health care reform where we’ve been where we are where we’re going health care reform where...
TRANSCRIPT
Health Care Reform Health Care Reform
Where we’ve beenWhere we’ve beenWhere we are Where we are
Where we’re goingWhere we’re going
MedicareMedicare
Part A
Part D Part B
Part C
Inpatient Hospital/SNF/HHA/Hospice Services
Prescription Drug
Coverage
MedicareAdvantage
Physician/Non-Physician
Practitioner/Ancillary
Suppliers/OutpatientHospitalServices
The U.S. Spends More on Health Care The U.S. Spends More on Health Care Than Other Developed CountriesThan Other Developed Countries
Costs of Doing NothingCosts of Doing Nothing
% Median Family Income to Purchase Health Insurance
1987 2006 2016
7% 17% 34%
Uninsured Numbers Continue to GrowUninsured Numbers Continue to Grow
Quality – Variations in CareQuality – Variations in Care
Federal Government P & L (2012) (in billions)Federal Government P & L (2012) (in billions)
RevenuesRevenues $2,469$2,469 (16% of GDP)(16% of GDP)
ExpensesExpenses
• Defense / Homeland SecurityDefense / Homeland Security $ 868$ 868
• Medicare / MedicaidMedicare / Medicaid $ 733$ 733
• Social SecuritySocial Security $ 773$ 773
• Other Mandatory and TARPOther Mandatory and TARP $ 746$ 746
• Other DiscretionaryOther Discretionary $ 450$ 450
• Net InterestNet Interest $$ 225 225$ 3795$ 3795 (24% of GDP)(24% of GDP)
DeficitDeficit ($1,326)($1,326) (8% of GDP)(8% of GDP)
Medicare Bankrupt 2024Medicare Bankrupt 2024
Options-Options-Reduce BenefitsReduce Benefits
Increase TaxesIncrease Taxes
Reduce Payments to ProvidersReduce Payments to Providers
Reduce UtilizationReduce Utilization
QUALITY QUALITY
TRANSPARENCYTRANSPARENCY
ACCOUNTABILITYACCOUNTABILITY
INTEGRATIONINTEGRATION
Who Decides What Quality Is?Who Decides What Quality Is?
CMSCMS 1972- Social Security Act1972- Social Security Act
Professional Standards Review Organizations (PSRO)Professional Standards Review Organizations (PSRO) 1982-Tax Equity and Fiscal Responsibility Act (TEFRA)1982-Tax Equity and Fiscal Responsibility Act (TEFRA)
PSROs become PROsPSROs become PROs 1992- Health Care Quality Improvement Initiative1992- Health Care Quality Improvement Initiative
PROs become Quality Improvement Organizations (QIO)PROs become Quality Improvement Organizations (QIO)Focus on quality rather than cost.Focus on quality rather than cost.
Each contract cycle- Revised Scope of Work or Statement of Work (SOW)Each contract cycle- Revised Scope of Work or Statement of Work (SOW) 1999- Aligned data elements and inclusion/exclusion criteria with JCAHO1999- Aligned data elements and inclusion/exclusion criteria with JCAHO 2003- voluntary reporting of process measures2003- voluntary reporting of process measures 2004- reporting tied to hospital payment2004- reporting tied to hospital payment 2005-Hospital Compare rolled out2005-Hospital Compare rolled out 2007-public reporting of risk-adjusted hospital mortality rates2007-public reporting of risk-adjusted hospital mortality rates 2009-American Reinvestment and Recovery Act2009-American Reinvestment and Recovery Act 2010-Patient Protection and Affordable Care Act2010-Patient Protection and Affordable Care Act
What is VBP?What is VBP?
VBP = Value Based PurchasingVBP = Value Based Purchasing
Part of the Patient Protection and Affordable Care Act Part of the Patient Protection and Affordable Care Act (PPACA, 2010)(PPACA, 2010) Final rule April 29, 2011Final rule April 29, 2011
Designed to reward hospitals with higher quality careDesigned to reward hospitals with higher quality care
Affects only CMS Medicare paymentsAffects only CMS Medicare payments
What is VBP? (cont.)What is VBP? (cont.)
Money comes from trimming CMS base operating DRG Money comes from trimming CMS base operating DRG payments (IPPS add-on payments excluded) to hospitalspayments (IPPS add-on payments excluded) to hospitals FY 2013: 1%FY 2013: 1% FY 2014: 1.25%FY 2014: 1.25% FY 2015: 1.5%FY 2015: 1.5% FY 2016: 1.75%FY 2016: 1.75% FY 2017: 2%FY 2017: 2%
Money then given back to some hospitals based on Money then given back to some hospitals based on performanceperformance
The Joint CommissionThe Joint Commission
IPPEIPPE
OPPEOPPE
FPPEFPPE
American Recovery and Reinvestment Act (ARRA)American Recovery and Reinvestment Act (ARRA)Summary of LegislationSummary of Legislation
Health Care Provisions – Care Delivery Organizations:
Federal Medicaid Funding $ 90 Billion
Health Insurance – Extension of COBRAfor early retirees $ 25 Billion
NIH Scientific Research Grants $ 10 Billion
HHS Wellness and Prevention Initiatives$ 10 Billion
Health Information Technology for Economicand Clinical Health Act (HITECH) $ 23 Billion
Total Potential Physician Payment ImpactTotal Potential Physician Payment Impact
PQRI 1% 0.5% 0.5% 0.5% (1.5%) (2%) (2%)
MOC 0.5% 0.5% 0.5% 0.5% 0% 0% 0%
E-Prescribing (ii) 1% (1%) – 1% (1.5%) – 0.5% (2%) (2%) (2%) (2%)
Meaningful Use (iii) 0% 0% 0% 0% (1%) (2%) (3%)
Value-Based Modifier N/A N/A N/A N/A TBD TBD TBD
Maximum Risk/Reward 2.5% (1%) – 2% (1.5%) – 1.5% (2%) – 1% (4.5%) (6%) (7%)
Program 2011 2012 2013 2014 2015 (i) 2016(i) 2017(i)
Hospital Payments at RiskHospital Payments at Risk
““It’s not the strongest species that It’s not the strongest species that survives nor the most intelligent but survives nor the most intelligent but the most adaptable.”the most adaptable.”
DarwinDarwin