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Healthcare Snapshot - September 2024

September 01, 2024

PSW On The Hill: Value-Based Care Advocacy

PSW CEO, Melanie Matthews, and Executive Director of ACOs, Jake Woods, spent a few days in Washington D.C. to meet with members of Senate and Congress on important ACO issues. They discussed bolstering incentives for ACO Participants, easing administrative burdens, and the challenges that ACOs have faced due to Significant, Anomalous, and Highly Suspect (SAHS) billing.

These visits highlighted the continued bipartisan support for value-based care. Many Representatives support the need for payment reform and agree that ACOs have a great opportunity to positively impact the quality of care for Medicare beneficiaries.

While there, Jake presented Representatives Kim Schrier and Suzan DelBene with the NAACOS Champion of Value in Health Care Award. Both Schrier and DelBene have been fierce advocates for ACOs and they both cosponsor the Value in Healthcare Act.

CMS Publishes Final Rule on Significant, Anomalous, and Highly Suspect Billing (SAHS)

The Centers for Medicare & Medicaid Services (CMS) recently finalized a rule aimed at mitigating the impact of Significant, Anomalous, and Highly Suspect (SAHS) billing activity within the Medicare Shared Savings Program.

This rule, effective October 15, 2024, excludes fraudulent and unnecessary claims, particularly for urinary catheters, from financial calculations for the 2023 performance year. The measure is part of CMS’s broader efforts to safeguard Medicare integrity and protect Accountable Care Organizations (ACOs) from the financial consequences of improper billing practices.

View the final rule fact sheet

Patient Success Story

During a weekly visit with one of our skilled nursing facility (SNF) partners, PSW's care management team worked with a patient recovering from a hip fracture who was ready for discharge on a Thursday. However, there was a significant barrier: access to durable medical equipment (DME). Due to the patient's rural location and limited financial means, purchasing the necessary items out-of-pocket was not feasible, and ordering online would delay the discharge.

Through our ACO's in-kind benefits, we were able to step in and purchase the non-covered DME—a toilet seat riser and shower chair—from a pharmacy in a neighboring city. The items were delivered to the SNF the same day, allowing the patient to be discharged home the following day, reducing their length of stay (LOS). Without this intervention, the patient would have remained in the SNF over the weekend due to the lack of local options for DME.

A nurse care manager followed up the next Monday to ensure continuity of care, and no gaps were identified. This seamless collaboration highlights our commitment to patient-centered care and timely transitions home.