Medicare Payment Policy

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gDR generic dispensing rate gI gastrointestinal H–CAHps ® Hospital Consumer Assessment of Healthcare Providers and Systems HCCI Health Care Cost Institute HeDIs ® Healthcare Effectiveness Data and Information Set ® HHA home health agency HHs Department of Health and Human Services HI Hospital Insurance (Medicare Part A) HIteCH Health Information Technology for Economic and Clinical Health [Act] HIV human immunodeficiency virus HMo health maintenance organization HopD hospital outpatient department Hos Health Outcomes Survey HpsA health professional shortage area HRet Health Research and Educational Trust HuD Department of Housing and Urban Development ICD–9 International Classification of Diseases, Ninth Revision ICD–9–CM International Classification of Diseases, Ninth Revision, Clinical Modification ICL initial coverage limit ICu intensive care unit IoL intraocular lens IoM Institute of Medicine Ipps inpatient prospective payment system Ips interim payment system IQI inpatient quality indicator IRF inpatient rehabilitation facility IRF–pAI Inpatient Rehabilitation Facility–Patient Assessment Instrument I–snp institutional special needs plan KFF Kaiser Family Foundation LCD local coverage determination LDKt live-donor kidney transplantation LIs low-income [drug] subsidy Lpn licensed practical nurse LtC long-term care LtCH long-term care hospital Ltss long-term care services and supports LupA low utilization payment adjustment LVeF left ventricular ejection fraction M&A mergers and acquisitions MA Medicare Advantage 396 Acronyms MACIe Medicare Ambulatory Care Indicators for the Elderly MACpAC Medicaid and CHIP Payment and Access Commission MA–pD Medicare Advantage–Prescription Drug [plan] MCBs Medicare Current Beneficiary Survey MCC major complication or comorbidity MDH Medicare-dependent hospital MDs Minimum Data Set MedpAC Medicare Payment Advisory Commission MedpAR Medicare Provider Analysis and Review [file] MeI Medicare Economic Index MgMA Medical Group Management Association MHA Missouri Hospital Association MI myocardial infarction MIppA Medicare Improvements for Patients and Providers Act of 2008 MMs Massachusetts Medical Society MMseA Medicare, Medicaid, and SCHIP Extension Act of 2007 MRI magnetic resonance imaging Ms–DRg Medicare severity–diagnosis related group Ms–LtC–DRg Medicare severity long-term care diagnosis related group Mss medical social services n/A not applicable n/A not available nAsBo National Association of State Budget Officers nBeR National Bureau of Economic Research nCHs National Center for Health Statistics nCQA National Committee for Quality Assurance nDC national drug code ngA National Governors Association nHe national health expenditure nIDDK National Institute of Diabetes and Digestive and Kidney Diseases nIH National Institutes of Health nQF National Quality Forum nsAs National Survey of Ambulatory Surgery ntA nontherapy ancillary ntIoL new technology intraocular lens oAsIs Outcome and Assessment Information Set oeCD Organisation for Economic Co-operation and Development oIg Office of Inspector General oop out-of-pocket
op outpatient opD hospital outpatient department opps outpatient prospective payment system oR operating room ot occupational therapy pAC post-acute care pAC–pRD Post-Acute Care Payment Reform Demonstration pCMH patient-centered medical home pD peritoneal dialysis pDe prescription drug event pDp prescription drug plan pDQ Providing Data Quickly [system] pet positron emission tomography pFFs private fee-for-service pFs physician fee schedule pHC4 Pennsylvania Health Care Cost Containment Council pMV prolonged mechanical ventilation pos Provider of Services ppACA Patient Protection and Affordable Care Act of 2010 ppo preferred provider organization pps prospective payment system pQRs Physician Quality Reporting System psI patient safety indicator RCt randomized clinical trial RDs retiree drug subsidy Rn registered nurse RpA Renal Physicians Association Rug resource utilization group RVg radionuclide ventriculography RVu relative value unit sCHIp State Children’s Health Insurance Program sgR sustainable growth rate sMI Supplementary Medical Insurance snF skilled nursing facility snp special needs plan ssI Supplemental Security Income ssI surgical site infection sso short-stay outlier teFRA Tax Equity and Fiscal Responsibility Act of 1982 tIA transient ischemic attack ttY/tDD Telecommunications device for the deaf/ teletypewriter uCsF University of California at San Francisco u.s. United States usRDs United States Renal Data System VBp value-based purchasing [program] Vsso very short-stay outlier Report to the Congress: Medicare Payment Policy | March 2013 397
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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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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
Page 372 and 373: 3). Most regions continue to have m
Page 374 and 375: tABLe 15-9 • Reinsurance—Medica
Page 376 and 377: tABLe 15-11 toward the OOP threshol
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
Page 386 and 387: endnotes 1 PPACA eliminates the cov
Page 388 and 389: References Boards of Trustees, Fede
Page 391 and 392: Commissioners’ voting on recommen
Page 393 and 394: Chapter 12: Hospice services The Co
Page 395: A p p e n D I X Moving forward from
Page 398 and 399: well as the cost of temporary repri
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Page 402 and 403: than primary care physicians (class
Page 404 and 405: achieving a total estimated 10-year
Page 406 and 407: would be costly, too, and they are
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Page 410 and 411: Final regulations on the ACO progra
Page 412 and 413: statemen nt of MedPAC’s position
Page 414 and 415: Cumulative percent change 70 7 60 6
Page 416 and 417: 390 Moving forward from the sustain
Page 418 and 419: Note: The availability and scoring
Page 421: Acronyms AAgR average annual growth
Page 427: Commission members glenn M. Hackbar
Page 430 and 431: a state society of the National Med
Page 432 and 433: on the Advocate Physician Partners
Page 435: 425 eye street, nW • suite 701
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Medicare Payment Policy

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