Tag Archives: value-based reimbursement

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.

Addressing challenges in the transition to value-based care and alternative payment models

With the shift to value-based payment for healthcare in the United States, an array of alternative payment models (APMs) has emerged that introduce challenges along with opportunities for providers. This paper by Milliman consultants highlights the key aspects of APM payment methodologies and uses the Centers for Medicare and Medicaid Services Oncology Care Model as a case study to illustrate these concepts.

Developing alternative payment models under MACRA

Alternative payment models (APMs) have become a popular way to tie payment to quality of care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created incentives for providers to participate in APMs. This paper by Daniel Muldoon and Pamela Pelizzari explores key clinical and financial considerations that need to be addressed in a robust APM proposal.

Implication of coding on risk adjustment and valued-based contracting

Healthcare providers are measured on certain performance metrics that dictate their payment amounts under value-based contracts. Risk adjustment plays an integral role in determining financial performance. In order for these contracts to be equitable for insurers and providers, risk adjustment must accurately capture changes in population morbidity to effectively measure the provider’s true cost impact.

In this article, Milliman’s Rong Yi, Howard Kahn, and Jared Hirsch highlight common data issues that affect risk scores. They also discuss practices that can improve coding efforts related to risk adjustment.

Risk adjustment modifications in view of potential CSR subsidy termination

If the cost-sharing reduction (CSR) subsidies of the Patient Protection and Affordable Care Act (ACA) were eliminated, it could expose insurance carriers to a substantial increase in selection risk related to their particular mixes of business. In August, the Centers for Medicare and Medicaid Services (CMS) announced its intention to propose a set of risk adjustment modifications for states in which insurance carriers raise silver premiums in response to potential CSR subsidy termination.

In this paper, Milliman’s Jeffrey Milton-Hall, Doug Norris, and Jason Karcher explore the CMS proposal along with the current ACA risk adjustment program and three other potential alternative modifications to risk adjustment in response to the possible elimination of CSR funding.

Exploring the nuances of MACRA

The major terms and conditions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are becoming more well-known during the first performance year, but some aspects of the new physician payment system law still can be elusive for physician practices and other healthcare organizations. In this article, Milliman’s Pamela Pelizzari discusses details that may be overlooked regarding participation in the Merit-based Incentive Payment System track and the advanced alternative payment model track of MACRA.

This article was published by the Healthcare Financial Management Association.