Here are the six best reimbursement stories from 2021 HealthLeaders’ coverage and beyond.
COVID-19 continued to impact healthcare reimbursement as the pandemic entered its second year. Yet, what’s different is that longer-term strategies and new business opportunities are emerging beyond crisis response. The Centers for Medicare & Medicaid Services (CMS) aided these plans by extending telehealth reimbursement. Conversely, the results of its value-based care programs remain mixed with the agency announcing a revamped road map. Otherwise, the tie that continues to bind reimbursement is healthcare’s increasingly complex value chain and how new services, therapies, and players will impact the delivery system. Here are the six best reimbursement stories from 2021 HealthLeaders’ coverage and beyond.
CMS EXTENDS TELEHEALTH REIMBURSEMENTS FOR PHYSICIAN SERVICES, MENTAL HEALTH
Virtual medicine isn’t going anywhere. In fact, it’s expanding thanks to 2021 final regulations from CMS. Recognizing that you can’t unscramble the egg that COVID cracked—i.e., primary care and mental health virtual visits that kept access alive during quarantine—the agency continued physician reimbursement for Medicare telehealth service through 2023. The list of reimbursable telehealth services is here.
With payers now introducing virtual-first health plans and the pandemic still a factor, there has been a national awakening that network inadequacy in rural areas is not the only reason people can’t access care. The final rule also makes virtual Medicare mental health services more broadly available in a field that is already suffering a provider shortage, in remote and urban areas alike.
COVID ELIMINATES COST-SHARING, PAYERS BRING IT BACK
The pandemic impacted healthcare cost in addition to access. Costs like copays and deductibles were waived for care no one could have anticipated, including hospitalizations. But that was 2020. In June 2021, HealthLeaders reported that “[m]any major payers … [had] lifted their cost-sharing waivers for COVID-19 bills based on a preprint University of Medicine study that is now final in the Journal of the American Medical Association (JAMA).
A related Health System Tracker survey from August 2021 found that while Delta was still surging, hospitalization costs were no longer waived by 72% of plans, specifically the two-largest plans in every state and the District of Columbia. Among these payers, only 2% planned to extend waivers through March 2022. While Omicron appears to be a weaker variant, hospitalizations continue—along with the cost burden of care.
Amazon’s impact on healthcare reimbursement
Jeff Bezos’ attempt to bend the employer cost curve through the Haven co-venture may have failed, but Amazon Care is taking off as HealthLeaders reported in March 2021. Amazon Care aims to strengthen in-home care by linking on-site and virtual services. It includes independent pilots as well as a multi-partner Moving Home Health coalition that is “dedicated to advancing home-based care policies and reimbursement models.” The company’s home-delivery prescription business is growing as well, including with payers who have spoken on background with HealthLeaders regarding their Amazon contracts.
VALUE-BASED CARE (VBC) CHARTS NEW WATERS
Depending on the lens you use, the pandemic either slowed or advanced value-based progress: the first via suspended or fewer VBC contracts (particularly for high-cost, condition-specific therapies), the latter via gains in telehealth usage and reimbursement that will likely remain permanent. Either way, COVID ensured that 2021 was a less-than-great year for data continuity, particularly the compared-to-baseline results needed to measure VBC, as the FFS chassis continued to dominate.
CMS’ YES—WAIT MAYBE?—ON VBC
Year two of COVID marked performance year one for CMS’ Global and Professional Direct Contracting (GPDC) program. GPDC, a next-next generation of accountable care organizations (ACO), puts a greater emphasis on capitation and higher risk models and opens the door to new types of participants.
This is according to industry consultant Jennifer Bresnick, who suggests sign-up has been lackluster with program applications now closed. New insurers like Clover Health are on the participant list but it remains to be seen whether GPDC can achieve the notable quality and cost improvements— with June 2021 HealthLeaders coverage suggesting price increases linked to ACO consolidation.
Congressional calls for more, please, on VBC progress as ACO participants dropped was followed by a strategy refresh announcement from CMS’ Center for Medicare & Medicaid Innovation (CMMI) that seeks to advance accountable care and other innovations, health equity, access, and system transformation. Look for more news in 2022 as part of the CMMI’s new 2030 vision.
Reimbursement and funding pathways for new services
Virtual health is not the only service seeing pandemic growth. Digital therapeutics (DTx), including those that require prescription (PDT), emerged in a big way in 2021 as did strategies to reimburse them. Even as CMS repealed its final rule on Medicare Coverage of Innovative Technology, payers, PBMs, employers, and DTx manufacturers forged ahead. And while there is plenty still to figure out, 2021 saw two big steps: the first state Medicaid program to plan reimbursement for PDT and the continued growth of PBM pipelines to manage DTx claims.
Advancing how to finance and reimburse novel therapies was another 2021 development. Avalere reported that 56% of payers have executed outcomes-based contracts (OBC), a value-based approach applied to extremely high-cost drug treatments—often cell- or gene-based and sometimes one-time curative therapies. Participation grew for some therapies while shrinking in others as health plan assess OBC challenges, including unique timelines for funding, cost-savings, and outcomes.
For More Information: 6 best reimbursement stories 2021
