First determination will be made in April 2013 and first spending reduction proposals will be due in January 2014. IPAB proposals may not ration care, raise Part B premiums or change benefits, eligibility or cost sharing. Hospitals (except CAH) and hospices will be exempt from IPAB spending reduction through 2019. (Sections 3403 and 10320).
Readmissions for conditions and procedures that are unrelated to the prior discharge or which fall below a minimum threshold will not be included. (Section 3025)
The productivity adjustment is an adjustment equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity (section 3401).
Secretary of HHS will select up to 8 conditions, taking into consideration acute and chronic conditions, mix of med and surg conditions, whether opp to improve quality and reduce costs, whether condition has significant variation in number of readmissions and expenditures for post-acute care, and whether condition is high volume and might result in high post-acute care costs. Participation is voluntary effective 2013 and may be expanded after 1/1/2015. Initial report will be submitted to Congress 2 years after implementation. (Section 3023).
Hospice: regulations will implement revisions to payment methodology based in 2011 data. Quality reporting program includes 2% penalty for non-reporting (Section 3132)
Hospital efficiency measures will include Medicare spending per beneficiary and adjustments will include factors such as age, sex, race and severity of illness (Section 3001) SNF, HHA, ASC: sections 3006 and 10301 Physician phase-in of the modifier will be over 2 years. (Section 3007)
Payments will be equal to the product of the national per resident amount for direct GME and the average number of FTE equivalent residents in the teaching health center’s training programs. Failure to report = 25% reduction in payments (section 5508)
See Section 1201 of Reconciliation Bill
Global payment: section 2705; bundled payment: section 2704
Eligible provider and supplier groups: group practices, networks of individual MD practices, partnerships b/t hospitals and ACO professionals, hospitals employing ACO professionals and others that the Secretary may identify. Only Subsection D hospitals may participate (excluding CAH, LTACH, psych H, cancer and children’s hospitals).
Technologies may include telehealth, remote patient monitoring, other Demo project targeting pediatric patients req’d to be developed for operation b/t 1/1/2012 and 12/31/2016. This will allow ped medical providers meeting criteria as ACOs into incentive payment program. They must meet performance guidelines and establish and achieve annual minimal expenditure savings. (Section 2706).
Entities eligible for grants must be either state, state-designated entity or Indian tribe or tribal org. Section 3502 No later than 1/1/2011, CMS must create Center for M/M Innovation. Purpose: test new payment and service delivery models with the goal of reducing program expenditures and increasing quality of care provided by beneficiaries. Significant $$ allocation--$10B during FY 2011-2020 At least $25M annually must be used for design, implementation and evaluation of various models. Congressional reports req’d and will include recommendations by the Secretary. See Section 3021.
IOASE: to require a referring physician to inform patients in writing at the time of the referral that patient may obtain specified imaging services or other DHS from another other than the referring physician, the same group practice, or a person directly supervised by same; also requires provision of a written list of suppliers who furnish services in the area where the patient resides, effective immediately
AKS: Section 6402; Stark: 6409; FCA: 6402 CMP: knowingly making a false statement that is material to obtaining payment for services or items furnished under a FHCP now= grounds for CMPs. Second, CMPs may be imposed on providers or suppliers who fail to grant timely access to info requested by the OIG to perform audits, inspections, evals or other statutory functions. (section 6408)
Funding: Section 6402. $95M in 2011 alone. Compliance programs: Secretary has discretion to dictate timelines for implementation as well as types of providers/suppliers req’d to adopt. Secretary to develop core elements. Section 6401. Exclusion: for those who knowingly make a false statement, representation or omission as part of Medicare enrollment or bidding from participating in Medicare. “ Credible”—Secretary is required to consult with OIG
Senate Finance Committee’s delivery system reforms (as well as those envisioned by the other congressional committees) aim to reduce the overall cost while improving the quality of care – in essence increasing the value of care received for a dollar spent, which is depicted as the “capstone” in the graphic. Experts believe that the “siloed” nature of how health care is provided and paid for creates perverse economic incentives that discourage collaboration across provider types and reward inefficient care practices. The SFC proposal aims to break down existing silos, encouraging providers to collaborate and hopefully resulting in high-quality, cost-effective care by significantly restructuring economic incentives. These proposals are the five pillars in the center of the slide that support the “capstone” goal. Finally, conventional wisdom is that one of the barriers to better collaboration among providers is a lack of information and an efficient infrastructure to communicate. As you can see at the bottom, legislation filling this “prerequisite” was passed with the stimulus package, which included funding for the implementation of electronic health records.
President Obama’s web site states that health reform should accomplish eight goals, which include: Investing in Prevention and Wellness Improving Safety and Patient Outcomes Reducing Cost Growth Assuring Affordable Coverage Maintaining Coverage During Job Transitions Ending Barriers for Pre-Existing Conditions Protecting Families from Medical Bankruptcy Guaranteeing Choice of Doctors and Health Plans The slide maps out the interrelationship among the goals. Theoretically, preventing chronic diseases and improving safety and the quality of care will reduce costs (along with other efficiency efforts), which will lead to affordable coverage. As coverage becomes more affordable, more people will have access to it in general, creating “deeper” risk pools that will allow insurance companies to remove barriers to coverage like pre-existing conditions. Also, more affordable coverage will allow people to maintain health insurance during periods of job transition. Finally, coverage available to all, especially during employment transitions, will protect more American families from medical bankruptcy and push the system in a direction that makes choice of physician and health plan possible.
As is illustrated across the top half of the page, multiple payment systems are currently used to reimburse care given by different provider types. The only real bundling that currently occurs is illustrated at the middle left, with the 72-hour rule where related outpatient services provided with three days of an inpatient admission are covered under the MS-DRG payment, and across the middle right, for home health services provided within a 30-day window. The Senate Finance Committee bill will expand the ongoing ACE demonstration project to test the feasibility of moving from the current fee-for-service payment system (top half of the page) to a bundled payment system, which is illustrated across the bottom of the page. In essence, a hospital would receive one payment for all services provided 30 days post discharge. The hospital would then pay the other providers of care out of that pool of funds. Payments under this system would be calculated as the MS-DRG plus the average post-acute care costs of treating patients in that MS-DRG. This payment would be adjusted to capture savings from anticipated efficiencies gained from improving patient care and provider coordination.