Healthmonix Advisor

The Future of Value-Based Care

A new ten-year experiment called ACCESS is about to test exactly that question — and it could reshape how chronic illness is cared for in America.

Topics: VBC, Value-Based Care, Conference, APG, healthcare, ACCESS

For most of 2024 and 2025, the dominant frame for AI in healthcare was the copilot: AI suggested, a clinician acted. The framing was reassuring. It kept a human in every loop and let institutions defer the hard question of governance, because the AI never did anything a human hadn't already approved.

That framing is breaking down. At the APG Spring Meeting in San Diego this May, 4 organizations — an FQHC, a national VBC enablement company, a Southern California physician group, and UC San Diego Health — described deployments that have moved past copiloting into something more autonomous.

Topics: VBC, Value-Based Care, Conference, AI, APG, healthcare

For roughly a decade, the operating assumption of value-based care has been that you transform outcomes and costs by transforming primary care:

• Attribute the patient to a PCP
• Hand the PCP a panel and a risk arrangement
• Give the care team a gap list
• Let the rest of the system carry on 

That model has produced real wins. It’s also produced a generation of risk-bearing organizations that have squeezed most of what they can out of the levers a primary care physician controls and now find themselves staring at the part of the spend they don’t.

Topics: CMS, VBC, Value-Based Care, Conference, APG

For a decade, the question was whether to take risk. Now it's whether your measurement infrastructure can keep up.

About 1,300 medical group executives gathered at AMGA in Las Vegas last month. Most have already committed capital to value-based care. The strategic debate is over. A new one is starting.

Topics: CMS, VBC, Value-Based Care, MIPS Reporting, Conference, AMGA, AI

As you report your MIPS data, it can feel like a lot of work with little ROI for the last two years. But wait. Sometimes we need to step back and evaluate the bigger picture. While we often focus on "getting the job done", there are changes in the healthcare economy that are occurring that are strategic.

Topics: MACRA & MIPS, APMs, VBC, Value-Based Care

The Centers for Medicare & Medicaid Services (CMS) continues to relax regulations to enable hospitals, clinics and other providers to boost their front-line medical staff during the COVID-19  pandemic. This pandemic has created an urgency for expansion of the use of virtual healthcare to reduce the risk of spreading the virus. It has also created a need to relax practice restrictions and allow more flexible care practices to meet the needs of patients.

Topics: CMS, Interoperability, Industry insights, Policy, Health IT, VBC, COVID-19

Since 2017, the Centers for Medicaid and Medicare Services (CMS) Merit-Based Incentive Payment System (MIPS) has provided eligible clinicians a score of zero -100 annually based on the clinician’s efforts and data collection in four program categories: Quality, Improvement Activities, Promoting Interoperability, and Cost. A clinician’s final score for each year’s MIPS performance ultimately dictates a payment adjustment that is applied to his or her Medicare Part B reimbursement rate two years later. In practical terms, this means that a clinician’s 2017 performance impacts all of his or her Medicare claims that are filed in the 2019 calendar year.

Topics: PRO Tips, MACRA & MIPS, Industry insights, VBC, ROI

In last week’s blog I laid out the case for opting into MIPS, an option that allows clinicians and groups to still receive a MIPS payment adjustment if they exceed 1 or 2, but not all, elements of the low-volume threshold. Although this option can be beneficial for a wide range of clinician types depending on their situation, today I want to focus on psychologists in particular. Because in my experience, they provide some of the most striking examples of this “MIPS hack” in action.

Topics: PRO Tips, MACRA & MIPS, Eligibility, Small Practice, VBC, ROI

Beginning in 2019, otherwise-eligible clinicians, groups, and APM entities can elect to opt-in to MIPS if they exceed 1 or 2, but not all, elements of the low-volume threshold. That means that for the first time, these previously ineligible clinicians have the opportunity to participate in the QPP and earn a payment adjustment.

Now maybe you haven’t had the time to pay close attention to policy minutiae, and this is the first you’re hearing of the opt-in option. Or maybe you’ve heard of it, but haven’t looked seriously at what it could mean for you or your organization. After all, on the surface it just sounds like work that isn’t required--and could it really make enough of a difference to your bottom line to be worth it?

Well, we highly recommend you do the math to find out. Because depending on your situation, you might be very, very glad you did.

Topics: PRO Tips, MACRA & MIPS, Eligibility, Small Practice, VBC, ROI

On April 22, the U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) announced the CMS Primary Cares Initiative, a new set of payment models that are part of HHS Secretary Alex Azar’s value-based transformation initiative. The CMS Primary Cares Initiative will be administered through the CMS Innovation Center. CMS expects the new programs to shift at least one quarter of people in traditional Medicare out of fee-for-service.

Topics: CMS, Policy, VBC