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Value-based Reimbursement Transition in the US

  • December 2015
  • 54 pages
  • Frost & Sullivan
Report ID: 3473683


Table of Contents

Market Due Diligence and Strategy Considerations

The US healthcare industry is undergoing a major transition toward value-based care, affecting all its stakeholders. Centers for Medicare and Medicaid Services (CMS) are steering this transition by developing policies and alternative payment models that affect all reimbursements for healthcare services. This document provides insight into CMS’s 2018 goals for this transition, the pathway adopted to achieve those goals, and current progress towards achieving these goals. Financial performance of various industry stakeholders including physicians, providers, and the Accountable Care Organizations as well as anticipated short term trends for the CMS implemented programs are highlighted. The document includes case studies that throw light upon innovative business models designed by healthcare vendors that support providers undergoing this transition.

- Payment reform has been the highlight of the US Healthcare industry in recent years.
- The journey from fee-for-service (FFS) to value-based reimbursement (VBR), as is evident by now, is slow and one that requires overcoming many hurdles.
- However, the industry is lumbering on under the mandates and guidance of public and private payers who are looking at value-based care as a means to reduce costs and improve efficiency in the healthcare system, while simultaneously improving patient care and outcomes.
- Most crucial guidance comes from the single largest healthcare payer in the US—the Center for Medicare & Medicaid Services (CMS).
- The Department of Human & Health Services (HHS), for the first time, has set specific goals for CMS payments in categories 2 through 4.

CEO’s Perspective
1 Most penalized providers continue to receive penalties in coming years under Readmissions Reduction and Value-Based Purchasing.

2 While all 900,000-odd physicians are likely to be financially affected by value-based care in 2017, they continue to find ‘meaningful use demonstration’ difficult, with costs and efforts outweighing benefits.

3 Pioneer model of Accountable Care Organizations is expected to continue disappointing members, while Medicare Shared Savings risk-free track gains additional momentum. Next-Gen model holds great promise.

4 Other Alternative Payment Models, such as Primary Care and Bundling are still in infancy and would require time beyond 2018 to contribute significantly to the transition to value-based care.

5 While all stakeholders, including vendors in the healthcare space, are adapting to this transition, the CMS-stated 2018 goals seem difficult to attain given current progress.

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