Roji Intel Blog

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ACOsFuture of Health CarePrimary Care PracticesValue-Based Health Care
July 24, 2019

Can ACOs Survive the Complicated New Landscape in Medicare Risk?

What a difference a year makes. In Spring 2018, many Accountable Care Organizations (ACOs) pondered a walkout over Medicare plans that included downside risk in ACO financials. Nonetheless, CMS finalized its plans to make provider risk a reality for all ACOs in its Pathways to Success overhaul of the Medicare Shared Savings Program (MSSP). ACOs’ lukewarm reception to the goal of compelled savings, however, was not forgotten. Fast forward to April 2019, when CMS announced five Primary Care Models to propel physician groups to adopt risk-based reimbursement directly—including capitation. Those models are now under fast-paced implementation, with application deadlines approaching.…
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ACOsFuture of Health CarePrimary Care PracticesValue-Based Health Care
July 10, 2019

Can Medicare Primary Care Risk Models Work in Today’s Practice Environment?

There’s now no doubt that Medicare is eager to move forward with Value-Based Health Care and risk-based reimbursement. CMS has rolled out major changes to make Accountable Care Organizations (ACOs) risk-bearing and add attractive benefits to capitated Medicare Advantage plans. Add to that two new classes of Primary Care Risk Models that introduce risk-based reimbursement into the general provider population, which, CMS says, are designed to stimulate primary care: Primary Care First (PCF) and Direct Contracting (DC). But we also know, from early CMS statements on direct contracting, that it intended to find other mechanisms to move physicians into Value-Based Health…
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Future of Health CareMedical Decision-MakingPrimary Care PracticesValue-Based Health Care
June 26, 2019

Follow the Pathway to PCP Success In Medicare Direct Contracting

Primary care physicians were sitting on the sidelines as Medicare developed financial risk models in various generations of ACOs. At best, they could only hope to participate in Medicare Advantage and/or join a larger ACO. But potential for financial gain was elusive when the physicians’ success depended on the actions of others to achieve savings. Now Medicare is offering a carrot to large primary care practices with its new Direct Contracting (DC) models, luring them with the possibility of capturing higher and more predictable revenues as well as shared savings. CMS recently announced an initiative to test risk-based reimbursement models…
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Consumers & PatientsFuture of Health CareValue-Based Health CareWomen and Health Care
June 12, 2019

Get the eBook “Not Second Best: Inject Value in Women’s Health Care”

Six months ago, I started writing about women’s health, in response to this simple question: What trends are emerging in health care for 2019? The New Year is filled with predictions about what is coming, and I thought this year’s list from health care leaders was too “last-year.” Artificial intelligence, medical science advancements in biologicals and genetic therapies, and business consolidation are not coming; they are already here and will simply go further. Witnessing the debate about health care rights in the country, and the increasing distrust of health care by consumers, I observed that most of those speaking are…
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MedicarePrimary Care PracticesValue-Based Health Care
June 5, 2019

Can Small PCPs Succeed in Medicare’s Primary Care First?

Medicare’s announced primary care models will provide an interesting test of whether financially-motivated primary care practices (PCPs) can improve hospital utilization, the key outcome measure that will determine provider revenues under the pilot. While provider risk for costs of patient care is inevitable for most physicians in the future, providers don’t have the same potential for financial success. That is especially true for PCPs, whose volume and roles in health care have been eclipsed by specialists and industry consolidation. Whether Value-Based Health Care can restore primary care to a central role of coordination—with the potential for cost reduction—is at the…
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ACOsBundled PaymentsFuture of Health CareRiskValue-Based Health Care
May 22, 2019

Can Provider Risk Cure High Medical Costs?

Fee-for-Service (FFS) has been on a slow march toward risk-based reimbursement for two decades. But FFS has proven to be remarkably resilient—until now. In the last six months, Medicare has doubled down on creating new provider risk models for ACOs, specialists and primary care physicians. All of them have methods to ensure that providers are held accountable for medical expenditure targets. Wait. Haven’t we been here before? What‘s different between now and the 1980s, when HMOs and provider risk first prevailed in the market—and then were purged as both ineffective and unpopular? Is provider risk a cure for high medical…
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Consumers & PatientsFuture of Health CareValue-Based Health CareWomen and Health Care
May 15, 2019

How Providers Must Improve Value in Women’s Health

Writing the Roji Health Intelligence® series on gender disparities and other women’s health issues has been a revelation. As a woman who has worked in so many parts of the health care industry, I was already aware of basic gender disparities, risk levels, incidence of disease, and economic issues that are predominant among women. Most women in health care have had their knowledge and judgment doubted as both patients and professionals. Women everywhere encounter the economic barriers associated with affordable health care, some much worse than others, and every woman who is a mother struggles with balancing the interests of…
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ACOsFuture of Health CareValue-Based Health Care
May 8, 2019

How Will New Primary Care Models Affect Providers in VBHC?

Embraced by some provider groups and disparaged by others, CMS’s five new payment models for practices focused on primary care include much to consider. All reflect a key departure of Medicare’s Value-Based Health Care (VBHC) efforts to date: they are direct efforts by Medicare to transition physician practice revenues to risk without the necessity of ACO participation. The primary care models will affect both providers and patients. In this article, we’ll address the provider issues. How patient choice of care and outcomes for patients and patient populations will be affected deserves dedicated scrutiny in a future post. No Surprise that…
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Consumers & PatientsFuture of Health CareValue-Based Health CareWomen and Health Care
May 1, 2019

Do “Women’s Health Centers” and Services Deliver on Value-Based Health Care?

Women make an astounding 80 percent of health care decisions for themselves and their families. But there’s a disconnect between what women need and how providers have organized health care for them. While Value-Based Health Care (VBHC) is struggling to achieve more value for every health care dollar spent, providers are simultaneously sabotaging women in their customer base. How? This might surprise you: through promotion of “women’s health” services. While providers may have good intentions for offering a dedicated place for women’s health needs, those services have actually fragmented care for women, especially those with more complex conditions. Let’s evaluate…
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ACOsPerformance ImprovementRisk
April 17, 2019

Bootstrapped ACOs Facing Risk? Adopt Cost Strategies With Long Term RoI

The experimental phase of Medicare ACOs has been officially declared dead, per CMS. Going forward, ACOs must agree to take on financial risk for expenditures beyond their targets. That’s sobering news for the majority of ACOs still struggling to succeed. The reality is that most ACOs are bootstrapped—light on extra funding and dependent on existing tools to do more. In fact, about two-thirds of ACOs report that funding is their most significant challenge. And that is probably understated, since patient engagement problems (also reported by two-thirds of ACOs) and lack of data (reported by 40 percent) are remedied by solutions…
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