Medicare Payment Policy

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R e C o M M e n D A t I o n s (The Commission reiterates its previous recommendations on improving Medicare’s payments to physicians and other health professionals. See Appendix B, pp. 371–392.)
physician and other health professional services Chapter summary In 2011, Medicare paid $68 billion for physician and other health professional services, 12 percent of total Medicare spending. About 850,000 clinicians billed Medicare—550,000 physicians, with the balance consisting of nurse practitioners and other advanced practice nurses, therapists, chiropractors, and other practitioners. Medicare pays for the services of physicians and health professionals under a fee schedule, and total payments are limited by the sustainable growth rate (SGR) formula. Because of years of volume growth exceeding the SGR limits and legislative and regulatory overrides of negative updates, fees for physicians and other health professionals will decline by about 25 percent in January 2014, according to the Congressional Budget Office. Assessment of payment adequacy Informing the Commission’s deliberations on payment adequacy for physicians and other health professionals are beneficiary access to services, volume growth, quality, and changes in input costs. Beneficiaries’ access to care—Overall, beneficiary access to physicians and other health professional services is stable and similar to access for privately insured individuals ages 50 to 64. Seventy-seven percent of beneficiaries reported that they never had to wait longer than they wanted for a routine visit, C H A p t e R 4 In this chapter • Repeal of the SGR: Urgent and should protect access, break the link between updates and expenditures, and be fiscally responsible • Are Medicare fee-schedule payments adequate in 2013? • How should Medicare payments change in 2014? Report to the Congress: Medicare Payment Policy | March 2013 75
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RepoRt to the CongRess Medicare Pay
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RepoRt to tHe CongRess Medicare Pay
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with the structure of the payment s
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table of contents Acknowledgments .
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executive summary
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of services—and pressure on feder
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current Medicare payments are adequ
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outpatient dialysis services Outpat
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some facilities are willing to acce
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coverage for conventional treatment
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of care for these conditions should
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Context for Medicare payment policy
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4 Context for Medicare payment poli
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FIguRe FIGURE 1-2 1-2 12% Out of po
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the level of health care spending a
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1-4 FIguRe 1-4 140 120 100 80 60 Do
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FIguRe 1-6 1-6 Growth rate (in perc
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FIGURE FIguRe Share of GDP (in perc
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Share of GDP (in percent) FIGURE 1-
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FIGURE FIguRe 1-10 1-10 8% African
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FIguRe 1-12 1-11 1800 1600 1400 120
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Americans than for other racial and
Page 50 and 51: References Agency for Healthcare Re
Page 52 and 53: Medicare Payment Advisory Commissio
Page 55 and 56: Assessing payment adequacy and upda
Page 57 and 58: The goal of Medicare payment policy
Page 59 and 60: may go up when payment rates go dow
Page 61 and 62: hospitals and that hospitals shift
Page 63 and 64: individual payment systems but also
Page 65 and 66: Hospital inpatient and outpatient s
Page 67 and 68: Hospital inpatient and outpatient s
Page 69: covered the fully allocated costs o
Page 72 and 73: 3-1 3-1 FIguRe 100 80 60 40 Number
Page 74 and 75: Visits or claims per 1,000 benefici
Page 76 and 77: 3-4 3-4 FIguRe 2012 dollars (in bil
Page 78 and 79: of physicians employed directly by
Page 80 and 81: FIguRe FIGURE Annual percent change
Page 82 and 83: FIGURE FIguRe Margin (in percent) 3
Page 84 and 85: FIGURE FIguRe Margin (in percent) 3
Page 86 and 87: tABLe 3-5 performance of efficient
Page 88 and 89: Act, the EHR Incentive Program also
Page 90 and 91: as Medicaid expands, the new insura
Page 92 and 93: ates for separately paid drugs resu
Page 94 and 95: endnotes 1 From 2002 to 2011, 479 h
Page 96 and 97: References Agency for Healthcare Re
Page 99: C H A p t e R4 physician and other
Page 103: from the SGR system in its October
Page 106 and 107: 4-1 4-1 FIguRe 40 35 30 25 20 15 10
Page 108 and 109: tABLe 4-1 Most aged Medicare benefi
Page 110 and 111: tABLe 4-2 Medicare beneficiaries ha
Page 112 and 113: payment adjustments for health prof
Page 114 and 115: tABLe 4-3 Year physicians primary c
Page 116 and 117: provider’s characteristics, geogr
Page 118 and 119: tABLe 4-4 type of service Change in
Page 120 and 121: tABLe 4-5 type of imaging Change in
Page 122 and 123: the patient-centered medical home T
Page 124 and 125: FIguRe FIGURE Cumulative percent ch
Page 126 and 127: References ABIM Foundation. 2012. C
Page 129 and 130: Ambulatory surgical center services
Page 131 and 132: Ambulatory surgical center services
Page 133 and 134: Background An ambulatory surgical c
Page 135 and 136: Differences in types of patients tr
Page 137 and 138: Differences in types of patients tr
Page 139 and 140: number of services grew from 2006 t
Page 141 and 142: tABLe 5-7 rapidly than nonowning ph
Page 143 and 144: Creating a value-based purchasing p
Page 145 and 146: Revisiting the ambulatory surgical
Page 147 and 148: endnotes 1 Because CMS updates paym
Page 149: Medicare Payment Advisory Commissio
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R e C o M M e n D A t I o n 6 The C
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128 Outpatient dialysis services: A
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tABLe 6-1 Characteristics of FFs di
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Physicians Association has publishe
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tABLe 6-3 Increasing number and cap
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Number of FFS dialysis beneficiarie
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FIguRe 6-3 Percent of dialysis bene
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and 2011, the proportion of adult h
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anticipated under the modernized pa
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endnotes 1 In this chapter, we use
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References ABIM Foundation. 2012. C
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C H A p t e R7 post-acute care prov
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encourages more 60-day episodes. Fu
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C H A p t e R8 skilled nursing faci
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skilled nursing facility services C
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adjust for differences in patients
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Description of beneficiaries who us
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snF prospective payment system and
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Number of SNFs FIguRe FIGURE 8-1 7-
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FIGURE FIguRe Percent 7-2 8-2 30 25
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and other SNF users were essentiall
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FIguRe FIGURE Program spending (in
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7-8 8-6 FIguRe 30 25 20 15 10 Medic
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(e.g., whether there is a requireme
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the Commission’s 2012 update reco
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tABLe 8-9 non-Medicare margins were
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found to be associated with one or
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Smith, V. K., K. Gifford, E. Ellis,
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R e C o M M e n D A t I o n s (The
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188 Home health care services: Asse
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tABLe 9-1 use and growth of home he
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FIGURE FIguRe Number of new agencie
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tABLe 9-2 of services. The review a
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tABLe 9-4 Community-admitted home h
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tABLe 9-5 type of county Claims dat
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tABLe 9-6 state County are collecte
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tABLe 9-8 Medicare margins for free
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tABLe 9-11 provider characteristics
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tABLe 9-12 Medicare visits per full
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strengthening incentives for effect
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endnotes 1 The exceptions pertain t
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C H A p t e R10 Inpatient rehabilit
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Inpatient rehabilitation facility s
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FIguRe FIGURE 10-1 9-1 Note: IRF (i
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Medicare IRF classification require
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tABLe 10-2 type of IRF 2004 2005 20
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tABLe 10-4 number of IRF beds decre
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weight for compliant cases was 1.39
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unobserved factors regarding patien
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freestanding IRFs were about $4,340
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increase for changes in the outlier
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References Centers for Medicare & M
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R e C o M M e n D A t I o n 11 The
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Quality of care—LTCHs only recent
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FIguRe FIGURE 11-1 10-1 Source: Med
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short-stay outlier cases in long-te
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tABLe 11-1 growth in the number of
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Chronically critically ill benefici
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Quality measures for long-term care
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tABLe 11-4 type of LtCH per case pa
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temporary legislative relief from s
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16 We observed growth over time in
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Durairaj, L., J. C. Torner, E. A. C
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Hospice services C H A p t e R12
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Hospice services Chapter summary Th
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Background Medicare began offering
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March 2009 Commission recommendatio
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March 2009 Commission recommendatio
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number peaking in 2009). With rapid
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tABLe 12-4 Hospice use has increase
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tABLe 12-5 Characteristic insurers
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three settings, respectively) (Tabl
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measures, it is likely that the vas
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tABLe 12-10 Category percentage poi
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• additional wage index changes,
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elieve the cost report data provide
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C H A p t e R13 the Medicare Advant
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288 The Medicare Advantage program:
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The Medicare Advantage (MA) program
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enchmark. If a plan’s bid is abov
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tABLe 13-3 projected payments excee
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We broke the fourth quartile into t
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tABLe 13-5 Distribution of enrollme
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tABLe 13-6 examples of measures inc
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tABLe 13-7 Between 2011 and 2012, l
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tABLe 13-9 admission-weighted ratio
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ecommended that payments be brought
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eport HEDIS measures based on admin
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C H A p t e R14 Medicare Advantage
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Medicare Advantage special needs pl
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integrating Medicaid benefits. We f
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tABLe 14-1 Distribution of snp enro
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previous Commission recommendations
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tABLe 14-4 Readmission rates by typ
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There has been recent movement in t
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of the quality measures that only S
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Separate appeals and grievances pro
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References Government Accountabilit
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status report on part D Chapter sum
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controlling growth in drug spending
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tABLe 15-2 and pharmacists who part
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Characteristics of Medicare benefic
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tABLe 15-6 Distribution of enrollme
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FIGURE FIguRe Percent of all Part D
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3). Most regions continue to have m
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tABLe 15-9 • Reinsurance—Medica
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tABLe 15-11 toward the OOP threshol
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tABLe 15-12 Cost-sharing amounts fo
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tABLe 15-14 enrollees—by about $9
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Drug price index equal to 1.0 at th
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Voluntary switchers Each year, Part
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endnotes 1 PPACA eliminates the cov
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References Boards of Trustees, Fede
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Commissioners’ voting on recommen
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Chapter 12: Hospice services The Co
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A p p e n D I X Moving forward from
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well as the cost of temporary repri
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payments rates be frozen at their c
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than primary care physicians (class
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achieving a total estimated 10-year
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would be costly, too, and they are
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payment accuracy. For example, such
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Final regulations on the ACO progra
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statemen nt of MedPAC’s position
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Cumulative percent change 70 7 60 6
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390 Moving forward from the sustain
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Note: The availability and scoring
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Acronyms AAgR average annual growth
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op outpatient opD hospital outpatie
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Commission members glenn M. Hackbar
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a state society of the National Med
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on the Advocate Physician Partners
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425 eye street, nW • suite 701
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