Health Spending Grew 4.6% in 2018, Outpaced by Overall Economy
Healthcare Spending is on the rise in the United States. The national healthcare spending has increased faster in 2018 than it did in 2017. Read the article below to see what the projected statistics of healthcare spending will be over the next seven years.nnHealthcare spending in the U.S. grew by 4.6% in 2018, totaling $3.6 trillion, according to data released Thursday by the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary.nnHealthcare, as a share of the overall economy, slipped to 17.7% of gross domestic product (GDP) in 2018, down slightly from 17.9% in 2017.nnThe statistics, published in Health Affairs, show that healthcare spending averaged $11,172 per person in 2018, while the total personal healthcare spending growth rate held steady at 4.1%.nnNational healthcare spending increased faster in 2018 than it did in 2017, but it equaled the rate seen in 2016. CMS attributed the recent increase to acceleration in health insurance costs, which grew by 4.3% in 2017 and 13.2% in 2018. Another contributing factor was the reinstatement of the health insurance tax after a one-year moratorium.nnFor the second consecutive year, the total number of uninsured people rose by 1 million.nn”Healthcare spending growth picked up across all major payers in 2018 as medical prices grew faster, due in part to the reinstatement of the health insurance tax on all health insurance providers,” Micah Hartman, a statistician in the CMS Office of the Actuary, said in a statement. “However, economic growth outpaced healthcare spending and the share of the economy devoted to health care fell.”nnRising medical prices accounted for an uptick in per capita healthcare spending last year. Hospital spending—which accounted for 33% of overall healthcare spending in 2018—led the way among goods and services spending growth, at 4.5%.nnGrowth in expenditures slipped slightly to 4.5%, though hospital prices rose from 1.7% in 2017 to 2.4% in 2018. Additionally, growth in total inpatient days slid from 1.7% in 2017 to 0.7% in 2018.nnPhysician and clinical services spending slowed to 4.1% in 2018, down from 4.7% in 2017, while retail prescription drug spending rose from 1.4% in 2017 to 2.5% in 2018.nnCMS released projections in February for average healthcare spending growth rates of 5.5% annually between 2018 to 2027, totaling nearly $6 trillion.nnThe study projected acceleration in hospital spending from 4.4% in 2018 to 5.1% in 2019, thanks to faster than expected growth in Medicare and Medicaid.nnThe study also attributed the growth in overall healthcare spending to more baby boomers entering Medicare and a 2.5% increase in medical goods and services through 2027.nnOn the payer side, private health insurance spending totaled $1.2 trillion, growing by 5.8% in 2018 compared to 4.9% in 2017.nnMeanwhile, both Medicare and Medicaid experienced spending growth increases of 6.4% and 3%, respectively.nnThe federal government’s healthcare spending rose by 5.6% in 2018, doubling the rate from 2017, as growth in Medicare and Medicaid expenditures increased significantly.nnThe largest portions of healthcare spending went to the federal government and households, each with 28%, private businesses at 20%, state and local governments at 17%, and “other private revenues” at 7%.nnOriginal article published on healthleadersmedia.com
This week we wanted to take a different approach to our surgery procedure coding and talk about a diagnosis in a TTE. Read below for an example of coding TTE’s.nnnExample: Coding TTE’s that has aortic valve stenosis with mitral valve insufficiency.nn[Since the provider does not specifically state that the cause of the valve disease was non-rheumatic, our guidelines tell us to assume rheumatic origin when valve disease affects multiple valves and the valvular heart disease is not described as non-rheumatic. If referring to the index within ICD-10, we would go to category I08.- which includes “multiple valve diseases specified as rheumatic or unspecified” and use I08.0.]nnAnswer: The correct code is I08.0 multiple valve disease. If you index the mitral valve insufficiency, you see the guidance there to w/aortic valve disease I08.0. If we index the aortic valve stenosis first, we are guided to I35.0 which has an Excludes 1 note (not coded here) aortic valve disorder of unspecified cause but with disease of mitral and/or tricuspid valve(s)(I08.-).nWhat makes coding valvular heart disease most confusing is that unlike the aortic, mitral & pulmonary valves, tricuspid valve disorders are presumed rheumatic on their own (without other valvular involvement).nn
Recently, Walgreens has teamed up with UnitedHealthcare to open in-store Medicare centers. Through this partnership, people will have easy access to comprehensive services for their specific needs and pharmacy services. Read the article below to find out more.nnMore seniors are opting into MA plans, which have become a lucrative business for insurers. Nearly one-third of all Medicare beneficiaries, or 22 million people, are enrolled in MA plans.nnThe deal gives UnitedHealthcare access to reach more members as Walgreens operates more than 9,000 drugstores with a presence in all 50 states. For Walgreens, the deal has the ability to drive additional foot traffic to stores as UnitedHealthcare commands the largest share of MA members, about 26% of the entire MA market, according to the Kaiser Family Foundation.nn”Through strategic partnerships like this, Walgreens store locations can offer comprehensive services tailored to the specific needs of the communities we serve that are conveniently accessible alongside our pharmacy services,” Rick Gates, senior vice president of pharmacy and healthcare at Walgreens, said in a statement released Monday.nnCVS Health, which owns its own insurance plan with Aetna, has made a similar move as it plans to open more than 1,500 HealthHUB stores across the country by the end of 2021. The HealthHUB stores earmark about 20% of CVS retail space to health services, with a special focus on preventive care and wellness.nnIn its bid for Aetna, CVS claimed the deal would serve as the “front door” to healthcare as a majority of Americans live just a few miles from a CVS store and tend to interact with pharmacists more than their doctor.nnOther nontraditional players, including Walmart, have jumped in the space as well. The company launched its first health superstore in Dallas, Georgia, this fall.nnThe recent developments underscore the rise of consumerism in healthcare in which more care is moving from outside the grip of hospitals to more convenient, lower-cost settings.nnComplete and original 
It is a word that brings dread to most people, AUDIT. The stress of an audit is real and can be felt just by walking into the room. So what can be done to help prevent all the drama? The short answer, like most things, is to be prepared. Get a plan in place and be ready when the time comes. Working with your external compliance auditors and having open lines of communication can play a big role in making sure you and your practice get the most out of it. Make sure they know what your concerns are going into their review. Have a clear and defined code set in, the addition of production reports helps to support the codes you wish to audit. In the end, they are there to help and provide an outside perspective.nnIn the November issue of the AAPC’s Healthcare Business Monthly, there is an excellent article with a six-step plan to audit success.n
Be sure to get your new Medicare card before the new year! Also, update your patients’ records before the office is hit with many new patients and appointments when the new year comes. Read below for more information from MLN Connects.nnDo not wait. Update your patients’ records and use Medicare Beneficiary identifiers (MBIs) now, before you are busy with other patient insurance changes in January.nnWe encourage people with Medicare to carry their cards with them since we removed the Social Security Number-based number; if your patients do not bring their Medicare cards with them:n
nnHappy Thanksgiving from all of us at Welter Healthcare Partners. We want to thank our partners and clients for their continuous support and business throughout the year. We are so grateful to you. We wish you a safe holiday with your loved ones.nnOvereating (R63.2) is defined in medical terms as “to eat to excess, especially when habitual.” Break the habit of this holiday and save some leftovers for tomorrow.nn 
After months of feedback from payers and providers unhappy with a proposal to mandate price transparency in healthcare, the Trump administration has now unveiled its final rule on the topic of hospital price transparency. This topic has been in talks for months and its effective date is being pushed to 2021.nnnDeclaring “a major victory” for patient choice and affordable healthcare, President Donald Trump on Friday unveiled his administration’s final rule on hospital price transparency.nn”I don’t know if the hospitals are going to like me too much anymore with this, but that’s OK,” Trump said at a White House event to announce the rule.nn”We’re stopping American patients from just getting, pure and simple, two very simple words: ripped off. Because they’ve been ripped off for years, for a lot of years,” he said.nnThe final rule—which takes effect on January 1, 2021, one year later than initially proposed—requires hospitals to provide patients with easily accessible information about standard charges for items and services offered.nnThis includes making all standard charges available in a single data file that can be read by other computer systems, as well as making “shoppable services” information available on their websites in a consumer-friendly manner.nnAdditionally, hospitals must make information about shoppable services, which can be scheduled by patients in advance, available in a “prominent location online” and describe the information in plain language.nnThe Centers for Medicare & Medicaid Services also issued a separate proposed rule that would impose price transparency requirements on health insurers.nn”I’m sure they’ll be thrilled,” Trump said of insurers. “This will allow you to see your out-of-pocket costs and other vital price information before you go in for treatment, so you’re going to know what it’s going to be and you’re going to be able to have lots of choices, both in terms of doctors, hospitals, and price.”nnThe final rule provides CMS with additional enforcement and auditing capabilities, including the ability to issue monetary fines of $300 per day for hospitals that don’t comply.nnThis announcement came less than four months after CMS released its proposed rule on hospital price transparency.nnHealth and Human Services Secretary Alex Azar applauded the president for implementing “revolutionary change” to the healthcare system.nn”Today’s transparency announcement may be a more significant change to American healthcare markets than any other single thing we’ve done, by shining light on the costs of our shadowy system and finally putting the American patient in control,” Azar said.nn
Hospitals Say They’ll SuenNot surprisingly, payer and provider stakeholders responded to the new final rule with a chorus of boos and promises of litigation.nnIn a joint statement, the American Hospital Association, Association of American Medical Colleges, Children’s Hospital Association, and Federation of American Hospitals called the proposed rule “a setback in efforts to provide patients with the most relevant information they need to make informed decisions about their care.”nn”Instead of helping patients know their out-of-pocket costs, this rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations in value-based care delivery,” the hospital groups said.nn”Because the final rule does not achieve the goal of providing patients with out-of-pocket cost information, and instead threatens to confuse patients, our four organizations will soon join with member hospitals to file a legal challenge to the rule on grounds including that it exceeds the Administration’s authority,” the hospitals said.nnBeth Feldpush, senior vice president of policy and advocacy at America’s Essential Hospitals, said the final rule “would unfairly advantage health plans in negotiations with providers and threaten essential hospitals’ ability to participate in networks and maintain access to services.”nn”Information without context—for example, how and why the cost of patient care varies among hospitals—is of little practical use to consumers,” she said. “Essential hospitals typically have higher costs due to their commitment to complex services vital to communities, such as trauma and behavioral health care.”nnAlso, Feldpush said the final rule would create an administrative nightmare for hospitals that would hurt patient care and drive up costs.nn”These policies undermine hospital’’ ability to negotiate equitable payments while giving consumers little actionable information with which to make informed care decisions,” she said.nnOn the payer side, Matt Eyles, president and CEO of America’s Health Insurance Plans, said price transparency “should aid and support patient decision-making, should not undermine competitive negotiations that lower patients’ health care costs, and should put downward pressure on premiums for consumers and employers.”nn”Neither of these rules—together or separately—satisfies these principles,” he said.nnOriginal 
Opioid Treatment Programs (OTP’s) have been a hot topic for several years. Among several new codes set to be implemented January 1st are new HCPCS codes specifically for OTP’s. nnHere are two sequences to be aware of:nGYYY1-GYYY3 (office-based treatment)nGXXX1-GXX19 (medication-assisted treatment)nnThese new codes will reimburse with bundled payments for the treatment of opioid use disorder (OUD). Refer to 
Since acquiring PillPack in 2018, Amazon has now bought Health Navigator in which they intend to offer to employees of Amazon. Many are certain Amazon will soon enter the healthcare market. Read the article below to find out more about this new acquisition that was made and learn some of Amazon’s goals.nnIn what is its first healthcare-related acquisition since spending $753 million in June 2018 to acquire PillPack, Amazon.com (NASDAQ: AMZN) inked a deal to buy Health Navigator, a start-up that provides digital triage tools and symptom lookup. The value of the deal was not disclosed.nnAmazon intends to offer Health Navigator services to its employees, shedding further light on where the e-commerce giant is heading in the healthcare market.nnIn late October, Amazon confirmed it purchased Health Navigator, telling CNBC it will fold it into Amazon Care, its new employee healthcare benefit that gives users access to virtual doctors and nurses. The idea is to leverage technology so employees can access healthcare providers in a convenient manner and at a lower cost. In addition to accessing virtual doctors and nurses, Amazon Care users (currently limited to employees in the Seattle area) can fill prescriptions through the e-commerce giant and choose between having them delivered or picked up at a participating pharmacy. By providing healthcare services to its employee base Amazon gets to test the waters and make fixes before the program is offered to a wider market. That serves to keep costs down and prevent it from making missteps on a large scale basis.nnAmazon hasn’t laid out all its plans in the healthcare market, but the acquisitions and initial products coming out of its healthcare joint venture with JPMorgan Chase (NYSE: JPM) and Berkshire Hathaway (NYSE: BRK-A)(NYSE: BRK-B) are starting to provide an outline for what it wants to do.nnCutting costs, increasing accessibility is Amazon’s goalsnAt the heart of Amazon’s aspirations is cutting the costs and challenges associated with healthcare, whether that means managing the price of medicine or increasing accessibility to doctors and nurses. In January 2018, it teamed up with JPMorgan Chase and Berkshire Hathaway to offer employees medical insurance. Now called Haven Healthcare, the group is gearing up to roll out its first products: two health insurance plans employees can begin to tap in 2020. The plans include free preventive care, no coinsurance or deductible, and $15 co-pays. This is the first product out of the secretive Haven Healthcare, but it showcases how Amazon and its partners are focused on lowering costs of medical care and insurance.nnThe acquisition of Health Navigator also helps Amazon achieve the goal of lowering the expenses associated with healthcare. Health Navigator’s technology is aimed at making it cheaper and easier to receive medical care. Microsoft is one of its many customers, providing the software giant with a clinical vocabulary and symptom checker technology to power a health bot. The bot uses layperson language to ask patients about their symptoms, ask relevant follow-up questions, and provide care options and potential causes. That eliminates the need for the sick employee to take time off from work, spend the money to get to the doctor and then wait in the office, for hours in some cases, to be seen. The bot can determine if it’s something as basic as a common cold and prescribe an over-the-counter remedy. A slew of telemedicine companies also uses Health Navigator’s technology.nnAmazon wants it alln
For some time now, Amazon has been laying the groundwork to enter the healthcare market, which is massive at $3.5 trillion and in need of some disruption. What better company to do it — Amazon has already changed retail and the way millions of people shop. While it’s been cagey about its intentions, many have speculated about what it will look like. Some think Amazon will disrupt the pharmacy market, dealing a direct blow to the likes of Walgreens and CVS Health. Others think it wants to own the telemedicine market, coming for the likes of Teladoc Health. But CB Insights, a market research company, thinks Amazon wants it all. It also thinks the retail giant has the size and reach to get just that.nnFor investors, These healthcare-related efforts may mean a new area of revenue growth at a time when Amazon is warning it could be slowing. For its fourth quarter, Amazon is projecting revenue of between $80 billion and $86.5 billion, which is lower than the $87.4 billion analysts were expecting. That comes even though the quarter includes the holiday shopping season. The healthcare market is also a huge opportunity to diversify further for the eCommerce giant.nn”Amazon’s potential foray into healthcare has already caused players in the space to scramble and reevaluate their core competencies. While Amazon has barely scratched healthcare’s surface, it has the potential to upend the space with its e-commerce expertise,” wrote CB Insights. “Without the need to make money in healthcare, the high margin and convoluted parts of the healthcare business are ripe for disruption.” All of which means there’s another bastion of growth Amazon can hang its head on if eCommerce growth levels off.nnOriginal 
Although the exact reason for denial was not given for this encounter we know this is considered investigational. Most insurances will not pay, it would have to be unlisted-23929. Click below for more information!nnnAs a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.nnThe following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:n
State healthcare officials have until November 15 to put together a final “state option” proposal for the legislature. Many are hoping new changes will be implemented due to the rise in healthcare costs. Read the article below to find out more on what legislation may be coming and what the concerns are with this program.nnIn what is shaping up to be the major health care battle at the state Capitol this coming legislative session, Colorado hospitals, and insurance companies both have raised concerns about a proposal to dictate hospital prices for a slice of people with private health coverage.nnThe idea, unprecedented across the country in its precise details, is part of an ambitious plan to create what Colorado health officials are calling a “state option” insurance program. The program would aim to lower insurance costs for people who buy coverage on their own.nnIt would largely achieve those lower rates by limiting how much hospitals can charge people covered by state option plans, which would be sold and administered by private insurance companies. Both hospitals and insurance companies would likely be required to participate in the program, though state officials have been vague on whether they have the authority to compel participation or whether they would need to ask the legislature for that authority.nnEither way, the state-option proposal has found hospitals and insurance companies — frequent foes in the battle over health costs — sharing unusual common ground.nnThe hospitals’ opposition is fairly simple to understand. They don’t want the government telling them what their prices can be.nn“Fundamentally, we as an organization are opposed to rate-setting,” said Katherine Mulready, the chief strategy officer for the Colorado Hospital Association. She said the proposal “misses the mark” and that its architects should return to the drawing board.nnBut the Colorado Association of Health Plans, the organization that represents health insurance companies in the state, also has raised concerns about the proposal, echoing two of the hospitals’ objections, though it supports the push to bring down the underlying costs of health care.nnFirst, insurers and hospitals say the program could make health insurance provided by employers more expensive. Why? Because hospitals might make up for the money they’re not getting for patients with state-option coverage by charging people with employer-sponsored coverage more.nnThe hospital association says this “cost shift” could be $1.5 billion over five years. (State officials argue that hospitals have already — and needlessly — shifted billions in costs onto the privately insured even as they have reaped record profits.)nn
“This one-size-fits-all approach would have the effect of increasing costs for employers,” Amanda Massey, the executive director of the Colorado Association of Health Plans, wrote in an emailed statement.nnSecond, both hospitals and insurers say patients could suffer by not having access to doctors. Hospitals warn that cuts to their bottom lines could lead to cuts in staffing. Insurers say private doctors’ offices, which wouldn’t be forced to accept the coverage, might choose not to see patients with state-option insurance.nn“The result will be reduced patient access to adequate networks and quality care,” Massey said.nnThe goal behind the state option — sometimes called the public option, even though the government wouldn’t administer the plans in Colorado’s proposal — is to ensure more choices and better prices for people who don’t get health coverage through their jobs. That group currently makes up about 7% of Coloradans.nnGov. Jared Polis has frequently touted the state option and reducing hospital prices as part of his “road map” for saving Coloradans money on health care.nnThe two-state officials putting the plan together — Kim Bimestefer, the executive director of the state’s Department of Health Care Policy and Financing, and Michael Conway, Colorado’s insurance commissioner — have in recent weeks held meetings across the state seeking input on their plan. They have also received more than 200 written comments.nnThe final proposal is due to the legislature by Nov. 15.nnOriginal 
Welter Healthcare Partners is providing new information regarding E/M changes in 2020. Read the updates below on what is coming next year for coding, along with changes to PCM and CCM.nnWhat’s New for 2020nnThe CY 2020 PFS conversion factor will increase to $36.0896, up to $0.05 from CY 2019. nnThree new Telehealth Service codes added to the Medicare-covered services list:n
Physician Assistants Make Ground n
CMS’ Innovation Center will delay the start of a new payment model called Primary Care First by a year, according to timeline updates on the model’s information page.nnPrimary Care First, announced in April, was slated to begin in January 2020. Now, it will begin in January 2021. The voluntary model is a set of five-year payment options that tie payment to value and quality metrics in hopes of reducing healthcare costs. Options under the Primary Care First model were set to be offered in 26 regions for a 2020 start date.nnPractices that wish to apply to the model to begin participation in January 2021 could begin applying Oct. 24, 2019. Applications close Jan. 22, 2020.nnRead more about the model 
2019 ICD‐10‐CM updates went into effect on October 1st. These changes will impact encounters for dates of service October 1, 2019 through September 30, 2020. It is imperative that your organization has up‐to‐date coding resources and a keen understanding of the changes that will impact your reimbursement! The new updates can also influence your organization’s MIPS/MACRA quality reporting scores.nnThis year’s ICD‐10‐CM updates include 325 code changes (273 new codes, 15 validity changes, 7 deleted codes, and 30 code revisions).nnHere are notable highlights of the 2020 updates: n
Reactive Hypoglycemia (ICD-10 code E16.1) or a sugar crash can do more than just make you tired. It can lead to feeling of hunger, irritability, anxiousness, headaches or even difficulty concentrating. With Halloween just around the corner, it seems there is a candy dish stocked full of treats everywhere you turn. It’s not just about the effects, it’s also about prevention. Here are a few fun reads on how to keep your blood sugar levels in check during the upcoming holidays.nnSugar Crash Effects and How to fix Them:nnThe sugar high is all fun and games until the resulting sugar crash affects the quality of your day. The term refers to the sudden drop in energy levels after consuming a large amount of carbohydrates. This can include pastas and pizza but is usually more common after eating simple carbohydrates, also known as simple sugars, such as desserts.nnA sugar crash often causes many undesired symptoms that can disrupt productivity and energy levels throughout the day.nnSanford Health, suggests balance, moderation and consistency are the most effective ways to avoid these crashes. Herrick shares her knowledge on sugar crashes, how to avoid them and what to do if you get one.nn
With the development of the health insurance exchange, prices for coverage for those in Colorado are going to drop. This will give families an average of $600-$700, back in their pockets. Read the article below to see when and how this new change will take place.nnFor the first time since Colorado opened its health insurance exchange, the prices people pay for coverage will drop — by a statewide average of 20.2%.nnAnd for families in western Colorado — who face some of the highest health insurance premiums in the nation — the savings could total more than $10,000 per year, according to final numbers for 2020 released by the Colorado Division of Insurance.nn“Just imagine: What could you do with that in your life?” Gov. Jared Polis said. “What could your family do with an extra $600 to $700 a month?”nnThe biggest reason for the price drop — which was higher than projected — is reinsurance, a bipartisan program created by state lawmakers during the 2019 session.nnThe program is basically a pool of $260 million in state and federal money that Colorado plans to use in 2020 to help cover some of the most expensive medical bills from the 250,000 people who buy plans through the state’s individual market. In exchange for the help, insurance companies lowered their monthly premiums.nn“It’s the same plans,” Polis said. “It’s just lower prices.”nnThat means problems such as people not using their insurance because of a high deductible will still exist, but the governor is hopeful that the lower monthly costs will lower the state’s uninsured rate.nn“We think this prices it into the market for many more families,” Polis said, though he didn’t commit to a specific number.nnDetails on the plan options can be found at connectforhealthco.com, with 2020 enrollment beginning Nov. 1.nnThe state lawmakers behind the reinsurance bill told The Denver Post they’re not done working on health care costs, either.nn“We have to attack the basic underlying costs,” said Sen. Bob Rankin, R-Carbondale. “This bill does not address why health care costs so much.”nnHis counterpart in the Colorado House, Rep. Julie McCluskie, D-Dillon, is optimistic about programs such as a public option and something called an alliance model that’s just starting in Summit County.nnPeak Health Alliance is a group of big employers that banded together to negotiate lower prices from their local providers and used those prices to get better rates from health insurance companies. When combined with the reinsurance reduction, McCluskie said, alliance members will see their premiums cut up to 50% next year.nnThe governor hopes that by 2021, many more of these alliances will exist, including a statewide group with state, county and city public employees.nn“There’s absolutely significant upside to an alliance model everywhere in our state, both the regional models and statewide,” Polis said. “We’re aggressively pursuing those opportunities to save people money.”nnOriginal 
For 2019, the U.S. is projected to have spent $3.82 trillion on healthcare. No other country in the world spends this much on healthcare. Below we assess the data and see what the research is saying regarding healthcare prices in the United States. Continue reading to find out more on this wasteful spending.nnnWaste accounts for about 25% of U.S. healthcare spending, new research indicates.nnNo other country spends more on healthcare than the United States, with the gross domestic product share of healthcare spending estimated at nearly 18% and rising. Earlier research on U.S. healthcare spending has estimated that waste accounts for about 30% of the spending total.nnReducing wasteful spending is a promising avenue to curb annual increases in the country’s healthcare spending, according to the co-authors of the new research, which was published today in the Journal of the American Medical Association. “Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in U.S. healthcare expenditures,” the researchers wrote.nnThe researchers examined data from 54 published reports. They tallied waste in six categories identified in 2010 by the Institute of medicine (IOM): failure of care delivery, failure of care coordination, over-treatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. Pricing failure includes medication pricing, payer-based health services pricing, and laboratory-based and ambulatory pricing.nnIn 2019, total U.S. healthcare spending is projected at $3.82 trillion.nnThe JAMA researchers generated several key data points:nnAnnual wasteful spending on healthcare is estimated from $760 billion to $935 billion.nnInterventions to reduce waste in the six IOM categories would result in annual savings from $191 billion to $282 billion.n
Assessing the datannThe highest amount of wasteful spending was associated with the administrative complexity category. The development and adoption of value-based payment models has the most potential to impact this category of wasteful spending, the researchers wrote.nn”In value-based models, in particular those in which clinicians take on financial risk for the total cost of care of the populations they serve, many of the administrative tools used by payers to reduce waste (such as prior authorization) can be discontinued or delegated to the clinicians, reducing complexity for clinicians and aligning incentives for them to reduce waste and improve value in their clinical decision-making.”nnReducing spending the second-highest wasteful category—pricing failure—poses daunting challenges because of the rising prices of pharmaceuticals, the researchers wrote. “New high-cost specialty drugs, which will soon exceed 50% of pharmaceutical spending, are raising new questions about how to maintain affordability. This topic has thus received considerable attention from policy makers, and numerous proposals are currently under consideration.”nnThe researchers say strategies to ease cost pressure in pharmaceuticals include increasing market competition, importing drugs from countries with lower medication prices, and reforming price transparency.nnThe big picture viewnnAn editorial accompanying the new research says the findings are a significant contribution to the ongoing effort to rein in the country’s healthcare spending.nn”At a time when the United States is once again mired in a great debate about the future of its healthcare system, the data reported in the article … should become part of the national discussion. It would be nearly impossible for all waste to be eliminated in any healthcare system, just as it is impossible to know the true cost of any change in the delivery and financing of healthcare without understanding possible savings, and recognizing that there is complexity in knowing the savings,” the editorial says.nnConcentrating on wasteful spending is crucial, the editorial says. “While no single solution will solve the continuous increases in U.S. healthcare spending, identifying, reducing, and eliminating waste are important and appropriate places to start.”nnOriginal 
Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn
Private payers have begun to embrace the possibilities of value-based care. Many are not including value-based incentives, which allows the patient to save money. Read the article below to find out more on how this value-based pay system has a future.nnValue-based care has created a conundrum: pretty much everyone in healthcare likes the idea of paying for outcomes, but no one is sure how to fairly implement it.nnThe Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) introduced a new world of value-based care to many physicians and was a major step away from fee-for-service. Gone was the Sustainable Growth Rate, replaced with a program that was supposed to drive costs down by reimbursing for quality patient outcomes.nn“Congress had revised the Sustainable Growth Rate many times over the past 20 years, and everyone was fatigued by it,” says Larry Kocot, JD, head of KPMG’s Center for Healthcare Regulatory Insight and a former CMS official. “Physicians were willing to take something new to not have to go through that exercise again.”nnDoctors suddenly found themselves trying to navigate new MACRA acronyms like MIPS and APMs to figure out where they fit as Medicare started moving away from fee-for-service in a bid to contain costs and improve care quality.nnAt the same time, more private payers began to embrace the possibilities of value-based care, working incentives into contracts that rewarded physicians who could use data to show patients were healthier and avoiding unnecessary hospitalizations. But fee-for-service contracts are still the norm.nnMeanwhile, physician organizations began to push back against MACRA as their members rebelled against the cost of the technology needed to comply and the complexity of the reporting measures. CMS responded by exempting hundreds of thousands of physicians, causing some to question the value of the program and if it was improving patient care or saving money.nnWith MACRA now a few years old, experts are looking at how it might be reformed, and what value-based care might look like in the future.nnMACRA: a misstep toward valuennMACRA has not worked to the extent policymakers hoped, says Frederick Southwick, MD, a practicing internist and healthcare researcher at University of Florida Health.nn“The goal was to drive a significant wedge in payments between those willing to step up and use Alternative Payment Models and those who remained on the sidelines,” says Southwick. “We’ve seen physicians take a shot on some things they might not have done in the past to get a bonus payment, but they have not reached the point where they’ll feel pain if they don’t. The MIPS side of this was supposed to be painful to physicians, but it’s mostly a big nothing-burger because so many have been excluded.”nnAs a result, there isn’t much money in the budget-neutral program to move from the poor performers to the good performers, eliminating much of the incentive. According to CMS, in the 2019 payment year (based on 2017 performance data), 71 percent of MIPS participants received a positive payment adjustment with a bonus for performance, 22 percent received a positive payment without the bonus, 2 percent didn’t receive a positive or negative adjustment and only 5 percent received a negative adjustment.nn“The more physicians that are excluded, the harder it is for those in the program to win,” says Kocot, noting that the maximum payment adjustment anyone received was 1.88 percent, while the maximum penalty was 4 percent.nnMIPS was intended to be the incentive to get physicians into some form of risk-sharing APM, but MIPS isn’t accomplishing that and the 5 percent positive payment adjustment APM participants can earn expires in 2024.nn“What is the incentive to get people into MIPS and into an APM as we move further down the line?” asks Kocot.nnMIPS also faces the problem of how to define “quality”.nn“Healthcare is so complicated, that’s hard to do,” says Chris Dawe, vice president of Evolent Health, which helps providers and health plans transition to value-based care, and a former health policy adviser in the Obama administration. “The best way would be through knowledgeable consumers who would ask questions about the cost-benefit and is it worth it to their health and wellbeing. The problem with that is patients don’t go to medical school.”nnEven if patients were making decisions, they would still have difficulty determining who the best doctor is because of the lack of objective information, and in many regions, the absence of choices in hospitals or physicians.nnMIPS participants have scored well on quality measures, but many doctors argue that the measures don’t have any connection to real-world medicine. The time spent reporting on quality has also proven burdensome for many, who say it takes more time away from patients and redirects money toward IT projects.nn“All of these initiatives require a tremendous amount of data accumulation and manipulation,” says William Spratt, Jr., JD, partner in the healthcare practice of Akerman LLP, in Miami. “There are so many different metrics and different ways to modify and manipulate the data in order to determine whether they are meeting various criteria or not, it’s challenging.”nnFor physicians without the support of a larger organization, the challenges are even greater. “It’s introduced an awful lot of complexity into the practice of medicine,” says Spratt. “It’s hard for them to change their practice administration in order to measure and hit those targets.”nAn unintended consequence of that difficulty has been an increase in physicians affiliating with health systems and hospitals so as to shift the reporting burden.nn“It’s probably strengthened the hand of the health systems and offers them another carrot for the primary care physician,” says Southwick. “They aren’t necessarily acquiring them, but at least getting them in the network. I don’t think this is what Congress had in mind.”nnHe adds that a lack of vision has hampered the success of programs like MACRA, because no one understands the end goal.nn“I’ve never heard anyone from the White House articulate what this should look like in five to 10 years,” says Southwick. “Doing so would help the market work toward that and be ready for this new world. Instead, we are just going from one program to the next. It would be a benefit if CMS would say what this would look like at the end.”nnThe future of value-based carennStill, while MACRA may not be working out as envisioned, many experts say it is an important first step toward implementing value-based care. “MACRA started the conversation,” says Spratt. “It has started moving medicine toward more value-based payment and away from the traditional fee-for-service model, which I think most policymakers realize is a good approach.”nnDespite the struggles of MACRA, experts say physicians should understand that their revenue from fee-for-service will continue to decline.n“From what I have seen, the transition to value-based care is a given,” says Andrei Gonzalez, MD, assistant vice president at Change Healthcare, a company that helps payers and providers move to value-based care. “It’s more about what are the right models and how are we going to get there?”nnWith CMS rolling out its new Primary Care First initiative, Gonzalez says their intent is clear. “They want to blow up fee-for-service, and the primary care initiative is a big step in that direction.”nnThe initiative encompasses a variety of models. It is expected to cover about 25 percent of Medicare beneficiaries, and include removing coding requirements for primary care physicians by paying a monthly per-patient fee or a flat per-visit fee.nnPrivate payers are creating similar programs, and large employers are asking commercial plans to use some of CMS’s strategies to save money. As a result, more private payer contracts are including value-based incentives.nn“I do think the private sector push will make it easier as clinicians see value-based care as the new normal and are subject to quality and cost targets that are not fee-for-service,” says Kocot. “That’s absolutely essential to the transition.”nn
Both public and private payers realize they need multiple plans in order to succeed, says Gonzalez.nn“Our research has shown that different models work for different conditions and different regions,” he says. In areas where there is a lot of consolidation among providers and health systems, ACOs or full capitation—where physicians receive a flat monthly fee for each patient— will make the most sense. In less-consolidated areas, models like the Patient-Centered Medical Home may be the primary option.nnWhile capitation was tried in the early days of HMOs, Gonzalez says the industry is a lot savvier on how to do it now. Payers and providers both are going in with more caution. Physicians are managing a patient population, but understand they will need to meet quality and cost metrics, although not the full risk burden like in the past.nnSpratt says smaller practices may need to affiliate with a hospital or health system, because payers see value in partnering with organizations with large numbers of physicians, ancillary services and even urgent care centers, because it gives them more control over the insured and better management of the premium dollar.nn“At the end of the day, it’s all about integration and the coordination of care,” says Spratt.nnCare coordination includes practices being more proactive with helping patients to lead healthier lifestyles and not just waiting for the patients to reach out to them.nn“A lot of practices already have this mentality, but it creates the need for a different set of aptitudes within the practice,” says Gonzalez. This could include, for example, having a nurse monitor COPD patients and ensuring they come in for regular visits.nnFuture value-based care models will also have a greater focus on the social determinants of health.nn“One thing value-based care leads us toward is a sort of untethering of the physician from historical medical tools and allowing them to think more holistically,” says Spratt.nn“Physicians will need to start figuring out how to help patients manage their conditions, how to navigate the health system and manage the social determinants of health,” says Gonzalez. “It’s not as big of a change as it seems, because not every patient requires assistance, but practices need the ability to identify who needs extra help.”nnThe role of the primary care doctornnNo matter what models emerge, experts see the primary care physician as the team leader. Dawe says the patient-centered medical home, with a primary care physician working with one or two NPs or PAs, a nursing staff and someone that goes into the community to help educate patients on how to manage their diseases is a good model, as is an ACO.nn“I think the basic structures for a good model are already in place,” says Southwick. “You can go a long way to creating a new payment ecosystem just on the basis of a primary-care based model, which is basically an ACO.” If that is combined with bundled payments for specialists, Southwick says, those two models work very nicely together.nn“The primary care physician has to be central to any aligned payment and care coordination working with the patient from start to finish,” says Kocot.nnBut primary care doctors should also expect to take on more risk-sharing with payers, whether it’s through an ACO or some other payment model. He warns the transition must come with assistance.nn“There’s a lot happening that primary care physicians have to process on a daily basis,” he says. “The transition needs to be moderated so we don’t lose them in the process. The CMS burden reduction program is very positive, but we have to strike the right balance of incentives and push, and I don’t know that we have yet.”nnExperts say that value-based care will continue to become more prominent in contracts, even though programs like MIPS might be revised or replaced in the future. But one thing is for sure: there is no hiding from it.nn“The move to value is alive and well,” says Kocot.nnOriginal