![打造价值之路 1200X630](/Areas/CMS/assets/img/blank.gif)
随着医保准入和CHIP再授权法案的通过 (MACRA)、国会和CMS已经发出信号,表示将永远放弃纯 fee-for-service reimbursement in favor of value-based payment. 这已经 CMS表示希望将医疗保险支付的50%转移到 alternative models by 2018. We should 不 expect MACRA to be the last major change; instead providers should expect a continued migration toward ever-greater accountability for cost and quality. 这篇文章 描述设置基于价值的报销策略的过程. 这是第一个系列的心电图将生产,以帮助 industry thrive in the value-based world.
THE (PERMANENTLY) CHANGING REIMBURSEMENT LANDSCAPE
In 近年来,国会和CMS一直在暗示他们打算采取行动 摆脱了纯粹的按bet8娱乐收费的bet8网站备用报销模式 favor of greater emphasis on cost and quality improvement. 几乎 每年,B部分报销的修改已被引入为 well as entirely new models. Most recently, with the passage of MACRA 2015年4月,国会发表了一份明确声明,表示它打算 永久摆脱传统的B部分按bet8娱乐收费 补偿模型. As a result, remaining on the sidelines of payment reform is no longer an option; provider organizations that bill for 联邦医疗保险B部分现在进入了价值业务,不管他们喜欢与否 不. This includes financial incentives for all medical specialties, 而现有的项目往往侧重于初级保健或特定的 medical and surgical specialties.
MACRA Final Rules: What You Need to K现在 Now
View this webinar to get the information on the contents of the rule, along with analysis on what to do about its provisions.
查看录音即便如此, 一些医疗机构表示,目前的医疗项目太复杂了, 让人困惑, 在他们的激励下积极管理绩效是不现实的,也是不值得的. 在他们看来, the only feasible approach is to adopt hope as a strategy and let the Medicare “chips fall where they may”; they believe that while the dollars at stake are 不 insubstantial, 还有其他的, 也许更有希望, opportunities for improving operating margins. This is certainly an understandable point of view, 如果人们期望当前的医疗保险模式代表最终的结局,这实际上可能是一个谨慎的行动方针, or that commercial payers will 不 follow suit.
然而, we believe that these would be unrealistic expectations,
rendering this approach short-sighted. The developments described above
不应将其视为孤立事件,而应视为一种趋势
在可预见的未来可能会继续,首先是医疗保险,然后是
商业付款人.
![侧边栏1](/user_area/uploads/Sidebar-1.1.png)
因此, absent a radical overhaul of Medicare’s benefits 设计,我们没有预见到政治意愿,我们应该这样做 expect Medicare to push more and more financial responsibility (i.e., risk) down to providers over a protracted period of time. CMS有 已阐明其转移50%医疗保健支出的目标 到2018年转变为基于价值的模式,所有迹象都表明他们会这样做 set their sights higher in subsequent years. Like-wise, we should expect that commercial payers will follow Medicare’s lead and introduce 类似的付费模式,就像他们在过去3-4年所做的那样 几十年(见侧栏1). Accordingly, provider organizations need to be thinking about how to perform under existing Medicare value-based models, in order to prepare for a future beyond what the current reimbursement landscape brings. Even if the existing models’ financial 激励本身并没有足够的说服力,它们是 预示着即将到来的事情,因此需要认真对待, 现在.
定义响应
Provider organizations are faced 有一系列令人眼花缭乱的医疗保险报销模式(择优) Incentive Payment System [MIPS], Medicare Advantage, Advanced Alternative Payment Models [APMs], other APMs, 等.). 这需要 确定如何参与的策略的发展 Medicare Part B and other payers’ programs. The right path forward will vary from one organization to the next, based on its readiness to 执行基于价值的报销,其意愿和能力 invest in the development of future capabilities, and also the applicability of the models themselves. These decisions are very complex 需要在四个主要阶段采取深思熟虑的、以事实为基础的方法.
Assessing Value-Based Readiness
想要转向基于价值的报销和做好充分准备并不一定是同义词. 走上一条通往价值的实际道路,首先要对组织的核心竞争力进行批判性和冷静的评估,并为转型做好全面准备. 对bet8网站备用当前能力进行系统和诚实的评估,可使领导层全面了解其组织及其战略发展能力, 在财务上, 操作上, 和技术上. 那些在基于价值的补偿下最成功的公司几乎总是在六个关键领域基本健全:支付模式, organizational foundation, 供应商网络, care model transformation, provider incentive design, and clinical and business informatics (see figure 1).
了解组织相对于这些因素所处的位置是至关重要的,这样不仅可以确定长期发展和/或改进的优先事项,而且还可以为bet8网站备用提供信心和基础,以便在短期内追求最合适的支付模式.
Identifying Viable Payment Options
要对采用哪种策略做出明智的选择,需要了解组织对基于价值的支付和支付模式本身的准备情况. 医疗保险已经引入了多种可供考虑的支付模式,并可能在未来几年引入更多. 对于那些在广泛的专业范围内雇用大量bet8网站备用的组织, it is necessary to hone in on a limited number of options.
并非所有模型都适用于所有组织(参见侧栏2和3)。. For those that are applicable, 选择过程应该通过组织的能力(如前一节所述)和模型本身对其施加的需求之间的交叉通道来通知. 不同的报销模式将在不同程度上强调组织的基于价值的准备(VBR)能力, and understanding where that fit, 或者缺乏, occurs will be important. 下面的插图提供了这个概念的一个假设的例子.
在这个例子中, 该组织拥有非常好的组织基础,因为它有坚实的财务业绩和高效的运作, and it also has a fairly well-developed provider network. 然而, it is less capable in the areas of care model transformation, 供应商激励机制, 和技术. 它的优势与支付模式A所要求的特征是一致的, and its weaknesses are 不 prohibitive with this model. 因此,支付模式A可能是该组织的一个很好的选择. 相反, 支付模式B可能不是一个可行的选择,因为它需要在护理模式转换和提供者激励方面比组织拥有更强的能力.
![图2](/user_area/uploads/Figure-2.1.png)
Assessing Financial Implications
Once the range of potential options has been narrowed, 现在是仔细研究哪些选择可能是发展的优先事项的时候了. 这个阶段的关键考虑因素之一是了解它们的财务含义. 我们并不是说财务考虑应该是一个组织战略的主要决定因素, but it is certainly a relevant input and at the very minimum, necessary for planning purposes. 评估应包括以下几个主要方面:
Range of outcomes for Part B reimbursement
很明显, 了解组织在任何给定的报销模式下的运作情况是很重要的. 这是很难准确预测的,因为许多输入超出了组织的控制和/或不会提前知道. 尽管如此, understanding the likely range of outcomes, particularly when comparing APMs to MIPS, 是很重要的. 即使有5%的奖金, 如果特定APM模型的性能标准在MIPS下明显更高,那么组织在APM下的表现可能比在MIPS下更差.
Congruence with existing commercial payer arrangements
As we mentioned previously, 一个组织可能正确地得出结论,在基于价值的补偿下,成功所涉及的投资和努力超过了这样做的财务利益, at least in the near term. 然而, 在某种程度上,商业合同可以反映政府的激励措施, there can be a significant multiplying effect.
Impact on both physician and hospital revenues
B部分的许多支付激励措施旨在减少医疗保险的总体支出,而A部分是医疗保险的主要组成部分. 因此, 在B部分下的成功很可能是以减少A部分报销为代价的, so this relationship needs to be understood and forecasted. 再一次。, 我们并不是说,这种评估的结果应该成为决策的驱动因素, but it is a factor that must be understood and planned for.
投资需要
发展基础设施以管理护理并在以价值为基础的世界中取得成功是一项重大投资. This will entail investments in electronic medical records, health information exchanges, business intelligence/ decision support capabilities, 护理协调员, 协议开发, 培训, 等.
Scenario planning/sensitivity analysis
任何财务评估都必须考虑一系列可能的结果, particularly given the uncertainty involved. 例如, 一个组织可能会把目光投向MACRA的APM轨道, 但如果达不到门槛标准,结果会怎样呢? 在大多数情况下, 这种努力将使组织在MIPS下表现良好,这可能是也可能不是一个不希望的结果. 类似的, 供应商组织应该仔细考虑努力达到APM参与门槛和收取5%奖金的财务影响, 而不是缓慢地提升,专注于在此过程中获得更好的结果.
Finalizing the 策略
在组织评估其基于价值的补偿的准备情况之后, identifies viable 补偿模型s/MIPS measures, and weigh their potential financial impact, 组织应该拥有所有必要的信息,以决定采用哪些模型和度量标准, 按照什么顺序. 在许多情况下,这些决定将是复杂的,并基于直觉和客观数据的判断. 确定战略时,应将整个护理过程中的关键利益攸关方纳入其中, 来自医疗集团, 医院, and increasingly health plans. 在设计策略时,需要考虑以下几个关键问题:
- What will ultimately serve our patients best?
- What is our level of risk tolerance? 为了接受可能出现的更大下行风险,我们必须对获得上行机会有多大的信心?
- 我们实现高水平绩效的可能性有多大? What are the consequences of 不 meeting our goals (for example, if we fail to qualify for the APM track of MACRA, 在MIPS下的优异表现会成为安慰奖吗?)
- How difficult will it be to close any gaps in our capabilities? 那要花多长时间? What level of change management is required? How many major initiatives can we manage concurrently?
- 参与一种特定的支付模式将如何帮助我们为将来可能引入的其他模式做好准备? 它会迫使我们拥抱未来,还是让我们把问题往后推?
Addressing these questions in a thoughtful manner, 征求利益相关者的意见是一个具有挑战性的过程,但对于平衡相互竞争的利益和实现认同是必要的. 在这个过程的最后,你的组织应该有一个明确的战略,提供: 清晰 组织与哪条报销路径最一致; 确认 of any capability gaps; and 量化 与所期望的战略相关的财务机会.
IMPLEMENTING THE STRATEGY
Whatever the selected strategy, it will require an implementation plan with discrete projects, 现实的时间线, 以及可识别的里程碑/可交付成果,以便有效地跟踪进度并保持问责制. 对于大多数组织来说, implementing a value-based reimbursement strategy will be a multi-year endeavor that involves upgrading capabilities in: exploring effective payment models; building a strong organizational foundation; expanding 供应商网络; transforming care models; designing provider incentive models; and, enhancing clinical and business informatics. Each of these domains is a large and complex, 因此,在接下来的几个月里,心电图将发布一系列深入的文章,专门关注这些领域,以帮助医疗保健组织成为蓬勃发展的基于价值的企业.
与此同时, 现在应该很清楚,不强调质量和成本管理的按bet8娱乐收费的时代正在迅速结束. 的过渡, 从《bet8网站备用》的通过开始, 正在加速, 我们不认为MACRA将是这个话题的最终定论. 这可能是我们在职业生涯中所经历的医疗保健行业最普遍、最动荡的变化. 成功的组织将是那些拥抱这种变化并开始为不可避免的未来做计划的组织.
Published October 14, 2016