In 2015, Centers for Medicare & Medicaid Services (CMS) expanded nearly all of its core programs, requirements and participants for value-based care. While some organizations have been successful with these new programs, many continue to struggle, especially as CMS adds more complex programs with higher levels of risk sharing.
ACOs continue to slowly grow
In 2015, accountable care organizations (ACOs) continued to grow both in number of organizations (now over 700¹) and number of covered lives (now over 23 million¹). While CMS programs cover more than 7 million of those lives, Medicaid or commercial programs mange the majority.
CMS also released their final rule on the ACO program, addressing a number of structural issues. These changes eased the burden for participating organizations based on the amount of risk they take. For example, the new Track 3 program allows ACOs to sign up patients to participate (prospective patient assignment), allowing ACOs to better anticipate patients for whom they will be accountable (similar to signing up for a commercial plan).
CMS has also added other tools to help participants, including co-pays to Tracks 2 and 3, enabling ACOs to guide patients to preferred providers. Waivers for some of the fee-for-service check and balances, including the three-day stay for SNFs, homebound criteria for home health agencies and payment to telehealth services are also available under the new rule. However, although CMS added a number of changes to help organizations move into a higher level of risk sharing, many anticipate that approximately 90 percent of participating organizations will remain in Track 1.
Bundled payment programs succeed
CMS's bundled payment program (BPCI) saw strong continued participation, with more than 1,600 organizations participating in Phase 2 and participants in all 48 episodes. This program impacted a number of areas, including reduced length of stay at acute settings, less use of sub-acute care (e.g. SNF, LTAC and IRF) and quality discussions between hospitals and post-acute care providers.
Based on the success of the BPCI program, CMS launched a new program to cover Comprehensive Care for Joint Replacement (CJR), which is mandatory for more than 900 hospitals (67 MSAs). The program, set to launch on April 1, 2016, has many similarities to the bundled payment program, but includes quality and patient satisfaction measures in addition to cost measures per episode. One key element of the program is that hospitals may not "outsource" their risk to a financial convener.
CMS prepares for the IMPACT Act
CMS implemented the first steps toward the Improving Medicare Post-Acute Care Transformation (IMPACT) Act with new Conditions of Participation (CoPs) for hospitals, critical access hospitals and home health agencies. Discharge planning for nearly all patients leaving the hospital and standardized patient-centric processes is at the core of these changes . The CoPs specifically highlight standards around patients transitioning to another facility, as well as patients transitioning home with or without services, including the information that must be shared.
CMS also put a lot of emphasis on patient choice in the new CoPs. Patient goals must be at the center of the process and providers now have to share insights into the quality (e.g. CMS star ratings) for step-down providers to better inform patient choice.
Interoperability remains a struggle
There was continued focus on interoperability with the release of the final rule for Meaningful Use Stage 3 (MU3) and the release of the ONC's 10-year roadmap for interoperability. MU3 increased the requirements for sharing information during the transition process, including greater numbers of patient transitions and a higher level integration requirement for transition information into receiving systems. CMS and ONC have also tried to reduce the burden of the regulations by simplifying many of the measures and increasing connectivity options for many organizations. Despite this, many organizations are still likely to struggle with the new regulations.
What's next for 2016?
Although a number of organizations have recommended that CMS take a slower approach to some of these programs, the speed of change toward value-based care and risk sharing is most likely to increase in 2016. Three key areas of focus are:
• Engagement—Hospitals will need to engage their post-acute and community provider network. Success in any of these models requires engaged, high-quality providers, including warm patient and clinical information hand-offs.
• Transparency—As hospitals engage their post-acute and community providers, all providers will need to provide transparency into what is and is not working so they can pivot together as new programs and changes emerge.
• Enhanced Support—Look at ways to support patients as they transition across the provider community. Many organizations are leveraging additional clinicians (e.g. care navigators) to support patients throughout the process, and data to optimize for longitudinal care.
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