Will Medicare's Proposed Reformations Affect Your Practice?

by  Wyn Staheli, Director of Content
June 12th, 2018

Recently, Medicare's Innovation Center released an informal Request for Information (RFI) seeking input on several different system reformation proposals. As the market moves towards more value based payment systems, innovation and new models are being sought to both reduce costs and increase quality. This article outlines the ideas presented in the RFI.

1. Expanded Opportunities for Participation in Advanced APMs

Alternative Payment Models have been picking up some steam since MACRA began in 2015. CMS must be seeing positive results because they are trying to figure out ways to further encourage provider participation.

2. Consumer-Directed Care & Market-Based Innovation Models 

Empowering consumers to make choices on how their healthcare dollars are spent can yield more bang for the buck. There were several ideas presented in this portion. One very interesting idea is allowing beneficiaries to contract directly with healthcare providers to come up with new payment arrangements such as bundled care. While some say this is a great idea, others are concerned that it opens the door to potential fraud. CLICK HERE to read an article in Modern Healthcare about this idea of allowing providers to bill patients directly.

3. Physician Specialty Models

One option presented is allowing specialists to become the primary source of care in order to promote better management of complex or chronic medical conditions. Managing the care of patients with these special needs is important and better management has shown to have far better outcomes.

4. Prescription Drug Models

Prescription medications are a big cost for insurance payers. CMS states, "Models that contemplate novel arrangements between plans, manufacturers, and stakeholders across the supply chain, including, but not limited to innovative value based purchasing arrangements, and models that would increase drug pricing competition while protecting beneficiaries’ access to drugs are of particular interest. "

5. Medicare Advantage (MA) Innovation Models 

CMS is currently implementing "the Medicare Advantage Value-Based Insurance Design (VBID) model, that provides benefit design flexibility to incentivize beneficiaries to choose high-value services; but this model could be modified to provide more flexibility to MA plans and potentially add additional states." They are looking for ideas for other alternatives as well.

6. State-Based and Local Innovation, including Medicaid-focused Models 

CMS has been working with states on creating and testing new payment models (e.g., Prevention of Chronic Diseases Model). They want to know what is working at the state level to improve care and assist in creating new models. These programs will be tested at the state level and those that work well could potentially be used in other federal programs (e.g., Medicare, Tricare).

7. Mental and Behavioral Health Models 

With the opioid crisis taking center stage, they are looking for models to combat this epidemic. Dementia care is also costly. What models can enhance the integration of care and/or utilize episode payment.

8. Program Integrity

As always, CMS is looking for ways to further reduce fraud, waste, and abuse in government healthcare programs. They stated that they are trying to find a balance between patient care and the increased physician workload and "effectiveness of the review". We are glad that they recognize the administrative burdens which these program integrity programs have placed on providers. Hopefully they can find ways to make reviews less burdensome.


If you have good ideas, now is the time to submit them to CMS. Let them know what you think. CLICK HERE to go the CMS Initiatives website.


Will Medicare's Proposed Reformations Affect Your Practice?. (2018, June 12). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/will-medicare-s-proposed-reformations-affect-your-practice-33965.html

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