Transition to risk: The future has arrived for health systems and physician groups

By Paul Jawin, JD and Lisa Fraser, MHA

The Centers for Medicare and Medicaid Services (CMS), the Federal government agency in charge of the Medicare and Medicaid programs, is the largest payer in the U.S. health care system.

CMS typically is the first mover on important changes in the health care system and, due to CMS’ stature as the dominant payor, commercial insurers generally follow CMS’ lead. The Patient Protection and Affordable Care Act of 2010 (ACA) contained funding for important demonstration programs which change the current fee-for-service payment system and introduce value and risk-based programs such as the Pioneer ACO Program, the Medicare Shared Savings Program (MSSP), another ACO program, and the Bundled Payment for Care Improvement Program (BPCI). These programs focus on shifting payment models away from the Fee-for-Service model we know today, towards those that incentivize care coordination, cost containment, and patient outcomes.


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