5 Transformative Changes from CMS to Disrupt the Healthcare

Sandeep Gupta
Fri 04 May 2018
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Since its inception in 1965, the Centers for Medicare and Medicaid Services has been focused on driving quality care and making the healthcare space efficient for its members. Upholding their goal of empowering patients and enhancing the healthcare efficiency, CMS keeps on introducing new regulations and rules. Last few months witnessed some major shifts in healthcare regulations, disrupting nearly every domain. Here are a few that caught everyone’s attention:

1. Revamping the measures

CMS is planning to revoke 19 quality measures and de-duplicate other 21 measures on which acute care hospitals are required to report. These measures mostly include the ones associated with infections, patient safety, and mortality outcomes.

Planned changes

  • Proposal to remove redundant and process-driven quality measures from multiple quality reporting and pay-for-performance programs.
  • Removing measures related to resource use, patient safety, and infections which are duplicative in the Hospital-acquired Condition Reduction Program.
  • Prospective Payment System (PPS)-exempt Cancer Hospital Quality Reporting (PCHQR) Program will also experience trimming in some quality measures.

Effects on the space

  • One of the primary motives is to lower the administrative burden of Medicare providers.
  • According to CMS, the elimination of a total of 25 measures across 5 programs would save over 2 million staff hours leading to the savings opportunity of nearly $75 million.
  • Long-term Care Hospitals would expect an increment in the payment rate by nearly 1.15% while the reimbursement rates for Inpatient Prospective Payment System are expected to rise by 3.4%.

2. Moving from “Meaningful Use” to “Promoting Interoperability”

Along with reducing the clinician burden, CMS proposes to empower themselves technologically and policy-wise. The agency has renamed the Medicare and Medicaid EHR Incentive Program (also known as “Meaningful Use”) to “Promoting Interoperability.”

Planned changes

  • Hospitals will need to meet the CMS-defined standards to make their EHR data accessible to the patients by 2019.
  • Providers will have to use the 2015 edition of certified EHRs to qualify for Medicare payments.
  • The updated guidelines will necessitate the hospitals to publicize the list of their standard charges.

Effects on the space

  • Patients would be able to collect their data from multiple providers, supporting their ability to share their health information with other providers and reducing the duplication of data.
  • Providers would gain incentives for making it easier for patients to access their medical records electronically.
  • It will open new ways for promoting healthcare interoperability and price transparency among patients and providers.

3. Controlling the maximum out-of-pocket and cost-sharing limits

While modifying the Medicare Advantage and Part D plans, CMS revised the regulations controlling the maximum out-of-pocket (MOOP) limits. CMS finalized the reduction in the maximum amount that beneficiaries pay for specific medicines known as ‘biosimilars.’

Planned changes

  • CMS modified the regulations to control the maximum out-of-pocket limits and finalized to lower the cost of prescription drugs which includes the adoption of several measures.
  • CMS revoked the compulsion that Part D plans had to “meaningfully differ” from each other and clarified the “any willing provider” requirement.

Effects on the space

  • Revising the regulations would enable CMS to bring any future change in the current methodology which uses the 85th and 95th percentiles of projected beneficiaries’ out-of-pocket Medicare spendings.
  • Beneficiaries who are benefitting from the discounts that 340B hospitals receive will be able to save $320 million on out-of-pocket payments for Part B drugs.
  • The modifications will enable CMS to update discriminatory cost-sharing standards using new standards beginning post CY 2020.

4. Greeting the revised Medicare Advantage and Prescription Drug Benefit Program

Medicare Advantage and the Prescription Drug Benefit Program also gained some new updates for the contract year 2019. The regulations aim at bringing flexibility and efficiency in these programs.

Planned Changes

  • CMS is redefining the uniformity requirements for Part C benefits offered to the enrollees of Medicare Advantage plans.
  • The delivery date of the Annual Notice of Change (ANOC) will be separated from that of Evidence of Coverage (EOC) allowing the Medicare beneficiaries to receive ANOC as a stand-alone document.
  • The final rule will further the last year’s initiative by CMS- “Patients Over Paperwork.”

Effects on the space

  • The final changes in the MA and Part D plans would result in an estimated savings of $295 million for the Medicare program over 5 years.
  • It would be easier for plans to communicate with beneficiaries by streamlining the government review process.
  • MA plans would gain new tools to improve care outcomes by allowing beneficiaries to focus on the most important information.
  • MA and Part D sponsors will be able to provide materials like EOC electronically.

5.Enhanced transparency for Star Ratings

The Star Ratings published annually by CMS constitute a significant indicator for the beneficiaries to help make informed choices. CMS currently uses these rating to calculate Quality Bonus Payments for Part C plans and announced changes to the Star Ratings framework, measures, and methodology.

Planned Changes

  • New measures like Statin Use in Persons with Diabetes (Part D) and Statin Therapy for Patients with Cardiovascular Disease (Part C) are being introduced.
  • Beneficiary Access and Performance Problems measure will be removed from CMS 2019 Star Ratings.
  • CMS is also setting new methods for applying scaled reductions while determining the completeness of data for the appeals measures to allow reductions in the seriousness of the data issue.

Effects on the space

  • Refinement in the principles for adding, updating, and removing the measures.
  • New modified methodologies for calculating and weighting the measures.
  • The scaled reductions would help in avoiding potentially disparate impacts on plans and ensuring them to be more commensurate with the identified issue.

The road ahead

Long back, when the outline of present healthcare system was formulated, no one ever thought that it would become such a complex system. CMS and other federal agencies are trying their best to develop strategies to push payers and providers to engage in a reform that focuses on improving quality, reducing expenditures, and promoting healthcare interoperability. Whether or not these changes will turn the tide of rising healthcare costs, it is certain that CMS, as ever, is pushing towards a multidisciplinary team-based approach and the best ways to use disruptive technologies to promote patient-centric care.


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Tags: Health IT, Healthcare, Healthcare data platform
Sandeep Gupta
5 Transformative Changes from CMS to Disrupt the Healthcare

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