There is a new sheriff in town, and she is a woman. Under the guidance of the administrator of CMS, Seema Verma and the Secretary of Health and Human Services, Alex Azar, a large number of innovations are being proposed at CMS.
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The categories of innovation are organized into seven categories.
Accountable Care Organizations and similar care models are designed to incentivize health care providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, high quality and efficient service delivery.
Episode-based Payment Initiatives (bundled care/payments)
Under these models, health care providers are held accountable for the cost and quality of care beneficiaries receive during an episode of care, which usually begins with a triggering health care event (such as a hospitalization or chemotherapy administration) and extends for a limited period of time thereafter.
Primary Care Transformation
Primary care providers are a key point of contact for patients’s health care needs. Strengthening and increasing access to primary care is critical to promoting health and reducing overall health care costs. Advanced primary care practices � also called �medical homes� � utilize a team-based approach, while emphasizing prevention, health information technology, care coordination, and shared decision making among patients and their providers.
Initiatives Focused on the Medicaid and CHIP Population
Medicaid and the Children�s Health Insurance Program (CHIP) are administered by the states but are jointly funded by the federal government and states. Initiatives in this category are administered by the participating states.
Initiatives Focused on the Medicare-Medicaid Enrollees
The Medicare and Medicaid programs were designed with distinct purposes. Individuals enrolled in both Medicare and Medicaid (the �dual eligibles�) account for a disproportionate share of the programs� expenditures. A fully integrated, person-centered system of care that ensures that all their needs are met could better serve this population in high quality, cost-effective manner.
Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models
Many innovations necessary to improve the health care system will come from local communities and health care leaders from across the entire country. By partnering with these local and regional stakeholders, CMS can help accelerate the testing of models today that may be the next breakthrough tomorrow.
Initiatives to Speed the Adoption of Best Practices
Recent studies indicate that it takes nearly 17 years on average before best practices – backed by research – are incorporated into widespread clinical practice�and even then the application of the knowledge is very uneven. The Innovation Center is partnering with a broad range of health care providers, federal agencies professional societies and other experts and stakeholders to test new models for disseminating evidence-based best practices and significantly increasing the speed of adoption.
Alternative Payment Models are part and parcel of the overall process and are not mutually exclusive from ACO, Bundled Payments, Primary care transformation nor the rest of CMS innovation.
2018. There are 649 ACOs across the U.S., according to the National Association of ACOs, including Medicare ACO program participants and independent ACOs. Around 12.3 million Medicare beneficiaries � 20 percent of all Medicare beneficiaries � participate in an ACO
As of July 2019, there are 559 Medicare ACOs serving more than 12.3 million beneficiaries with hundreds more commercial and Medicaid ACOs serving millions of additional patients. This is a reduction of 90 ACOs or roughly 20%. The survival rate is about 80% after one year. Organizing and implementing a new “group practice” in its own right and adding the goal of increasing savings if a challenge. Administrative costs for the organization, marketing and recruitment are substantial. It is surprising that almost 80% survived their first year of operation. Many of the still-functioning ACOs are in hazardous waters financially. It will be interesting to see what plays out in the next five years.
2. Episode-based Payment Initiatives
Problems with bundled medical codes