Medicare Payment Policy

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Durairaj, L., J. C. Torner, E. A. Chrischilles, et al. 2005. Hospital volume-outcome relationships among medical admissions to ICUs. Chest 128, no. 3 (September): 1682–1689. Gage, B., L. Smith, M. Morley, et al. 2011. Post-Acute Care Payment Reform Demonstration: Report. Prepared under contract to the Centers for Medicare & Medicaid Services. Baltimore, MD: CMS. Gould, C. V., R. Rothenberg, and J. P. Steinberg. 2006. Antibiotic resistance in long-term acute care hospitals: The perfect storm. Infection Control and Hospital Epidemiology 27, no. 9 (September): 920–925. Institute of Medicine. 2000. Interpreting the volume-outcome relationship in the context of health care quality: Workshop summary. Washington, DC: IOM. Kahn, J. M., N. M. Benson, D. Appleby, et al. 2010. Long-term acute care hospital utilization after critical illness. Journal of the American Medical Association 303, no. 22 (June 9): 2253–2259. Kahn, J. M., C. H. Goss, P. J. Heagerty, et al. 2006. Hospital volume and the outcomes of mechanical ventilation. New England Journal of Medicine 355, no. 1 (July 6): 41–50. Kahn, J. M., T. R. Ten Have, and T. J. Iwashyna. 2009. The relationship between hospital volume and mortality in mechanical ventilation: An instrumental variable analysis. Health Services Research 44, no. 3 (June): 862–879. Kahn, J. M., R. M. Werner, G. David, et al. 2013. Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness. Medical Care 51, no. 1 (January): 4–10. Kandilov, A., and K. Dalton. 2011. Utilization and payment effects of Medicare referrals to long-term care hospitals (LTCHs). Prepared under contract to the Centers for Medicare & Medicaid Services. Research Triangle Park, NC: RTI International. Kennell and Associates, Inc. 2010. Determining medical necessity and appropriateness of care for Medicare long-term care hospitals. Prepared under contract to the Centers for Medicare & Medicaid Services. Falls Church, VA: Kennell and Associates, Inc. Macintyre, N. R. 2012. Chronic critical illness: The growing challenge to health care. Respiratory Care 57, no. 6 (June): 1021–1027. Marchaim, D., T. Chopra, C. Bogan, et al. 2012. The burden of multidrug-resistant organisms on tertiary hospitals posed by patients with recent stays in long-term acute care facilities. American Journal of Infection Control 40, no. 8 (October): 760–765. 256 Long-term care hospital services: Assessing payment adequacy and updating payments Mayr, F. B., S. Yende, W. T. Linde-Zwirble, et al. 2010. Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis. Journal of the American Medical Association 303, no. 24 (June 23): 2495–2503. Medicare Payment Advisory Commission. 2011. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2010. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2009. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2008a. Comment letter to CMS on IPPS proposed rule. March 24. Medicare Payment Advisory Commission. 2008b. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC Medicare Payment Advisory Commission. 2004. Report to the Congress: New approaches in Medicare. Washington, DC: MedPAC. .Morley, M., N. Coomer, B. Gage, et al. 2011. Post-acute care episode risk adjustment using CARE assessment data. Report prepared for the Assistant Secretary for Planning and Evaluation. Waltham, MA: RTI International. Munoz-Price, L. S., and A. Stemer. 2010. Four years of surveillance cultures at a long-term acute care hospital. Infection Control and Hospital Epidemiology 31, no. 1 (January): 59–63. Nelson, J. E., C. E. Cox, A. A. Hope, et al. 2010. Chronic critical illness. American Journal of Respiratory and Critical Care Medicine 182, no. 4 (August 15): 446–454. Nelson, J. E., and A. A. Hope. 2012. Integration of palliative care in chronic critical illness management. Respiratory Care 57, no. 6 (June): 1004–1012; discussion 1012–1003. Nelson, J. E., D. E. Meier, A. Litke, et al. 2004. The symptom burden of chronic critical illness. Critical Care Medicine 32, no. 7 (July): 1527–1534. Nelson, J. E., A. F. Mercado, S. L. Camhi, et al. 2007. Communication about chronic critical illness. Archives of Internal Medicine 167, no. 22 (December 10): 2509–2515. Nierman, D. M., and J. E. Nelson. 2002. Chronic critical illness. Critical Care Clinics 18, no. 4: xi–xii. RAND Corporation. 1990. Methodology for measuring case-mix change: How much change in the case-mix index is DRG creep? E–90–5. Arlington, VA: RAND Corporation. April.
Scheinhorn, D. J., M. S. Hassenpflug, J. J. Votto, et al. 2007. Post-ICU mechanical ventilation at 23 long-term care hospitals: A multicenter outcomes study. Chest 131, no. 1 (January): 85–93. Unroe, M., J. M. Kahn, S. S. Carson, et al. 2010. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: A cohort study. Annals of Internal Medicine 153, no. 3 (August 3): 167–175. White, A. C. 2012. Long-term mechanical ventilation: Management strategies. Respiratory Care 57, no. 6 (June): 889– 897; discussion 898–889. Zilberberg, M. D., M. de Wit, and A. F. Shorr. 2012. Accuracy of previous estimates for adult prolonged acute mechanical ventilation volume in 2020: Update using 2000–2008 data. Critical Care Medicine 40, no. 1 (January): 18–20. Zilberberg, M. D., R. S. Luippold, S. Sulsky, et al. 2008. Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States. Critical Care Medicine 36, no. 3 (March): 724–730. Report to the Congress: Medicare Payment Policy | March 2013 257
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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
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the patient-centered medical home T
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FIguRe FIGURE Cumulative percent ch
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References ABIM Foundation. 2012. C
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Ambulatory surgical center services
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Ambulatory surgical center services
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Background An ambulatory surgical c
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Differences in types of patients tr
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Differences in types of patients tr
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number of services grew from 2006 t
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tABLe 5-7 rapidly than nonowning ph
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Creating a value-based purchasing p
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Revisiting the ambulatory surgical
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endnotes 1 Because CMS updates paym
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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
Page 232 and 233: tABLe 9-12 Medicare visits per full
Page 234 and 235: strengthening incentives for effect
Page 236 and 237: endnotes 1 The exceptions pertain t
Page 239 and 240: C H A p t e R10 Inpatient rehabilit
Page 241 and 242: Inpatient rehabilitation facility s
Page 243 and 244: FIguRe FIGURE 10-1 9-1 Note: IRF (i
Page 245 and 246: Medicare IRF classification require
Page 247 and 248: tABLe 10-2 type of IRF 2004 2005 20
Page 249 and 250: tABLe 10-4 number of IRF beds decre
Page 251 and 252: weight for compliant cases was 1.39
Page 253 and 254: unobserved factors regarding patien
Page 255 and 256: freestanding IRFs were about $4,340
Page 257 and 258: increase for changes in the outlier
Page 259: References Centers for Medicare & M
Page 262 and 263: R e C o M M e n D A t I o n 11 The
Page 264 and 265: Quality of care—LTCHs only recent
Page 266 and 267: FIguRe FIGURE 11-1 10-1 Source: Med
Page 268 and 269: short-stay outlier cases in long-te
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Page 272 and 273: Chronically critically ill benefici
Page 274 and 275: Quality measures for long-term care
Page 276 and 277: tABLe 11-4 type of LtCH per case pa
Page 278 and 279: temporary legislative relief from s
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Page 285 and 286: Hospice services C H A p t e R12
Page 287 and 288: Hospice services Chapter summary Th
Page 289 and 290: Background Medicare began offering
Page 291 and 292: March 2009 Commission recommendatio
Page 293 and 294: March 2009 Commission recommendatio
Page 295 and 296: number peaking in 2009). With rapid
Page 297 and 298: tABLe 12-4 Hospice use has increase
Page 299 and 300: tABLe 12-5 Characteristic insurers
Page 301 and 302: three settings, respectively) (Tabl
Page 303 and 304: measures, it is likely that the vas
Page 305 and 306: tABLe 12-10 Category percentage poi
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Page 311: C H A p t e R13 the Medicare Advant
Page 314 and 315: 288 The Medicare Advantage program:
Page 317 and 318: The Medicare Advantage (MA) program
Page 319 and 320: enchmark. If a plan’s bid is abov
Page 321 and 322: tABLe 13-3 projected payments excee
Page 323 and 324: We broke the fourth quartile into t
Page 325 and 326: tABLe 13-5 Distribution of enrollme
Page 327 and 328: tABLe 13-6 examples of measures inc
Page 329 and 330: tABLe 13-7 Between 2011 and 2012, l
Page 331 and 332: 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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