Welcome back! We’ve gotten through the general reforms and are ready to tackle the exchange. As always, you can follow along at congress.gov, which offers a (very dry) summary and a (even drier) full text version.
Sorry for the gap between parts. Self-care is really important right now, and as you well know, there’s been a lot of draining news coming from the Republican administration the past couple weeks. I’m still plugging away, but as the parts get longer, it’s going to stay fairly slow because I can only do it in small chunks. Stay well, and let me know if you’re interested in helping 🙂
Today we’re starting with “Title III: Improving the Quality and Efficiency of Health Care”. Spoiler alert: there are TEN titles. TEN. We’re on THREE. So this is going to be a long series.
Transforming Health Care
This section is all about “Subtitle A: Transforming the Health Care Delivery System”. This subtitle has three parts.
Linking Payment to Quality Outcomes
The first part is an effort to link payments made by Medicare to quality outcomes; in essence, you do a better job, you get more money. The first of these reforms is for hospitals: hospitals that do well with heart attacks, heart failure, pneumonia, surgeries (presumably reducing post-surgical infections, judging by the name of a previous act that this is expanding), and healthcare-associated infections (as in, you go to a hospital, you come away with an infection) get more money as an incentive. The exact details are left for the Secretary to come up with. The Secretary was commanded to make the details available at the Hospital Compare website, and also to make the overall website more accessible, since apparently it was pretty poorly designed at the time. There are also a few reports about hospital care commissioned by this act.
The next reform puts together some demonstration programs for value-based purchasing around inpatient critical access hospital services and for hospitals excluded based on not having enough case studies. This changes the way hospitals are paid by Medicare overall, so that they are paid based on the quality of care rather than the quantity of services. Furthermore, programs are established (a little later in the act) for value-based purchasing in nursing centers, home health agencies, and ambulatory surgery centers. I find myself at a loss to comment really, since I don’t understand the nuances of hospital billing, but the link above is a great place to start learning about it if you want.
The existing Physician Quality Reporting System was extended by the ACA, and more penalties were added for physicians not reporting their stats, so I guess that was working well.
Long-term care hospitals, inpatient rehabs, and hospice programs are a particular focus of the ACA, as we saw in part four; here, they’re asked to start reporting quality metrics the same way physicians were, along with cancer hospitals. The Secretary gets to define what measures they report on.
Finally, the bottom quartile (so, worst 25%) of hospitals for hospital-acquired conditions (or, in essence, the ones that are the least clean and sanitary) get a penalty on their payment rates for procedures: they lose 1% of their fees for every patient coming through.
Strategy to Improve Health Care Quality
Part two is the “National Strategy to Improve Health Care Quality”, which is pretty straightforward. This isn’t particularly exciting; it’s all about putting up funds to create programs to actually do things, which is pretty much how the government usually works.
The first thing is the creation of the eponymous National Strategy, which you can read in its entirety at the link I provided. To summarize, the Secretary suggested:
- Reducing the harm done in the delivery of care, such as hospital-acquired infections (1.7 million per year, costing $5 billion annually)
- Improving communication and coordination between providers and patients
- Ensuring that care is not only lead by the patient but also their family
- Promoting effective treatments for common diseases, starting with cardiovascular disease (1 in 3 deaths, costing $500 billion annually)
- Working with communities to improve healthy living
- Making care more affordable
Yet another website is commissioned; for basically all the initiatives in the ACA, someone has to make a webpage explaining it. Better than the alternative, I suppose. Furthermore, a workgroup was created with members of 24 different agencies to create a holistic plan of action to streamline activities relating to public health concerns.
At least once every three years, the Secretary is asked to look over the existing quality measures and search for gaps where more attention is needed. They are able to create grants and government contracts to reward people based on these extra measures. A multi-stakeholder group is set up to allow various interested parties to discuss and recommend quality measures to be implemented. And finally, the Secretary is charged with gathering reports and publishing them on a public website.
New Patient Care Models
The next part is “Encouraging Development of New Patient Care Models”. When the act was written, the best recommendations were incorporated and rewarded, to try and bring our care up to the current recommended level. But what about the future? This part allows for the creation of a Center for Medicare and Medicaid Innovation to test out new payment and service delivery models to see if they improve the standard of care. These models include:
- Payment and practice reform for primary care, including centers that specialise in particular types of care
- Using comprehensive care plans to coordinate multiple physicians for geriatric care
- Using home-“telehealth” technology and a chronic disease registry to better treat people who are likely to need hospitalization
- Rewarding doctors who use imaging technology by paying them more
- Paying doctors more who use tools to help patients manage their own care
- Paying more for hospitals who use the latest recommendations for cancer treatments
- Allowing patients to coordinate their own outpatient care, such as physical therapy, without needing a referral
This part also includes the creation of a shared services program for Medicare . Best I can tell, this is meant to convince suppliers and providers to work together for the good of the patients, improve accountability, and encourage investment in infrastructure that both sides need. Basically, a bunch of medicare suppliers and providers get together in an organization, and if they report that they’ve saved money and become more efficient, they get money from the government as a reward.
The next program is a pilot on payment bundling. Okay so, basically, sometimes you have an incident and you have to go to the hospital, right? For the three days leading up to the hospital, the length of the hospital stay, and the month after the hospital, you’re likely going to need care for the whatever it was. This might include inpatient services, outpatient services, doctor visits, nursing, rehab, stuff like that. This program sets up bundles of services, so like, a torn ligament hospital trip plus the PT you need to rehabilitate after plus a few visits to a sports medicine specialist to check on how well the function is coming back might be one bundle, with one set price for Medicare to pay. They also would have to report a whole bunch of metrics about whether this helps you rehabilitate faster or better than someone who doesn’t have this bundle. I guess the idea is that people’s copays stack up and they drop out of the program.
There’s another program set up to determine whether a model that allows a physician and/or nurse practitioner to treat certain patients continuously at home would prevent hospital readmissions, reduce emergency room visits, improve health outcomes, and improve patient and family satisfaction. This is aimed at people with two or more chronic illnesses who have been hospitalized and who require help with basic necessities like dressing, feeding, and toileting. Rather than rely on untrained family members, having a nurse come by frequently might help reduce the overall cost of care if it reduces hospital visits.
Another program, called the Hospital Readmissions Reduction Program, penalizes hospitals that have “excessive” readmissions of patients, implying that they are not giving them good care to begin with. It also allows for the Secretary to create programs to help those hospitals reduce their readmission rates, and one to transition high-risk patients to non-hospital care. This last program specifically calls out Depression as one of the eligible conditions, implying that this can be a suicide prevention tactic; presumably, being release from the hospital prematurely after a suicide attempt can lead to a second attempt and hospitalization, while support groups and the like can help prevent relapse.
Finally, to help with the budgeting, the Deficit Reduction Act of 2005 is extended in the ACA.
The next subtitle is “Subtitle B: Improving Medicare for Patients and Providers”. Here we have, as before, three parts.
Access to Care
Part one is about “Ensuring Beneficiary Access to Physician Care and Other Services”. The first thing it does is tweak the calculations on how expensive a physician is relative to other physicians in the area, amending the Social Security Act that created Medicare. I think that means you’re allowed to see a more expensive doctor, but I’m not 100% on that; again, as with all the bits that amend other bits, I find myself at a bit of a loss to explain, as I am not a lawyer and have little understanding of what the previous amendments were.
The next few pieces have all expired: they extended a few existing exceptions to rules until 2010 or 2011. This includes paying labs directly when they’re being outsourced to from rural hospitals, paying for air ambulance rides in urban areas, and increasing the bonuses paid to ground ambulances. I have no idea if they were extended again or have totally expired.
They also allow a physician assistant who is collaborating with a physician instead of working under them to certify that a patient needs extended post-hospital care. This closes a loophole about who can sign off on the paperwork to make it easier to get care.
The next item offers more choice to vets and their families. This is a bit complicated, but essentially, Original Medicare has two parts: hospital-only emergency coverage (part A), and regular medical insurance (part B). There’s also something called TRICARE, which is available to military retirees, their spouses, and their children. If you are on TRICARE and eligible for Medicare Part A, and you have declined part B, you get a year to change your mind and go on Part B.
The next item sets the payment for bone density tests to 70% of what it was in 2006, and commissions a study to look into the ramifications of doing so. I believe this is related to a 2009 recommendation that fewer women get the tests; my hunch is that medicare stopped paying for them around then, and this restores the coverage. I could be wrong here.
The Medicare Improvement Fund was defunded by this act.
Another demo project is created here as well, this one measuring a way to pay for complex lab services separately.
Finally, the payments for midwife services is increased to 100% of what a physician would be paid for the same service; previously, it was 60%.
“Part II: Rural Protections” must not exist, given Obama never did anything for rural white folks. I kid, I kid.
The first thing it does is extend an existing “hold harmless” agreement, giving extra money to hospitals who would receive less payments under the newer Outpatient Prospective Payment System than they did under the cost-based payment systems (up to 85% of the difference). Furthermore, it removes the 100-bed minimum for hospitals that are the only hospital in a given area to qualify.
The ACA extends a lot of existing agreements, actually. It extends an existing act that provides more reimbursement for small (under 50-bed) hospitals for clinical diagnostic laboratories. It extends and expands the Rural Community Hospital program to continue testing its effects on small rural hospitals. It extends the Medicare-Dependant Hospitals program, which adjusts payments for small hospitals who do most of their business with medicare. It extends and expands the Community Health Demonstration Project to pay more for hospitals that provide critical care but don’t get enough patients to keep them solvent on their own, and adds more payments for them for ambulance rides and outpatient care. It extends the FLEX program to pay for more preventative services at these hospitals. And finally, it establishes a program to study how well rural hospitals are being paid.
“Part III: Improving Payment Accuracy” starts out strong, commanding the Secretary to adjust payments for in-home services based on the average cost of providing care, as well as the number, type, and level of intensity of services seen in a typical episode. It also commands the Secretary to study and report on Medicare beneficiaries who are in “medically underserved” areas with varying severities of illness, and put together a program to help them.
The next few revisions are around hospice care: the Secretary is asked to study and come up with a plan to revise the way hospices are paid in a budget-neutral way. There is also a medical review requirement put in place for any hospice stay of over 180 days.
To reflect the lowered cost of acute hospital care, the price Medicare will pay for it is reduced in this act. The Secretary is authorized to reduce payments for other services if physicians are being overpaid, or increase them if they are underpaid. Generally, though, care costs have been skyrocketing, so it’s likelier to reduce the payments than increase.
The next bit gets complicated. Basically, when calculating how much use a hospital should get out of a specific imaging machine, like an x-ray machine, previously, the government assumed it was in use 50% of the time; half the session, someone’s using the machine. The ACA increases that to 75%, though only for high-tech imaging systems (meaning not x-rays or ultrasounds, but yes on fMRI and so on). This affects how much is paid for the imaging session, but I can’t tell if it goes up or down; most of the sources I’ve found assume you know how this is billed already. I think it goes up, because it pays for 45 minutes worth of machine use out of a 1 hour appointment? But I’m not sure. It also reduces the payout on second and third body parts you scan in the same session, because it doesn’t actually take that much work to set up the machine to run the same patient a few times compared to a few different patients, so they can’t scam the system by claiming the full price.
When purchasing power wheelchairs, Medicare is required now to pay in installments over time instead of in a single lump-sum, except for the most high-end wheelchairs.
There is some weird shell game involving temporarily reclassifying a hospital in a low-payment area as being in a high-payment area so it gets paid more; the ACA extends it.
The Secretary is charged with coming up with a plan to reform the hospital wage index. This appears to be a big index that spells out how much each type of physician in each area should be paid, so Medicare can tell if they’re being paid fairly or not.
There’s a study to see if cancer-related hospitals that do not qualify to be paid for inpatient services are charging more for outpatient services and, if so, what should be done about it.
For antibodies, enzymes, and other non-vaccine biological products, the ACA created a rate at which Medicare will pay for what is basically a generic version as opposed to the brand-name.
Another experiment is set up where patients who are in hospice can also receive other services under Medicare at the same time, to see if that’s effective. There’s another study commissioned to see if urban hospitals require more payment for inpatient services. And finally, there’s an extra protection for home health benefits, so that nothing here can reduce them on accident.
I was going to go further in this post, but I’m ill at the moment, ironically, and I want to keep forward momentum. So stay tuned for more.