Rhonda Taller, MHA

Rhonda Taller has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs and strategic consulting.  Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use and health reform.  Rhonda have held volunteer positions with HIMSS and WEDI including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing HIMSS ICD-10 Task Force (2013-2014) and co-chair of WEDI ICD-10 Transition Workgroup.

On July 25, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule (on display in the Federal Register) titled Advancing Care Coordination through Episode Payment Models (EPMs).

The proposed rule would create mandatory episode payment models for acute myocardial infarction (AMI) and CABG in certain geographical areas (98 metropolitan statistical areas in all) that would be randomly selected for participation.

Similar to the Comprehensive Care for Joint Replacement (CJR) mandatory bundle, hospitals will become the risk-bearing entity for the five-year pilot, which is proposed to start on July 1, 2017 and continue through Dec. 31, 2021. Also included in the proposed rule is a cardiac rehabilitation incentive payment episode. Eligible clinicians participating in the acute myocardial infarction (AMI) and the CABG episodes will have the opportunity to qualify as participants in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Advanced Alternative Payment Model as well, with a proposed start date in 2018.  

The episode is slated to begin upon inpatient admission to an anchor hospital and will include medical and surgical services for beneficiaries during the hospital stay while also covering the 90-day period post-discharge. The proposed rule includes certain MS-DRG designations included for AMI, percutaneous coronary intervention (PCI), and CABG.  

This proposed rule is a continuation of the movement to a value-based system announced by U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell in January 2015. The proposed rule does include information on existing programs under the direction of CMS’s Center for Medicare and Medicaid Innovation that would have beneficiary exclusions. In addition to meeting financial targets in the model, quality measure targets are also included for both AMI and CABG.  

While the episode payment models (EPMs) are retrospective payment models, CMS will phase in target prices over the five-year timeline using a combination of historical hospital-specific data and regional data, with adjustment for complexity of treatment. In the initial program year, hospitals will not incur any downside risk, with varying amounts of downside risk occurring during the remainder of the program years. For the cardiac rehabilitation incentive payment, a retrospective payment will be made to hospitals participating, and it will vary based on the volume of services provided.  

Similar to AMI and CABG hospital selection, CMS is proposing to select a targeted group for 90 geographic locations split equally between those areas in the mandatory bundles and those not included. The proposed rule was published in the Aug. 2 edition of the Federal Register, and comments are due by Oct. 3. Additional information on EPMs can be accessed online at https://innovation.cms.gov/initiatives/epm.

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of the WEDI ICD-10 Transition Workgroup.

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r tallerThe recently released proposed rule regarding the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 includes a lengthy section detailing what advanced alternative payment models (APMs) are, how to qualify, and which APMs are being considered for the first performance year. Clinicians participating to a certain degree in advanced APMs will qualify for incentive payments. 

From 2019-2024, a clinician meeting the standards for advanced APM participation is excluded from the Merit-Based Incentive Payment System (MIPS) adjustments and would receive a 5-percent Medicare (Part B) incentive payment. Beginning in 2026 and beyond, clinicians who continue to meet the standards for advanced APM participation are excluded from MIPS adjustments and would receive a higher fee schedule update than those not in an advanced APM. 

Advanced APMs are APMs in which clinicians are providing coordinated, high-quality care while accepting a certain risk criteria. In the proposed rule, three criteria are given for meeting the standards for an advanced APM. The first criteria relates to financial risk, as participants are required to bear risk representing at least 4 percent of the APM spending target, marginal risk for which the advanced APM entity is responsible for of at least 30 percent, and a minimum loss rate of no greater than 4 percent. 

The proposed rule includes more granularity for each of these concepts. The second set of criteria relates to basing payments on quality measures comparable to those in the MIPS quality performance category. In discussing this concept, CMS noted that quality measures must be evidence-based, reliable, and valid – and, where available, one of the measures must be an outcome measure (if an appropriate measure for the advanced APM is on the MIPS measure list). 

The third criteria relates to the requirement that an advanced APM mandate that at least 50 percent of clinicians use a certified electronic health record (EHR) technology  in the first performance year, and this increases to 75 percent in the second performance year. The proposed rule also details rules for medical home models that would be expanded under the Center for Medicare & Medicaid Innovation (CMMI) authority enabling them to qualify as an advanced APM. 

For performance year one, the models that are proposed to qualify as advanced APMS include Comprehensive Primary Care Plus, Medicare Shared Savings – Tracks 2&3, Next-Generation ACOs, Comprehensive End Stage Renal Disease Care Models (large dialysis organization arrangement), and Oncology Care Model Two-Sided Risk (available in 2018). 

CMS is seeking comment on other models that could qualify as advanced APMs and intends to update the list on an annual basis. To qualify for incentive payments requires significant participation, and clinicians would qualify based on either payments received or patients seen in an advanced APM. For 2019 and 2020, participation requirements are Medicare-only (payments or patients). Beginning in 2021 (performance year 2019), the participation requirements expand to include non-Medicare patients or payors, and thresholds increase as well. The proposed rule also has an extensive section defining other payor advanced APMs. MACRA legislation established the Physician-Focused Payment Technical Advisory Committee (PTAC), whose purpose is to review/assess physician-focused payment models submitted to the Committee and make recommendations on them to the Secretary of the U.S. Department of Health and Human Services. Additional details on the role of PTAC and physician-focused payment models is also included in the proposed rule. PTAC has held two meetings and recently released a draft document on the process for reviewing physician-focused payment models, with public comment due by mid-May. For additional information on PTAC, go online to https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee.

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of the WEDI ICD-10 Transition Workgroup.

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Recently the Centers for Medicare & Medicaid Services (CMS) published results for the second year of the value-based payment modifier (value modifier). The value modifier was established as one of the pay-for-performance initiatives under the Patient Protection and Affordable Care Act (PPACA). The 2016 value modifier is based on 2014 performance and is applied to physicians in groups with 10 or more eligible professionals (EPs), with all groups being identified by their Medicare-enrolled taxpayer identification number (TIN). 

In autumn 2015, physician groups and solo providers were able to review information on their quality and cost performance in the 2014 annual Quality Resource and Use Reports (QRURs). Payment impacts are based on cost and quality tiering covering a spectrum of low, average, or high cost and low, average, or high quality for TINs with 10 or more EPs. Quality tiering is defined as the methodology used to evaluate a group’s performance on the cost and quality measures used in the value modifier. While the value modifier is currently being phased in, it will apply in 2017 to all physicians (solo practitioners and groups) based on 2015 performance. In 2018 the value modifier will be applied, based on 2016 performance, also to nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists in groups with two or more EPs. 

The recent CMS announcement indicated that as it pertained to data collected up until Dec. 18, 2015,  a total of 128 physician groups exceeded the value modifier quality and cost efficiency benchmarks, meaning they will receive an increase in their payments under the Medicare physician fee schedule (PFS) of either 15.92 or 31.84 percent. However, 59 groups did not perform well under the value modifier and will see a decrease in their PFS payments of 1 to 2 percent. There were also 8,208 physician groups that met the minimum reporting requirements (or, in some cases, there was insufficient data to calculate their value modifier), and their PFS payments will remain unchanged in 2016. Of note is an additional 5,418 groups that did not meet the minimum reporting requirements and thus will see a 2-percent decrease in their 2016 PFS payments. 

CMS continues to encourage groups and solo practitioners to report the Physician Quality Reporting System (PQRS) data in an accurate, complete, and timely manner to avoid this automatic downward adjustment to PFS payments in the future. Still pending are 1,390 groups awaiting results from PQRS or value modifier informal review as of Dec. 18, 2015. Medicare Administrative Contractors (MACs) were slated to begin paying claims based on the updated payment amounts after March 14, and groups should expect to see claim adjustments within the next six weeks. Additional information on the value modifiers can be found online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/index.html.

 

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment, with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of WEDI ICD-10 Transition Workgroup.

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The Healthcare Payment Learning and Action Network (LAN) was very busy during its formative year, 2015, educating participants and partners through its inaugural LAN Summit in October 2015, monthly webinars, newsletters, and communication on the activities of the Guiding Committee, as well as the three work groups that have been established. A prior article focused on the final version of the APM framework document released in January 2016.

The LAN’s Population-Based Payment Work Group (PBP WG) released its initial draft white papers on patient attribution and financial benchmarking in early February, with a comment period open through March 7, 2016. Presentation of the final white papers is targeted for April 4, 2016. The draft white paper, Accelerating and Aligning Population-Based Payment Models: Patient Attribution, discusses the methods for assigning patients to providers accountable for total cost of care and quality outcomes in a population-based payment model. 

In releasing the draft white paper, the PBP WG noted: “patient attribution, which identifies a patient-provider health care relationship, is a foundational component in a PBP model, and forms the basis for performance measurement, reporting and payment.” The draft white paper includes 10 recommendations for use by payors when determining which patients are attributed to provider groups within the PBP model. Within the white paper is a detailed explanation of each recommendation, along with a patient attribution flow chart (Figure 3) and comparison of the PBP WG recommendations versus Centers for Medicare & Medicaid Services (CMS) program approaches to attribution in various accountable care organization (ACO) models such as Medicare Shared Savings, Pioneer ACOs, and Next Generation ACOs (Figure 5). 

The draft white paper titled Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking is intended “to provide a blueprint that can help guide the work of establishing, updating and rebasing financial benchmarks in PBP models.” The draft white paper includes five key principles regarding financial benchmarks along with recommendations relative to PBP models in categories 3 & 4 (detailed in the final APM framework document). These categories assume that providers will accept accountability for the full continuum of care. Both of the first two recommendations are further divided into sub-recommendations. For individuals and organizations considering commenting on each of the draft white papers, the PBP WG is seeking feedback on the following areas:

  • The overall white papers and recommendations;
  • Diagrams, flowcharts and tables used to illustrate key concepts; and
  • Examples that would be useful for illustrating the recommendations

Comments will be accepted through the LAN website (Patient Attribution Comment Form and Financial Benchmarking Comment Form) or online through a discussion forum on Handshake. Additional information on the LAN can be found online at https://hcp-lan.org/.

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform.  Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of the WEDI ICD-10 Transition Workgroup.

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The initial deliverable of the Healthcare Payment Learning & Action Network’s (LAN’s) first work group, the Alternative Payment Model (APM) Framework and Progress Tracking Work Group, was the release of the draft APM framework document on Oct. 22, 2015. The document was reviewed at the LAN Summit on Oct. 26, with public comments accepted through Nov. 20. In addition, listening sessions were held via webinar for states, consumer and patient advocates, and purchasers and the provider community. 

The intent of the framework document is to provide terms and definitions that will be used as foundational work on the part of the work group. On Jan. 12, 2016, a webinar was held to review the final version of the document. During the webinar it was noted that 113 comments (totaling 285 pages) were received from 79 unique submitters, with 51 percent of individuals acting as representatives of their organizations. 

Using the framework released earlier in 2015 by the Centers for Medicare & Medicaid Services (CMS), this document builds upon that effort and contains a schematic divided into four categories (and sub-categories). This includes Category 1 – Fee-for-Service, No Link to Quality & Value; Category 2 – Fee-for-Service, Link to Quality & Value; Category 3 – APMs built on Fee-for-ServiceArchitecture; and Category 4 – Population-based Payment, with examples noted within each area. The document also contains an addendum with case studies submitted to the work group that are included within categories 2-4. Seven key principles for the APM framework are included as recommendations in the document to provide context for understanding the recommendations. These include:

  1. Principle 1
    Changing the financial reward to providers is way to sustain innovative approaches to the delivery person-centered care. In the future, it will be important to monitor progress ininitiatives that empower patients to have a voice in model design, to seek care from high-value providers (via performance metrics, financial incentives, and other means) and become active participants in shared decision-making.
  2. Principle 2
    As delivery systems evolve, the goal is to drive a shift toward shared risk and population-based payment models that incentivize improvements in the quality and efficiency of person-centered care.
  3. Principle 3
    To the greatest extent possible, value-based incentives should reach providers across the care team that directly delivers care.
  4. Principle 4
    Payment models that do not take quality and value into account will be classified in the appropriate category, with a designation that distinguishes them as a payment model that is not value-based. They will not be considered APMs for the purposes of tracking progress toward payment reform.
  5. Principle 5
    Into reach the LAN’s goals for healthcare reform, value-based incentives should be intense enough for providers to invest in and implement delivery reforms, and they should increase over time. However, the strength of incentives does not affect the classification of APMs in the APM framework.
  6. Principle 6
    For tracking purposes, when health plans adopt hybrid payment reforms that incorporate multiple APMs, the payment dollars will count toward the category of the most dominant APM. This will avoid double-counting payments through APMs.
  7. Principle 7
    Centers of excellence, patient-centered medical homes, and accountable care organizations are delivery models, not payment models. In many instances, these delivery models have an infrastructure to support care coordination and have succeeded in advancing quality. They enable APMs and need the support of APMs, but none of them are synonymous with a specific APM. Accordingly, they appear in multiple categories of the APM framework, depending on the underlying payment model that supports them.

The Jan. 12 webinar also included a brief update on the current and future sprints of the other LAN workgroups, i.e. Population-Based Payment and Clinical Episodes. Additional information on how to participate in the LAN, along with archived webinars and material produced by the work groups, can be found online at https://publish.mitre.org/hcplan/

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment, with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of WEDI ICD-10 Transition Work Group.

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Monday, 23 November 2015 20:17

MACRA, LAN Developments Garner Attention

Activity continues to build on both the Medicare Access & CHIP Reauthorization Act (MACRA) and Healthcare Payment Learning & Action Network (LAN) fronts. When MACRA was passed by Congress in April to repeal the sustainable growth rate formula, it also altered Medicare’s physician payment models, incorporating value-based payment incentives into the future of healthcare. There are two tracks for eligible professionals (EPs) reimbursement in the future: the Merit-based Incentive Payment System (MIPS), which is based on a composite performance score with weighting in four categories (quality, resource use, EHR meaningful use measures, and clinical practice improvement) or Alternative Payment Models (APMs), which feature incentives for EP participation. On Oct. 1, the Centers for Medicare & Medicaid Services (CMS) released a request for information in the Federal Register “regarding implementation of the MIPS, promotion of APMs, and incentive payments for participation in eligible APMs.” While a relatively short document, it contained 127 questions CMS posed to the industry to assist them as they construct the MACRA proposed rule, which is tentatively scheduled for release in winter 2016. The RFI provided an opportunity for public comment on operationalizing MACRA provisions for MIPS and APMs. Comments were initially due by Nov. 2, however CMS extended the comment period until Nov. 17. More to come on this topic in 2016.

The LAN, which was announced earlier in 2015, has expanded its activities through monthly webinars, newsletters, and an initial LAN Summit held on Oct. 26 in Arlington, Va. With a LAN Guiding Committee in place, three work groups are also operational. The first workgroup, the APM Framework & Progress Tracking Work Group, recently released a draft APM framework document, with comments accepted through Nov. 20. The APM framework builds upon and expands the four-category framework issued by CMS in early 2015. Category 1 is fee-for-service with no link to quality; Category 2 is fee-for-service with a link to quality; Category 3 is APMs built on a fee-for-service architecture; and Category 4 is population-based payment. Integral to the draft APM framework document are seven principles that are discussed within. Individuals can receive LAN updates and review materials, including the draft APM framework document by accessing: https://publish.mitre.org/hcplan.      

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of the WEDI ICD-10 Transition Workgroup.

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A valuable resource for individuals interested in alternative payment methods is the Healthcare Payment Learning & Action Network (LAN). The MITRE Corporation, as the operator of the Centers for Medicare & Medicaid Services (CMS) Alliance to Modernize Healthcare Federally Funded Research and Development Center, is independently managing the LAN on behalf of CMS. With Secretary of Health and Human Services Sylvia Mathews Burwell's January 2015 announcement to accelerate the transition to alternative payment methodologies (APM) for Medicare (30 percent by 2016 and 50 percent by 2018), the LAN is tasked with sharing best practices in the acceleration of these goals. 

Since the formation of the LAN was announced, a 24-member Guiding Committee co-chaired by Dr. Mark McClellan and Dr. Mark Smith has held a number of meetings. Individuals selected for the Guiding Committee are considered leaders in their respective fields. The Guiding Committee chartered the LAN's first workgroup, which is focused on APM framework and progress tracking.  

At the July 30 Guiding Committee meeting, plans for the next two workgroups were announced, with a focus on population-based payment models and clinical episode-based payment. Nominations for members of these workgroups recently were named as well, and it's expected that the workgroups will begin their activities this fall. Meeting materials and a members listing for the Guiding Committee and the APM Framework workgroup are available on the LAN's website. Other materials available include the slides, recordings, and question/answer document from the LAN Learnings monthly webinars. The first LAN Learnings webinar focused on the Blue Cross Blue Shield of Massachusetts alternative quality contract, with presenters from both the payor and provider realm appearing in June. Subsequent LAN Learnings webinar topics included an oncology care payment model (July), the CMS mandatory Comprehensive Care for Joint Replacement (CCJR) bundle (August), and an accountable care organization (ACO) within a large health system (September). The webinars present an opportunity to learn about current or future programs focused on APMs and provide an opportunity for a question/answer period. 

Upcoming webinars are scheduled for Oct. 15 and Dec. 2. The first LAN Summit is scheduled for Oct. 26 in Arlington, Va., and registration for the event is now open. The Summit will provide an opportunity to get updates on the work of the LAN and to hear from organizations engaged in APMs. Other communication tools utilized by the LAN include the eNewsletter and the Collaboration Portal, which enables individuals to connect with other participants for discussions on payment models and to share resources. Participation in the LAN is open to the public, and individuals can register at http://innovationgov.force.com/hcplan. Information on the LAN is also available on the Center for Medicare and Medicaid Innovation (CMMI) website: http://innovation.cms/gov, under the Healthcare Payment Learning and Action Network section.

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment, with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of the WEDI ICD-10 Transition Workgroup.

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r tallerThe Hospital Value-Based Purchasing Program (HVBP) was established by the Patient Protection and Affordable Care Act, and further defined in Section 1886(o) of the Social Security Act as a quality incentive program built on the Hospital Inpatient Quality Reporting measure reporting infrastructure. Payments to hospitals for inpatient services are adjusted based on their performance on a set of measures. 

For 2016, this is funded by a 1.75-percent reduction from hospitals’ base operating diagnosis-related group payments. HVBP includes four domains: clinical process of care (eight measures), patient experience of care (eight HCAHPS measures), outcomes (three mortality measures, a PSI-90 composite measure, plus CLABSI, CAUTI, and SSI measures), and efficiency (Medicare spending per beneficiary measure). Domain weights for 2016 are 25 percent for both the efficiency and patient experience of care domains, 10 percent for the clinical process of care domain, and 25 percent for the efficiency domain. The Centers for Medicare & Medicaid Services (CMS) released the 2016 Inpatient Prospective Payment System’s final rule on July 31, and it was published in the Aug. 17 Federal Register.  

In the 2016 final rule, CMS finalized the removal of IMM-3 (influenza immunization) because it was noted this measure was topped out. Also, CMS removed AMI-7a (fibrinolytic therapy received within 30 minutes of hospital arrival) since few hospitals report this measure today. CMS also finalized the removal of two measures from the clinical care process sub-domain, and therefore finalized the proposal to move PC-01 (elective delivery) from clinical care process to the safety domain.  

r tallerOn March 25, the Health Care Payment Learning and Action Network (LAN) held a kickoff meeting featuring remarks from U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell and President Obama. 

The goal of moving 30 percent of all Medicare payments into alternative payment models (ACOs, bundled payments, patient-centered medical homes, etc.) by 2016 and getting that rate up to 50 percent by 2018 was initially announced in January by Secretary Burwell, and that notion featured prominently in remarks made during the meeting. A summary for the March meeting, both the morning and afternoon sessions, is now available on the LAN section of the Centers for Medicare & Medicaid Services (CMS) innovation site. 

A follow-up Webinar titled “A Report from the Guiding Committee” was held on June 10, hosted by the CMS Alliance to Modernize Healthcare (CAMH). Since the LAN launch meeting in March, CAMH established a guiding committee to provide executive leadership for achieving LAN's goals.  

The first meeting of the Committee was held on May 27 and a full-day session was slated for June 22. During the June 10 LAN webinar, Mark McClellan reviewed the guiding committee's focus areas, noting that the top priority is to define terms and concepts associated with alternative payment methodologies (APM), i.e. value, types of APMs, and concepts. In a recent announcement candidates were sought for the first workgroup, which will focus on APM definitions and approaches to measuring progress toward adoption.  

A key activity of the network is also sharing of best practices and lessons learned. During the June 10 Webinar presenters from Blue Cross Blue Shield of Massachusetts and the Mt. Auburn Cambridge Independent Practice Association shared their learnings from participation and implementation of the Alternative Quality Contract (AQC) initiative, including key reasons contributing to AQCs’ success. A 2014 New England of Medicine article on savings relative to the AQC control group during the 2009-2012 time frame also was cited by the presenters.  

The future activities of the LAN and its guiding committee will be of interest to organizations interested in APMs. Additional information on the LAN and the guiding committee can be found online at: http://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network/

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs, and strategic consulting. Her expertise covers topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of WEDI ICD-10 Transition Workgroup.

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r tallerOn April 30, the Inpatient Prospective Payment System (IPPS) proposed rule for the 2016 fiscal year was published in the Federal Register. As with regulations from prior years, in the rule's language the Centers for Medicare & Medicaid Services (CMS) previewed proposed changes to the value-based purchasing (VBP) program. CMS is seeking public comment on the various changes being proposed. For the 2016 fiscal year, the reduction in based operating MS-DRG payment amount is 1.75 percent (maximum penalty). The actual dollar figure available for potential incentive payments will be provided in the final rule, which will be published in August. One change being proposed for the 2018 fiscal year is the addition of a three-item Care Transition Measure (CTM), which would add three questions to the HCAHPS survey for patients to complete. This was adopted for the hospital Inpatient Quality Reporting (IQR) program in 2013.

CMS is also proposing removal of the clinical care process subdomain for the 2018 fiscal year since two measures included (AMI-7a and IMM-2) are being removed from the VBP program. The third measure in the subdomain (PC-01) is being proposed to move to the safety domain. Public comments are being requested for renaming the clinical care outcomes subdomain as the clinical care domain. In the 2021 fiscal year, CMS is proposing to add hospital 30-day all-cause, risk-standardized mortality rate following COPD hospitalization to the VBP program (this measure is in the hospital IQR program). As part of the CMS process to re-adopt measures in the VBP program for subsequent years, the proposed rule cites the adoption of total knee arthroscopy and total hip arthroscopy along with the AHRQ PSI-90 composite measure for the 2019 program year.

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