Title: CMS: Innovating to Achieve Better Care, Smarter Spending, and Healthier People
Abstract: The Centers for Medicare & Medicaid Services (CMS) has long been an integral part of the fabric of the nation's health care system. But today-in addition to providing health insurance to more than 100 million beneficiaries through Medicare, Medicaid, and the Children's Health Insurance Program (CHIP)-CMS has also become a leader in transforming health care delivery in the United States. Accelerated by the passage in 2010 of the Affordable Care Act (ACA), CMS has embarked on a large-scale effort to achieve better care, smarter spending, and healthier people. To achieve these goals, CMS is taking a multi-pronged approach based in large part on the principle that payment should be tied to quality of care, rather than volume of care. This article describes the programs and models CMS is employing to transform health care delivery, reviews early results from these efforts, and identifies future opportunities to drive further change.Payment Reform as a Driver of TransformationUntil recently, payment for health care in the United States was almost exclusively fee-forservice. This system, and its provider incentives, may have contributed to higher health care costs without a commensurate increase in quality. Care was fragmented, producer-centered, and volume-driven. CMS aims for a future in which care is coordinated, people-centered, and outcomes-driven.One driver of this transformation will be new payment models and policies that reward value, not volume. Payment to health care providers can be viewed along a continuum (see Table 1, page 74). In Category 1, fee-for-service payments are based on volume of services and not linked to quality or efficiency. In Category 2, payment is still fee-for-service but at least a portion of payments vary, based on the quality or efficiency of health care. Category 3 includes alternative payment models built on a fee-for-service architecture. Under these models, payments are still triggered by delivery of services, but there are opportunities for shared savings (or two-sided risk) linked to effective management of a population or an episode of care. Finally, Category 4 is population-based payment, in which payment is not triggered by service delivery (and therefore not linked to volume).In January 2015, U.S. Health and Human Services Secretary Sylvia M. Burwell made a historic announcement (http://goo.gl/BgLoDm) that the Department has set a goal of tying 30 percent of traditional Medicare payments to quality or value through alternative payment models (Categories 3 and 4) by the end of 2016, and 50 percent by the end of 2018. In addition, a goal was set to tie 85 percent of all traditional Medicare payments to quality or value (Categories 2, 3, and 4) by 2016 and 90 percent by 2018.CMS already has moved the majority of Medicare payments out of Category 1 and into the other categories along this continuum through implementation of numerous legislative provisions, many of which stem from the ACA. For example, statutory programs-such as the Hospital Value-Based Purchasing Program, the Physician Value-Based Modifier, and the Hospital Readmissions and Hospital-Acquired Condition Reduction Programs-all link payment to quality (Category 2). Through these programs and others, by 2017, 8 percent of a hospital's payments, and up to 9 percent of a physician's payments, will be tied to efficiency, quality reporting, and quality performance (opportunity for either upward or downward adjustment).In addition, CMS has implemented a new program, the Medicare Shared Savings Program, and is testing several new payment and delivery system models that are firmly planted in Category 3 (alternative payment models), including accountable care organizations (ACO), primary care medical homes, bundled payments, and others. Thousands of providers and millions of beneficiaries across the country are participating in these alternative payment models. CMS is also using population-based payments (Category 4) in certain models. …
Publication Year: 2015
Publication Date: 2015-07-01
Language: en
Type: article
Access and Citation
Cited By Count: 1
AI Researcher Chatbot
Get quick answers to your questions about the article from our AI researcher chatbot