FEATURE
From: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html
(continued from page 23)
Coverage Advisory Committee (MED CAC) recommended
to CMS that for high cost complex services that CMS request
the manufacturer include patient reported outcome measures
(PROM) with its submission for coverage. This is a signal that
Medicare is looking for more input from consumers/patients
in assessing quality of care and value of services. still unclear the direction that the Trump administration and the
old-line guard within CMS will move in the future, but it is clear
that it will not be to restore fee-for-service.
By combining efforts in cost management and quality metrics,
CMS hopes to have 80 percent of its payments to physicians come
in Value Based Payment programs. Most physicians are aware of
the programs on Physician Value Based Modifier program, Hos-
pital Readmission Reduction, Total Joint Replacement and others.
But in October 2018, CMS introduced its Bundled Payments for
Care Improvement (BPCI). This is the first advanced alternative
payment model (Advanced APM) of the Trump administration.
This is a model in which all services are paid for on an episode of
care payment model rather than fee for service. All physicians, the
hospital and eligible non-physician providers share in the single
payment. Currently, this model includes 832 acute care hospitals and
715 physician group practices – a total of 1,547 Medicare providers
as participants. They are located in 49 states plus Washington, D.C.
and Puerto Rico. 1.) Final policy, payment and quality provisions changes to the Medicare
physician fee schedule for calendar year 2019., Nov. 1, 2018 https://
www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quali-
ty-provisions-changes-medicare-physician-fee-schedule-calendar-year
These are all steps being taken by CMS in its move from fee-for-
service to a value-based reimbursement. Programs such as BPCI and
the changes in reimbursement for ambulatory services are directed
to change the referral patterns and to streamline health care. It is
24
LOUISVILLE MEDICINE
Dr. James is the Senior Medical Director for Highmark Inc. in Pittsburgh,
PA.
Citations:
2.) What small practices need to know; 2019 Medicare physician fee schedule
final rule, Nov. 19, 2018. https://www.practicefusion.com/blog/2019-
medicare-physician-fee-schedule-final-rule/
3.) What are the value based programs? https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Pro-
grams/Value-Based-Programs.html
4.) CMS Newsroom. CMS Announces Participants in New Value-Based
Bundled Payment Model, Oct. 18, 2018. https://www.cms.gov/news-
room/press-releases/cms-announces-participants-new-value-based-bun-
dled-payment-model accessed Jan 1, 2019
5.) CMS Quality Strategy 2016. https://www.cms.gov/Medicare/Quality-Ini-
tiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/
Downloads/CMS-Quality-Strategy.pdf