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The Rise of the Narrow Network

Posted by Continuum on Feb 21, 2017 10:30:00 AM

Despite helping reduce costs, are narrow networks the true way of the future?

It's time for a change. As limited provider choice in exchanges rises, and the need to track quality across the patient’s care delivery continuum creates a bigger impact on providers’ bottom lines, practices will need to find means to protect their revenue. This is forcing more and more provider organizations to develop preferred partner lists—another way of saying narrow networks.

There are two key groups impacted by this shift, and they seem to have different feelings about the pros and cons of narrow networks.  

  •  Patient benefits: The healthcare industry can expect to see more narrowing as time goes on. This is, in part, thanks to the benefits to healthcare consumers. Narrow networks offer cheaper premiums—on average, those premiums are 17 percent less than plans with broader networks.[i] In fact, nearly 70 percent of the lowest priced plans are built around narrow networks, ultra narrow networks, and tiered narrow networks.[ii] The downside, though, is higher prices for out-of-network costs—which were, on average, 300 percent higher than the average Medicare rates for 97 common medical procedures.[iii]
  •  Provider concerns: This trend is causing some anxiety amongst providers, and for a couple of different reasons. Providers’ ability to retain their patients may be challenged if their system of narrow networks is not clearly defined. In addition, providers may not have a clear understanding of how their participation or performance will be measured—or what may cause them not to be invited to participate in an ultra-narrow network.
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Topics: healthcare exchanges, narrow network

Hitting the Trails: Take a guide on your value-based care journey

Posted by Continuum on Jan 10, 2017 11:00:00 AM

The healthcare payment landscape seems to change every week. Developing a strategy for success is nearly as tough as assessing what alternative payment model (APM) programs you should pursue. Is there a benefit to staying focused on
fee-for-service? Are pay-for-performance models the right path for your organization? How much risk is too much risk for you?New Call-to-action

The good news is there’s no one path to value-based care success. The various programs offer different benefits to healthcare organizations of all types. Understanding the full ecosystem of programs available to you is critical to make sure you start your journey to future success on the right path.

As with any journey, keeping a guide handy is a smart plan. Continuum’s value-based payment experts have developed a new reference to help you make sure you’re on the right track. This infographic, “The Trail Guide to Value-Based Care Success,” offers key insights and reminders about the benefits for various payment programs, common challenges, and tips for making the most of your participation.

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Topics: value-based reimbursement, payment reform

MACRA Final Rule: 4 Key Changes

Posted by Continuum on Nov 15, 2016 11:15:00 AM

The Centers for Medicare & Medicaid Services (CMS) recently released its final rule for sweeping reimbursement regulations that start on Jan. 1, 2017.
Known as MACRA (the Medicare Access and CHIP Reauthorization Act of 2015), this legislation will have a profound impact on physicians and their practices.

On the plus side, the final rule softens some of the proposed regulations. This easing should help providers comply and thereby support CMS’s goals: to enhance care quality, reduce overall costs of care, and improve patient satisfaction. The best-performing providers will receive the greatest payment increases.

At the same time, eligible Medicare providers who have not yet prepared for MACRA should move quickly. Those who ignore the new reporting requirements completely -- by not submitting data to CMS -- will receive the full 4% payment penalty for 2017, and greater reductions thereafter.

MACRA establishes the Quality Payment Program (QPP), which offers providers a choice between two reporting tracks: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (Advanced APM).

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Topics: MACRA

The medical home model: What physicians need to know

Posted by Continuum on Nov 1, 2016 1:08:19 PM

The concept of a “medical home” has evolved over the years, starting in the 1960s as the center of medical records for a child with special healthcare needs. Today, that definition is greatly expanded: A medical home is a partnership between the patient, family and primary care provider, in cooperation with specialists and community supports, according to the U.S. Department of Health and Human Services. It can encompass children and adults, regardless of their healthcare needs.

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Topics: Value-Based Healthcare, MIPS, APMs

Do you have what it takes to thrive as an independent physician?

Posted by Continuum on Aug 30, 2016 2:00:00 PM

Fortune favors the bold

The primary care market is shifting. Shifting regulations and evolving payment models are shaking the foundations of traditional independent primary care practices—and these market forces are even stronger than new and old competitors. As the CEO of a physician practice in Maryland recently told us:

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Topics: CIN, ACO, independent physician practice

Medicare Quality Data: Who Must Report?

Posted by Continuum on Aug 16, 2016 11:00:00 AM

Starting next year, most doctors will be required to report quality data under Medicare’s new Merit-Based Incentive Payment System (MIPS). MIPS will apply to other clinicians, too, such as physician assistants and nurse practitioners. However, many thousands of practitioners will be exempt from these requirements, if they meet certain criteria.

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Topics: value-based reimbursement, MIPS, APMs, Alternative Payment Models

Five ways to balance the cost side of the VBM equation

Posted by Continuum on Aug 2, 2016 11:00:00 AM

Continuum’s recent white paper, “How Physicians Can Win in the New Healthcare Environment,” explored several key strategies on how to transform the physician practice to capitalize on healthcare reform initiatives. In that paper, we examined five ways to maximize the value-based payment modifier adjustment, primarily from a quality perspective.

There’s another dimension to the quality improvement that value-based care aims for: there’s the means to reduce cost. Not just the cost to your practice, it’s the total cost of care. Here are five key methods to help reduce high costs in the value-based care world.

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Topics: Value-Based Modifer

Understanding Alternative Payment Models' (APMs) Impact on a Practice

Posted by Continuum on Jun 21, 2016 4:28:25 PM

As healthcare shifts from a fee-for-service to a value-based system, Medicare is making sweeping changes to how it reimburses physicians. The Centers for Medicare and Medicaid Services (CMS) has introduced new regulations and reporting requirements – as well as unprecedented potential for financial rewards and penalties.Commercial payers are adopting similar models, further expanding the potential impact of these changes.

Choose Your Path

The Medicare Access & CHIP Reauthorization Act (MACRA) of 2015 created the Quality Payment Program (QPP), which offers physicians a choice between two different reporting paths. Both start in the 2017 reporting year; the Merit-Based Incentive Payment System (MIPS)  and Advanced Alternative Payment Models (APMS). For more information on MIPS, see our previous blog post and read our whitepaper.

In this blog, we focus on APMs, payment arrangements in which clinicians accept financial risk for providing coordinated, high-quality care. As an incentive to take on this risk, CMS offers increased monetary rewards. CMS has designated specific payment models as Advanced APMs – including certain medical homes, accountable care organizations (ACOs) and bundled payment models -- and it will continue to approve new models. Advanced APMs are similar to one another, with variations based primarily on the different quality measures they use – such as those for primary care, oncology, and end-stage renal disease. 

The APM track offers higher financial rewards than the MIPS track, but requires more advanced levels of value-based activities. APMs also require physicians to be part of a larger group (such as an ACO or medical home), and to bear greater financial risk (more on that below). Most physicians who see Medicare patients will be required to report under either the MIPS or Advanced APM track starting in January 2017. Those in Advanced APMs must still complete MIPS reporting for the first year (2017) so CMS can determine whether they meet the Advanced APM requirements. Additionally, 2017 MIPS reporting will provide spending benchmarks for a prospective Advanced APM.


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Topics: value-based reimbursement, CMS, Alternative Payment Models

Alternative Payment Models (APMs) Preview

Posted by Continuum on Jun 7, 2016 11:00:00 AM

As healthcare shifts from a fee-for-service to a value-based system, Medicare is making sweeping changes to how it reimburses physicians. The Centers for Medicare and Medicaid Services (CMS) has introduced new regulations and reporting requirements – as well as unprecedented potential for financial rewards and penalties. 

Indeed, doctors who achieve the highest levels of “value” will earn substantial increases in their Medicare Part B payments. Conversely, those who do little or nothing to address the new requirements will incur significant reductions. Commercial payers are adopting similar models, further expanding the potential impact of these changes – positive or negative – on a practice.

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Topics: value-based reimbursement, CMS, Alternative Payment Models

Know Thy Patient: The Importance of Accurate Patient Attribution

Posted by Continuum on May 17, 2016 11:00:00 AM

As healthcare payment and delivery models continue to evolve, providers are increasingly being held more accountable for the health, quality of care, and overall costs associated with their patient population. Provider reimbursements are dependent on the quality of care delivered and the overall risk of their assigned patients. Attribution, or the process of assigning patients to primary care providers (PCP), has therefore become a critical component in maximizing reimbursement and succeeding under the rules and regulations of a shared savings contract.

Understanding Attribution

Unfortunately, there is no exact science for accurately defining a patient population. There are many variables to consider, especially when patients are free to seek care from any provider they choose. If a patient sees multiple providers in multiple networks, only the attributed provider (or provider group) is responsible for the patient’s cost and quality of care. For this reason, it is very important for physicians to understand who their patients are – prioritizing those who are sickest – and to coordinate care effectively in order to keep costs low and avoid duplicate services.

Effective care coordination, however, is only possible if the provided data is reliable. Attribution lists from payers typically depend on retrospective data, usually based upon the previous 12 months, which makes it difficult for physicians to predict and address patient needs in the year ahead. Most payers also attribute patients to PCPs, but a patient with chronic or urgent conditions may see a specialist physician more than a PCP.

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Topics: patient satisfaction, patient attribution, patient experience

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