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Physicians and health care providers continue to improve quality
of care, lower costs Affordable Care Act Accountable
Care Organization initiatives put patients at the center of their care while
generating more than $1.29 billion in total Medicare savings since 2012
The Centers for Medicare &
Medicaid Services (CMS) today announced the 2015 performance year results for
the Medicare Shared Savings Program and the Pioneer Accountable Care
Organization Model that show physicians, hospitals, and health care providers
participating in Accountable Care Organizations continue to make significant
improvements in the quality of care for Medicare beneficiaries, while achieving
cost savings. Collectively, Medicare Accountable Care Organizations have
generated more than $1.29 billion in total Medicare savings since 2012.
“The coordinated, physician-led
care provided by Accountable Care Organizations resulted in better care for
over 7.7 million Medicare beneficiaries while also reducing costs,” said CMS
Acting Administrator Andy Slavitt. “I congratulate these leaders and look
forward to significant growth in the program in the coming year.”
In 2015, Medicare Accountable Care
Organizations had combined total program savings of $466 million, which
includes all Accountable Care Organizations’ experiences, for 392 Medicare
Shared Savings Program participants and 12 Pioneer Accountable Care
Organization Model participants. The results show that more Accountable Care
Organizations shared savings in 2015 compared to 2014 and those with more
experience tend to perform better over time.
Today’s results from the Medicare
Shared Savings Program and the Pioneer Accountable Care Organization Model show
significant improvements in the quality of care providers are offering to an
increasing number of Medicare beneficiaries. Accountable Care Organizations are
judged on their performance, as well as their improvement, on an array of meaningful
metrics that assess the care they deliver. Those metrics include how highly
patients rated their doctor, how well clinicians communicated, whether patients
are screened for high blood pressure, and their use of Electronic Health
All 12 participants in the Pioneer
Accountable Care Organization Model improved their quality scores from 2012 to
2015 by more than 21 percentage points. Overall quality scores for nine out of
12 Pioneer participants were more than 90 percent in 2015.
Accountable Care Organizations in
the Medicare Shared Savings Program also continued to show improvement, with
Accountable Care Organizations that reported in both 2014 and 2015 improving on
84 percent of the quality measures that were reported in both years.
Additionally, comparing 2014 and 2015 results, average quality performance
improved by more than 15 percent on key preventive care measures including
screening for risk of future falls, depression screening and follow-up, blood
pressure screening and follow-up, and providing pneumonia vaccinations.
By meeting quality performance
standards and their savings threshold, 125 Accountable Care Organizations
qualified for shared savings payments. Since the passage of the Affordable Care
Act, more than 470 Medicare Accountable Care Organizations – serving nearly 8.9
million Medicare beneficiaries – have been established through the Medicare
Shared Savings Program, the Pioneer Accountable Care Organization Model, the
Next Generation Accountable Care Organization Model, and the Comprehensive
End-Stage Renal Disease Care Model.
“Accountable Care Organization
initiatives in Medicare continue to grow and achieve positive results in
providing better care and health outcomes while spending taxpayer dollars more
wisely,” said Dr. Patrick Conway, CMS Principal Deputy Administrator and Chief
Medical Officer. “CMS continues to work and partner with providers across the
country to improve the way health care is delivered in the United States.”
Accountable Care Organizations were
created to change the incentives for how medical care is delivered and paid for
in the United States, moving away from a system that rewards the quantity of
services to one that rewards the quality of health outcomes. They are groups of
doctors, hospitals, and other health care providers who voluntarily come
together to develop and execute a plan for a patient’s care and share
information, putting the patient at the center of the health care delivery
system. In addition, under the proposed Quality Payment Program, health care
providers that sufficiently participate in advanced tracks of Medicare
Accountable Care Organizations may qualify for exemption from payment
adjustments under the Merit-based Incentive Payment System, as well as the
additional incentive payments available beginning in 2019 for participation in
Advanced Alternative Payment Models.
The Affordable Care Act provides
tools, such as Medicare Accountable Care Organizations, to move our health care
system toward one that provides patients with high-quality,
cost-effective care. Today’s announcement is part of the Administration’s
broader strategy to improve the health care system by paying providers for what
works, unlocking health care data, and finding new ways to coordinate and
integrate care to improve quality. These efforts support the Administration’s goal to have 50 percent
of traditional Medicare payments flowing through alternative payment models by
2018 (already, 30 percent of Medicare payments go through alternative models).
continues for the Affordable Care Act as enrollment figures hit less than half
of the initial projection, and insurance companies continue to pull out of
already sparsely populated markets.
Just 11.1 million people have signed up for health coverage through the
federally and state-operated online exchanges as of this year – significantly
behind the Congressional Budget Office’s February prediction of 24 million by
2016. With a risk pool of much older, much sicker policyholders than originally
expected, major insurance companies have been exiting the exchanges in a hurry,
eager to avoid further financial losses.
As a result, every healthcare stakeholder, from provider networks to insurance
agents to consumers, is being squeezed by the shrinking marketplace. The Kaiser
Family Foundation put out a report this month estimating that more than one in
four counties is at risk of having a single insurer on its exchange, and
industry experts say that barring a significant shift in policy, the situation
is unlikely to change soon.
“In this environment, only carriers with extraordinarily large risk pools can
survive,” David Reid, chief executive with broker benefits software group
EaseCentral, told Insurance Business America. “The cost of healthcare is
going up and provider networks are consolidating. That’s why you’re seeing so
many groups looking to consolidate.”
But the US Justice Department has moved to block two of the largest mergers –
those between health insurers Aetna and Humana, and Anthem and Cigna – and
without the ability to mitigate risk through larger risk pools, health
insurance premiums will continue to rise.
That puts pressure on brokers to perform, particularly in the small group
health area, Reid said.
“We’re seeing very significant cost increases out there: between 59% and 69% in
Texas, and the East Coast is the same,” he said. “When customers face big cost
increases, they’re looking to their broker to provide some alternatives beyond
deductibles in the $3,500 and $5,000 range. They’re looking for new creative
mechanisms designed to help costs.”
Three of the most popular alternatives to traditional group health have proven
to be small business exchange-style platforms, the use of telemedicine and the
adoption of defined contribution benefit schemes.
This last option is particularly promising. These reimbursement structures, in
which employers provide workers with a lump sum to use in purchasing their own
insurance, are still gaining traction. Just 2% of employers use defined
contributions, according to a recent Arthur J. Gallagher survey, but that’s
expected to jump an additional 15% by 2018.
Reid describes this as a “great response to what’s happening” in the market,
and was firm on the importance of a trusted advisor in facilitating this and
other health insurance alternatives.
“I have no doubt the broker will be involved and have a position in the
market,” he said. “As long as you’re bringing efficiency and consultative
services that provide companies with an advocate on their side, they will play
a high-touch, valuable role in the healthcare system.”
And as to the issue of commission compression, which is driving many of those
brokers out of the market?
“The reduction in commission is very real, but those agencies that are using
tech-based solutions are able to operate more efficiently and get a greater
return on investment,” Reid said. “There are actually new people jumping into
the business because of these opportunities.”
CMS proposes new standards to strengthen the
Marketplace for 2018
The Centers for Medicare
& Medicaid Services (CMS) today issued the proposed annual Notice of
Benefit and Payment Parameters for 2018, which proposes additional steps to
strengthen the Health Insurance Marketplace. CMS is issuing this rule
earlier in the calendar year in order to provide more certainty to the
Marketplace as it continues to mature.
"Right now, we are preparing
to serve millions of consumers with a new set of innovations during the
upcoming Marketplace Open Enrollment. As we do this, we are proposing today a
set of critical actions based upon our first 3 years' experience that, if
finalized, would improve how consumers and health plans interact with the
Marketplace," said Acting Administrator of the Centers for Medicare and
Medicaid Services Andy Slavitt. "These proposals help fulfill the promise
that affordable, quality health coverage can be provided to everyone who needs
Beginning in 2017, the proposed
policies will take important steps to strengthen one of the Marketplace’s key
tools for protecting consumers’ access to high-quality, affordable coverage
options: the risk adjustment program. The rule introduces changes that will
make risk adjustment even more effective at pooling risk, allowing issuers to
focus on meeting the needs of consumers. First, the rule proposes updates
beginning in 2017 to better reflect the risk associated with enrollees who are
not enrolled for a full 12 months. Second, beginning in 2018, the rule proposes
to use prescription drug utilization data to improve the predictive ability of
our risk adjustment models. Third, also beginning in 2018, the rule proposes to
establish transfers that will help to better spread the risk of high-cost
enrollees, a change that would improve the risk-sharing benefits of the
In addition to these improvements
to risk adjustment, this proposed rule contains other provisions to improve the
Marketplace consumer experience and strengthen the individual and small group
markets as a whole. The proposed rule would give consumers additional tools for
assessing the networks of competing plans; broaden availability of this year’s
new standardized plan options by accommodating state cost-sharing rules; and
create consumer protections for consumers enrolling through the direct
enrollment channel. The proposed rule would also create multiple child age
bands that address instances in which consumers could face large premium
changes after turning age 21; amend the guaranteed renewability regulations to
provide additional flexibility for issuers to remain in an insurance market in
certain situations; and codify several special enrollment periods that are
already available to consumers in order to ensure the rules are clear and to
limit abuse. It also seeks information on a number of suggestions offered by
issuers, consumers, providers, and others on further improving the risk pool,
such as additional changes to special enrollment period policies or outreach;
clarifying coordination of benefit rules between Medicare, Medicaid, and the
Marketplace; and providing greater certainty on the amount of user fee revenue
spent on education and outreach.
Today’s proposed rule builds on
other recent actions to strengthen the Marketplace, including a recent request for
information seeking public comment on concerns that some health care providers
and provider-affiliated organizations may be steering Medicare or Medicaid
enrolled or eligible people into a Marketplace qualified health plan to obtain
higher reimbursement rates; the announcement of a new outreach strategy
targeting young adults; and the introduction of a pilot project in certain
states to display information regarding QHP provider networks to promote
greater transparency on HealthCare.gov.
health care costs are expected to increase 5.0% in both 2016 and 2017.
Here are some of the measures employers are using to control costs:
of employers have added programs to ensure appropriate use of high-cost
drug; 88% indicated that their top priority over the next three years is
managing pharmacy spending, especially for high-cost specialty drugs:
of employers have already implemented surcharges for spousal coverage when
it is available through a spouse’s own employer
of employers have differentiated benefit coverage to encourage employees
to use centers for excellence for specialty services
Texas Medicaid has issued a
standing order allowing participating pharmacies to provide mosquito repellent
to eligible patients in Medicaid and Children’s Health Insurance Plan without a
prescription from a patient’s healthcare provider.
Eligible patients enrolled in
Healthy Texas Women no longer require a prescription for mosquito repellent to
be covered by their insurance. Patients enrolled under this program may now
request mosquito repellent directly from a pharmacy.
Pharmacies have been provided
with the claims processing information for use of the standing order and for
the processing of claims for patients enrolled in Healthy Texas Women.
Patients in Medicaid and CHIP
without access to a pharmacy that uses a standing order for the dispensing of
mosquito repellent will continue to require a prescription for the repellent.
For these patients, prescribers are recommended to use telephone, fax or
electronic prescribing to send prescriptions to pharmacies and to avoid
requiring an office visit solely to provide a prescription for mosquito
examines inappropriate steering of people eligible for Medicare or Medicaid
into Marketplace plans
Concerns raised about impact of 3rd party premium provider &
affiliated organization payments
The Centers for Medicare & Medicaid
Services (CMS) today issued a request for information seeking public comment on
concerns that some health care providers and provider-affiliated organizations
may be steering people eligible for, or receiving, Medicare and/or Medicaid
benefits into Affordable Care Act-compliant individual market plans, including
Health Insurance Marketplace plans, for the purpose of obtaining higher
reimbursement rates. CMS also sent letters to all Medicare-enrolled dialysis
facilities and centers informing them of this announcement.
The request for information and
letters to providers focus on situations where patients may be steered away
from Medicare or Medicaid benefits, which can among other concerns, result in
beneficiaries experiencing a disruption in the continuity and coordination of
their care as a result of changes to their network of providers. These actions
reflect ongoing efforts by the CMS Center for Program Integrity to address
possible issues in the Marketplace that could affect the integrity of the programs
for both consumers and issuers, and the costs of the individual insurance
market, while at the same time help ensure patients are enrolled in the right
plan for them.
“Ensuring access to high quality
patient care is a top priority for us. We are concerned about reports that some
organizations may be engaging in enrollment activities that put their profit
margins ahead of their patients’ needs,” said CMS Acting Administrator Andy
Slavitt. “These actions can limit benefits for those who need them, potentially
result in greater costs to patients, and ultimately increase the cost of
Marketplace coverage for everyone.”
“It is improper to influence people
away from Medicare or Medicaid coverage for the purpose of financial gain,”
said Shantanu Agrawal, M.D., CMS Deputy Administrator and Director of the
Center for Program Integrity. “Our goal is to protect patients from being
unduly influenced in their decisions about their health insurance options, and
to protect the integrity of all the programs we oversee.”
Currently, third-party payment of
premiums and cost sharing of qualified health plans in the individual market by
health care providers such as physicians, medical facilities or affiliated
non-profit organizations are discouraged, but the ultimate decision about
accepting those payments are left to health insurance companies. This guidance
does not apply to certain federal, state or local government programs, Ryan
White HIV/AIDS programs or Indian tribes, tribal organizations and urban Indian
organizations, which are expressly permitted to pay insurance premiums for
consumers under CMS regulations. Recently, concerns have been raised that
certain providers or organizations affiliated with specific providers may steer
consumers into individual market plans, including Marketplace health plans,
because they would receive higher payment rates under a private plan than under
Medicare or Medicaid.
In addition to asking for more
information on instances of problematic steering of consumers to individual
market plans, CMS is also considering potential regulatory and operational
options to prohibit or limit premium payments and routine waiver of
cost-sharing for qualified health plans by health care providers, revisions to
Medicare and Medicaid provider enrollment rules, the imposition of civil
monetary penalties for individuals that fail to provide correct information
about consumers enrolling in a plan, and potential changes that would allow
issuers to limit their payment to health care providers to Medicare-based
amounts for particular services and items of care. In particular, CMS is
looking at authorities to impose civil monetary penalties on health care
providers when their actions result in late enrollment penalties for Medicare
eligible individuals who are steered to an individual market plan and, as a
result, are delayed in enrolling in Medicare.
See the quick reference guide for
step-by-step instructions to address the following possible issues:
Turn off your computer’s pop-up blockers.
Download and use the free web browsers that work best
with the MLMS: Firefox or Google Chrome.
Download the latest version of Adobe Flash to optimize
display of animations.
Access the training for registration on a desktop or
laptop computer. (The Marketplace training cannot be accessed on a tablet
or other hand-held/mobile device.)
Check with your network provider for more assistance if
you encounter bandwidth and server issues.
you must access both the MLMS and CMS-approved vendor training via the CMS
Enterprise Portal. For a better user
experience, the best days and times to access registration and training are
Monday through Friday, between 5:00 PM and 11:00 AM ET and on the weekends.
... a landmark
piece of legislation [like the Affordable Care Act] would be adjusted over time
to improve it. ACA is far overdue for that. Republicans have not wanted to make
commonsense adjustments because they have wanted the whole law to collapse. To
me a major opportunity is to change the age-rating bands so that a 65-year-old
can be charged 5 times what a 21-year-old is charged rather than 3 times. This
will enhance the viability of the exchanges and in general make health
insurance more popular among younger, healthier people." —
David Williams, co-founder of the Boston consulting firm Health Business Group,
told AIS's Health Plan Week.
... services delivered by
telehealth are covered by Medicare, including emergency department or initial
inpatient consultations, office or other outpatient visits, and individual
psychotherapy provided in rural areas.