January 2, 2018 | Rosemarie Day

Part B News: Providers take on risk, OCR goes after ‘juicy’ violations, MIPS habits change and more

Prediction: More providers will migrate to risk based models, including accountable care organizations (ACOs).

A major risk model is the ACO — including ones managed by Medicare that the Trump administration and CMS Administrator Seema Verma haven’t meddled with in their first year. “HHS hasn’t pulled back support on ACOs [and related performance based programs],” says Rosemarie Day, president of Day Health Strategies in Somerville, Mass., and a former deputy director of the Massachusetts Health Connector. “Maybe it’s because it doesn’t have the Obama label on it.” Indeed, Trump’s nominee for HHS secretary, Alex Azar, praised Medicare ACOs in his committee hearings (PBN 12/11/17)

Prediction: End of the ACA individual mandate would mean higher premiums and maybe cuts to Medicare and Medicaid — but some states may step up.

“The repeal of the individual mandate to purchase health insurance that’s contained in the tax bill is a problem, and we know that from our experience in Massachusetts, from having had reform without the mandate, that the healthier people didn’t purchase insurance until the mandate kicked in, even if they qualified for subsidies,” says Day. “So it does matter.
It’s been proven.”

Day also expects the Republicans will come after Medicare and Medicaid as part of their “entitlement reform” plan soon. After the tax bill, “there’ll be ‘not enough money’ for Medicare and Medicaid,” she predicts. “So, they’ll ask, how do we tighten up the programs?”

While states can’t do much with Medicare, they can do something about their own insurance markets — in fact, some Californians have proposed that the state put in its own mandate, as Massachusetts did in the days of Romneycare. “I’ve had some states ask me about that behind the scenes,” says Day. “I think a state with a state based exchange that has the infrastructure and a critical mass of people in the government who understand enough to work with the insurance commissioner on it could create a potential nexus of advocacy to support the legitimacy of a state based individual mandate.”

And while Medicaid cuts will be painful, the added state flexibility of waivers and vouchers that Republicans often tout as the upside of reform could be used by more progressive states to improve care for some of its most needful citizens. “Something we’re working on here in Massachusetts is ACOs for Medicaid — an idea that has only gained a modest foothold in this country,” says Day. “Massachusetts is committed to making the model work for its harder to serve population.””

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