Our Latest Thinking

We are constantly scanning the health care market for new and interesting developments; then we write about them here. Check out our latest thinking.

Centers for Medicare and Medicaid Services (CMS)

The “Exit Polls”: Initial Thoughts on PTAC’s First Meeting

May 11th, 2017

Background The Centers for Medicare and Medicaid Services (CMS) has initiated a process whereby physicians and other stakeholder entities can design physician-focused payment models (PFPMs) that fit with their clinical practices, while also providing better outcomes for patients, and recommend such models to the Health and Human Services Secretary (the Secretary) for consideration and/or further […]

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Charlie Brown, Lucy, and Risk Corridor Payments

February 17th, 2017

On October 13, 2015, your humble blogger received the AIS Inside Health Insurance Exchange quote of the day related to non-payment of the Risk Corridor payments, “…. there was a contract going into this that there would be certain protections… and plans would price as best as they could, knowing that there was no actuarial precedent for the risk. The news that CMS could pay carriers 12 cents for every dollar requested for the first year of the risk corridor program felt like Lucy moving the football at the last second.”

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The Cost of Quality: How Star Ratings Can Influence Monthly Premiums in Medicare Advantage Plans

November 14th, 2016

The Centers for Medicare and Medicaid Services assigns a star rating to Medicare Advantage plans to help beneficiaries better understand and select their insurance plan.

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Medicare Advantage: CMS’ First Step into Value Based Care is Now Coming Full Circle

September 1st, 2016

Medicare Advantage (MA) offers Medicare benefits through private health plans, providing an alternative to the traditional, federally-administered program. Also known as Medicare Part C, this private option traces its roots to the 1970s and received its current name and form in the Medicare Modernization Act of 2003. Since then, the number of enrollees has grown […]

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CMS Proposes New Mandatory Bundled Payment Models: 4 Observations

July 29th, 2016

On July 25, 2016, CMS announced a proposed rule to provide additional incentives for hospitals to provide higher quality care at a lower cost. The proposed rule seeks to increase coordination of care and decrease costs for heart attack and bypass surgery patients, creates a new Surgical Hip/Femur Fracture Treatment model (SHFFT), and outlines a […]

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CMS Announces OCM Participants: Three Notable Facts

July 8th, 2016

On June 29, HHS announced its selection of oncology physician group practices and health insurance companies to participate in the Oncology Care model (OCM), a five-year bundled payment initiative that starts July 1 and will cover more than 3,200 oncologists and 155,000 Medicare beneficiaries. The program provides a $160 care management payment per beneficiary per […]

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Oncology Care Model (OCM) Bundle: 8 Summary Thoughts

June 24th, 2016

Recently I had the opportunity to research CMS’ Oncology Care Model (OCM) bundle and to interview a number of c-suite individuals across oncology hospitals and clinics. Below please find eight summary thoughts. Difficulty of bundling oncology. Joint replacements (the focus of CMS’ new mandatory bundled payment program) have a clear beginning and end for the episode […]

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Comprehensive Primary Care Plus (CPC+): 4 Positive Implications & 2 Practice Strategies

June 9th, 2016

As a former primary care clinic manager and COO of a medical group engaged in value-based contracts, I was excited to see CMS’ announcement on Comprehensive Primary Care Plus (CPC+). I welcome this shift in Medicare primary care payments away from the quagmire of Fee-For Service (FFS) and into the higher ground of partial capitation, […]

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