Transcript Health Care Reform and Quality Reporting Why, What, How

Health Care Reform
Where we’ve been
Where we are
Where we’re going
Medicare
Inpatient Hospital/
SNF/HHA/Hospice Services
Part A
Prescription
Drug
Coverage
Part D
Part B
Part C
Medicare
Advantage
Physician/NonPhysician
Practitioner/
Ancillary
Suppliers/
Outpatient
Hospital
Services
The U.S. Spends More on Health Care
Than Other Developed Countries
Costs of Doing Nothing
% Median Family Income to Purchase Health Insurance
1987
2006
2016
7%
17%
34%
Uninsured Numbers Continue to Grow
Quality – Variations in Care
Federal Government P & L (2012) (in billions)
Revenues
$2,469
(16% of GDP)
Expenses
• Defense / Homeland Security
$ 868
• Medicare / Medicaid
$ 733
• Social Security
$ 773
• Other Mandatory and TARP
$ 746
• Other Discretionary
$ 450
• Net Interest
$ 225
$ 3795
(24% of GDP)
($1,326)
(8% of GDP)
Deficit
Medicare Bankrupt 2024
OptionsReduce Benefits
Increase Taxes
Reduce Payments to Providers
Reduce Utilization
QUALITY
TRANSPARENCY
ACCOUNTABILITY
INTEGRATION
Who Decides What Quality Is?
CMS
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1972- Social Security Act
Professional Standards Review Organizations (PSRO)
1982-Tax Equity and Fiscal Responsibility Act (TEFRA)
PSROs become PROs
1992- Health Care Quality Improvement Initiative
PROs become Quality Improvement Organizations (QIO)
Focus on quality rather than cost.
Each contract cycle- Revised Scope of Work or Statement of Work (SOW)
1999- Aligned data elements and inclusion/exclusion criteria with JCAHO
2003- voluntary reporting of process measures
2004- reporting tied to hospital payment
2005-Hospital Compare rolled out
2007-public reporting of risk-adjusted hospital mortality rates
2009-American Reinvestment and Recovery Act
2010-Patient Protection and Affordable Care Act
What is VBP?
VBP = Value Based Purchasing
Part of the Patient Protection and Affordable Care Act
(PPACA, 2010)
 Final rule April 29, 2011
Designed to reward hospitals with higher quality care
Affects only CMS Medicare payments
What is VBP? (cont.)
Money comes from trimming CMS base operating DRG
payments (IPPS add-on payments excluded) to hospitals
 FY 2013: 1%
 FY 2014: 1.25%
 FY 2015: 1.5%
 FY 2016: 1.75%
 FY 2017: 2%
Money then given back to some hospitals based on
performance
The Joint Commission
IPPE
OPPE
FPPE
American Recovery and Reinvestment Act (ARRA)
Summary of Legislation
Health Care Provisions – Care Delivery Organizations:
Federal Medicaid Funding
$ 90 Billion
Health Insurance – Extension of COBRA
for early retirees
$ 25 Billion
NIH Scientific Research Grants
$ 10 Billion
HHS Wellness and Prevention Initiatives
$ 10 Billion
Health Information Technology for Economic
and Clinical Health Act (HITECH)
$ 23 Billion
Total Potential Physician Payment Impact
Program
2011
2012
2013
2015 (i) 2016(i) 2017(i)
2014
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%)
Hospital Payments at Risk
“It’s not the strongest species that
survives nor the most intelligent but
the most adaptable.”
Darwin