Value-based care and reimbursement
The healthcare industry is transitioning from the traditional fee-for-service system to reimbursement structures that tie payment to quality and cost of care. Value-based care and reimbursement aim to improve patient outcomes and reduce healthcare spending while improving the experience for patients and clinicians.
Top Stories
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Feature
25 Nov 2024
Collaboration key to using data standards for value-based care
Panelists at Xtelligent Healthcare's Payer + Provider Summit discussed the promise and challenges of using data standards for value-based care. Continue Reading
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22 Nov 2024
How do FQHCs affect accountable care organizations?
FQHCs help accountable care organizations reach a more diverse patient population and potentially enable better patient access to preventive care. Continue Reading
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14 Nov 2024
Back surgeries: Low-value care swells Medicare spending
According to new research from the Lown Institute, unnecessary back surgeries led to an estimated $2 billion in Medicare spending over a three-year period. Continue Reading
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30 Oct 2024
Medicare Shared Savings Program saves $2.1 billion in 2023
Accountable care organizations in the Medicare Shared Savings Program earned performance payments totaling $3.1 billion in 2023, the highest since the program's establishment. Continue Reading
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25 Sep 2024
CMS rule targets suspect billing in Shared Savings Program
A new CMS rule is addressing "significant, anomalous, and highly suspect" billing activity within the Medicare Shared Savings Program to mitigate financial impacts for ACOs. Continue Reading
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22 Aug 2024
SNF integration might discourage BPCI-A participation
A study found that SNF integration was linked to a statistically significant reduction in BPCI-A participation for major joint replacement of the lower extremity (MJRLE) episodes. Continue Reading
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25 Jul 2024
AHA cautions against mandatory organ transplant payment model
The American Hospital Association urged the CMS Innovation Center not to implement the proposed Increasing Organ Transplant Access Model. Continue Reading
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01 Jul 2024
CMS rule to address suspect billing in Shared Savings Program
A proposed rule from CMS looks to address “significant, anomalous, and highly suspect” billing impacting ACO reconciliation in the Medicare Shared Savings Program. Continue Reading
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24 Jun 2024
Risant to add Cone Health to value-based system
The organizations signed a definitive agreement under which Cone Health will become part of Risant Health, a new value-based venture from Kaiser. Continue Reading
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01 May 2024
Breaking down the new CMS proposed bundled payment model: TEAM
The bundled payment model would provide hospitals with a target price to cover all costs associated with an episode of care for certain surgical procedures. Continue Reading
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Answer
29 Apr 2024
How to address health equity in alternative payment models
Aligning strategies across all healthcare stakeholders is necessary to successfully incorporate health equity into alternative payment models. Continue Reading
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15 Apr 2024
AMA, NAACOS, AHIP share how to succeed in value-based care arrangements
Participants in value-based care arrangements must have clear plans for financial risk, risk adjustment, and quality performance metrics. Continue Reading
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09 Apr 2024
AMGA urges Congress to extend value-based care incentives, prevent pay cuts
AMGA asked leaders to extend the Alternative APM value-based care incentives and approve reforms to the Medicare Shared Savings Program. Continue Reading
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04 Apr 2024
Strategies for integrating specialty care into value-based care models
The CMS Innovation Center prioritizes strategies that improve specialty care performance data, implement financial incentives, and support episode-based models. Continue Reading
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20 Mar 2024
MSSP accountable care organizations share key priorities and challenges
Health system consolidation and Medicare Advantage growth posed recruitment and retention challenges for MSSP accountable care organizations. Continue Reading
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19 Mar 2024
CMS announces new ACO model focused on primary care
The voluntary ACO model will be part of the Medicare Shared Savings Program for low-revenue participants starting in 2025. Continue Reading
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01 Mar 2024
Consumer Advocacy Orgs Share How to Move Away From Fee-For-Service Payment
Policymakers must improve payment incentives, invest in primary care, and establish national data-sharing standards to move away from fee-for-service payment and delivery models. Continue Reading
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29 Feb 2024
How Can Providers Establish Successful Accountable Care Organizations?
Providers must be prepared to address patient needs across the care continuum and be equipped with proper capabilities before joining or establishing an accountable care organization. Continue Reading
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26 Feb 2024
Making ACOs More Accessible for Long-Term and Post-Acute Care Providers
CMS must improve model alignment, financial methodology, quality measurement, and data-sharing to increase ACO participation among long-term and post-acute care providers. Continue Reading
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21 Feb 2024
HAC Reduction Program Penalizes Safety-Net Hospitals At Higher Rates
Teaching and safety-net hospitals in the Hospital-Acquired Condition Reduction Program were more likely to be penalized and receive worse performance scores. Continue Reading
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05 Feb 2024
Overcoming the Barriers to Value-Based Payment in Primary Care
Comprehensive primary care is essential to holistic health, but practices cannot make impressionable improvements without stable value-based payment and adequate resources. Continue Reading
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30 Jan 2024
After Slowdown, ACO Participation in Shared Savings Program Grows
ACO participation in the Medicare Shared Savings Program grows to 480 participants, while 245 organizations are in two Innovation Center models. Continue Reading
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18 Jan 2024
New Medicaid Payment Model Targets Behavioral Health Integration
CMS announced an 8-year Medicaid payment model that will incent behavioral health integration for people with Medicare and Medicaid. Continue Reading
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11 Jan 2024
Primary Care Model Did Not Reduce Healthcare Spending or Improve Care
Healthcare spending growth was lower among practices participating in the primary care model and the Medicare Shared Savings Program simultaneously. Continue Reading
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09 Jan 2024
Does Medicare Value-Based Purchasing Exacerbate Racial Care Disparities?
Black adults with pneumonia faced widening gaps in mortality at hospitals participating in the Value-Based Purchasing Program, highlighting racial care disparities. Continue Reading
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03 Jan 2024
NY Healthcare Orgs Collab to Deliver Value-Based Hospice, Palliative Care
In addition to promoting value-based hospice and palliative care, the partnership will establish a transitional care program to improve in-home care. Continue Reading
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15 Dec 2023
CMS Model Aims to Improve Maternal Health Outcomes, Access to Care
CMS will select up to 15 state Medicaid agencies that will receive technical and financial assistance to improve maternal health outcomes. Continue Reading
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11 Dec 2023
Understanding the Value-Based Reimbursement Model Landscape
As value-based reimbursement models become more popular, providers must choose carefully to maximize revenue while maintaining high-quality care. Continue Reading
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28 Nov 2023
Most Surgeons Earned MIPS Bonus Payments in 2021, Study Finds
Most surgeons earned MIPS bonus payments and the median increase in Part B payments was $1,341. Continue Reading
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17 Nov 2023
Despite Value-Based Care Growth, Room for Improvement Remains
Standardizing program benchmarks and providing incentives for non-clinical staff could help improve value-based care models. Continue Reading
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13 Nov 2023
Understanding the Fundamentals of Accountable Care Organizations
Accountable care organizations promote higher care quality at lower costs while shifting risk to providers, making the model a staple of value-based care. Continue Reading
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08 Nov 2023
More Provider Orgs Have Value-Based Contracts With Private Payers
The share of provider organizations with commercial value-based contracts grew from 50 percent in 2018 to 76 percent in 2022. Continue Reading
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30 Oct 2023
Value-Based Reimbursement Grows as Providers Take on More Risk
Fee-for-service rates stagnated as more value-based reimbursement flowed through risk-based models last year, the latest LAN data shows. Continue Reading
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16 Oct 2023
Unlocking the Future of Value-Based Care With Data
Megan Reyna, a system VP at Advocate Health, shares how to overcome barriers to value-based care adoption and the critical role of technology. Continue Reading
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10 Oct 2023
Value-Based Payments in Medicaid Tied to More Behavioral Health Visits
Under New York state’s Medicaid value-based payment program, patients with depression saw an increase of 0.91 behavioral visits. Continue Reading
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03 Oct 2023
How Vermont's All-Payer ACO Model Paves the Way for Value-Based Care
The Vermont All-Payer ACO Model is forging a path for value-based care and reimbursement following its recent successes. Continue Reading
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08 Sep 2023
NAACOS: Medicare Payment Incentives Favor Clinicians in Fee-For-Service
Congress should pass legislation extending the original 5 percent payment incentive for clinicians participating in advanced APMs, NAACOS said. Continue Reading
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07 Sep 2023
Top 10 Accountable Care Organizations by Medicare Shared Savings
The performance year financial and quality results are in, revealing a successful year for accountable care organizations in 2022. Continue Reading
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24 Aug 2023
Medicare Shared Savings Program ACOs Saved $1.8B in 2022, CMS Reports
ACOs in the Medicare Shared Savings Program also performed better on quality measures related to diabetes, smoking cessation, and cancer screenings. Continue Reading
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17 Aug 2023
What Technologies Do Providers Need for Value-Based Care Success?
As more healthcare providers get on board with value-based care, they must invest in technologies and resources to ensure success. Continue Reading
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16 Aug 2023
CMS Updates ACO REACH Model for 2024 to Improve Health Equity
Changes to the Health Equity Benchmark Adjustment under the ACO REACH model will help identify underserved beneficiaries living in high-cost areas. Continue Reading
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15 Aug 2023
Study Can’t Link Hospital Competition to Quality Improvements
A new study questions the belief that greater hospital competition will lead to quality improvements by analyzing surgical outcomes across markets. Continue Reading
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02 Aug 2023
Investments Are Needed to Implement Value-Based Care in Pediatrics
Value-based care implementation lags in pediatrics, but investments in behavioral health and health equity can improve long-term population health for the youngest patients. Continue Reading
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31 Jul 2023
CMS Will Test APM for Medicare Beneficiaries with Dementia, Caregivers
The model will reimburse participants for providing care coordination and other support services to Medicare beneficiaries with dementia and their caregivers. Continue Reading
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31 Jul 2023
AHIP, AMA, NAACOS Share Best Practices for Value-Based Care
Ensuring access to comprehensive, actionable data and improving data collection will foster value-based care success, the organizations said. Continue Reading
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26 Jul 2023
NAACOS: Medicare Shared Savings Program Needs Full-Risk Option
The full-risk option in the Medicare Shared Savings Program should allow participation at the individual level and offer advanced waivers. Continue Reading
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06 Jul 2023
Hospitals with Health Equity Factors Face Value-Based Penalties
Researchers are calling for change to CMS value-based payment programs after finding positive associations between some health equity factors and penalties. Continue Reading
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28 Jun 2023
How Beneficiary Preferences Can Impact Hospital VBP Payment Incentives
When beneficiaries placed the most weight on clinical outcomes, payment incentives shifted for smaller rural hospitals. Continue Reading
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13 Jun 2023
Study: Hospital Spends $5M Per Year on Quality Reporting
According to a new JAMA study, Johns Hopkins Hospital spent $5M and over 108K person-hours on quality data preparation and reporting in 2018. Continue Reading
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09 Jun 2023
CMS Primary Care Model Provides Value-Based Path for Practices
The primary care model will offer participants additional revenue to build infrastructure and make value-based primary care more accessible. Continue Reading
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08 Jun 2023
Most Practices Not Joining Enhancing Oncology Model, Survey Finds
Practices said CMMI should increase the payment incentives and eliminate the downside risk option in the Enhancing Oncology Model. Continue Reading
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24 May 2023
Home Health Value-Based Purchasing Model Lowered Medicare Spending
The decline in Medicare spending was driven by an $807 million reduction in inpatient hospitalization stay expenditures and a $235.8 million decrease in skilled nursing facility spending. Continue Reading
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23 May 2023
Community Service Navigation Helped Reduced Emergency Department Use
Emergency department use was 8 percent lower among Medicare beneficiaries receiving community service navigation under the Accountable Health Communities Model. Continue Reading
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12 May 2023
AMGA: Pharmacy Claims Data Key to Value-Based Care Progress
The trade association endorsed an amendment to a pharmacy benefit manager reform bill requiring commercial payers to share claims data with providers. Continue Reading
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09 May 2023
What Kaiser’s Acquisition of Geisinger Means for Value-Based Care
The proposed acquisition between the two organizations could help encourage other health systems to pursue value-based care. Continue Reading
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04 May 2023
Benchmark Regionalization in MSSP Disincentivized Higher-Spending ACOs
ACOs that entered MSSP after regionalized benchmarks were introduced had baseline spending deviations that were 3.5 times lower than ACOs entering before the change, indicating fewer participating higher-spending ACOs. Continue Reading
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02 May 2023
How Primary Care Acquisitions Can Advance Value-Based Care
Primary care practices help further value-based care by generating downstream revenue for acquiring health systems and delivering quality patient care. Continue Reading
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26 Apr 2023
Less than Half of Primary Care Physicians Participate in Value-Based Care
Around 70 percent of primary care physicians reported receiving fee-for-service payments, while 46 percent received payments through value-based care models. Continue Reading
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18 Apr 2023
Lower Clinical Spending Needed in BPCI-A Program to Avoid Losses
BPCI-A participants would’ve had to reduce clinical spending by around 3.8 percent in the first two performance periods for CMS to avoid financial losses, but they only reduced spending by 0.53 percent. Continue Reading
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14 Apr 2023
NAACOS Offers Guidance for Hybrid Primary Care Payment Model in MSSP
NAACOS said CMS should establish two approaches to the hybrid primary care payment model: one where CMS pays practices directly and one where the agency pays the ACOs. Continue Reading
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04 Apr 2023
Community-Level Social Risk Adjustment Did Not Address Payment Disparities
Area Deprivation Index, a community-level social risk measure, explained only 0.02 percent of spending variation in value-based payment models and did not address payment disparities. Continue Reading
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31 Mar 2023
How CMMI Value-Based Care Models Have Impacted Costs, Quality
Accountable care organizations are the most successful value-based care models, but most programs lack adequate data collection, leading to health equity issues. Continue Reading
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30 Mar 2023
Medicare ACO Healthcare Spending Recovered to Pre-Pandemic Levels
While non-COVID-19 healthcare spending in MSSP returned to pre-pandemic levels in 2021, inpatient spending was 12.4 percent lower and outpatient spending was 3.8 percent higher than in 2019. Continue Reading
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27 Mar 2023
Healthcare Orgs Push for Hybrid Primary Care Payment Option in MSSP
The hybrid primary care payment option in MSSP should address beneficiaries’ social needs, support coordinated care, and be voluntary for ACOs, the organizations said. Continue Reading
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24 Feb 2023
NAACOS, AMA Push for Long-Term Value-Based Care Efforts
The organizations asked lawmakers to encourage the shift to value-based care by extending incentive payments, removing participation barriers, and creating broader pathways for engagement. Continue Reading
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21 Feb 2023
AMGA Calls on Congress to Advance Value-Based Care, Support Providers
AMGA’s letter to congressional leaders emphasized how establishing a more sustainable Medicare program can help advance value-based care and ensure patient care access. Continue Reading
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16 Feb 2023
Digging into CVS’ Latest Proposed Purchase: Oak Street Health
Oak Street Health leverages a value-based model to provide comprehensive primary care and coordinated specialty care to seniors at over 160 locations. Continue Reading
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13 Feb 2023
Value-Based Platform Will Join CMS Incentive Program to Support Rural ACOs
Rural providers participating in ACOs that leverage the value-based care platform Signify Health will receive advanced incentive payments when they join the Medicare Shared Savings Program. Continue Reading
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07 Feb 2023
Long-Term Care ACOs Present an Opportunity for the Most Complex Populations
Increasing participation in long-term care accountable care organizations (ACOs) can improve health outcomes for high-cost, high-needs populations and help accelerate the shift to value-based care. Continue Reading
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18 Jan 2023
New ACOs Push CMS Closer to Accountable Care Goals
More than 700K healthcare providers and organizations will participate in one of three ACO models in 2023, bringing CMS closer to achieving full accountable care by 2030. Continue Reading
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17 Jan 2023
Study Finds MIPS Scores Don’t Reflect True Quality Performance
MIPS scores were inconsistently related to performance, with physicians treating medically complex and socially vulnerable patients seeing the biggest issue. Continue Reading
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10 Jan 2023
Bundled Payment Model Reduced Spending on Medical, Surgical Episodes
Hospitals participating in the Bundled Payments for Care Improvement model achieved cost savings for medical and surgical episodes, but participating physician groups only saw savings for surgical episodes. Continue Reading
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15 Dec 2022
Bipartisan Bill Calls for Extended Value-Based Payment Incentives
The value-based payment incentives, set to expire at the end of the year, encourage providers to transition into alternative payment models and share accountability for the quality and cost of patient care. Continue Reading
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13 Dec 2022
Lawmakers Ask CMS to Inspect ACO REACH Model to Prevent Fraud, Abuse
Allowing organizations with records of healthcare fraud and abuse to participate in the ACO REACH model would put Medicare beneficiaries and taxpayer dollars at risk, the legislators said. Continue Reading
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13 Dec 2022
The Most Successful Alternative Payment Models from CMMI, To Date
The Center for Medicare & Medicaid Innovation (CMMI) runs over 50 alternative payment models and care delivery demonstrations, but not all have brought in net savings. Continue Reading
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07 Dec 2022
CJR Model Policy Changes Boosted Penalties for Safety-Net Hospitals
After Medicare implemented policy changes for its Comprehensive Care for Joint Replacement model, 87.9 percent of safety-net hospitals and 71.7 percent of hospitals with high Black and Hispanic populations received penalties. Continue Reading
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05 Dec 2022
Value-Based Payment Models May Help Curb High Healthcare Spending
Value-based payment models, including accountable care organizations, bundled payment models, and capitation models, can generate savings for providers and limit healthcare spending. Continue Reading
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28 Nov 2022
APG Direct Contracting Entities Helped Save Medicare $70M in 2021
While 53 direct contracting entities generated savings for Medicare, 38 of the entities achieved $47 million in shared savings in 2021 by participating in the Direct Contracting model. Continue Reading
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23 Nov 2022
Accounting for Observation Stays Shrunk Hospital Readmission Reductions
The hospital readmission rate fell from 22.14 percent to 20.65 percent after the Hospital Readmissions Reduction Program’s implementation but decreased from 23.32 percent to 22.66 percent when accounting for observation stays. Continue Reading
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17 Nov 2022
KLAS: Epic, Arcadia, Innovaccer Earn Top Marks for Value-Based Care
As payers and providers anticipate greater value-based care reimbursement over the next couple of years, they are turning to a smaller number of vendors to help. Continue Reading
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14 Nov 2022
Key Plans for Advancing Accountable Care, Value-Based Payment
Integrating specialty care and achieving multi-payer alignment are two strategies for advancing not only accountable care as providers know it, but a new definition of the concept. Continue Reading
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09 Nov 2022
Value-Based Payment, Fee-for-Service Levels Hold Steady
There was no significant difference in the percentage of reimbursements flowing through fee-for-service and value-based payment models from 2020 to 2021, although some payers saw greater movement. Continue Reading
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09 Nov 2022
Advanced Bundled Payment Model Reduced Payments for High-Risk Patients
Participation in the BPCI-A helped reduce Medicare payments for high-risk patients and was associated with a $1,412 decrease in costs per episode for frail patients and a $1,045 reduction for patients with multimorbidity. Continue Reading
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04 Nov 2022
Bipartisan Letter Requests Extended Value-Based Payment Incentives
The 5 percent value-based payment incentives encourage participation in Alternative Payment Models and allow providers to invest in care coordination and social determinants of health initiatives. Continue Reading
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03 Nov 2022
Healthcare Orgs Urge Congress to Improve Value-Based Care Participation
Extending incentive payments for Advanced APMs and revising the various thresholds in the Quality Payment Program would help accelerate the shift to value-based care, the groups said. Continue Reading
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26 Oct 2022
Who is Leading the Value-Based Care Transition in Primary Care?
Primary care physicians who are value-based care leaders because their participation in risk-based capitation models tend to be more experienced with larger, older patient panels. Continue Reading
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19 Oct 2022
NAACOS Calls on CMS to Adjust Digital Quality Measurement Requirements
NAACOS asked CMS to improve data standardization and adjust EHR certification criteria to streamline digital quality measurement for accountable care organizations. Continue Reading
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17 Oct 2022
Staff, Technology Investments Help Practices Shift to Value-Based Care
Nearly 75 percent of primary care practice leaders have invested in additional staff to accommodate the shift to value-based care, while 71 percent have added new technology. Continue Reading
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17 Oct 2022
Are Readmission Rates The Best Measure of Hospital Quality?
A group of doctors argues that it is time to deemphasize value-based payment models that use readmission rates to dock hospital pay. Continue Reading
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13 Oct 2022
Urethral Suspension Use Not Impacted by Medicare Payment Policy Changes
Urethral suspension use with prostatectomies was already rising at a rate of 0.3 percent per quarter before the 2016 Medicare payment policy changes that reduced reimbursement for prostatectomies. Continue Reading
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12 Oct 2022
ETC Model Did Not Significantly Boost Home Dialysis Rates
Home dialysis rates were only 0.12 percentage points higher in hospital referral regions assigned to the End-Stage Renal Disease Treatment Choice model, a study found. Continue Reading
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11 Oct 2022
Cancer Care Alternative Payment Model Didn’t Reduce Novel Drug Use
A new study finds the Oncology Care Model, a voluntary alternative payment model run by CMS, did not dampen novel drug use despite early experiences suggesting reduced use of expensive drugs. Continue Reading
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07 Oct 2022
MSSP Exit More Common Among ACOs Serving Racial, Ethnic Minorities
Over a third of ACOs caring for high shares of racial and ethnic minorities exited the MSSP between 2012 and 2018, compared to 27 percent of ACOs serving low proportions of minorities. Continue Reading
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03 Oct 2022
NAACOS, AMA Ask Congress to Extend Advanced APM Incentive Payments
If Congress lets the 5 percent Advanced APM incentive payments expire at the end of 2022, it could discourage future APM participation and hurt patient care, the organizations said. Continue Reading
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28 Sep 2022
4 Key Areas of Value-Based Care Transformation
With healthcare spending at an all-time high, value-based care transformation can solve the cost problem while shifting healthcare dollars so providers can focus on population health outcomes. Continue Reading
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26 Sep 2022
ACOs Improve Quality, Physician Burnout As New Opportunities Emerge
ACOs have done more for value-based care than any other program, improving spending and quality, among other things, says CHS CMO Brian Steele. But new ACO models are causing a stir. Continue Reading
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14 Sep 2022
Social Risk Adjustment Reduced HRRP Penalties for Safety-Net Hospitals
One study found that additional social risk adjustment in the Hospital Readmissions Reduction Program would decrease annual aggregated readmission penalties by $1.7 million for safety-net hospitals. Continue Reading
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30 Aug 2022
Shared Savings Program ACOs Cut Costs Again, With 58% Earning Payouts
Shared Savings Program ACOs saved over $1.6B in 2021 while maintaining high quality scores, leading to over half of participants earning payouts. Continue Reading
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30 Aug 2022
APMs Support Better Primary Care, But Value-Based Care Obstacles Remain
An APM for primary care practices led to meaningful care delivery changes. However, lessons learned from the demonstration could advance value-based care for CMMI. Continue Reading
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30 Aug 2022
Value-Based Payment Makes Up Just 6.7% of Primary Care Revenue
Value-based payment is severely lacking as a percentage of total medical revenue across practices as providers face scheduling and billing challenges. Continue Reading
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22 Aug 2022
CMS Urges States to Tie Nursing Home Medicaid Payment to Quality
A new bulletin to states says that tying nursing home Medicaid payment to quality measures will improve patient outcomes and advance health equity. Continue Reading
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09 Aug 2022
ACO Participation Cuts Medicare Spending on Serious Mental Illness
A new study shows that ACO participation in the Medicare Shared Savings Program modestly reduced Medicare spending for patients with serious mental illness, suggesting more effort to be made. Continue Reading