explore the answers to the following questions:

• How will MACRA affect MA plans’ provider payments?
• What synergies exist between MACRA’s quality scoring and the MA Stars quality program?
• How can MA plans help providers achieve Qualifying Participant (QP) status?
• What incentives exist under MACRA for providers to improve risk score coding?
• How are MA plans in the market responding to MACRA?

Read Milliman’s “MACRA: The series” to learn how the legislation will affect providers, alternative payment models, and health plans

Advanced APM considerations for clinicians

Two value-based reimbursement models exist under the Medicare Access and CHIP Reauthorization Act (MACRA) that tie Part B payments to clinician performance: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (Advanced APM) track. The Advanced APM track encourages groups of clinicians to shift from fee-for-service to delivery models in which clinicians assume more accountability and risk for the cost and quality of care. In the initial years of the program, MACRA provides incentive payments to early APM adopters.

This paper written by Milliman’s Lynn Dong and Pamela Pelizzari explores the definition of an Advanced APM, how providers can qualify to be paid under the provisions of the Advanced APM track instead of under MIPS, and why that might be desirable. In addition, the authors highlight the need for careful evaluation regarding APM participation because there is often a complex interaction between the risk inherent in an Advanced APM and the benefits under MACRA.

The article is part of a series examining the impacts of MACRA on providers, alternative payment models, and health plans. To read other articles in the series, click here.

MACRA issues for providers to consider

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) presents several key issues for providers. In this article, Milliman’s Lynn Dong, Colleen Norris, and Christopher Kunkel examine the five considerations below related to MACRA and how they may affect providers. The authors also highlight details from the proposed regulation as well as potential implications for providers.

1. Under MACRA, the Medicare Part B fee schedule increases only slightly through 2019 and not at all from 2020 through 2025. After 2025, there will be minimal annual increases to the Part B fee schedule.

2. The Merit-Based Incentive Payment System (MIPS) consolidates and streamlines three existing programs, resulting in both negative and positive adjustments to providers’ current reimbursements.

3. MACRA encourages providers to participate in Alternative Payment Models.

4. Providers will need to make numerous decisions regarding the submission of quality metrics, participation in Clinical Practice Improvement Activities (CPIAs), and Advancing Care Information.

5. Participation in an Alternative Payment Model (APM) requires a careful review of potential financial risks and opportunities.

The article is part of a series examining the impacts of MACRA on providers, alternative payment models, and health plans. To read other articles in the series, click here.

Pioneer ACOs in action

California Healthline looks at San Diego-based Sharp HealthCare’s selection as a Pioneer accountable care organization (we blogged about this brand of ACOs earlier this week). Here is an excerpt:

According to Alison Fleury, CEO of the Sharp HealthCare ACO, the ability to inform beneficiaries ahead of time whether they were assigned to an ACO was an important step in learning about the population Sharp will be managing.

Under the program, beneficiaries who received the majority of their care from a care provider within an ACO network during the past three years are aligned with that ACO.

Finally, the ability to move from a shared-savings model to a population-based payment arrangement was very important for many organizations.

“One thing at least some of the organizations are excited about is that eventually CMS would be willing to go to a capitated approach. I think a lot of these Pioneer ACOs, given that they are leaders in care coordination already, like that option,” said John Pickering, principal consulting actuary with the actuarial and consulting firm Milliman…

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Evaluating bundled payment contracting

Alternatives to traditional fee-for-service (FFS) reimbursement have gained attention as financial pressures mount and as many recognize how FFS may not provide incentives for efficient care. The recent Centers for Medicare and Medicaid Innovations (CMMI) Bundled Payments for Care Improvement Initiative is a prominent example, as are private payor contracts.

This healthcare reform briefing paper provides an overview of bundled payments and discusses recent developments, as well as an analysis of considerations in contracting for bundled payments.