On February 24th, CMMI announced revisions to the Medicare FFS Global and Professional Direct Contracting (GPDC) model, which will now be re-branded as the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model. As part of this revision, there will be an application window for this program spanning March 7th through April 22nd.
This session will discuss this new program’s requirements and financial components, including how this program compares to the existing GPDC model as well as MSSP. Attendees will develop a deeper understanding of the ACO REACH model, and the pros and cons of joining or staying in the program vs exploring other options.
In this session, Milliman experts provide relevant, timely and useful information about the state of the MSSP ACO market. Given that MSSPs represent such a large portion of the Medicare FFS landscape, it is worthwhile to look at the available data for how ACOs have performed and evolved over time. We can then use this data to better understand what MSSP features may be associated with financial success. It is just as important to see what factors are not correlated with success or failure in the program.
In order to provide insights on these drivers, Milliman analyzed CY 2020 experience for MSSP ACOs as reported in CMS 2020 Shared Savings Program Public Use Files, as well as 2015-2019 PUFs, to identify and examine key MSSP trends and patterns in shared savings/loss rates, participation, and other key metrics.
Financial results for 2020 may have been materially impacted by the pandemic as well as CMS’s modifications to MSSP rules and regulations. Due to the potential for skewed results, as well as to highlight potentially longer-term observations, prior year savings outcomes were analyzed as well.
In this session, Milliman experts present their findings that the drivers of recent success are quite different and, in some cases, the opposite of what they were in 2015. With Pathways to Success, CMS endeavored to reshape the MSSP by adjusting incentives, encouraging greater accountability in ACOs, and offering options specific to each ACO’s ability to take on risk. Their analysis gives early indication that these changes are rewarding ACOs for attained efficiency levels, possibly enhancing the attractiveness of the program. Furthermore, the authors also see evidence of at least some correlation between tracks with downside risk and higher gross savings, supporting CMS’s case for accountability as a policy priority, though voluntary track selection may also be playing a role. Lastly, the authors see some indication that ACOs strongly emphasizing primary care are having greater success than their peers.
The pandemic has shifted how and where Americans gain access to care, a shift large enough to influence multiple aspects of price and utilization and, thus, medical cost trend. PwC tells us that the aftereffects of the pandemic and the health system’s response to changes and failures observed during the pandemic are expected to drive up spending (inflators) in 2022. At the same time, some positive changes in consumer behavior and provider operating models that occurred during the pandemic are expected to drive down spending (deflators) in 2022.
The impact of the COVID-19 pandemic on healthcare costs has become clearer. For the first time during the 16-year history of the Milliman Medical Index, healthcare costs decreased during the past year (between 2019 and 2020). Eliminated care more than offset the cost of COVID-19 testing and treatments in 2020. But in 2021, Milliman projects healthcare costs to grow again, with the cost of healthcare for a hypothetical family of four insured through an employer PPO standing at $28,256.
This session provides detailed discussion of medical cost trend calculations, projections, components and implications addressed in this year’s release of the PwC Behind the Numbers, and Milliman Medical Index Reports, with time provided for audience Q&A.
Additional Tags: cost, utilization, premium, self-insurance, self-funding, TPA
Welcome to another MCOL Podcast edition. Rong Yi discusses Chinese Healthcare and more with MCOL's Clive Riddle. Dr. Rong Yi is the principal responsible for Milliman’s Greater China Healthcare Analytics Practice. She joined Milliman in 2009. She will also be discussing Chinese Healthcare and more in future posts at http://www.mcolblog.com/
This session explores the current and future impact of COVID-19 on Alternative Payment Models for providers, examining the current state of APMs, the key effects of COVID-19 on the dynamics involved in provider payments, the impact of COVID-19 on the main types of APMs and the implications for providers considering current or potential risk-based contracting arrangements.
Milliman Critical Point Podcast Episode 28: The COVID-19 pandemic has spurred—and aggravated—a range of mental health and substance use issues in the United States, and Milliman’s Stoddard Davenport discusses recent statistics on the topic and what the road ahead may look like for mental health in America.
The COVID-19 pandemic will have a significant impact in all segments of healthcare for a prolonged period. As such, health plans have critical financial decisions to make in the upcoming months with limited data available and wide uncertainty on how the COVID-19 pandemic will transition toward the end of 2020 and into 2021.
This session explores how COVID-19 may impact a health plan’s medical loss ratio (MLR) requirements in general and provides specific considerations for the Commercial, Medicare Advantage and Medicaid markets at the end of 2020 and into the future.
Critical Point podcasts, brought to you by Milliman: In this episode of Critical Point, we're going to be talking about the rise of telehealth in the wake of the COVID-19 pandemic, and what that could mean for the future of healthcare in the United States.
In this episode we're talking about artificial intelligence and its potential to transform healthcare, including processes and patient outcomes. One area where we're beginning to see AI put to use is in lung cancer screening using CT scans. Lung cancer is the number-one cancer killer in the US, so methods to improve the screening process hold a lot of promise, but AI technology in this area is also not without its challenges. Joining us is one of the foremost experts on the topic. Jim Mulshine is a thoracic medical oncologist who spent 25 years at the National Cancer Institute in Bethesda, Maryland. He's now at Rush University Medical Center. Also joining us is Bruce Pyenson here at Milliman who has worked closely with Jim studying this topic.
Milliman’s Melody Craff, Francesca Hammerstrom, Adam Wallace and Edward Jhu present practical guidance to help organizations analyze the impact of COVID-19 on healthcare cost and utilization trends
This webinar, and Milliman’s accompanying white paper “Frameworks and considerations for COVID-19 related analyses,” present practical guidance to help organizations analyze the impact of COVID-19 on healthcare cost and utilization trends. The intent is to provide initial supportive resources for healthcare organizations, as they navigate dramatic changes in the healthcare landscape.
Employees value choice when it comes to health benefits. When employers facilitate these choices, the method for setting employee premium contributions can create selection bias toward certain options. Selection bias happens when a sicker and more costly population tends to choose one option over another. In order to reduce the selection bias, employers should adjust each option for morbidity. Risk adjustment is used to adjust applicable costs of two or more cohorts of people so all cohorts can be compared as if each had the same morbidity.
Topics Include:
- The concepts of selection bias and risk adjustment
- The implications and justification for applying risk adjustment
- The methodologies involved in setting employer contribution rates and application of risk adjustment
- Illustrative examples in the application of risk adjustment
Additional Tags: Slef-Insurance, Self-Funding, TPA, Actuarial
Milliman shares a historical view of the Employer Stop Loss (ESL) market, including portfolio characteristics, underwriting measures, pricing measures, historical results, and product terms offered. Milliman will also address the considerations and implications for health plans evaluating ESL market opportunities.
- The employer stop-loss market opportunity for health plans
- A historical view of the employer stop-loss market
- Employer stop-loss market characteristics, measures, results and products
- Considerations and implications for health plans evaluating employer stop-loss market opportunities
Additional tags: Self-Insurance, Self-Funding, Reinsurance, TPA
Milliman shares several data mining tactics that they have seen successful ACOs adopt to effectively guide strategies to reduce medically unnecessary services and in turn reduce the ACO’s total population costs.
With the MSSP final rule, CMS is offering greater shared savings potential to ACOs participating in the BASIC track and making the BASIC track available to a broader set of ACOs. The effect of these rule changes on specific ACOs will vary significantly depending on an ACO’s size, region, cost and quality performance, and structure. It is critical that ACOs fully consider all of the implications of these rules in order to identify both the risks and the opportunities specific to their organizations.
Explore the implications and impact of ACO experience in Medicare ACO performance, in the Avalere study considering the tenure of ACO services in performance, and as a predictor of success; examine the Dobson DaVanzo & Associates study that found MSSP ACOs generated gross savings of $1.84 billion for Medicare in 2013–2015, nearly double the $954 million estimated by CMS; and consider the opportunities and issues involved from CMS proposed regulations regarding telehealth and other non-face-to-face services.
While there are always uncertainties regarding the outcome of any proposed regulation, a deeper understanding of the Pathways to Success program and its implications is essential for stakeholders to best position themselves going forward. This session provides a summary and analysis of the proposed regulation’s key provisions and discusses how they might impact the MSSP.
This session explores application of risk adjustment and predictive modeling through brief case studies involving key topics; examines the potential of enhanced models to identify patients with rising risk; and considers the impact and implications of analyzing prescription data to determine future patient costs and serve as predicators regarding opioid abuse patients.
CMS released Comprehensive Care for Joint Replacement (CJR) model results for Performance Year 1 (episodes with start dates between April 1st and September 30, 2016 and end dates on or before December 31st, 2016.) The CJR model is a mandatory bundled payment model in which 799 participating hospitals from 67 metropolitan statistical areas (MSAs) were originally required to participate. Each episode begins with a lower extremity joint replacement procedure, and completes after 90 days post-discharge. There was no downside risk for Performance Year 1, but future years will include downside risk. Going forward, a recent CMS final rule will allow hospital participation in 33 of the 67 MSAs to become voluntary, which will result in fewer participating hospitals in the program.
As the prevalence of commercial value based contracts grows, so too does the variability of a provider's overall compensation. In value based contracting, providers are "measured" on certain performance metrics that will dictate ho much they are ultimately paid. In this environment, risk adjustment plays an integral role in determining the provider's "measurement" of financial performance.
The Eighth Annual Accountable Care Web Summit features a 90 minute webinar with three prominent national Accountable Care speakers from Catalyst Health Network, the National Business Group on Health and Milliman that will share their spectrum of knowledge to help ACO stakeholders position themselves for 2018.
Additional Tags: contracting, provider network, self-insurance, self-funding, TPA
As technology, innovation, treatment options and care coordination all continue to advance, the impact and implications of organ and tissue transplant resource utilization becomes even more significant for healthcare stakeholders. Possessing and understanding current intelligence regarding transplant costs, utilization and demographics is critical in this regard.
There has been a great deal of uncertainty in recent months surrounding the use of episode-based payment models at CMS. The voluntary Bundled Payments for Care Improvement (BPCI) models have been operational since 2012, and the mandatory Comprehensive Care for Joint Replacement (CJR) program was implemented in April of 2016 and has hundreds of participants nationally.
The Medicare Access and CHIP Reauthorization Act (MACRA) makes significant changes to the Medicare payment system by introducing a quality-based payment model.
In this webinar, a framework and metrics for measuring SNF performance is discussed, followed by an exploration of SNF performance levels across the United States in order to provide a quantitative assessment of the opportunity to reduce spending for SNF services through steerage of patients to more cost-efficient SNFs.
Milliman reviews their RAPS to EDS transition study and discuss transition problems and how Medicare Advantage organizations should respond.
Sessions include: Five Common Pitfalls in Commercial ACO Shared Risk Arrangements; The Aledade ACO Perspective; and ACOs, Risk, and Paradigm Shifts
Explore the dynamics of how MACRA will impact all parts of the healthcare market; the key concepts surrounding how MACRA will impact provider reimbursement; and specific strategies for how both providers, health systems, and health plans can leverage MACRA to its fullest effect to further organizational goals and reimbursement.
A discussion regarding applying risk adjustment to value based payment models.
Sessions include: Five Health Care Trends that will Impact Your Population Health Strategy; Capturing Triple Aim Value Across the Care Continuum in Value-Based Programs ; and Telemedicine and the long-tail problem in healthcare.
This session explores the crucial role of diagnosis coding by focusing on the role of certain variables—including carrier size, market share, and market size—on the ACA risk adjustment formula.
Presentations include: Analysis of Medicaid Managed Care Administrative Costs; The Colorado State Innovation Model, a Case Study; and Fostering Medicaid Accountable Care Organization Development in New Jersey
During this presentation, an overview will be given of the key features of the CCJR model. Examples of possible savings opportunities will be provided, and participants will learn how they can estimate the potential effect CCJR will have on their practice pattern and revenue cycle.
Sessions will include: Population Health Management: Innovations in Risk Adjustment and Predictive Modeling; Risk Adjustment and Shared Savings Agreements; and Connecting Predictive Modeling and End-Users: the Last Mile Problem.
Sessions include: Tools for Managing and Monitoring Population Health for Health Plans and Hospitals; Expanding Access to Diabetes Self-Management Education: The Economic Case; and Integrating Behavioral Health: Essential for Population Health.
Milliman insights on key health plan issues pre and post the Supreme Court King v. Burwell decision.
In-depth session on Medicare Bundled Payment PAC Utilization Benchmarking.
Implications of DSH changes for hospitals by area, with details of the mechanics of the new DSH and Uncompensated Care payments, and issues specific to Medicare Advantage plans.
Topics addressed include: (1) predictive analytics research into evaluation of provider efficiency in order to advance techniques for value based provider payments; (2) ways hospitals have used analytics for staffing optimization; and (3) predictive analytics applied to users of a health behavior change program in order to predict future engagement.
Known regulatory and market changes impacting estimates, and techniques and approaches for adjusting morbidity assumptions in the absence of claims data, so that plans can take advantage of data sources to gain some perspective into future pricing
Sessions include: The Journey to Physician Gain-Sharing Success; Legal Issues Arising Out of the Operation and Expansion of ACOs; and Actuarial Perspectives on ACO Provider Payment Rates.
Essential Health Benefit and State Benchmark Plan requirements, guidelines and process, and findings from Milliman's analysis of state variability in benefits.
Descriptions of the currently uninsured population, where they may be getting coverage under different scenarios, their health status, the impact to Medicaid plans and the Exchanges, and how to design risk adjustment to reflect their unique characteristics.
Sessions include: Evolving Toward the Accountable Future: Aetna's Accountable Care Vision and Collaborations; Cigna National Collaborative Accountable Care Strategies and Initiatives; and How to avoid the mistakes of the 2010s - pitfalls of risk-based contracts, the importance of data and how to strategize to be a successful ACO
Will Fox of Milliman overviews the concepts and issues involved with Transparent Cost Networks including provider pricing and contracting and consumer selection, and how the Networks could work. This presentation was made as part of the 2012 Consumerism Web Summit.