Medicare Payment Policy

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References ABIM Foundation. 2012. Choosing wisely. Five things physicians and patients should question. http://www.abimfoundation.org. American Renal Holdings. 2011. Form 10-K for the fiscal year ended December 31, 2010. Annual report pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934. Commission file number 333–170376. http://www.sec.gov/Archives/edgar/ data/1504735/000119312511084560/d10k.htm. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012a. ESRD prospective payment system. Overview of 2011 claims-based monitoring program. Baltimore, MD: CMS. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012b. Medicare program; end-stage renal disease prospective payment system, quality incentive program, and bad debt reductions for all Medicare providers. Final rule. Federal Register 77, no. 218 (November 9): 67450–67531. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2010. Medicare program; end stage renal disease prospective payment system. Final rule. Federal Register 75, no. 155 (August 12): 49029–49214. Cooper, B. A., P. Branley, L. Bulfone, et al. 2010. A randomized, controlled trial of early versus late initiation of dialysis. New England Journal of Medicine 363, no. 7 (August 12): 609–619. Eggers, P. W. 1988. Effect of transplantation on the Medicare endstage renal disease program. New England Journal of Medicine 318, no. 4 (January 28): 223–229. Evans, M., G. Tettamanti, O. Nyren, et al. 2011. No survival benefit from early-start dialysis in a population-based, inception cohort study of Swedish patients with chronic kidney disease. Journal of Internal Medicine 269, no. 3 (March): 289–298. Food and Drug Administration. 2011. Prescribing information for Epogen ® (epoetin alfa). http://www.accessdata.fda.gov/ drugsatfda_docs/label/2011/103234Orig1s5166_103234Orig1s5 266lbl.pdf. Fresenius Medical Care AG & Co. KGaA. 2006. Fresenius Medical Care completes the acquisition of the phosphate binder business from Nabi Biopharmaceuticals. http://www.fmc-ag. com/640.htm. Government Accountability Office. 2012. End-stage renal disease: Reduction in drug utilization suggests bundled payment is too high. Washington, DC: GAO. 146 Outpatient dialysis services: Assessing payment adequacy and updating payments Kasiske, B. L., D. Cohen, M. R. Lucey, et al. 2000. Payment for immunosuppression after organ transplantation. American Society of Transplantation. Journal of the American Medical Association 283, no. 18 (May 10): 2445–2450. Kazmi, W. H., D. T. Gilbertson, G. T. Obrador, et al. 2005. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. American Journal of Kidney Diseases 46, no. 5 (November): 887–896. Laupacis, A., P. Keown, N. Pus, et al. 1996. A study of the quality of life and cost-utility of renal transplantation. Kidney International 50, no. 1 (July): 235–242. Medicare Payment Advisory Commission. 2012. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2008. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2003. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2001. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2000. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. National Institute of Diabetes and Digestive and Kidney Diseases. 2008. Vascular access for hemodialysis. Bethesda, MD: NIDDK. http://kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess/index. htm. Nissenson, A. R., F. W. Maddux, R. L. Velez, et al. 2012. Accountable care organizations and ESRD: The time has come. American Journal of Kidney Diseases 59, no. 5 (May): 724–733. Ojo, A. O., F. K. Port, R. A. Wolfe, et al. 1994. Comparative mortality risks of chronic dialysis and cadaveric transplantation in black end-stage renal disease patients. American Journal of Kidney Diseases 24, no. 1 (July): 59–64. Renal Physicians Association. 2010. Shared decision-making in the appropriate initiation and withdrawal from dialysis. Rockville, MD: RPA. Rettig, R. A., and N. G. Levinsky. 1991. Kidney failure and the federal government. Washington, DC: National Academy of Sciences.
Seeking Alpha. 2012. Warren Buffett is bullish on DaVita Inc.: Should we take notice? http://seekingalpha.com/article/655901warren-buffett-is-bullish-on-davita-inc-should-we-take-notice. Stel, V. S., F. W. Dekker, D. Ansell, et al. 2009. Residual renal function at the start of dialysis and clinical outcomes. Nephrology Dialysis Transplantation 24, no. 10 (October): 3175–3182. Traynor, J. P., K. Simpson, C. C. Geddes, et al. 2002. Early initiation of dialysis fails to prolong survival in patients with endstage renal failure. Journal of the American Society of Nephrology 13, no. 8 (August): 2125–2132. United States Renal Data System, National Institute of Diabetes and Digestive and Kidney Diseases. 2012. USRDS 2012 annual data report. Bethesda, MD: NIDDK. Report to the Congress: Medicare Payment Policy | March 2013 147
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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
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References Agency for Healthcare Re
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Medicare Payment Advisory Commissio
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Assessing payment adequacy and upda
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The goal of Medicare payment policy
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may go up when payment rates go dow
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hospitals and that hospitals shift
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individual payment systems but also
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Hospital inpatient and outpatient s
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Hospital inpatient and outpatient s
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covered the fully allocated costs o
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3-1 3-1 FIguRe 100 80 60 40 Number
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Visits or claims per 1,000 benefici
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3-4 3-4 FIguRe 2012 dollars (in bil
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of physicians employed directly by
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FIguRe FIGURE Annual percent change
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FIGURE FIguRe Margin (in percent) 3
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FIGURE FIguRe Margin (in percent) 3
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tABLe 3-5 performance of efficient
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Act, the EHR Incentive Program also
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as Medicaid expands, the new insura
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ates for separately paid drugs resu
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endnotes 1 From 2002 to 2011, 479 h
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References Agency for Healthcare Re
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C H A p t e R4 physician and other
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physician and other health professi
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from the SGR system in its October
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4-1 4-1 FIguRe 40 35 30 25 20 15 10
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tABLe 4-1 Most aged Medicare benefi
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tABLe 4-2 Medicare beneficiaries ha
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payment adjustments for health prof
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tABLe 4-3 Year physicians primary c
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provider’s characteristics, geogr
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tABLe 4-4 type of service Change in
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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
Page 152 and 153: R e C o M M e n D A t I o n 6 The C
Page 154 and 155: 128 Outpatient dialysis services: A
Page 156 and 157: tABLe 6-1 Characteristics of FFs di
Page 158 and 159: Physicians Association has publishe
Page 160 and 161: tABLe 6-3 Increasing number and cap
Page 162 and 163: Number of FFS dialysis beneficiarie
Page 164 and 165: FIguRe 6-3 Percent of dialysis bene
Page 166 and 167: and 2011, the proportion of adult h
Page 168 and 169: anticipated under the modernized pa
Page 170 and 171: endnotes 1 In this chapter, we use
Page 175: C H A p t e R7 post-acute care prov
Page 178 and 179: encourages more 60-day episodes. Fu
Page 181 and 182: C H A p t e R8 skilled nursing faci
Page 183 and 184: skilled nursing facility services C
Page 185: adjust for differences in patients
Page 188 and 189: Description of beneficiaries who us
Page 190 and 191: snF prospective payment system and
Page 192 and 193: Number of SNFs FIguRe FIGURE 8-1 7-
Page 194 and 195: FIGURE FIguRe Percent 7-2 8-2 30 25
Page 196 and 197: and other SNF users were essentiall
Page 198 and 199: FIguRe FIGURE Program spending (in
Page 200 and 201: 7-8 8-6 FIguRe 30 25 20 15 10 Medic
Page 202 and 203: (e.g., whether there is a requireme
Page 204 and 205: the Commission’s 2012 update reco
Page 206 and 207: tABLe 8-9 non-Medicare margins were
Page 208 and 209: found to be associated with one or
Page 210 and 211: Smith, V. K., K. Gifford, E. Ellis,
Page 212 and 213: R e C o M M e n D A t I o n s (The
Page 214 and 215: 188 Home health care services: Asse
Page 216 and 217: tABLe 9-1 use and growth of home he
Page 218 and 219: FIGURE FIguRe Number of new agencie
Page 220 and 221: 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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Medicare Payment Policy

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