Reimbursement in 2015 saw impacts from CMS and additional changes in everything from ICD-10 to new joint bundled payments regulations, new sepsis regulations and new discharge requirements.
Here are what three experts tell Healthcare Dive they see as the most pertinent regulation changes for 2015 and impacts ahead for 2016.
Puneet Maheshwari, CEO of DocASAP:
ICD-10 is particularly interesting in that we’ve already started seeing some benefits since the official conversion, but our fragmented system will also pose some key challenges that we’ll start confronting in . For example, do providers – clinical and operational staff – really understand the value of ICD-10 and are they qualified to code appropriately? Can these codes work across provider groups seamlessly as patients move from provider to provider? How will the diagnosis get in sync with what’s happening with a patient in real-time? All bets are off on optimizing “the system” with ICD-10 until we reach a more mature and fluid state of interoperability.
In terms of the new sepsis regulations, the intent is good but it will lead to an unnecessary rise in short-term costs. If we don’t think a little bit more about the directive and perhaps find a better way to apply it, we’re going to see more people being provided care and treatment that might not actually need it.
Also, as 2016 approaches with the Medicare Advantage advanced notice and final call letter, many in the healthcare industry are holding their breath for the direction CMS provides each year. Not being able to predict and align with a long-term vision is a big challenge CMS has today in terms of the way it issues new regulations.
Rebecca O. Johnson, associate program director of graduate and professional studies for the End of Life Care Program at Sarah Lawrence College:
Medicare Part B reimbursement for advance care planning services marks the end of the death panels era and ushers in a more realistic and compassionate approach for physicians seeking to help patients who are interested in understanding their options as they face health and care transitions. A next important step is the provision of training to primary care providers. Advance care planning (ACP) is not taught in medical schools and is rarely available in a comprehensive way in continuing medical education. CMS and IOM are seeking to encourage ACP that focuses on quality of life. These reimbursement codes are a first, very necessary step in that direction.
Patrick Pilch, managing director and national healthcare advisory leader of The BDO Center for Healthcare Excellence & Innovation:
- Hospitals will start transitioning control over some aspects of health care to the community - but only those communities that have resources to integrated care will be able to handle the changes successfully. States with funding such as Medicaid waivers will be able to lead the way. In states without such incentives, care providers developing bundled payments will seek funds to better coordinate community care.
- Commercial payers will follow CMS' lead by not directing treatment at hospitals, nursing homes and home health agencies with fewer than 3 stars.
- 20% of skilled nursing homes may see a dramatic drop in business as CMS has connected bundled payments for hip and knee replacement treatment to star ratings.
- 2016 may be a year of regulatory mandates for health insurers: After seeing Anthem and Premera Blue Cross experience cyber breaches exposing over 90 million records, the National Association of Insurance Commissioners will need a concrete means of enforcement.
- As mega-mergers move forward, newly integrated payers many not gain economic efficiencies they sought as fast as they'd like, and as a result, commercial insurers will struggle to integrate their Medicare Advantage acquisitions efficiently.
- FTC-prompted spin-offs could lead to a new wave of larger middle-market health plans.