Steven Lash shared PPT on how a Peak Into the Future Healthcare Systems & Hospitals. He shows different-2 health plans for your coming years. Watch and share the info if you think this help for you and others as well.

1. August, 2016

2. Need to Know Where the Puck is
Going

3.  Consolidation of Health Plans
5 major plans down to 3
Regional consolidations
Health Systems starting their own plans
Moving the financing “upstream”
 Federal and State Governments
MACRA legislation
Bundling of major surgical services
Presidential & Congressional election
 Physician Practice Arrangements
Currently more than 200,000 employed
Accenture projects 67% will be employed within 3 years

4.  The Big 5 become the Big 3
Aetna (acquiring Humana)
Anthem (acquiring CIGNA)
United
131 Million covered lives
 Reasons for mergers
Scale Economics
Negotiating leverage with hospitals & physicians
Diversification (more MA plans)
 The consequence for Hospitals & Systems
Anthem has access to national Blues rates; typically lower
Anthem converts all CIGNA agreements to BCBS rates
Margins drop for hospitals

5.  Declining Hospital I/P margins
 Increasing complexity of patient population
 Medical inflation (CMS projects 4.9% - next 3 years)
 Niche players taking profitable lines
 Increasing regulatory developments & scrutiny
 Health Plan negotiating leverage dropping
 New payment models
Bundled payments – CMS
Ortho & Cardiac
Commercial payers to follow
Advanced Alternative Payment Models
NextGen ACOs

6.  MACRA replaces The Sustainable Growth Rate (SGR)
 Will impose 4-9% reimbursement reductions on physicians who do not
move to value based payment methodology
 Annual reimbursement increases are prescribed
 MACRA charts the path for physician compensation for the
next 10 years in 2 separate tracks
 Merit Based Incentive Payments (MIPs)
 Alternative Payment Models (APMs)
 Physicians will wonder the following:
 “How can I avoid the 4-9% cuts in reimbursement under MIPs?”
 “How can I get exempted from MIPs and lock in the annual bonus
payment of 5% under the APM track
 “How do I join an APM?”

7. 2026 and beyond
0.25% annual updates 0.75 annual updates
2019-2025
4-9% penalties/bonuses* 5% lump sum bonus
2015-2018
0.5% annual updates
Merit-based Incentive
Payments (MIPs)
Alternative Payment Models
(APMs)
*Bonuses may be higher
Physicians will Follow the Money

8. ADVANCING CARE
INFORMATION 25%
COST 10%
CLINICAL PRACTICE
IMPROVEMENT ACTIVITIES
15%
(
Performance Category Weights for MIPS
Quality
50%

9. 20192017 2018
MIPS Performance Period
 All MIPS performance categories are aligned to a
performance period of one full calendar year
 2017 performance measurement period
 2019 1st payment year
2024 20252020 2021 I
I
I
2023
25%
2022
50% 75%

10.  Requires Participants (physicians & hospitals) to use certified
EHR technology
 Bases payment on Quality measures comparable to MIPS
quality performance category
 The APM either:
Requires APM entities (hospitals and physicians) to bear more than
nominal risk for monetary losses
Is a Medical Home Model expanded under CMMI
 What are the current APMs under MACRA
MSSP (Track 2 and 3)
NextGen ACO
ESRD
CPC+
OCM (2 sided risk beginning in 2018)

11.  Newest of ACO models; went live in July 2016 with 21
organizations participating
 This is the 3rd version of ACOs
Pioneer (2012- part of ACA)
32 participants; 9 left
Burdensome reporting, limited upside, difficult quality measures
Medicare Shared Savings Program (MSSP)
404 participants; most successful
Fixed some flaws of Pioneer model
2 tracks for cost management; 1/3 received any bonus payments
NGACO
Financial risk of care coupled with quality measures
2 tracks – 80% of savings or losses of 100%
2nd year move to capitation aka a Medicare Advantage Plan

12. Max Adjustment
(+/-)
+5%bonus
(excluded from MIPS)
Fee
Schedule
MIPS
Advanced
APMs

13.  Financial performance
 Improve eroding I/P margins through efficiency & supply chain productivity
 Add new services that are higher in margin
 Improve cash flow through enhanced contracting and denials recovery
 Effective Population Health Management including risk stratification
 Compete on the basis of “Demonstrated Value”
 Best customer experience
 Best price
 Best service
 Documented best outcomes
 Failure to build a robust & viable physician organization
 Ensures the ability to compete in new payment models
 Counterbalance to commercial payors contracting leverage
 Locks in referrals to hospitals
 By sharing risk and quality profitability improves
 For the most part, Physicians are seeking the comfort of the hospital