Medicare Payment Policy

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measures, it is often the case that initial rates for the new element are low and subsequent rates show dramatic improvement. When the National Committee for Quality Assurance (NCQA) introduces a new HEDIS measure, the results for the first year the measure is used are not publicly reported; when CMS has included new outcome measures in the star rating system, the new measure is given a weight of 1 in the first year and 3 for subsequent years. This approach allows plans time to become familiar with the measure and make any reporting or other administrative changes to be able to accurately report the measure. Thus, if the measure results show improvement over time initially, it can be due to better record keeping and data collection, as well as better performance now that the process or outcome measure is being measured. 11 Another factor to consider in evaluating recent HEDIS results is a change in reporting methodology that has occurred. In our yearly analysis of MA quality results, we have traditionally analyzed HMOs and PPOs separately because of a major difference between the two plan types in the specifications for hybrid measures. It was not until 2010 that PPOs were permitted to report hybrid measures using medical record review. Previously, PPO reporting of such measures was based exclusively on administrative records, while HMOs had the option of using medical record review (which generally resulted in higher rates). Because the new specifications for PPOs began in 2010, we did not view the extremely low 2010 results for PPOs as entirely credible for purposes of comparison with HMO hybrid measure results (see, for example, the June 2011 MedPAC data book, Table 4-7 (Medicare Payment Advisory Commission 2011b)). The improvement in PPO results on HEDIS hybrid measures over the past three years—including between 2011 and 2012—suggests that the improvement can be attributed in large part to better record keeping and data collection. PPOs changed from reporting based solely on administrative data for all HEDIS measures to instituting processes for medical record review and data extraction from a sample of medical records as a basis of reporting HEDIS hybrid measures. 12 Finally, we expect the introduction of the star rating system to motivate plans to improve outcomes and their documentation, record keeping, and reporting systems for a pay-for-performance program tied to results on quality measures. NCQA staff recently published a commentary on whether the star rating system has improved quality in MA. Citing the improvement in HEDIS measures among Medicare plans between 2011 and 2012—a level 302 The Medicare Advantage program: Status report of improvement not mirrored in the performance of commercial plans—the authors noted that “anecdotally, we are seeing that several plans that before paid minimal attention to their star scores are now aggressively working to improve” (Cotton et al. 2012). Plans will pay attention to both aspects of quality measurement—better documentation as well as efforts to improve the quality of medical care. Comparing 2011 and 2012 results in quality indicators Between 2011 and 2012, a number of HEDIS measures that MA plans report to CMS improved, but little change occurred in measures collected through member surveys— the patient experience measures of CAHPS, the HOS care measures, and the HOS-based determination of improvement or decline in enrollees’ health status. For other star measures, on average, comparing all plans rated in both years, scores for three contract administration measures and disenrollment rates improved between 2011 and 2012. Measures reported exclusively by SNPs also improved. 13 By plan type, local PPOs, as well as regional PPOs and PFFS plans, improved their scores on the HEDIS hybrid measures (those based on documentation from medical records). 14 For local PPOs reporting on the 45 HEDIS measures in both 2011 and 2012, 13 of the 45 measures had an improved average rate that was statistically significant, while 1 measure declined and the rest were unchanged. Of the 13 improved measures, 10 were hybrid measures (Table 13-7). For HMOs, the results for most of the hybrid measures remained unchanged over the past year. Thus, local PPOs are catching up with HMOs on these measures and have narrowed wide differences between the performance of PPO plans and HMOs (one hybrid measure—cholesterol control among patients with cardiovascular conditions—has a higher average rate for local PPOs, though the difference between HMOs and local PPOs is not statistically significant). The shift in the star ratings for local PPOs between 2012 and 2013 that we have discussed (Table 13-4, p. 298, and Table 13-5, p. 299)—with more plans moving to the 4-star or higher level—is primarily due to the gains local PPOs have made in the hybrid measures, given their (appropriately) greater weight in the CMS star rating system. As shown in Table 13-7, local PPO rates improved for all three HEDIS intermediate outcome measures that are components of the star system, as did regional PPO rates for these measures (not shown in Table 13-7). The
tABLe 13–7 Between 2011 and 2012, local ppo plans improved on a number of HeDIs ® hybrid measures, and ppo rates are now closer to HMo rates Measure name Weight for star rating (if element of star ratings) three measures (cholesterol and blood sugar control among diabetics and control of blood pressure among members with hypertension) make up about 20 percent of the overall weighting of the 36 Part C components of the stars. For the 10 other measures for which local PPOs improved between 2011 and 2012, 7 are hybrid measures. Four of Mean (2011) ppo HMo Mean (2012) percent change Mean (2011) Mean (2012) percent change Measures showing improvement among ppos reporting in both years Hybrid measures Adult BMI assessment 1 36.5 63.6 74% 49.7 68.2* 37% Colorectal cancer screening Poor blood glucose control among 1 41.3 55.4 34 57.0 60* 5 diabetics† Control of cholesterol among patients 3 34.3 28.4 17 26.3 25.7 2 with cardiovascular conditions 50.6 57.4 13 56.4 56.8 1 Control of cholesterol among diabetics Controlling high blood pressure in 3 46.0 51.6 12 51.6 52.8 2 members with hypertension 3 55.8 62.0 11 61.4 63.6* 4 Blood pressure control among diabetics Blood glucose control among diabetics 55.7 61.5 10 61.8 63 2 (< 8.0%) Cholesterol screening for patients with 58.2 63.5 9 65.3 65.9 1 cardiovascular conditions 1 87.0 88.4 2 88.5 89.1 1 Monitoring diabetic nephropathy 1 87.2 88.3 1 89.2 90* 1 Administrative-only measures Use of high-risk medications in the elderly—one prescription† Use of high-risk medications in the 22.0 19.1 13% 22.3 18.6* 17% elderly—at least two prescriptions† Persistence of beta blocker use after a 5.1 3.7 27 5.2 3.6* 31 heart attack 83.4 87.2 5 83.0 87.8* 6 Measure that declined among ppos reporting in both years Initiation of alcohol and other drug dependence treatment (administrative measure) 59.7 48.7 –18% 44.5 40.6* –9% Note: PPO (preferred provider organization), HEDIS ® (Healthcare Effectiveness Data and Information Set ® ), BMI (body mass index). All listed PPO measures had statistically significant differences in average rates between 2011 and 2012 (p < 0.05). *Indicates a statistically significant change for HMO results between the two years for plans reporting in both years. †Lower rate is better. Source: MedPAC analysis of CMS HEDIS public use files. the seven measures are included in the star rating system (but weighted at 1). The remaining 31 HEDIS measures for local PPOs were stable between 2011 and 2012. Of the 13 measures that had statistically significant improvement for local PPOs reporting in both 2011 and 2012, 7 also had statistically significant improvement Report to the Congress: Medicare Payment Policy | March 2013 303
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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
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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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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
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Page 293 and 294: March 2009 Commission recommendatio
Page 295 and 296: number peaking in 2009). With rapid
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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
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Page 321 and 322: tABLe 13-3 projected payments excee
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Page 325 and 326: tABLe 13-5 Distribution of enrollme
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Page 331 and 332: tABLe 13-9 admission-weighted ratio
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Page 337 and 338: C H A p t e R14 Medicare Advantage
Page 339 and 340: Medicare Advantage special needs pl
Page 341: integrating Medicaid benefits. We f
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Page 348 and 349: tABLe 14-4 Readmission rates by typ
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Page 366 and 367: Characteristics of Medicare benefic
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Page 370 and 371: FIGURE FIguRe Percent of all Part D
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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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