ACOs Flock to CMS Shared Savings Program, NSA Averts Surprise Billing

January 31, 2024 - The CMS Medicare Shared Savings Program (MSSP) saw an uptick in accountable care organization (ACO) involvement.

The agency announced that 480 ACOs are participating in the MSSP and 245 organizations are involved in two CMS Innovation Center ACO models. As a result of these and other efforts, nearly half of all Traditional Medicare beneficiaries will be associated with an ACO in 2024.

The No Surprises Act, which was intended to avert surprise billing, has prevented as many as 10.1 million surprise bills, according to AHIP and BCBSA. However, the number of independent dispute resolutions (IDRs) was much higher than expected in 2023.

Additionally, a bipartisan bill reintroduced in the Senate seeks to dismantle barriers to telemental health in Medicare. And the use of retail clinics and urgent care centers is on the rise in pediatrics.

Kyle Murphy 

Hello and welcome to Healthcare Strategies | Headlines edition Today's episode:

• Senators Seek to Remove Obstacles to Telemental Health
• AHIP, BCBSA Report Progress on Surprise Billing
• CMS Reports Growth in Medicare Shared Savings, Other Programs
• Pediatric Urgent Care, Retail Care Use on the Rise

Hello, listeners. Welcome to today's episode. This is Kyle Murphy, vice president editorial at Xtelligent Healthcare Media. And as always, I am joined by managing editor, multimedia manager Kelsey Waddill.

Hello, hello, how you doing?

Kelsey Waddill 

I'm doing good.

Kyle Murphy 

All right. Well, we got big news. Big news. Let's kick it off with...

A bipartisan group of US senators has reintroduced the tele Mental Health Care Access Act, which aims to remove the requirement for Medicare beneficiaries to have an in-person visit before accessing mental health services via telehealth. The reintroduction of the bipartisan bill by Senators Ben Cardin, Bill Cassidy, Tina Smith, and John Thune follows its initial introduction in 2021. It seeks to address the in-person requirements stipulated in the Consolidated Appropriations Act of 2020  and aligns with the Medicare coverage adjustments and aligns with the Medicare coverage adjustments for substance use disorder telehealth services introduced in the Support for Patients and Communities Act of 2018.

The bill has garnered support from various organizations such as the American Nurses Association and the American Psychiatric Association. It aims to provide easier access to telemental health services, especially in rural areas, and for vulnerable populations. So we know from research that Medicare beneficiaries with serious mental illnesses engage more in mental health visits when care is available through high telehealth use practices. So the reintroduction of the bill is hoping to improve this access and hopefully provide a quality experience for Medicare beneficiaries.

Kelsey, this initiative comes in the context of the significant rise in virtual care...

Kelsey Waddill 

Yep.

Kyle Murphy 

...during the pandemic, you know, with a notable ongoing high usage in mental health care. So, how crucial is removing these barriers to mental health care access, in your opinion?

Kelsey Waddill 

It's really, really important, especially for the older population, which historically maybe has not had as much access to begin with. So I mean, I think the in-person visit requirement has been a common barrier, not just for Medicare, but across the board. So getting that out of the way is important.

Kyle Murphy

Boy, we'll miss those handshakes, though, those awkward initial introductions, right? Probably better off there. Alright, no one likes that. Alright, what else we got?

Kelsey Waddill

So AHIP and BCBSA report progress on surprise billing.

The No Surprises Act...

Kyle Murphy 

Woo!

Kelsey Waddill 

...went into effect on January 1, 2022.

Kyle Murphy 

Come on!

Kelsey Waddill 

And AHIP and BCBSA report that it has prevented approximately 10.1 million surprise medical bills between January and September of 2023.

Kyle Murphy 

Thank goodness.

Kelsey Waddill 

Yeah, that's a pretty big number.

Kyle Murphy 

It's huge.

Kelsey Waddill 

Using national estimates, the researchers determined that around 8 million of the NSA-eligible claims were resolved through an initial payment...

Kyle Murphy 

Oh nice.

Kelsey Waddill 

...which means that they did not have to go through an independent dispute resolution, also known as

Together 

IDR

Kelsey Waddill 

A process between the provider and the payer, which can be grueling. And of the 25% or so that did enter into an IDR, around 73 percent of those claims were resolved without starting the IDR process.

Kyle Murphy 

Excellent.

Kelsey Waddill 

So CMS did underestimate, however, the number of IDRs that would occur. It anticipated 17,000 each year when in fact, April 2022 to March 2023 saw over 334,800 disputes.

Kyle Murphy 

That's a big, that's...

Kelsey Waddill 

It's 14 times what they expected. So that's a little awkward.

Kyle Murphy 

Someone's not good at math over there.

Kelsey Waddill 

Yeah, a little concerning but... AHIP and BCBSA estimated that around 670,000 claims were submitted from January to the end of September 2023.

So, Kyle, this IDR process has been in the works for a while what do you take away from these numbers?

Kyle Murphy 

I think it's excellent that the actual process, the IDR process, is being avoided. I know there's no shortage of legal contest to this particular process, particularly how CMS determines what price this that and the other.

I will say that any of these things that can be resolved right the first time and even, you know, the second time of asking--we're talking about billing and insurance related activities that are being decreased, the amount of money that needs to be spent on resolving these things. I would call that administrative waste. So I think it's a win for everybody.

And hopefully, you know, patients aren't paying for this. There's no balance billing. But hopefully this has a positive impact on overall health care spending. And we should see, you know, even with the increases in utilization, we should see a decrease, some kind of significant decrease in spending. But it's way too soon for that. But I'm optimistic because the process, historically, has stunk. So I don't think it can get any stinkier than what it was.

Kelsey Waddill 

Yeah, hopefully, we get down to that 17,000 at some point too, as well.

Kyle Murphy 

That would be incredible.

Kelsey Waddill 

I hope that that's just a year-one kind of deal and not like, they consistently are at 334,000. That would be...

Kyle Murphy 

Oh, yeah, no, no. 17,000 is the goal. We'll get there.

Alright, let's talk about some of the positive news. So CMS has just reported some positive developments in its Shared Savings Program and some other programs focused around value based care and alternative payment models. So the Centers for Medicare and Medicaid Services announced that participation in Medicare Shared Savings Program by ACOs accountable care organizations has increased to 480...

Kelsey Waddill 

Wow.

Kyle Murphy 

...including 50 new and 71 renewing ACOs plus 19 participating in a novel payment option. The latter, introduced in the 2023 Medicare Physician Fee Schedule final rule, offers more than $20 million in advance payments, particularly those aiding rural and underserved communities. Additionally, 245 organizations are involved in two CMS Innovation Center ACO models: ACO REACH and Kidney Care Choices. These models target underserved populations in those with chronic kidney disease or end stage renal disease, respectively.

CMS expects nearly half of all traditional Medicare beneficiaries, approximately 13.7 million, to be associated with an ACO in 2024. That's a big one right there, with 10.3 million in the MSSP Program. Despite a recent decline in participation due to COVID-19 and other financial risks, regulations, numbers have rebounded in 2024--love a good rebound--with a significant increase in participating health centers, rural clinics and hospitals. Federal or national associations have praised the work that's being done by CMS and CMS views this robust participation is crucial for achieving its strategic goals in health care transformation, equity, and person-centered care.

Kelsey, is it safe to say the value base cares back?

Kelsey Waddill 

Gee, I sure hope so. I think I mean, I was going to say, I feel like the key words that were standing out to me were: serving chronic disease populations, underserved populations, rural populations. That's what ACOs are kind of built for. And if we can get value-based care coverage for those populations, I mean, that's a major win, so....

Kyle Murphy 

Woo to care coordination and planning and preventive care and chronic disease management. That's the sweet spot. Oh, my goodness.

Kelsey Waddill 

Exactly.

Kyle Murphy 

All right. What do we got left on the docket?

Kelsey Waddill 

All right. So we've talked a lot about retail care, Kyle. And what we are seeing now is that pediatric care is turning towards retail care and urgent care in increasing numbers.

So the rate of pediatric care occurring in the retail and urgent care settings is rising. The Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, or MMWR--

Kyle Murphy 

MMWR (sounding out the acronym).

Kelsey Waddill 

MMWR (sounding out the acronym).

...found that 28.4 percent of kids ages 17 and younger received care at a retail clinic or urgent care setting in 2022. The previous year, 21.6 percent of this population received care in these settings. Children ages five and under saw a particularly high spike in retail and urgent care access. And additionally, 26.2 percent of kids ages 6 to 11 and 30.3 percent of 12 to 17 year olds receive care in these settings.

The report didn't really assess the driving factors behind these increases. But separate research has shown that increases in retail clinic visits might be tied to foregoing other high acuity care sites like emergency departments, and an overall trend in pediatrics away from primary care and toward convenient care sites when it comes to acute care needs.

Kyle, like I said, we've talked about this and been really interested in this retail trend. What do you think about this rise in this particular population amongst children's care

Kyle Murphy 

As a parent of two young children seven and six--shout out to Charlie and Will, love you guys--I will say that when your child is sick, there's nothing you want more than an immediate response. And whether you love it or not, your PCP is just really not available for that.

Kelsey Waddill 

Yeah.

Kyle Murphy 

And health plans are structured in such a way that it's actually encouraged financially for you to seek out care in these approved urgent care and retail health settings. There's so many of them now and you just want to quickly get some kind of service and hopefully get your kid back on the up and up--and then, if you're a parent, back at school so you can carry on with your job. Because when you've got a sick kid at home, even if you're working remote, it is a very difficult task to mentally balance this.

So I think what you're seeing is, there's always been this need. In the past it's been "Oh, we have to wait or we have to go to the probably the worst place to receive care, which is the ED," for such minor little things that can easily be serviced in a CVS and, oh my goodness, anywhere you go nowadays, hey, as a retail kind of center. I've gone down streets where they're right next to each other competing brands all over the place.

Kelsey Waddill 

Yeah.

Kyle Murphy 

They serve a need the important thing that has to be rounded out those is: are they going to then contact the PCP and keep them up to date? Does the PCP need to be alerted to you had cold? You had the pink eye? Does that really need to occur? Not really sure yet. But I know for a fact that the convenience of these things is real. And parents want this--it's not exactly instant gratification, but you want there to be healthcare on demand when you need it.

Kelsey Waddill 

Yeah.

Kyle Murphy 

Look at Amazon. We joked last week about or maybe the week before, but all their different offerings, what are they about? They're about convenience.

Kelsey Waddill 

Yeah. And I mean, we've seen we saw a big drive at one point for employers to have on site locations for that exact reason for the convenience of it. But I think it's interesting to now to see the children are now also kind of going into more convenient care settings, and that the rise in the supremacy of convenience in healthcare is just still going up. I mean, before COVID-19, that was the trend and now it's just even buckling down on that. So, interesting trends. We'll see where they go.

Kyle Murphy 

Interesting trends. Yeah, we'll have to watch it. And we'll see who gets rich and who doesn't and who benefits and who doesn't.

Kelsey Waddill 

Right.

Kyle Murphy 

That's obviously you know, these centers, are they everywhere? There's a CVS almost everywhere, so I imagine they're there. But I wonder if if certain communities are going to have more choices, or the prices of these places, maybe make it more difficult for folks to be able to afford it or access it. So it's interesting, but it's definitely something that worth keeping an eye on healthcare is changing. There's a lot of money to be made and folks obviously will pay for convenience. So that's huge.

Kelsey Waddill 

Yeah.

Kyle Murphy 

Well, Kelsey, that concludes today's episode of Healthcare Strategies | Headlines. It's good to see you as always. Thank you to our listeners.

Kelsey Waddill 

Yes.

Kyle Murphy 

Like, subscribe, follow, do anything you can do. Alright, take care everybody.