Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Public Payers News

Tom Price and His Stance on Value-Based Care Reimbursement

With regard to value-based care reimbursement and bundled payment models, Representative Tom Price has had some reservations.

By Vera Gruessner

Representative Tom Price, an orthopedic surgeon, was nominated to be the next Secretary of the Department of Health & Human Services (HHS) on November 29. What does this nomination mean for value-based care reimbursement in the Medicare program?

CMS bundled payment programs

Bundled Payment Models

This past September, Price and two other congressmen sent a letter to the Centers for Medicare & Medicaid Services (CMS) outlining several problems they found with the Comprehensive Care Joint Replacement Model and the Cardiac Bundled Payment Model. Price sought to pull back the regulatory framework of bundled payment models, which are a key aspect of value-based care reimbursement.

Price claimed that the Center for Medicare and Medicaid Innovation went beyond its authority and did not engage clinicians and other stakeholders when creating the bundled payment models. Additionally, Price alleges that these bundled payments would have a negative impact on elderly Medicare beneficiaries.

The way Medicare beneficiaries could be affected, according to the letter, is through healthcare access issues where the bundled payment models may lead to a decline in provider participation in Medicare and its value-based care reimbursement platforms. With fewer providers participating, elderly Medicare beneficiaries would have scant doctors available to them.

The decline in Medicare participation could lead to a decrease in quality of care among elderly patients. The letter also claimed that the bundled payment models were created without industry stakeholder input.

Representative Tom Price’s viewpoints on value-based care reimbursement also delve into greater scrutiny of the Medicare Access and CHIP Reauthorization Act (MACRA), according to a press release from Price’s website.

“This final [MACRA] rule deserves careful scrutiny in light of the serious concerns members of the Congressional Doctors Caucus raised last week in our letter to CMS on its proposed MACRA regulation," said Congressman Price, M.D. "We are deeply concerned about how this rule could affect the patient-doctor relationship, and I look forward to carefully reviewing it in the coming days to determine whether the Administration has addressed those concerns and put the interests of patients first.”

Value-based care in the private sector

Whether or not the Medicare program slows its advancement in value-based care reimbursement under the new HHS Secretary remains to be seen. When it comes to the private health insurance market, value-based care reimbursement remains a necessary strategy for reducing wasteful healthcare spending among many national payers.

For example, Humana is one payer that has been expanding their value-based care programs and is currently serving 63 percent of their enrollees in a value-based care payment model.

“Our goal here at Humana is to continue to support those physicians and other providers to be successful in value-based relationships while, at the same time, growing new relationships with providers in value-based care,” said Michael Funk, Vice President, Thought Leadership, for the Provider Development Center of Excellence at Humana.

Blue Cross Blue Shield of Michigan is another health payer that has embraced value-based care reimbursement and established these alternative payment models by renovating healthcare delivery. The payer has worked with their provider network to incentivize physicians to treat patients through a patient-centered medical home.

“The vision started out with this notion of shoring up primary care, which was in disarray, underfunded, and poorly supported,” David A. Share, M.D., the Senior Vice President for Value Partnerships at Blue Cross Blue Shield of Michigan, told last month. “This was not just primary care isolation but the idea at the outset was, as we strengthen primary care, we’d find ways to create a sense of interdependence and achieve integration across the primary care and specialist community.”

“As our thinking evolved, coincidentally, the patient centered medical home model became better articulated in the provider community,” he continued. “So we were able to harness that.”

While the future for value-based care reimbursement at CMS may undergo some regulatory changes under the new administration, the private sector is likely to continue pursuing alternative payment models.

To read Congressman Price's statement on the HHS nomination, click here.


Dig Deeper:

How to Overcome the Challenges of Bundled Payment Models

Time, Commitment Required for ACO, Value-Based Care Success


Sign up for our free newsletter:

Our privacy policy

no, thanks