APPROPRIATIONS Comparative Effectiveness Research $1.1B for comparative effectiveness programs, including $300 M for AHRQ, $400 M for NIH, and $400 M for HHS. Establishes a Federal Coordinating Council. comparative effectiveness REPORT LANGUAGE: Mentions "reducing health care expenditures" or no prescribing "more expensive" interventions Scientific Research n/a NIH: $2 B, including $750 M for additional research comparative clinical effectiveness REPORT LANGUAGE: Further clarifies that funding is for comparing the "clinical effectiveness, risk and benefits". Further, the goal is to "improve health care quality and patient outcomes" NIH: $10 B, including $9.2 B for additional research comparative effectiveness REPORT LANGUAGE: The conferees do not intend [this research] to be used to mandate coverage, reimbursement, or other policies for any public or private payer... [but to] evaluate and compare the clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments. NIH: $10 B, including $7.4 B for additional research University Research Facilities: $1.5B for NIH to renovate university research facilities CDC: $462 M for buildings and facilities. No similar provision CDC: $412 M University Research Facilities: $1 B (as part of the $10 B) No similar provision Pandemic flu: $900M including $430 M for BARDA, $420 M to prepare for a pandemic influenza, and $50 M for cyber security No similar provision $50 M for cybersecurity Prevention and n/a $3B to fight preventable chronic No similar provision $1 B, including $300 M for 317 Wellness diseases, including $335 M for program, $650 M for evidencebased HIV/AIDS, viral hepatitis, STD, community prevention and TB prevention programs. activities, and $50 M for All $3B is specifically allocated healthcare associated infection for particular projects. reduction. All $1 B allocated. Community Health n/a $1.5B, including $1B to Provides $1.87 billion for $2 B, including $1.5 B for Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 1
Centers renovate clinics and make HIT Training Primary n/a Care Providers MANDATORY SPENDING PROVISIONS Prompt Pmt to NFs Extends prompt payment to nursing facilities (NFs) from April 1, 2009 to Dec. 31, 2010. Temporary Federal All states would receive an increase in their Medical Assistance FMAP by certain percentage points; and Percentages (FMAP) States with large increases in unemployment Increase would receive an additional increase in their FMAP directly related to the increase in their unemployment rates. Moratorium on Medicaid Regulations Certain percent of FMAP across the board and certain percent based on the bonus structure. Maintenance of Effort - States must maintain eligibility. This language would not allow states to put Medicaid moneys obtained through enhanced FMAP into rainy day funds hence forcing states to use these funds in their Medicaid program and not divert funds at a time of economic strain. The bill would extend through June 2009, the current law moratorium on six regulations which expires on March 31, 2009, and would also include a seventh Medicaid regulation relating to outpatient hospital services. The six regulations include (1) targeted case management, (2) provider taxes, (3) school-based administration and transportation services, (4) intergovernmental transfers, (5) GME, and (6) rehabilitation services. improvements. $600 M to address provider shortages construction, renovation and equipment No similar provision construction, renovation, and equipment $500M for provider shortages and Title 7/8 No similar provision Included No similar provision FMAP increase: 4.9% % FMAP: 50 % unemployed: 50 FMAP increase: 7.6% % FMAP: 80 % unemployed: 20 Prompt pay requirements: Prevents states from receiving FMAP under this section when a state is out of compliance with prompt pay requirements of section 1902(a)(37)(a). FMAP increase: 6.2% % FMAP: 65 % unemployed: 35 Prompt pay requirements: Prevents states from receiving FMAP under this section when a state is out of compliance with prompt pay requirements of section 1902(a)(37)(a). Effective 10/1/2008 through 12/37/2010 All moratoria included No similar provision Includes 4 moratoria (#1-3 and outpatient hospital services) SoS on others (#4-6) Medicaid DSH n/a Increases Medicaid DSH Allow a 16 percent increase in Same as House Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 2
allotments for states by 2.5 percent in FY2009, and another 2.5 percent in FY2010. Indian Health Provisions Eliminate cost-sharing (co-payments) for American Indians and Alaska Natives in Medicaid, exempt certain Indian property from inclusion in resource determinations for Medicaid and CHIP, exempt certain Indian property from estate recovery in Medicaid, and require consultation with the Tribal Technical Advisory Group. Included Medicaid DSH funding to continue through the first quarter of fiscal 2011 for several states, at a cost of nearly $323 million. Included Included Modernize aging hospitals and health clinics (including health IT) IME moratoria Reverses the phase out of the Medicare hospital indirect medical education (IME) adjustment factor as of October 1, 2008. Estimated to cost $191 M. Hospice wage index Provides a moratorium for fiscal year 2009 moratoria on a provision in the FY09 Hospice Wage Index final regulation phasing-out the budget neutrality adjust factor for hospice wage payments. LTCH Technical Provides technical corrections to Section 114 Corrections of the Medicare, Medicaid and SCHIP Extension Act of 2007 (P.L. 110-173) affecting long-term care hospitals. Special Disability Provides states with $3 billion on additional Workload Project payments to the States for Medicare program liability s a result of the Special Disability Workload Project. INSURANCE PROVISIONS COBRA Subsidizes the first x number of months of COBRA coverage for eligible persons who have lost their jobs on or after September 1, 2008 at a certain percentage subsidy rate. $550 M $550 M $500 M Included Included Included Included No similar provision Included Included No similar provision Included No similar provision Included No similar provision # months: 12 % subsidy: 65 Also had an older and tenured # months: 12 % subsidy: 65 # months: 9 % subsidy: 65 Adds a cap so that indiv with annual incomes above $145,000 Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 3
worker provision. COBRA II COBRA extension for certain TAA-eligible individuals and PBGC recipients Transitional Medical This current transitional medical assistance Assistance (TMA) expires on June 30, 2009. The bill would extend the current law through 2010. Extension of QI Provides a one-year extension of the program Qualified Individual (QI) program thru 2010. HEALTH IT Standards Development and Discretionary Programs Broadband (not Establishes a Broadband Technology HHS) Opportunities Program to provide, among other items, education, awareness, access, equipment and support to medical and health care providers. Applications can be received by States, political subdivisions, non profit foundations, corporations, institutions or associations, Indian tribes, or other NGOs. HIT Funding n/a Total $: 22.2 B Medicare/Medicaid: $20.2 B ONCHIT: $2 B NIST (part of ONCHIT): $20 M No similar provision No similar provision Included Included Included Included No similar provision Included Included No similar provision Included Included Total $: 19 B Medicare/Medicaid: $16 B ONCHIT: $3 B NIST (part of ONCHIT): $20 M (single) and $290,000 (couples) would not be eligible. Phase out begins at $125,000 and $250,000. Total $: 19 B Medicare/Medicaid: $17 B ONCHIT: $2 B Definitions Includes definitions for certified EHR technology, enterprise integration, health care provider, health information, health information technology, health plan, HIT policy committee, HIT standards committee, individually identifiable information, Additional provider: a practitioner (as described in section 1842(b)(18)(C) 1 of the Social Security Act) Additional providers: emergency medical services provider (without further definition), community mental health center (as defined in section 1913(b)), renal dialysis Additional providers: All of the additional providers were added Broader definition of HIT: Adds access to the uses (but does not clarify that the items include, but 1 A practitioner as described under 1842(b)(18)(C) means (i) A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)), (ii) A certified registered nurse anesthetist (as defined in section 1861(bb)(2)), (iii) A certified nurse-midwife (as defined in section 1861(gg)(2)), (iv) A clinical social worker (as defined in section 1861(hh)(1)), (v) A clinical psychologist (as defined by the Secretary for purposes of section 1861(ii)), and (vi) A registered dietitian or nutrition professional. Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 4
laboratory, national coordinator, pharmacist, qualified electronic health record, and State Definition of health care provider includes (in both the House and Senate versions) hospital, skilled nursing facility, nursing facility, home health entity or other long term care facility, health care clinic, Federally qualified health center, group practice (as defined in section 1877(h)(4) of the SSA, an ambulatory surgical center described in section 1833(i) of the Social Security Act, a pharmacist, a pharmacy, a laboratory, a physician (as defined in section 1861(r) of the SSA), a provider operated by or under contract with the Indian Health Service (as defined in the Indian Self- Determination and Education Assistance Act), tribal organization, urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act), a rural health clinic, a covered entity under section 340B, and any other category of facility or clinician determined appropriate by the Secretary. facility, and blood center Broader definition of HIT: Adds access to the uses and clarifies that the items include (but are not limited to) key components. are not limited to, key components) Discretionary Incentives, Grants, and Loans Note: This definition of health care provider only applies to the discretionary programs. However, whenever the Secretary must provide grants (e.g., grants to States to develop loans for health care providers), all of the corresponding facilities and clinicians are included. 5 new grant programs: Infrastructure HIT Implementation Assistance: State Grants Included Included Included Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 5
Competitive Grants to States and Indian Tribes Demo grant to integrate IT into clinical education IT professionals grant HIT Mandatory Programs Rewards and Penalties for Physicians and other professionals Rewards and penalties for Hospitals Provides incentive payments to Section 1861(r) providers (physicians) who adopt and utilize EHRs, including reporting on clinical quality measures. Hospital-based providers are not eligible for the program. Physicians may receive up to $41,000 over five years. Payments are phased down in later years. After some time, Medicare payments are then reduced by a percentage of allowed charges for non-ehr users. The Secretary may provide a time-limited exemption from the payment reductions to professionals who demonstrate a significant hardship. Provides incentive payments to Section 1886(d) hospitals that adopt and utilize EHR technology, including reporting on clinical quality measures. Beginning in FY2011, hospitals that demonstrate they have adopted and are utilizing an approved EHR system are eligible to receive incentive payments through Part A. Incentive payments are phased down. The market basket update is reduced for any eligible hospital that has not adopted a EHR Bonus ends: after 2015 Penalties begin: 2016 Penalties begin: FY2016 Discharge calculation: Base of $200 for the 1150th to 23,000th discharge (creating one tier). Bonus ends: after 2014 Penalties begin: 2015 Early adopters bonus payment: Total of $44,000 for adopting in 2011 or 2012. Rural providers bonus payment: Additional 25% Harsher penalties: In 2015, the allowed charges can be decreased by an additional 1% (to 2% total) if the eligible professional does not also participate in e-prescribing. Penalties begin: FY2015 Discharge calculation: Three tiers: (1) $200 for each discharge starting with its 1,150th discharge through its 9,200th discharge, (2) an additional $100 for each discharge from its 9,201st through its 13,800th discharge, and (3) an additional $60 for each discharge from its 13,801st to its 23,000th discharge. Bonus ends: after 2016 Penalties begin: 2015 Early adopters bonus payment: Total of $44,000 for adopting in 2011 or 2012. Rural providers bonus payment: Additional 25% Harsher penalties: In 2015, the allowed charges can be decreased by an additional 1% (to 2% total) if the eligible professional does not also participate in e-prescribing. Penalties begin: FY2015 Discharge calculation: Base of $200 for the 1150th to 23,000th discharge (creating one tier). Hospital eligibility: Expands the coverage to critical access hospitals (CAHs). Creates a separate penalty structure specific to CAHs. Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 6
by a particular date. The Secretary may provide a time-limited exemption from the payment reduction to professionals who demonstrate a significant hardship in meeting the meaningful use criteria. Hospital eligibility: Expands the coverage to critical access hospitals (CAHs). Creates a separate penalty structure specific to CAHs. CAHs are capped at receiving a maximum of $1.5 M. Rewards and Penalties for Professionals Affiliated with Medicare Advantage (MA) HMOs Incentives to Other Medicaid Providers Similar payment incentives and reductions will apply to hospitals which are affiliated with certain staff/employee model Medicare Advantage (MA) plans and have less than one-third of their total discharges covered under Medicare fee-for-service. Beginning in 2011, incentive payments would be paid to encourage meaningful use EHRs by eligible professionals who are affiliated with certain MA organizations. The term qualifying MA organization means an MA organization that is organized as an HMO. An eligible professional is one who: (1) is employed by the organization or is employed by or is a partner of an entity that through contract furnishes at least 80% of the entity s patient care services to enrollees of the organization; and furnishes a certain percentage of their professional services to enrollees of the organization; and (2) furnishes, on average, at least 20 hours per week of patient care services. After some time, payments to qualifying MA organizations would be reduced if they have not adopted EHRs. Provides incentives to providers participating in the Medicaid program that are administered by State Medicaid programs. Eligible practitioners include: (1) physicians Penalties begin: 2016 Professional services percent: 80 Program ends: 2019 % for physicians: 85 % for children s hospitals: 100 Penalties begin: 2015 Professional services percent: 75 Cap for economies of scale: Caps the incentive payment to 5,000 eligible professionals. Cap for payment adjustment: For payment adjustments for MA organizations in which not all providers are EHR users, if more than 5000 eligible professionals are not EHR users, then the number is reduced to 5000 for purposes of the payment adjustment calculation. Program ends: 2018 % for physicians: 85 % for children s hospitals: 100 Penalties begin: 2015 Professional services percent: 80 Program ends: 2016 % for physicians: 85 % for children s hospitals: 100 Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 7
as defined in Sections 1861(r)(1) and (2), nurse practitioners, and certified nurse midwives with at least 30% of patient volume attributable to Medicaid patients, (2) children s hospitals, (3) acute care hospitals with at least 10% of their patient volume attributable to Medicaid, and (4) FQHCs and rural health clinics with at least 30% of their patient volume attributable to such individuals. Everyone would be eligible to receive a certain percentage of the costs of implementing and operating HIT up to $75,000 over a period of six years, or $63,750 in federal spending. Appropriates $40M for each of fiscal years 2009-2015 and $20M for each succeeding fiscal year. % for acute care hospitals: 100 % for CHCs and RHCs: 100 % for acute care hospitals: 100 % for CHCs and RHCs: Secretary decides but not less than 85 % for acute care hospitals: 100 % for CHCs and RHCs: 100 Assistance to Rural Hospitals HIT Medicaid NF Grant Program (Note: There are no penalties associated with this incentive payment, and the bonus amount is tied to the actual costs of the EHR.) Requires HHS to provide assistance to eligible professionals and rural and underserved hospitals to successfully choose, implement and use EHRs through, if practicable, existing entities with expertise in such goals. Provides $600 million for 10 state grants over 3 years, not to exceed 90% of costs of adoption and operation, giving priority to those States with a high proportion of total national nursing facility days paid under Medicaid. The grants may be used for Included Included Not included Included No similar provision. No similar provision. Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 8
adoption and meaningful use of EHRs as defined by the Secretary. (Note: There are no penalties associated with this incentive payment, and the bonus amount is tied to the actual costs of the EHR.) PRIVACY PROVISIONS Accounting of disclosures Individuals may to request an accounting of disclosures three years prior to the request (in the case of EHR use). Timeline: Requires the Secretary to issue regulations within 18 months after the date of enactment regarding accounting for these disclosures. Effective date: For EHRs as of January 1, 2009, then the disclosure requirement (for the past three years) is in effect January 1, 2014. For all others, it is the later of (a) January 1, 2011 or the date that a EHR is acquired. Included Fundraising n/a Removes fundraising from the HIPAA definition of health care operations. Special Rule for Information to Reduce Medication Errors and Improve Patient Safety Clarifies that noting under the new privacy constructs shall prevent a pharmacist from communicating with patients to reduce medication errors and improve patient safety, provided that there is no remuneration other than for the treatment of the individual and the payment for such treatment. The Secretary may by regulation authorize a pharmacy to receive remuneration that does not exceed their reasonable out of pocket costs for such communication if the Secretary determines that allowing this remuneration improves patient care and protects protected health information. Included but the regulations must also take into account the usefulness of the disclosure information and the interests of the individual seeking the information. Also allows the Secretary to set a later effective date. No similar provision Included but the regulations must also take into account the usefulness of the disclosure information and the interests of the individual seeking the information. Also allows the Secretary to set a later effective date. Allows individuals to have the opportunity to opt out of fundraising. Included No similar provision No similar provision Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 9
Psychotherapy notes n/a No similar provision Explicitly states that the Secretary shall revise the definition of psychotherapy notes in section 164.501 of title 45, CFR to include test data that is related to direct responses, scores, items, forms, protocols, manuals, or other materials that are part of a mental health evaluation, as determined by the mental health professional providing treatment or evaluation. STUDIES AND REPORTS Different Reports n/a and Studies Reimbursement incentives: Requires the Secretary to submit an annual report to Congress on the efforts toward facilitating the electronic exchange of HI nationwide and requires a study of methods to create efficient reimbursement incentives for improving healthcare quality. Breach: Requires the Secretary, in consultation with the FTC to submit recommendations to Congress regarding: (1) the requirements relating to security, privacy, and notification in the case of a breach of PHI, including the applicability of an exemption to notification in the case of PHI that has been rendered indecipherable through the use of encryption or alternative technologies, with Open source: Require HHS in consultation with other agencies to issue a report on the current availability of open source HIT systems to federal safety net providers, including small, rural providers. Duplication of funding: By July 1, 2012, the Secretary must submit a report on the implementation of the various payment incentives to assure no duplication of funding. Economic downturn: Requires the GAO to submit recommendations for addressing the needs of States during a period of economic downturn. Privacy provisions: Requires the GAO to report on the impact Secretary shall study the definition of psychotherapy notes to see if revision is necessary and may issue regulations. Breach: Essentially the same Open source: Essentially the same Privacy provisions: Broadened to include all provisions of the bill (not just privacy), must also examine quality and other items Economic downturn: Essentially the same Does not include the House reimbursement incentive or breach report. Does not include the Senate duplication of funding report. Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 10
respect to PHR vendors; and (2) the Federal agency best equipped to enforce those requirements. Annual expenditures: GAO report on annual expenditures and whether the Secretary is following the legislative directives. of the new privacy provisions on health care insurance premiums and overall health care costs. Initially Prepared by Georgetown Health Policy Center and updated by Hart Health Strategies on 2/13/2009 Page 11