CMS’s Mandatory AMI Bundle Is Cause for Chest Pain

This week the Centers for Medicare & Medicaid Services (CMS) announced a new mandatory bundled payment program for cardiac care. The proposed 5-year demonstration would go into effect on July 1, 2017, in 98 to-be-identified markets. The model would make hospitals financially accountable for the cost and quality of care for acute myocardial infarction (AMI) and coronary artery bypass graft (CABG) during inpatient stays and for 90 days following discharge. Continue reading

Oncology Care Model Practices Announced

This post was written by Jessica Turgon, Principal, Matt Sturm, Senior Manager, and Meagan O’Neill, Senior Consultant.

Earlier this week the Centers for Medicare & Medicaid Services (CMS) announced the nearly 200 organizations that have been selected for participation in the Oncology Care Model (OCM), one of the new payment and care delivery initiatives introduced by the Center for Medicare & Medicaid Innovation (CMMI) in 2015. The 5-year pilot is slated to begin July 1, and according to CMS, the number of participants is twice the size as initially anticipated – it will include approximately 3,200 oncologists and provide coverage for 155,000 Medicare beneficiaries. Continue reading

AMCs, Teaching Hospitals Stand to Gain Under New CMS Model

This blog post was written by Michelle Wilkinson, Manager, and Emma Mandell Gray, Senior Manager.

Last month, the Centers for Medicare & Medicaid Services (CMS) announced a new initiative geared toward improving healthcare delivery. The Accountable Health Communities (AHC) model attempts to bridge a critical gap between clinical care and community and social services by screening Medicare and Medicaid beneficiaries for certain health-related social needs in the core areas of housing, food, utilities, interpersonal violence, and transportation. CMS’s goal is to ultimately improve overall care and health outcomes by steering patients to the appropriate community resources available to them. Continue reading

CMS Targets New Payment Model for Oncology

On February 12, 2015, the CMS Innovation Center released details for a new payment and care delivery model designed to improve coordination for cancer care. The Oncology Care Model (OCM) is aimed at physician practices that administer chemotherapy and bill for services under the Medicare Physician Fee Schedule. Continue reading

Is your organization at risk of going from a profit to a loss when Health Exchanges are introduced?

I recently analyzed client data to evaluate the potential impact of health exchanges entering a market. Although I expected a moderate impact, I was surprised at how much a hospital could be affected by poor health exchange contracts.

As shown in the table below, the introduction of health exchanges to an example hospital’s market is expected to significantly reduce the number of patients covered under commercial insurance. In addition, the number of Medicaid beneficiaries will go up, and the number of self-pay patients will go down. Ultimately, this hospital will shift from a profit of $2.1 million to a loss of approximately $1.2, a change of $3.3 million. Analyzing the potential financial impact for your organization within a likely range of both reimbursement rates and payor mix shift will be a key component of your strategic planning for health exchanges.


Be aware of the potential utilization and cost-of-care risks of health exchange-covered patients. You will need to determine if the care for any given patient population is manageable based upon likely rates of reimbursement. Preparing for health exchanges will require significant due diligence to analyze the potential impact and develop a proactive negotiation approach to secure network agreements that place your organization in a positive financial position.

Read more about how health exchanges might have an effect on your bottom line. What are some of your concerns about health exchanges?