May 18, 2016|Categories: Medical Billing and Payers
It’s been exciting to see all the buzz around last week’s release of PayerView 2016, the 11th edition of athenahealth’s annual report on the performance of the largest payers in our network. While much has been made about this year’s unusually diverse top ten list, the rankings are only one piece of the bigger PayerView story for 2016. We also take a closer look at industry changes for payers and providers – truthfully, for the entire healthcare marketplace. Big trends which have been gaining steam for years, especially in the six years since passage of the Affordable Care Act, are converging to challenge the status quo like never before.
What are these big trends?
The transition from a “fee for service” to a “fee for value” reimbursement model is accelerating, with Medicare leading the charge and the commercial market following closely behind. The pace and complexity of this transition - underscored by the recently proposed MACRA rule from CMS – will likely continue to challenge payers and providers, especially as more and more value-based reimbursement models come online.
Right now, there are more questions than answers in this space. Will the complexities of alternative payment models disrupt the traditionally strong performance of commercial payers and Blues? How will payers and providers effectively meet the demands of data-sharing, analytics, reporting, and financial settlement required to participate in these new models?
Government payers’ share of the overall payer mix is increasing. The number of Medicare beneficiaries is growing as the population ages. Medicaid enrollment also continues to climb as coverage expands under the Affordable Care Act. At the end of the day, both of these trends mean that providers are treating more patients with government-sponsored coverage, resulting in a mixed impact on claim payment.
Though Medicare and Medicaid are both government programs, the clarity of their adjudication requirements varies greatly. Medicare publishes consistent guidelines, while Medicaid programs are administered on a state-by-state basis, with lots of variation. The impact of this on the claims payment cycle is stark: Our PayerView analysis shows that Medicare Part B payers denied only 6.3% of claims in 2015 while, at the other end of spectrum, Medicaid payers denied an average of 15.0% of claims.
This begs a number of questions: What additional challenges will increasing Medicaid and Medicare enrollment present to providers? Will further reform at the federal level (and, in the context of Medicaid, at the state level) add more layers of complexity to the government payer equation? At a minimum, we expect that providers will want to remain one step ahead of new or changing rules and work with their partners, like athenahealth, to help drive process improvements.
How can payers, providers, and other stakeholders meet the challenges and take advantage of the opportunities that these trends represent? In our view, it is all about collaboration – embracing transparency, sharing information, and forging new partnerships. It is with this need for collaboration in mind that we offer this year’s PayerView findings with an accompanying infographic, which identifies strategies to help providers and payers zero in on opportunities for collaboration in our evolving healthcare world.
By injecting transparency into payer performance, athenahealth strives to offer insights that can benefit both providers and payers, standing at the nexus of collaboration. It’s another example of our network knowledge and insight being put to work every day on the front lines of a rapidly changing healthcare marketplace.
We can’t wait to see what the future holds for payers and providers, especially in the context of the accelerating transition from volume to value and the growth of government payers’ share of the payer mix. We look forward to revisiting exciting trends like these in PayerView 2017!
To read the full 2016 PayerView Report, visit www.athenahealth.com/PayerView.