Health Care Reform Overview Teleconference

Transcription

1 Health Care Reform Overview Teleconference Patient Protection and Affordable Care Act (as amended by the Health Care and Education Reconciliation Act of 2010)

2 Agenda for Today s Call Overview Christiane Mitchell cmitchell@aamc.org (202) Medicare DGME and IME Payments Lori K. Mihalich-Levin lmlevin@aamc.org (202) Hospitals and Demonstrations Karen Fisher kfisher@aamc.org (202) Program Integrity and Physicians Ivy Baer ibaer@aamc.org (202)

3 3 Agenda for Today s Call (Cont.) Quality Jennifer Faerberg jfaerberg@aamc.org (202) Research Provisions (including CER and CAN) Dave Moore dbmoore@aamc.org (202) Workforce and Health Professions Programs Tannaz Rasouli trasouli@aamc.org (202) Student Loans Matthew Shick mshick@aamc.org (202)

4 The Health Care Reform Laws Patient Protection and Affordable Care Act (PPACA) Enacted March 23, 2010 [PL ] Health Care and Education Reconciliation Act (HCERA) Side-Car Bill that amended PPACA Enacted March 30, 2010 [PL ] 4

5 Coverage Expansions in PPACA Reduces by 32 million the number of uninsured individuals (over ten years) beginning in % of legal residents ultimately covered How increased coverage will occur 16 million covered through exchanges 16 million will enroll in Medicaid/CHIP 23 million remain uninsured 1/3 are unauthorized immigrants 5

6 Cost of PPACA The net cost of PPACA is $788 billion over ten years $938 billion in expenditures $149 billion in penalties and taxes PPACA reduces the federal deficit by $143 billion over ten years $124 billion via health care and revenue provisions $19 billion via education provisions 6

7 PPACA: Significant Provisions Creates individual mandate and employer penalties Significant insurance reforms (pre-existing conditions, rescissions, lifetime and annual limits, etc) Expands Medicaid to 133%: Feds pay 100% for new Medicaid , 95% in 2017, 94% in 2018, 93% in 2019 No IME or DGME Cuts Closes Medicare prescription donut hole Imposes taxes on insurers, pharma, high income individuals, and Cadillac plans Establishes Independent Payment Advisory Board 7

8 8 MEDICARE DGME AND IME PAYMENTS

9 Resident Limit Redistribution Program ( 5503) Cap Reductions: 65% of slots unused for past 3 years Look back at last 3 settled or submitted cost reports 9

10 Resident Limit Redistribution Program ( 5505), Cont. Hospital Prioritization for Receiving Slots: 70% of slots: In state with resident-to-population ratio in lowest quartile 30% of slots: In state that is in top 10 in terms of population in HPSAs and rural hospitals CMS also required to consider: Likelihood of using the slots within first 3 cost reporting periods beginning July 1, 2011 Whether hospital has a rural training track program 10

11 Resident Limit Redistribution Program ( 5505), Cont. Other issues: Max of 75 cap slots per hospital New slots effective July 1, 2011 IME payment for redistributed slots = 5.5% 75% of slots must be used for primary care or general surgery for 5 years 11

12 Preserving Cap Slots from Closed Programs ( 5506) Permanently redistributes resident caps from hospitals that close Currently only temporary redistribution until residents complete training Applies to hospitals that close on or after March 23,

13 Preserving Cap Slots from Closed Programs ( 5506), Cont. Priority for distribution? Same CBSA Contiguous CBSA Same state Same region General redistribution program criteria as last resort No reopening of cost reports unless DGME / IME appeal pending as of March 23,

14 Counting Resident Time in Nonhospital Sites ( 5504) Hospital may count time residents spend training in nonhospital sites if the hospital: Currently: Incurs 90% of the sum of resident stipends & benefits & supervisory physician costs Health Reform Bill: Incurs resident stipends & benefits while residents are at nonhospital sites Effective Date: July 1,

15 Counting Resident Time for Didactic and Research Activities ( 5505) Allows hospitals to count didactic time in hospital for IME payments Allows hospital to count nonhospital didactic time for DGME payments Allows counting of vacation, sick, and other approved leave in FTE count Ratifies October 1, 2001, regulation that excludes research time for IME payments Effective dates: vary 15

16 Counting Resident Time for Didactic and Research Activities ( 5505) DGME IME Hospital Patient Care Vacation/Sick Didactic Research Non-Hospital Patient Care Vacation/Sick Didactic (July 1, 2009+) NOT Research Hospital Patient Care Non-Hospital Patient Care Vacation/Sick Vacation/Sick Didactic (Jan. 1, 1983+) NOT Didactic NOT Research (Oct. 1, 2001+)* NOT Research Note: Text in italics indicates language in health reform bill. * The health reform bill clarifies that IME research time does not count after Oct. 1, It does not answer the question of whether IME research time counted prior to this date (the section states that it "shall not give rise to any inference as to how the law in effect prior to such date should be interpreted"). 16

17 17 HOSPITALS

18 Hospital Payment Updates ( 3401 of PPAC and and 1105 of HCERA) Hospital update reductions (-$112.6b/10y) Applies to inpatient and outpatient, rehab, and psych 2010/11: = Market basket increase (MB) minus /13: = MB-productivity adjust.* : = MB-productivity adjust /16: = MB-productivity adjust /18/19: = MB-productivity adjust and beyond: = MB-productivity adjust. *Productivity adjustment estimate: 0.8% to 1.2% 18

19 19 Medicare DSH Payment Reductions ( 3133 and and 1104 of HCERA)) Begin in year reduction = $22.1 billion 75 percent reduction to eliminate DSH payments not empirically justified Additional payments available to hospitals based on: National insurance coverage percent growth Hospital-specific uncompensated care costs as a share of national uncompensated care costs

20 Medicaid DSH Reductions ( 2551) 10-year reduction = $14 billion Reductions in state DSH allotments for FYs (bigger reductions in later years) Secretary will establish methodology for reductions Largest reductions on states with lowest percentages of uninsured individuals, or Do not target DSH payments to hospitals with high volumes of Medicaid and uncompensated care 20

21 Payment Penalties for Readmissions ( 3025) 10-year reductions = $7.1 billion Payment reductions if 30-day readmission rates for heart attack, heart failure and pneumonia exceed risk-adjusted expected rates Effective date: October 1,

22 Price Transparency ( 1001; 2718 of PHS) Requires each hospital to establish (and update) and make public a list of the hospital s standard charges for items and services provided by the hospital, including for diagnosis-related groups 22

23 IOM Variation and Wage Index Studies (Not in Legislation) March 20, 2010 Letter from Secretary Sebelius Two IOM Studies: Evaluate hospital and physician geographic payment adjustments Implement changes by Evaluate geographic variation in the volume and intensity of health care services Sec. will convene a National Summit on Geographic Variation, Cost, Access and Value in Health Care later this year 23

24 24 PILOTS AND DEMONSTRATIONS

25 Center for Medicare and Medicaid Innovation ( 3021 and 10306) The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures.while preserving or enhancing the quality of care... Budget neutrality not required initially Secretary may waive requirements as may be necessary Funding: $5m in FY 2010; $10b in FYs

26 HIZs Included in the CMI Establishing comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities that, through their structure, operations, and joint-activities deliver a full spectrum of integrated and comprehensive health care services to applicable individuals while also incorporating innovative methods for the clinical training of future health care professionals. 26

27 27 Medicare Payment Bundling ( 3023 and 10308) Would apply to 1 or more of 10 conditions as determined by the Secretary Episode is 3 days prior and 30 days post discharge OR as determined by the Secretary Includes hospital (inpat and outpat), physician (in and out of hospital), post acute care, and other services the Secretary deems appropriate Bundled payment is made to the participating entity which may include a hospital, physician group, SNF, or HHA Must be established no late than

28 Medicare Shared Savings (aka Accountable Care Organizations) ( 3022 and 10307) Be accountable for the quality, cost and overall care of the Medicare fee-for-service beneficiaries assigned to the ACO Potential ACOs (all must have mechanism for share governance): group practices; hospitalphysician joint ventures; hospitals employing physicians; others designated by the Sec. To be established no later than

29 Medicaid Pilots and Demos Bundle payment demonstration in up to 8 states ( 2704) Global Payment System Demonstration Project ( 2705) Pediatric ACO Demonstration Project ( 2706) 29

30 New Reporting Requirements for Tax-Exempt Hospitals ( 9007) Community health needs assessment and implementation strategy every three years Adopt, implement and publicize financial assistance policy and emergency medical care policy Limit charges to no more than amounts generally billed to insured patients No extraordinary collection actions before determining if individual eligible for assistance If more than 1 hospital, each hospital must meet requirements 30 $50,000 penalty for failure to meet

31 31 PHYSICIANS

32 Medicare Physician Fee Schedule Changes No SGR fix; lots of GPCI changes Work floor extended through 12/31/ : Blend ½ national, ½ local increases if <1 hold harmless if reduction By 1/1/12: modify methodology; budget neutral 1/1/11: Floor of 1.0 for frontier states (ND, SD, WY, MT, UT) 32

33 Physician Quality Provisions PQRI Incentives through % for % for Additional 0.5% bonus possible if participating in MOC practice assessment Penalties start in % reduction in % reduction 2016 and beyond Plan to align with meaningful use by

34 Physician Payment & Quality PQRI penalties: starting : 0.5% increase related to Maintenance of Certification (MoC) Programs: Submit quality data through MoC Participate in MoC more than is required Successfully complete MoC Program practice assessment Value-based modifier: rulemaking during 2013; select physicians and groups 2015; everyone

35 Physician VBP Modifier Based on quality and composite cost scores Rulemaking in 2013 Differential fee schedule payments: 2015: modifier applied for some physicians/groups 2017: modifier applies to all physicians/groups Modifier budget-neutral 35

36 Physician Payment By 2017 at least 5% of the fee schedule payment could be at risk from the following: PQRI (-2%) EHR meaningful use (-3%) Value-based modifier (TBD) 36

37 Physician Feedback Program Episode Groupers By 1/1/12: development of groups of clinically relevant services into episodes of care Standardized costs Risk adjusted based on socio-demographic Feedback reports to physicians Coordinate with VBP initiative Reports to physicians: individual resource use vs. patterns of other physicians 37

38 38 Physician Payment and Ownership Sunshine Provisions Requires annual reporting of payments, other transfers of value to physicians and teaching hospitals from manufacturers of drugs, devices, biological, or medical supplies Requires reporting of physician ownership or investment interests in manufacturers listed above Excludes payments of less than $10 unless annual aggregate exceeds $100 Requires description of the nature of the payment (e.g., consulting fees, education, research, speaking at medical education programs) Secretary to post reports on public Web site Reporting begins March 31, 2013

39 39 PROGRAM INTEGRITY

40 Program Integrity By 12/31/10: RAC expansion to Medicare Parts C and D; Medicaid Compliance programs that contain core elements to become mandatory Medicare self-disclosure protocol for actual or potential violations of Stark law Can suspend Medicare and Medicaid payments pending investigation of a credible allegation of fraud 40

41 More on Program Integrity HHS to report information to NPDB on final adverse actions (except those with no findings of liability) related to health care fraud and abuse OIG given broad authority to obtain information related to Medicare and Medicaid program integrity Overpayments to be returned within later of: 60 days from discovery or date next cost report due 41

42 FCA Modifications For anti-kickback law, no need to have actual knowledge or specific intent to commit a violation To be an original source : Prior to public disclosure voluntarily discloses information on which allegations are based or Has knowledge that is independent of and materially adds to publicly disclosed allegations or transactions 42

43 Money for Fighting Fraud 2011: $105m 2012: $65m : $40m : $30m : $10m 43

44 44 QUALITY

45 Quality Provisions Value Based Purchasing ( 3001) Budget neutral Medicare Hospital Acquired Conditions ( 3008) -$1.4billion/10years Medicaid Health Care Acquired Conditions ( 2702) 45

46 Hospital Medicare Value Based Purchasing Budget neutral Performance based payments on select quality measures Incentive pool funded by reductions to all MS- DRGs 1% in FY 2013, 1.25% in FY 2014, 1.5% in FY 2015, 1.75% in FY 2016, and 2.0% in FY 2017 and beyond 46

47 Hospital-Acquired Conditions -$1.4b/10years 1% reduction in payment for all DRGs if in top quartile for rate of Hospital Acquired Conditions Effective Date: October 1,

48 48 RESEARCH

49 Research Provisions Authorizes independent Patient-Centered Outcomes Research Institute and Patient- Centered Outcomes Research Trust Fund to identify and fund comparative clinical effectiveness research priorities. Funding from appropriations, transfers from Medicare trust funds, and transfers from health insurance and self-insured health plans. NIH and AHRQ will be preferential entities for research contracts. 49

50 Research Provisions, cont. Establishes Cures Acceleration Network (CAN) within the Office of the NIH Director to accelerate the development of high need cures. Authorizes through SAMHSA a network of National Centers of Excellence for Depression for research, training, and treatment services. Emphasis on translational research through collaborations with mental health centers and patient-oriented organizations. 50

51 Research Provisions, cont. Prohibits health insurers from denying access to an approved clinical trial and requires that routine patient costs are covered. Encourages expanded research in a number of areas, including pain, postpartum depression, congenital heart disease, breast cancer. Designates the National Center on Minority Health and Health Disparities at NIH as an Institute. 51

52 Research Provisions, cont. Amends Federal False Claims Act s public disclosure/original source rule, increasing likelihood of qui tam suits filed against medical schools and teaching hospitals. Report, hearing, audit, or investigation would have to be Federal to be public Original source exception no longer requires private whistleblower plaintiffs to have direct and independent knowledge of publically disclosed allegations and transactions 52

53 53 WORKFORCE & HEALTH PROFESSIONS PROGRAMS

54 Composition: 54 National Health Care Workforce Commission ( 5101) 15 individuals representing broad range of stakeholders Majority should not be directly involved in health professions education or practice Duties: Submit annual reports to Congress and Administration on: Required topics (including implications of Federal workforce policies, such as Title VII and Medicare & Medicaid GME) Specified high priority area of choice (such as aligning GME with national workforce goals) Oversee State Health Care Workforce Development Grants

55 Health Professions Programs under Title VII of the PHSA PPACA updates and reauthorizes grant programs through HRSA supporting education and training activities designed to strengthen: Workforce supply, including primary care and interdisciplinary activities Workforce distribution, including training opportunities in rural and underserved settings Workforce diversity, including recruitment, retention, and faculty development Congress will need to fund the new programs authorized in the legislation. 55

56 Other Workforce Programs Teaching Health Centers (THCs) Authorizes development grants ( 5508(a)) Appropriates funding for direct and indirect expenses of residency programs to CHCs and other qualifying THCs ( 5508(c)) Primary Care Extension Program ( 5405) Establishes grant program to assist primary care providers in implementing patient-centered medical home, to enhance dissemination of research findings, and other activities Public Health Sciences Track ( 5315) Establishes track for medical students and other health professions students Emphasizes team-based service, public health, epidemiology, and emergency preparedness and response 56

57 57 MEDICAL EDUCATION DEBT

58 National Health Service Corps Funding Authorizes funding up to $1.15B in FY2015 New CHC Fund with dedicated funding for NHSC up to $310M in FY2015 Benefits Allows for half-time service by increasing service length or decreasing award amount Increases the annual maximum award from $35,000 to $50,000 Teaching can count for up to 20% of the NHSC service obligation Excludes from federal and state taxable income loan repayments for HPSA-targeted programs

59 Student Loans and Repayment Health Professions Student Loans Revises the Title VII Primary Care Loan o New 10-year maximum primary care service length o Decreases total non-compliance interest rate from 18% to 7% o Allows waiver of parental income information Student Loan Reform in Reconciliation Decreases the monthly student loan payment under the Income-Based Repayment program from 15% to 10% of discretionary income Restructures federal student loans, originating all new loans under the Direct Loan Program

60 60 WRAP UP

61 Additional Health Care Reform Information Available on AAMC s website at: 61

62 Replay Information A replay of today s call will be available for 7 days (until April 27, 2010). Replay #: Pass code:

63 Upcoming Calls Topic: Comparative Effectiveness Research (CER) and Cures Acceleration Network (CAN) Date: April 22, 2-3:30pm EDT Topic: Physician-related provisions (includes fraud and abuse, quality, Sunshine Act) Date: April 27, 2-3:30pm EDT Topic: Hospital-related provisions (includes fraud and abuse, GME, quality, community benefit) Date: April 29, 2-3:30pm EDT 63 Topic: GME (includes redistribution of unused Medicare resident cap slots; counting didactic and other time in hospital and non-hospital settings; permanently distributing cap slots from closed hospitals) Date: May 3, 2-3:30pm EDT

64 Upcoming Calls (Cont.) Topic: Student Loans (closed call; only financial aid administrators) Date: May 4, 2-3:30pm EDT Topic: Quality Provisions (includes quality reporting and performance-based payments for hospitals and physicians) Date: May 10, 2-3:30pm EDT Topic: Workforce, Title VII, Public Health, and Disparities Date: May 12, 2-3:30pm EDT 64 Topic: Demonstration Projects and the CMS Innovation Center Date: May 13, 2-3:30pm EDT