The shift to value in healthcare is no easy feat. While the Centers for Medicare and Medicaid Services (CMS), accountable care organizations (ACOs) and healthcare systems are all working towards it, true success requires a commitment to collaboration, communication and transparency.
The data is clear – policymakers are making every effort to reduce healthcare costs, particularly as states struggle with significant budget deficits across the country. To do this, many state governments have elected to outsource the management of Medicaid and Medicare programs to managed care companies. According to Modern Healthcare, 34% of Medicare beneficiaries are now enrolled in a Medicare Advantage plan, which is administered by a private payer. Similarly, 77% of Medicaid beneficiaries are enrolled in some form of managed care plan.
Earlier this month, CMS announced changes to future payments for Medicare Advantage plans that will take effect in 2020. While a pay raise is part of the plan, what’s causing a stir is that payment will now be based on a higher percentage of patient encounter data (up to 25% from 10%). Many (especially payers) have argued that encounter data is often incomplete and inaccurate when compared to diagnoses, since encounter data relies on provider documentation.
Balancing the competitive landscape that comes with physician practice consolidation combined with population health and the shift to value-based care is a lot to consider for busy hospital physician practices. Add in the constant changes in regulatory guidelines, enhancing the patient experience and most importantly – a continued focus on quality and safety and most hospital administrators have little resources left to focus on improving the revenue cycle.
Lots of questions and headlines began swirling earlier this month after the Centers for Medicare and Medicaid Services (CMS) released its hospital star ratings – a “seemingly” simple system designed to help consumers make informed decisions about hospitals and the care they deliver. While consumers are used to 5-star ratings for hotels and restaurants, the healthcare industry is clearly far more complex. As such, a cloud of mystery and skepticism surrounds this incredibly powerful rating system – especially for the thousands of hospitals who participate in Medicare and are therefore automatically subject to stardom whether they like it or not.
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