This weekend, the American Hospital Association will convene its 2026 Annual Membership Meeting in DC. Its purpose is to equip leaders to engage with lawmakers and government officials on issues of consequence to hospitals.
The agenda includes panels on age friendly health systems, post-acute services, AI and more interspersed with punditry from members of Congress and political commentators. It’s a federally-focused meeting at a time when the current administration has signaled distaste for healthcare and frustrations with hospitals. (see “In OMB’s FY 2027 Proposed Budget, Healthcare is the Big Loser”, https://paulkeckley.com/the-keckley-report/2026/4/6/in-ombs-fy-2027-proposed-budget-healthcare-is-the-big-loser).
Perspective
The two major issues facing hospitals today are (1) their role in the emergent technology-driven health ecosystem, and (2) sustainability, or how they’ll stay afloat. On the former, AHA has asserted that hospitals should be hubs and all others spokes, and on the latter, AHA blames unnecessary regulations, prescription drug prices, underpayments by Medicare and Medicaid and corporate insurer greed for eroding hospital finances and threatening insolvency.
Neither topic—role and sustainability– gets adequate attention in hospital strategic plans, and three others need to join the list:
1-Affordability: For employers and consumers, it’s issue one. CPI data show higher prices for hospital outpatient services the biggest component of health cost escalation. Coupled with explosive administrative costs, it is the root cause for public concern.
Reality: Most hospitals and AHA reference affordability in their commentary quickly laying blame on others. Polls show employers and consumers think hospitals also complicit, noting executive compensation, lack of price transparency, waste, fraud and consolidation (vertical and horizontal) as key deterrents. Affordability is more talk than do in most hospital strategic plans. Last week’s releases of the BLS’ CPI report and U of MI Consumer Sentiment Index underscore the public’s growing appetite for affordable solutions.
The key questions: how should affordable hospital care be defined, measured and achieved? Are price controls the answer? How should hospitals demonstrate affordability is taken seriously?
2-Profitability: Data from reliable industry sources including AHA favorite Kaufman Hall show a wide range of financial results for hospitals based primarily on size, location and system affiliation. Whether not-for-profit or investor owned, bigger systems are more financially healthy than smaller, and many– rural, safety net, teaching, specialty hospitals—aren’t at all.
Reality: Corporatization of hospital care is understandable: going big or getting out is a widely used strategy to protect or strengthen market advantages. The shift from inpatient to outpatient services required hospitals to re-position capital away from inpatient hubs to regional and virtual services. It also afforded hospitals an unusual opportunity to acquire medical practices thus gaining leverage over insurers while adding facility fees and locations. And market dominance (aka hospital concentration) has rewarded hospitals with profits.
Key questions for hospitals: how should hospital profitability be defined (measured) and should it be regulated? Should tax exemptions and community benefits be revisited for not-for-profit hospitals to level the field? What methodology is needed to consistently measure the total cost of care?
3-Value-based Care: Noticeably, the AHA Annual Meeting program does not feature a session on “value-based care” and it’s understandable. VBC 2.0 (Pay for Performance was VBC 1.0) has stumbled from day one. In the 60+ alternative payment model pilots, consultants fared well, participating hospitals and doctors so-so, and Medicare savings were modest at best. MedPAC concluded only 6 models showed promise in moving the system’s incentives from volume to value.
Reality: What’s immediately clear for VBC are new models (like TEAM) with mandatory participation and downside risk. But how CMS and CMMI orchestrate widespread adoption of value-driven healthcare is unclear. Gratefully, VBC has already contributed to simplicity in measurements of quality (i.e. Joint Commission, et al) and forced attention to valid and reliable approaches to processes and outcomes. Nonetheless, quality in the context of value-based care is subordinated to short-term financial results rather than longer-term systemic changes in most hospitals.
Key questions for hospitals: What does value mean in our organization? To whom is our value focus directed? Is quality in our organization an end in itself or a means to a financial result? Is participation in VBC projects helpful to our organization or is watchful waiting prudent?
The American Hospital Association, its state affiliates and its members face unprecedented challenges in 2026 and beyond. While attention is focused on short-term rules and regulations that protect hospital revenues (340B, site neutral payments, Medicaid cuts, et al), equal consideration is needed to the long-term role and scope of hospitals in emergent systems of health. That makes the AHA Board’s selection of retiring CEO Rick Pollock’s successor and the deliberation of the AHA Board about the long-term future for hospitals even more consequential.
Paul
Annual Meeting – Homepage | AHA Annual Meeting April 19-21, 2026
Sections in today’s report
- Quotables
- Economy
- Hospitals
- Insurers
- Physicians
- Prescription Drugs
Quotables
WSJ on consumer sentiment: “Consumer sentiment fell in April to the lowest level recorded in the 70-plus-year history of the University of Michigan’s survey, evidence of Americans’ concerns that the Iran war will hit the domestic economy.
The survey’s initial April reading came in at 47.6, versus 53.3 in March. Analysts polled by The Wall Street Journal were expecting a drop to 52. The April reading is below the previous low point of 50 recorded in June 2022, when the economy was facing searing inflation.
The April results, based on March 24-April 6 interviews, are below the prior low of 50 recorded in June 2022.”
Consumer Sentiment Hits Record Low, Michigan Survey Shows – WSJ
Altman on affordability, chronic disease: “The uninsured is not the most politically salient problem in health care now—that’s affordability—nor is it the non-problem some say it is. But it’s coming back. And the problem of the chronically ill uninsured is glaring.
With 92% of the population covered by some kind of health insurance, the problem driving health to the forefront in polls now is no longer the uninsured—as it was back in 2010 when the Affordable Care Act passed and for years before that—it’s the cost concerns of the vast majority of the population people WITH insurance. That’s one reason why affordability is displacing universal coverage as a rallying cry in health care. Another is the heightened concern the public has about affordability generally—for food, housing, utilities, gas, and for health care. But the uninsured haven’t disappeared and one large group, the chronically ill uninsured, is particularly hard hit in our health system. “
Affordability Is the Issue Now, But Look for the Uninsured to Make a Comeback | KFF
Corporate Board Member on organizational transformation and governance: “Research on corporate transformation outcomes continue to surface the face that most transformations hit, at the very least, similar rough patches. A recent Bain & Company study found that while more than a third of large organizations are undergoing business transformations at any given time, only about 12% achieve their original ambition. The causes for failure vary, but one thread runs through nearly every postmortem: By the time the board acts, the window for a graceful correction has long since closed. Somewhere between the roadmap and reality, the board loses the thread.
The governance failure hiding inside most transformation disasters is a board that signs off on a vision and then waits for results, when what’s actually needed is sustained, disciplined engagement with the messy, nonlinear, organizationally resistant process of getting there. “Transformation tends to surface which kind of board you have,” says Bill Flynn, CEO of Catalyst Growth Advisors, a consultancy. “Oversight boards monitor whether the transformation is on schedule. Stewardship boards ask whether the organization is learning to operate differently. One of those questions tells you whether a plan was executed—the other tells you whether anything changed.”
Successful Corporate Transformations Playbook – Corporate Board Member
Meekins on affordability: “Years of Americans’ ennui around health care seems to have reached a depth that now politicians in both parties are seriously talking about costs and outcomes rather than being mainly Democratic talking points. This is a level we arguably have not seen since before creation of [Medicare] Part D…”
Jamie Dimon, JPMorgan Chase CEO on $39 trillion national debt: “The best way to deal with the problem is to actually deal with the problem—to acknowledge it, to work on it. Years ago, we had a solution, the Simpson-Bowles Commission. It didn’t get done. I wish it had gotten done. It would have been a home run for all of Americans, and it would have resolved some of these issues… If we grew (the GDP) at 3% and not 2% … the debt to GDP would start going down. This is the most innovative nation the world’s ever seen. And so, I think we should focus a little bit in that to solve the problem, too, not just raise taxes or cut expenditures.”
Jamie Dimon NPR’s Newsmakers podcast. April 9, 2026
Atlantic on fraud: “As laid out in the March executive order, (VP) Vance will be focusing specifically on benefits fraud: the crime of claiming benefits for social services that you don’t actually qualify for. (It’s a real phenomenon, but despite some of the administration’s rhetoric, reducing it won’t do much to chip away at the federal deficit. The Trump administration has tried to address this issue through legislation (for example, the One Big Beautiful Bill Act changed eligibility requirements for food stamps) and through targeted enforcement efforts such as DOGE, a far-reaching initiative to trim the fat across the federal government. DOGE’s progress was hard to track: Its website saw repeated overstatements, deletions, and contradictions about the state of the agency’s work. The department ultimately failed in its mission. Despite shutting down several government agencies, DOGE actually ended up leading to more federal spending, rather than less.”
Vance’s ‘Fraud Czar’ Title May Come Back to Haunt Him – The Atlantic
Ken Terry on failure of value-based care: “According to the Health Care Payment Learning & Action Network, in 2023 only 34% of traditional Medicare revenues came through two-sided financial risk contracts, which create care budgets that incentivize cost reduction. 43% of Medicare Advantage payments to providers were risk-based. With Medicaid and commercial insurance payments included, however, only 28.5% of all provider revenues flowed through financial risk arrangements.
This means that the majority of providers are still not taking risk and that many of those who do under some contracts are still being paid largely fee-for-service. Considering that two-thirds of physicians’ revenues must be risk-based before they change how they practice, this is one reason why VBC has not achieved its stated aims: Most doctors and hospitals are still operating in a predominantly fee-for-service environment.”
Ken Terry 4sightHealth.Terry_Price_Controls_and_VBC.4_7_25.03.pdf
DOJ on new fraud unit: “…Accordingly, to honor our commitment to the public, the Department has established the National Fraud Enforcement Division. The core mission of the National Fraud Enforcement Division is to zealously investigate and prosecute those who steal or fraudulently misuse taxpayer dollars. The National Fraud Enforcement Division will fulfill that mission by coordinating with agencies responsible for administering benefit programs; partnering with federal, tribal, state, territorial, and local law enforcement on fraud-fighting efforts; developing systems and processes that ensure efficient identification of fraud against taxpayer dollars; and equipping prosecutors and law enforcement with state-of-the-art tools and resources needed to bring criminal actors to justice. The attorneys in the National Fraud Enforcement Division will work every day to protect the financial integrity of our government and the tax system that supports it.”
Memorandum from Acting Attorney General Todd Blanche Regarding the Creation of the National Fraud Enforcement Division April 7, 2026
Amy Gleason on new White House Health Tech initiative: “…last July, we announced what we call the Health Tech Ecosystem at the White House, and we have 60 companies that signed up to pledge to come and work alongside of us and to deliver solutions in 6 months to a year. So, this is our first real milestone in this work, and so we have practices here, like Cleveland Clinic, Tennessee Oncology, and AtlantiCare, that are now live…
The system allows patients to use an app on their phone that creates a QR code which allows them to share their medical records straight to the provider, and it goes straight into their electronic health record…In order to share the record, the patient first uses an existing identification app — such as login.gov, id.me, or CLEAR — to authenticate themselves.”
Medicare Debuts Digital Health Record System for Enrollees | MedPage Today
CDC National Vital Statistics: 2025 U.S. birthrate: “The U.S. birth rate declined by 1% in 2025, according to preliminary data released by the Centers for Disease Control and Prevention. The cesarean delivery rate increased slightly to 32.5% in 2025, up from 32.4% in 2024. The 2025 rate is the highest since 2013, which was 32.7%. The preterm birth rate was 10.41% in 2025, unchanged from 2024. “
Births: Provisional Data for 2025 https://www.cdc.gov/nchs/data
Economy
BLS March CPI Report: “The Consumer Price Index for All Urban Consumers (CPI-U) increased 0.9% on a seasonally adjusted basis in March, after rising 0.3% in February… Over the last 12 months, the all-items index increased 3.3% before seasonal adjustment.
The index for energy rose 10.9% in March, led by a 21.2% increase in the index for gasoline which accounted for nearly three quarters of the monthly all items increase. The shelter index also increased in March, rising 0.3%. The index for food was unchanged over the month as the index for food away from home rose 0.2%, while the index for food at home fell 0.2%.
The medical care index decreased 0.2% in March, after rising 0.5% in February. The index for prescription drugs decreased 1.5% over the month. Conversely, the physicians’ services index increased 0.7% over the month and the hospital services index rose 0.4%. “
Unadjusted last 12 months:
- All items: +3.3%
- Food: +2.7%
- Energy: +12.5%
- Medical care commodities: +0.3% (Prescription drugs: -0.2%, non-prescription drugs: 0%, medical equipment: +4.1%)
- Medical care services: +3.7% (physician services: +2.4%, dental: +7.2%, eye care: +1.6%, hospital inpatient: +6.2%, hospital outpatient: +6.6%, nursing home: +5.2%, home care: +7.6%, health insurance: -5.3%)
Consumer Price Index Summary – 2026 M03 Results
HCCI: Drivers of higher spending: “Health care spending reflects a combination of the price of services, the number of services used, and the types of services used (also called ‘service mix’). Of these three factors, prices account for most of the variation in health care spending, while the use of services and service mix drive variation to a lesser extent. High spending metro areas more often had higher prices than use or service mix…
Of the service categories, high overall health spending is more closely related to high outpatient hospital spending than the other categories.
There is considerable evidence that prices for health care services are higher in areas where hospital markets are less competitive… Of the metro areas studied, 236 (88%) have highly or very highly concentrated hospital markets, while only about 3% have unconcentrated markets.”
HCL Overview Brief April 2026
Census report: Aging population: “The nation turns 250 this year and Americans’ median age — the age at which half of the population is younger and half is older — continues to rise, climbing from 39.2 in 2024 to 39.4 in 2025.
We use population estimates released today to examine changes in the U.S. age structure by sex from 2001, when the median age was 35.6, to 2025.
One striking shift is that while women continued to outnumber men at older ages, the gap between the sexes narrowed in the past 25 years. In 2001, there were 70.6 males for every 100 females age 65 and older. By 2025, the ratio had increased substantially to 81.6.
The gap among those age 80 and older narrowed even more dramatically — from 50.9 males per 100 females in 2001 to 68.3 in 2025.
National Population by Characteristics: 2020-2025 https://www.census.gov/data/tables/time-series/demo/popest/2020s-national-detail.html
Hospitals
CMS issues Inpatient Payment rule: The Centers for Medicare & Medicaid Services issued a proposed rule that would increase Medicare inpatient prospective payment system rates by a net 2.4% in fiscal year 2027, compared with FY 2026, for hospitals that are meaningful users of electronic health records and submit quality measure data.
This payment update reflects a hospital market basket increase of 3.2% as well as a productivity cut of 0.8%. Overall, it would increase hospital payments by $1.9 billion in FY 2027 compared to FY 2026. This includes a proposed decrease in disproportionate share and uncompensated care payments of $564 million. This is despite the fact that the estimated uninsured rate is estimated to increase from 8.7% to 9.1%.
The AHA responded that the IPPS bump is not enough.
AHA Today www.aha.org
Study: Critical access hospital (CAH) utilization: “From 2017 – 2024, outpatient services accounted for an increasing share of total patient revenue at the average Critical Access Hospital (CAH) in the study sample, rising from 76.0 to 82.3%. This change was primarily attributed to increases in outpatient daily revenue.
Adjusted for inflation, the average sampled CAH experienced a 4.7% decrease in inpatient daily revenue across the study period ($37,888 to $36,102) and experienced a 50.0% increase in outpatient daily revenue ($132,454 to$198,719).
From 2017 – 2024, inpatient average daily census (ADC) among the average sampled CAH decreased by 5.3% from 7.6 to7.2. Similar trends were observed when stratifying CAHs by rurality, Census region, ownership, or system affiliation, with some small differences across groups.”
Trends in Inpatient Revenue and Volume Among Critical Access Hospitals https://www.flexmonitoring.org/sites/flexmonitoring.umn.edu
Study: Utilization of Maryland hospitals vs. U.S.: “Maryland hospitals have operated under all-payer global budget models since 2014. Within Medicare, evaluations have estimated the resulting cost savings to be $1.6 billion for the period 2014–22. To understand the aggregate inpatient and outpatient utilization changes underlying these savings and how utilization changed across all ages, we analyzed trends in Maryland relative to other states during the period 2013–23. We used national commercial claims data alongside Medicare fee-for-service claims. After we adjusted for population aging and other demographic changes, hospital utilization in Maryland decreased 11 percentage points more than in other states, primarily driven by outpatient utilization trends, which were 19 percentage points lower in Maryland than elsewhere. These results are nationally relevant, given broad interest in addressing rising hospital outpatient utilization. However, there are risks in such utilization reductions, and global budget designs must consider payment levels that are fair for both payers and providers while embedding mechanisms that maintain quality and discourage stinting on patient care.
Hospitals sue for DSH payment recovery: On March 30, more than 130 hospitals filed a lawsuit in the U.S. District Court for the District of Columbia against HHS challenging how the agency calculates disproportionate share hospital payments, arguing the policy unlawfully reduces reimbursement for facilities serving low-income patients.
The hospitals argue CMS’ 2023 final rule — which retroactively applies a policy including certain Medicare Advantage days in the Medicare fraction while excluding them from the Medicaid fraction — improperly reduces DSH payments. The hospitals allege that CMS’ methodology skews both fractions in ways that reduce reimbursement.:
AHA (Thompson) on LTCH reforms: “The AHA remains concerned about ongoing shortfalls in reimbursement for Long-term Care Hospitals (LTCHs). Under the current payment system, LTCHs have been unable to maintain the same volume of care, and many LTCHs have been forced to close. We appreciate that CMS did not increase the outlier threshold this year. However, additional reforms are needed to stabilize the LTCH sector and ensure critically ill patients continue to have the ability to receive care at LTCHs. We will work with the Administration and Congress to pursue the AHA’s LTCH reform principles to protect access to LTCHs.”
Note: Last week, CMS proposed increasing the long-term care hospital standard rate payments by 2.4% in fiscal year 2027 relative to FY 2026 which includes a 3.2% market basket update, reduced by a 0.8 percentage point productivity adjustment. In addition, CMS also proposes to maintain the outlier threshold at $78,936, the same level as FY 2026. Per AHA, LTCH prospective payment system payments will increase by $55 million relative to FY.
American Hospital Association www.ahatoday.org
Insurers and coverage
CMS final rule changes for Medicare Advantage Plans: Major changes: Updates to Star Ratings: “The Star Ratings system helps Medicare beneficiaries compare health and drug plan quality. Star Ratings also determine Quality Bonus Payments and impact rebates for MA contracts, currently rating MA-PD contracts on up to 43 measures, MA-only contracts on up to 33 measures, and Part D plans on up to 12 measures across five categories: outcomes, intermediate outcomes, process, patient experience, and access.
CMS is finalizing two sets of major changes to the Part C and Part D Star Ratings system. First, for the 2027 Star Ratings, CMS is not implementing the Excellent Health Outcomes for All reward (previously called the Health Equity Index reward) …. Second, CMS is streamlining and refocusing the measure set by removing 11 measures focused on administrative processes and areas where beneficiaries cannot distinguish performance between plans due to high performance and little variation.
Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4208-F)
https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final
JD Power Plan satisfaction: Key findings from 2026 JD Power Plan Satisfaction study:
- Mobile app adoption rate increases among commercial plan members: 38% of commercial health plan members now use their plan’s digital app, up from 31% last year. Among Medicare Advantage plan members, however, app usage has declined to just 20%, down 4 percentage points from last year.
- Familiarity breeds delight: Among both commercial and Medicare Advantage plan members, mobile app satisfaction increases significantly with member tenure and channel familiarity.
- Satisfaction with mobile apps drives customer loyalty: 76% of commercial health plan members and 74% of Medicare Advantage plan members say they “definitely will” continue to use their health plan’s mobile app in the future when they have an excellent digital experience, (overall satisfaction scores of 800 or higher). Conversely, just 29% of commercial plan members and 21% of Medicare Advantage members say they “definitely will” continue to use their health plan’s mobile app in the future when they have a poor digital experience (overall satisfaction scores of 500 or less).
2026 U.S. Healthcare Digital Experience Study | JD Power
CMS Klomp on Medicare Advantage (MA) changes: “We are fundamentally shifting our approach to quality. This isn’t just about adjusting measures; it’s about redefining success. We are moving away from a system that incentivizes administrative box-checking and are instead laser-focused on what truly matters: the clinical outcomes and health of our beneficiaries. This is a critical first step toward a more efficient, effective, and patient-first healthcare system.”
Chris Klomp, Director of the Center for Medicare and Chief Counselor of the U.S. Department of Health and Human Services April 2, 2026 Medicare Beneficiaries to See Simpler and More Flexible Plan Choices, Better Drug Coverage, Higher Quality and Lower Costs in 2027 | CMS
MedPAC on Medicare supplemental benefits: Clearly, there are important public policy debates to be had regarding the $1.1 trillion annual cost of Medicare. Policymakers and stakeholders can discuss the fairness of the roughly half of beneficiaries enrolled in MA receiving a total of $76 billion—or an average of $2,660 per enrollee—in extra benefits that are not available to TM beneficiaries; these benefits are financed by the difference between what CMS pays MA plans and the plans’ cost of providing traditional Medicare benefits. The cost of the extra benefits for MA increases Part B premiums for all beneficiaries by an estimated $15 billion.
Policymakers should consider proposals that would reduce MA overpayments, with some of the savings used to expand benefits in TM and/or decrease Medicare spending. But all of those issues, important as they are, do not invalidate the factual question of whether payment to MA plans exceeds what would have been spent had the enrollees been in TM.
CMS guidance on immigrant coverage: “Given these changes, beginning October 1, 2026, with limited exceptions, FFP will no longer be available for full Medicaid or CHIP benefits furnished to qualified noncitizens who are not also FFP eligible noncitizens (e.g., asylees, refugees, parolees, or victims of trafficking) unless they have another immigration status or category15 that meets the definition of an FFP-eligible noncitizen.”
Section 71109: Implementation of “Alien Medicaid Eligibility” CMS April 8, 2026
CMS: supplemental benefits changes: “CMS is refining its regulations regarding cannabis products by amending current regulatory language to state more precisely that cannabis products that are illegal under applicable State or Federal law, are not allowable as SSBCI. This clarification aligns MA benefit policies with current federal law while maintaining safeguards.
Provisions Related to Supplemental Benefits Being Finalized from the CY 2026 Proposed Rule: CMS is finalizing two supplemental benefit policies that were proposed in the CY 2026 rule: (1) strengthening SSBCI administration by clarifying eligibility requirements, and increasing transparency by requiring plans to publicly post their plan-developed SSBCI eligibility criteria; and (2) codifying and clarifying requirements for administering supplemental benefits through debit cards… Other changes:
Reducing Regulatory Burden and Costs in Accordance with Executive Order 14192:
- Exempting account-based plans (such as health reimbursement arrangements, flexible spending accounts, and health savings accounts) from creditable coverage disclosure requirements.
- Rescinding the requirement for MA plans to send mid-year notices about unused supplemental benefits.
- Eliminating the requirement for MA quality improvement programs to include activities that reduce health disparities.
- Eliminating health equity requirements for MA Utilization Management Committees, including requiring a health equity expert member, conducting annual health equity analyses, and publicly posting these analyses.
- Waiving the requirement for the Limited Income Newly Eligible Transition program to maintain toll-free customer call centers open from 8 a.m. to 8 p.m. in all regions.
- Removing restrictions on the time and manner by which beneficiaries can have conversations with licensed agents and brokers
Physicians
Survey: Perceptions of access—physician vs. patient: A growing perception gap: Nearly half (46%) of providers believe patient access is better than last year, but only 18% of patients agree — a gap that widened despite year-over-year gains on both sides.
Top roadblocks to patient access: Authorizations, insurance verification, and cost of care are the top roadblocks to patient access:
- 36% of patients had difficulty with authorizations for a procedure
- 28% of patients experienced care delays due to insurance verification
- 73% of providers say patients delay/skip care if cost estimate not available
- 36% of providers say regulatory changes create access obstacles
Staffing shortages: a worsening crisis: Though technology is helping improve operations, health care organizations continue to struggle with workforce capacity and training deficits, which directly affect patients’ ability to receive care.
- 64% of providers: say staffing shortages reduce patient access — up from 57% in 2025
- 39% report that insufficient staff training negatively impacts access
- 27% report access to practitioners as their top challenge — consistent for the fourth year
State of patient access survey results | Medical Economics
Roji on alternative payment models: “TEAM and ASM deliver a clear message about the direction of Value-Based Care: mandatory accountability.
These are not one-off experiments in accountability for costs and outcomes in surgery and treatments. They are proof of concept that the voluntary participation phase is closing in Value-Based Care. Now CMS is taking steps to drive systemic change by ensuring that providers are invested in patient outcomes and costs.
That future will include shifting reimbursement away from Fee-for-Service and toward per-patient or per-episode payments. It will also involve a series of quality and cost measures that will hold providers responsible for meeting patient outcome goals and cost targets. There will always be some exceptions, such as the recent announcement of the ACCESS model, which tests the effects of outcome-aligned payments to providers for technology-assisted care that helps patients adhere to treatment plans.”
What TEAM and ASM Tell Us About the Future of Value-Based Care
Prescription Drugs
Implementing Medicare Part D Provisions of the Inflation Reduction Act (IRA) of 2022: “CMS is codifying changes for 2027 and beyond, including eliminating the coverage gap phase, establishing a reduced annual out-of-pocket threshold, removing cost sharing for enrollees in the catastrophic phase, and incorporating the Manufacturer Discount Program that replaced the Coverage Gap Discount Program on January 1, 2025. CMS is also codifying additional operational changes including updates to True Out-Of-Pocket cost calculations, specialty-tier rules, reinsurance payment methodologies, and implementation of the Selected Drug Subsidy.
Revise List of Non-Allowable Special Supplemental Benefits in MA Plans for the Chronically Ill (SSBCI):
