Alternative Payment Models
Alternative payment models are becoming more advanced as the government drives to accelerate generated savings. Track and stay ahead of this evolution to identify strategic partnerships and measure results.
CMS Updates CAR-T Reimbursement for 2022 in IPPS Final Rule
Finalized policy for Medicare’s CAR-T inpatient reimbursement builds on policies solidified in last year’s rulemaking. Looking ahead, stakeholders will continue to weigh the appropriateness of payment.
New Hires Bolster Avalere Health’s Market Access Practice
Two new additions expand expertise in drug pricing, payer engagement, CMS coverage and payment, and strategic market access and commercialization.
CMS Proposes Changes to Radiation Oncology Model Timing and Design
On July 19, the Centers for Medicare & Medicaid Services (CMS) released the CY 2022 OPPS/ASC Proposed Rule, which includes a number of proposals to modify the timing and design of the Center for Medicare & Medicaid Innovation’s forthcoming Radiation Oncology (RO) Model. The design proposals include changes to the set of included modalities and cancer types, reduction of the CMS discount factors applied to the prospective payments, and adoption of an extreme and uncontrollable circumstances policy. Looking ahead, stakeholders should continue to assess the model payment methodology and design in the context of evolving care delivery and practice patterns.
OCM Lung Cancer Episode Costs Have Increased Dramatically Over Time
An Avalere analysis found that Oncology Care Model (OCM) lung cancer episode expenditures increased over 20% from performance periods 2 to 6 while the benchmark price increased about 10% during this period. During this same period, The Center for Medicare & Medicaid Innovation (CMMI) included 20 lung-cancer-specific changes to the OCM Novel Therapy Adjustment (NTA) list. This dynamic supports the inclusion of tumor-specific adjustments in the future Oncology Care First (OCF) model to further account for advancements in cancer management.
TPNIES Adjustment Promotes Access for Innovative ESRD Technologies
Medicare offers an add-on payment to facilities furnishing qualified new and innovative renal dialysis equipment and supplies via the Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES).
OCM, OCF, and the Future of Cancer Care: 5 Things to Look Out For
As the Oncology Care Model (OCM) approaches its conclusion, stakeholders are anxiously awaiting the details of the Center for Medicare & Medicaid Innovation's (CMMI’s) next oncology episodic payment model, Oncology Care First (OCF).
Differences in Spending and Demographic Profiles in Medicare KCC Model
The Kidney Care Choices (KCC) model, a new alternative payment model launched by the Center for Medicare and Medicaid Innovation (CMMI), is scheduled to begin on January 1, 2022. This model will provide population-based payments for beneficiaries with both advanced-stage chronic kidney disease (CKD) and end-stage renal disease (ESRD) to improve patient health outcomes and lower Medicare fee-for-service (FFS) spending.
Understanding Success Among OCM Participants
Avalere analysis finds that success in the first 4 performance periods of the Oncology Care Model (OCM) was correlated with reductions to inpatient expenditure and spend reductions within certain high-cost tumor types. Further, smaller community-based practices and those that had lower per-episode expenditure in the baseline period tended to be more successful.
Comparing Part B and D Treatment Patterns of ACO and Non-ACO Providers
New analysis from Avalere finds that Medicare beneficiaries are more likely to receive Part D autoimmune drugs and less likely to receive Part B autoimmune drugs from providers who are part of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) compared to non-ACO providers.
Mandatory Kidney Care Model Introduces Financial Incentives and Risks
The ESRD Treatment Choice model demonstrates an increased focus on improving health outcomes for Medicare patients receiving dialysis by realigning incentives to favor the adoption of home dialysis and increasing the rate at which patients receive kidney transplants. This mandatory model could lead to significant disruption for stakeholders in the coming years. Understanding the risk and opportunities associated with this model will be critical for patients, providers, and manufacturers alike.
MSSP Sees Continued Growth in Downside Risk ACOs
New analysis from Avalere finds that more accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) have assumed downside risk as the program matures, with the greatest growth over the past 3 years.
Proposed Radiation Oncology Model Could Lower Payments for Treating Prostate Cancer
New analysis from Avalere finds the proposed case-mix adjustment for the radiation oncology model underestimates payments for prostate cancer .
Podcast: E3 – Avalere Insights on Recent CMS Proposed Payment Rules: ESRD PPS and Quality Incentive Program
Tune in to hear the final episode in our 3-part series that focuses on CMS’s most recent proposed payment rules. In episode 3, we’ll be focusing on the End Stage Renal Disease (ESRD) Prospective Payment System, with a focus on proposed payment changes for innovative drugs, supplies, and equipment and updates to the Quality Incentive Program (QIP).
BPCI Advanced Continues to See Robust Participation, Even as Providers Begin to Take on Risk
Providers in the Bundled Payments for Care Improvement Advanced initiative began to assume financial risk on March 1, 2019.
Next Generation ACOs Outperform 2-Sided MSSP ACO Counterparts
ACO Experience Again Proves to Be an Indicator of Success
Hospital Willingness to Assume Risk Growing
The majority of hospitals in BPCI Advanced, the second iteration of CMS’ largest bunded payment initiative, have no prior experience with risk in the original BPCI program.
Experienced Medicare Accountable Care Organizations Generate Savings
Assuming risk appears to be a less important factor than experience in predicting ACO success.
CMS Proposal Encourages Advanced Alternative Payment Model Participation
Early adoption and participation in an AAPM can provide a higher incentive payment to Medicare clinicians than MIPS.
Readmission Rates Are 6 Times Higher for Some Conditions in Medicare’s New Bundled Payment Program
As the deadline approaches for providers to make decisions on their participation in BPCI Advanced, Avalere analysis shows that certain conditions may provide greater opportunity for success.
The Future of the Center for Medicare & Medicaid Innovation
On April 24, 2018, Avalere experts were joined by Aledade CEO, Farzad Mostashari, MD, to discuss the latest developments coming out of the Center for Medicare & Medicaid Innovation (CMMI).