Medicare Payment Policy

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References Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012a. 2013 Part C and D plan ratings. Fact sheet. Baltimore, MD: CMS. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012b. Medicare health & drug plan quality and performance ratings 2013 Part C & Part D technical notes. Updated October 10. Baltimore, MD: CMS. Cohen, R., J. Lemieux, J. Schoenborn, et al. 2012. Medicare Advantage chronic special needs plan boosted primary care, reduced hospital use among diabetes patients. Health Affairs 31, no. 1 (January): 110–119. Cotton, P., B. Datu, and S. Thomas. 2012. Early evidence suggests Medicare Advantage pay for performance may be getting results. Health Affairs blog, October 29. http://www. healthaffairs.org/blog/. Friedman, Bernard, H. J. Jian, C. Steiner, et al. 2012. Likelihood of hopsital readmission after first discharge: Medicare Advantage vs. fee-for-service patients. Inquiry 49, no. 3 (Fall): 202–213. Government Accountability Office. 2012. Medicare Advantage: Quality bonus payment demonstration undermined by high estimated costs and design shortcomings. Washington, DC: GAO. Landon, B. E., A. M. Zaslavsky, R. C. Saunders, et al. 2012. Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003–09. Health Affairs 31, no. 12 (December): 2609–2617. 310 The Medicare Advantage program: Status report McWilliams, J. M., J. Hsu, and J. P. Newhouse. 2012. New risk-adjustment system was associated with reduced favorable selection in Medicare Advantage. Health Affairs 31, no. 12 (December): 2630–2640. Medicare Payment Advisory Commission. 2012a. Report to the Congress: Medicare and the health care delivery system. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2012b. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2011a. Comment letter on the Centers for Medicare & Medicaid Services’ (CMS’s) proposed rule entitled: Medicare program; proposed changes to the Medicare Advantage and the Medicare Prescription Drug Programs for contract year 2012 and other proposed changes. January 6. Medicare Payment Advisory Commission. 2011b. A data book: Healthcare spending and the Medicare program. Washington, DC: MedPAC. National Committee for Quality Assurance. 2011. The state of health care quality 2011: Continuous improvement and the expansion of quality measurement. Washington, DC: NCQA. Newhouse, J. P., M. Price, J. Huang, et al. 2012. Steps to reduce favorable risk selection in Medicare Advantage largely succeeded, boding well for health insurance exchanges. Health Affairs 31, no. 12 (December): 2618–2628.
C H A p t e R14 Medicare Advantage special needs plans
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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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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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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 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
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Page 352 and 353: of the quality measures that only S
Page 354 and 355: Separate appeals and grievances pro
Page 356 and 357: References Government Accountabilit
Page 359 and 360: status report on part D Chapter sum
Page 361: controlling growth in drug spending
Page 364 and 365: tABLe 15-2 and pharmacists who part
Page 366 and 367: Characteristics of Medicare benefic
Page 368 and 369: tABLe 15-6 Distribution of enrollme
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Page 378 and 379: tABLe 15-12 Cost-sharing amounts fo
Page 380 and 381: tABLe 15-14 enrollees—by about $9
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Page 384 and 385: 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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