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1 Reimbursement/Medicare PPS and Legislative Update Reimbursement/Medicare PPS and Legislative Update Larry Goldberg Larry Goldberg Consulting August 2,

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Presentation on theme: "1 Reimbursement/Medicare PPS and Legislative Update Reimbursement/Medicare PPS and Legislative Update Larry Goldberg Larry Goldberg Consulting August 2,"— Presentation transcript:

1 1 Reimbursement/Medicare PPS and Legislative Update Reimbursement/Medicare PPS and Legislative Update Larry Goldberg Larry Goldberg Consulting August 2, 2012

2 2 Agenda  Accessing the Federal Register  PPS Updates  IPPS  SNF  IRF  Hospice  IPF  Where is Medicare Heading  Accountable Care Organizations (ACOs)  Value-Based Purchasing Programs (VBP)  Bundling

3 3 Agenda  Proposed PPS Updates  OPPS  HHA  ESRD  Physician  Where is Medicare Heading  Accountable Care Organizations (ACOs)  Value-Based Purchasing Programs (VBP)  Bundling

4 4 Federal Register Access Prior to Publication Date  1. Start here:  inspection/ inspection/  2. Scroll down and click on:  View the Special Filing Document List View the Special Filing Document List  Look under Centers for Medicare & Medicaid

5 5 Federal Register Access After Publication Date  1. is now “deactivated :http://www.gpoaccess.gov/fr/index.html  2. Go to:  3. Choose Federal Register from right side menu  4. Know date  5. Select CMS

6 6 The Fiscal Cliff  The following expire and/ or need to be addressed on December 31, 2012  Bush era tax cuts  The Payroll tax holiday  The debt ceiling  The sequester – 2.0 percent for all Medicare services  The doc fix

7 7 FY 2013 IPPS

8 8 IPPS FY 2013  Posted August 1 st  Copy at   Published in Federal Register on August 31  Tables on CMS website only  Becomes effective October 1 st 2012

9 9 Update  Market Basket is 2.6 percent [proposed at 3.0]  ACA adjustments are -0.8 percent (net 1.8 percent)  Productivity is (0.7 percent)  Statutory is (0.1 percent)  Documentation & Coding adjustment is +1.0 percent  Minus 0.5 percent for Hospital Specific Rates

10 10 Update  Other adjustments:  VBP (1.0 percent now, but budget neutral)  Readmits – (0.3 percent) CMS estimate  Rural demo – (0.001 percent)  PPS excluded hospitals to receive 2.6 percent increase

11 11 Rates National Adjusted Operating Standardized Amounts (68.8 Percent Labor Share/31.2 Percent Nonlabor if Wage Index Is Greater Than ) Comparison of FY 2012 Standardized Amounts to the FY 2013 Standardize Am ount with Full and National Adjusted Operating Standardized Amounts (62 Percent Labor Share/38 Percent Nonlabor Share if Wage Index Is Less Than or Equal To Full Update (1.8 percent)Reduced Update (-0.2 percent) Labor-relatedNon-labor-relatedLabor-relatedNon-labor-related $3,679.95$1,668.81$3,607.65$1, Full Update (1.8 percent)Reduced Update (-0.2 percent) Labor-relatedNon-labor-relatedLabor-relatedNon-labor-related $3,316.23$2,032.53$3,251.08$1,992.59

12 12 IPPS Documentation & Coding  Recap:  CMS proposed to correct 4.8 percent with adoption of MS-DRGs over 3 years 1.2 percent 1.8 percent 1.8 percent  Congress said no – take instead 2008 – 0.6 percent 2009 – 0.9 percent 2009 – look back and correct in FYs 2010,

13 13 IPPS Documentation & Coding  CMS look back & found  2008 should have been 2.5 percent (1.9 still needed)  2009 should have been 4.8 percent (3.9 still needed)  In other words CMS says 5.8 percent overpaid

14 14 IPPS Documentation & Coding  Took ½ for FY 2011 (2.9 percent)  Took another ½ for FY 2012 (2.9 percent)  OK – we are even (may be)  CMS says that FY 2010 was over paid by 3.9 percent since no adjustments were made in 2010  Took 2.0 percent of 3.9 percent in FY 2012  Taking Balance of 1.9 in FY 2013

15 15 IPPS Documentation & Coding  Convoluted explanation  Proposing to complete D&C adjustments by:  Removing (adding back) 2.9 percent in effect in FY 2012  Removing the 1.9 percent it didn’t take in FY 2012  CMS is NOT as proposed removing an additional 0.8 percent for FY 2010  Will there be more coding adjustments? Statutory ??

16 16 IPPS Documentation & Coding  Hospital-specific rate reduced, too  CMS says HSR should also be subject to D&C  Will reduce HSR by -0.5 percent

17 17 Comparison of FY 2012 Standardized Amounts to the FY 2013 Standardized Amount Full Update (1.8 percent); Wage index is greater than Full Update (1.8 percent); Wage index is less than or equal to Reduced Update (-0.2 percent); Wage index is greater than Reduced Update (-0.2 percent); Wage index is less than or equal to FY 2012 Base Rate, after removing geographic reclassification budget neutrality, demonstration budget neutrality, cumulative FY 2008 and FY 2009 documentation and coding adjustment, FY 2012 documentation and coding recoupment, and outlier offset (based on the labor-related share percentage for FY 2012) Labor: $4, Nonlabor: $1, Labor: $3, Nonlabor: $2, Labor: $4, Nonlabor: $1, Labor: $3, Nonlabor: $2, FY 2013 Update Factor

18 18 Comparison of FY 2012 Standardized Amounts to the FY 2013 Standardized Amount Full Update (2.1 percent); Wage index is greater than Full Update (2.1 percent); Wage index is less than or equal to Reduced Update (0.1 percent); Wage index is greater than Reduced Update (0.1 percent); Wage index is less than or equal to FY 2013 DRG Recalibration and Wage Index Budget Neutrality Factor FY 2013 Reclassification Budget Neutrality Factor FY 2013 Rural Demonstration Budget Neutrality Factor Proposed FY 2013 Outlier Factor Documentation and coding adjustments required under sections 7(b)(1)(A) and 7(b)(1)(B) of Pub. L Rate for FY 2013 Labor: $3, Nonlabor: $1, Labor: $3, Nonlabor: $2, Labor: $3, Nonlabor: $1, Labor: $3, Nonlabor: $1,992.59

19 19 Capital  Federal rate will be $  Proposed at $  Corrected Proposed $ FY 2012FY 2013ChangePercent Change Update Factor GAF/DRG Adjustment Factor Outlier Adjustment Factor Capital Federal Rate$421.42$

20 20 Outliers  Threshold will be $21,821  Currently at $22,385  Estimated a 6 percent payout for FY 2012  Now estimated at 5.0 percent for FY 2012  Estimated FY 2011 at 4.7 percent

21 21 Wage Index  Using data from FY 2009  New occupancy mix adjustment applied  Based on survey data submitted on July 1, 2011  Massachusetts  5.5% increase for those hospitals Rural floor effect Impact is $118 million  Frontier floor continues for 4 states  MT, SD, ND, WY

22 22 Wage Index  Imputed floor continues for New Jersey  663 hospitals have reclassification status  193 approved for FY 2013  MGCRB reclassification applications for FY 2014  Due September 4 th  Instructions on website  See Table 4J for out-migration hospitals

23 23 Readmissions  Per ACA provisions  Section 3025 & Section  Effective October 1 st  CMS estimates hospitals will lose $300 million  Three measures for FY 2013  AMI (ICD-9 codes )(20 codes)  Heart failure (ICD-9 codes , plus 428)(10 codes)  Pneumonia (ICD-9 codes )(31 codes)

24 24 Readmissions  Three years of data ending  Base operating rate includes new technology, but no DSH or IME  Only about 34 percent of all hospitals will avoid an adjustment  Max cap is 1.0 percent for FY 2013 (about 14 percent)  Hospital will know by June 20 th  30-day appeal period

25 25 Readmissions  Distribution of Readmission Adjustment Factors Percent Reduction Number of Hospitals Percent of Hospitals No Adjustment1, % Up to -.09 Percent % -0.1 Percent to Percent % Percent to Percent % Percent to Percent % Percent to Percent % Percent to Percent % Percent to Percent % Percent to Percent % Percent to Percent772.30% Percent to Percent762.20% -1.0 Percent % Total3, %

26 26 Rural Issues  “Clarifying” SCH status reg  CMS can act unilaterally  Make a change retroactively  MDHs wishing to become SCHs  MDH program ends on September 30 th  Can apply to switch at least 30 days ahead

27 27 Rural Issues  Usual update of the RRC criteria  CMI  Discharges  Low-Volume Adjustment  Special (ACA) adjustment sunsets on September 30 th  Reverts back to pre-ACA rules  Hospital must make request by September 1 st to keep it

28 28 IME / GME  IME multiplier unchanged at 1.35  Claims for MA enrollees  Must comply with regs for timely filing  Including nursing / allied health  Include labor / delivery beds in bed count  Effective with cost reporting periods on / after October 1, 2012

29 29 IME / GME  “Five year window” for new programs  To grow resident count  Then cap would be set  Effective for new programs only on October 1, 2012  Must fill half of new (§ 5503) slots (from closed programs) by one of following:  First 12-month c.r.p.  Second 12-month c.r.p.  Third 12-month c.r.p

30 30 MS-DRGs  See rule’s table 5 for MS-DRGs and weighting factors  Hospital Acquired Conditions  Would add diagnosis codes & – Blood stream infection, and local infection due to central venous catheter  Would add surgical site infection following Cardiac Implantable Electronic Device (CEID) with diagnosis codes or in conjunction with 21 associated procedure codes  Contains other minor changes

31 31 MS-DRGs MS- DRG DescriptionFY 2012 Weight FY 2013 Weights Percent Diff 65Intracranial hemorrhage or cerebral infarction w CC Chronic obstructive pulmonary disease w MCC Chronic obstructive pulmonary disease w CC Chronic obstructive pulmonary disease w/o CC/MCC Simple pneumonia & pleurisy w MCC Simple pneumonia & pleurisy w CC Perc cardiovasc proc w drug-eluting stent w/o MCC Circulatory disorders except AMI, w card cath w/o MCC Heart failure & shock w MCC Heart failure & shock w CC Cardiac arrhythmia & conduction disorders W CC Cardiac arrhythmia & conduction disorders w/o CC/MCC Syncope & collapse Chest pain G.I. hemorrhage w CC Esophagitis, gastroent & misc digest disorders w/o MCC Major joint replacement or reattachment of lower extremity w/o MCC

32 32 MS-DRGs MS- DRG DescriptionFY 2012 Weight FY 2013 Weights Percent Diff 641Nutritional & misc metabolic disorders w/o MCC Renal Failure w MCC Renal Failure w CC Kidney & urinary tract infections w/o MCC Septicemia or severe sepsis w/o MV 96+ hours w MCC Septicemia or severe sepsis w/o MV 96+ hours w/o MCC

33 33 Quality Reporting  Will reduce 17 measures for FY 2015 reporting  SCIP-Venous Thromboembolism (VTE) measure: “SCIP-VTE-1: Surgery patients with recommended VTE prophylaxis ordered”  Eight HAC measures: Air Embolism; Blood Incompatibility; Catheter-Associated Urinary Tract Infection (UTI); Falls and Trauma: (Includes Fracture Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock); Foreign Object Retained After During Surgery; Manifestations of Poor Glycemic Control; Pressure Ulcer Stages III or IV; and Vascular :

34 34 Quality Reporting  Three AHRQ IQI Measures : IQI-11: Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume); IQI-19: Hip fracture mortality rate; and IQI-91: Mortality for selected medical conditions (composite)  Five AHRQ PSI Measures: PSI 06: Iatrogenic pneumothorax, adult PSI 11: Postoperative Respiratory Failure PSI 12: Postoperative PE or DVT PSI 14: Postoperative wound dehiscence PSI 15: Accidental puncture or laceration

35 35 Value-Based Purchasing  Effective for FY 2013  13 measures adopted in 2 domains  Increased to 17 measures for FY 2014  Several measures are suspended for FY 2014  Including the spending-per-beneficiary for one year  Definition of “base operating payments”  Excludes outliers, DSH, IME & LV adjustment  But does include the new-tech add on

36 36 Value-Based Purchasing  1.0 percent cut to base operating payments in FY 2013  Will make an estimate of reduction for each hospital in advance  Then summing each estimated reduction to get total for pool  Getting the adjustment payment is explained  Appeals process is created  30 days from posting of report  To “review and correct”

37 37 Value-Based Purchasing  Domain Weighting by Year FY 2013 FY 2014 FY 2015  Clinical Process of Care 70% 45% 20%  Patient Experience of Care 30% 30% 30%  Outcomes - 25% 30%  Efficiency - 20%  Total 100% 100% 100%

38 38 Value-Based Purchasing  Correction Notice

39 39 LTCH PPS  Update  MB is 2.6 percent  ACA adjustment (0.7%) for productivity (0.1%) per statute  Coding adjustment (1.3 percent) for this year, starting on More to come in future years  Standardized amount is $40, Current is $40,222.05

40 40 LTCH PPS  Quality reporting  Adding five measures for FY 2016  In addition to three (adopted last year) for FY ‘14  Labor-related share will be percent  Current is percent  Wage Index tables are 12A & B  Outlier threshold will be $15,408  Current is $17,931  Proposed one-year delay to 25 percent rule

41 41 LTCH PPS  Correction to Proposed one-year delay to 25 percent rule  LTCHs and LTCH “satellite facilities with a cost reporting period beginning on or after July 1,2012, and before October 1, 2012 would have to comply with §§ and for discharges occurring in that respective cost reporting period  These facilities would then have a moratorium the following (2014) FY

42 42 Skilled Nursing PPS

43 43 SNF PPS  Posted on  Published in Federal Register  Copy at: _PI.pdf  Link Changes  Notice – no proposed rulemaking  CMS says no need for proposed rule inasmuch as no policy changes made  Overall payments to increase $670 million

44 44 SNF PPS Update  Market Basket Increase – 2.5 percent  Less MFP adjustment – 0.7 percent  Net Update = 1.8 percent  Labor Share to from  Budget neutrality factor  NO market basket error rate adjustment  Was positive 0.1 percent (CMS’ favor)  Threshold is 0.5 percent

45 45 SNF PPS Update  Notice contains the wage index addenda  CMS says its continuing to monitor:  Recalibration of the FY 2011 SNF parity adjustment to align overall payments under RUG-IV with those under RUG-III.  Allocation of group therapy time to pay more appropriately for group therapy services based on resource utilization and cost.  Implementation of changes to the MDS 3.0 patient assessment instrument, most notably the introduction of the Change-of-Therapy (COT) Other Medicare Required Assessment (OMRA).

46 46 Inpatient Rehabilitation Facilities PPS

47 47 Inpatient Rehabilitation Facilities PPS  Posted July 25 th  Published in Federal Register on July 30 th  Copy at:  pdf  Notice -- no proposed rulemaking  CMS say no new policy changes  No adjustments to the facility-level items

48 48 Inpatient Rehabilitation Facilities PPS  Market Basket at 2.7 percent  Less MFP adjustment 0.7 percent  Less ACA adjustment 0.1 percent  Net increase 1.9 percent  CMS says payments to increase $140 million – net update =$130 million + Outlier increase of $10 million  Area Wage index on line only  Labor share =  Conversion factor = $14,343, currently $14,076

49 49 Inpatient Rehabilitation Facilities PPS  High cost outliers  Paid at 2.8 percent for 2012  Says overall IRF increase to be 2.1 percent  1.9 rate by changing outlier threshold  Outlier threshold to be $10,466

50 50 Inpatient Rehabilitation Facilities PPS  Quality  See hospital OPPS rule for details

51 51 Hospice

52 52 Hospice Wage Index Update  Posted July 25 th  Published in the Federal Register on July 27 th  Copy at:  27/pdf/ pdf  Notice only – no proposed rulemaking  CMS says no new policy changes  Continuing to phase-out Budget Neutral Adjustment Factor  Now down to 55 percent Phase-out at 15 percent per year over next 3 years

53 53 Hospice Rate Update  Market Basket at 2.6 percent  MFP adjustment of 0.7 percent  Further reduced by ACA of 0.3 percent  Net update at 1.6 percent  Taking into account the 1.6 percent market basket update (+$240 million), in addition to the updated wage data ($10 million), and the additional 15 percent reduction in the BNAF ($90 million), hospice payments would increase by $140 million

54 54 Hospice Wage Index Update  Quality – see proposed HHA notice

55 55 Hospice Wage Index Update  CMS states providers need to report additional diagnoses on claims  Hospices required to start reporting quality data as of October 1, 2012  If not, will face 2.0 percent update reduction for FY 2014  No change from quality measures promulgated last year

56 56 Hospice Rate Update  Issued via Program Transmittal (CR 249CP)  Copy at:  Guidance/Guidance/Transmittals/2012-Transmittals- Items/R2497CP.html Co de DescriptionRate Wage Component Subject to Index Non- Weighted Amount 65 1 Routine Home Care$153.45$105.44$ Continuous Home Care Full Rate = 24 hours of care $=37.32 hourly rate$895.56$615.34$ Inpatient Respite Care$158.72$85.92$ General Inpatient Care$682.59$436.93$245.66

57 57 Inpatient Psychiatric PPS

58 58 Inpatient Psychiatric PPS  Posted August 2  Published August 7 tht  Market Basket 2.7 percent less 0.7 and 0.1  Per Diem will be $  Current is $  ECT at $  Outlier Threshold at $11,600  Current $7,340  Labor at

59 59 Proposed OPPS

60 60 Hospital OPPS  For CY 2013  Published on July 30, 2012  Copy at:  30/pdf/ pdf  Comments due by September 4, 2012  Final rule by November 1, 2012

61 61 OPPS Update  MB is +3.0% (1.0% for non-reporters)  Offset by ACA mandates of – 0.9%  (0.8%) is for productivity  (0.1%) for good measure  Net is +2.1 percent

62 62 OPPS Update  Proposed CF would be $  Current is $ X 2.1 percent X proposed wage index adjustment X cancer hospital adjustment of X drug pass-through = $  Would be $ for non-reporters  CMS says OPPS payments will total $48.1 billion; ASC 4.10 billion

63 63 OPPS Wage Index  Labor-related share remains 60%  See website for proposed values  Not making an adjustment for Massachusetts

64 64 OPPS Outliers  Proposed threshold would be $2,400  And 1.75 times the APC payment  Current threshold is $2,025  Payment remains 50percent of cost above the threshold  Pool remains at 1.0 percent with 0.12 earmarked for CMHCs

65 65 OPPS APC Weights  Moving to geometric mean costs  Has been median costs  Supposedly makes little difference  Can you verify???  File on website allows comparison  Proposed weights on website  Addenda A & B

66 66 OPPS Rural Issues  Continue +7.1 percent add-on to rural SCHs  TOPs ends on

67 67 OPPS Cancer Hospitals  Proposed Payment with a Payment to Cost Ratio of 0.91

68 68 OPPS Drugs  ASP +6% for separately payable  That do not have pass-through status  Includes blood-clotting factors  23 drugs lose pass-through status  21 drugs maintain pass-through status  Adjustment for non-Highly Enriched Uranium radioisotopes  + $10  Packaging threshold would be $80, up from $75

69 69 OPPS Composite Rates  CMS is proposing to continue its composite policies for extended assessment and management services, LDR prostate brachytherapy, cardiac electrophysiologic evaluation and ablation services, mental health services, multiple imaging services, and cardiac resynchronization therapy services  Refer the rule for exact APCs involved and their proposed payment amounts  Expect to see expansion of composite rates in the future

70 70 Other  Revised statewide cost-to-charge ratios  See Table 12  Revised APC groupings  Revised list of I/P procedures only  Seeking comment on observation days

71 71 Partial Hospitalization  Using geometric mean costs  Amounts proposed for free-standing:  APC $87.76  APC $  Amounts for hospital-based:  APC $  APC $232.74

72 72 OPPS Quality  No new measures for FY 2015 and subsequent years

73 73 ASCs  Revising policy on new-technology IOLS  FDA-approved label must contain a specific clinical benefit  Must be supported by evidence of improved outcomes  Proposed CF of $  Up from $ currently  See website for rates for specific procedures  1.3 percent increase  No change in quality reporting  A few newly covered procedures

74 74 Inpatient Rehabilitation Facilities Quality Reporting  CMS is proposing to  1) adopt updates on a previously adopted measure for the IRF QRP that will affect annual prospective payment amounts in FY 2014;  (2) adopt a policy that would provide that any measure that has been adopted for use in the IRF QRP will remain in effect until the measure is actively removed suspended, or replaced; and  (3) adopt policies regarding when notice-and-comment rulemaking will be used to update existing IRF QRP measures

75 75 Inpatient Rehabilitation Facilities Quality Reporting  CMS is making the following proposals:  (1) CMS is proposing to adopt changes made to the NQF #0138 CAUTI measure which will apply to the FY 2014 annual payment update determination;  (2) CMS is proposing to adopt the CAUTI measure, as revised by the NQF on January 12, 2012, for the FY 2015 payment determination and all subsequent fiscal year payment determinations; and  (3) CMS is proposing to incorporate, for use in the IRF QRP, any future changes to the CAUTI measure to the extent these changes are consistent with CMS’s proposal

76 76 ESRD Proposed

77 77 ESRD PPS  Posted on  Published in Federal Register  Copy at:  11/pdf/ pdf  Comments due by COB on  Contains legislative mandated Bad Debt revisions  ESRD payments expected to total $8.7 billion  Payments for ESRD to increase by $320 million

78 78 ESRD Update  Market Basket at 3.2 percent  Productivity offset is – 0.7 percent  Wage Index positive BN adjustment of  Proposed base rate is $  Current rate is $  Proposed composite rate (CR) is $  Current is $141.94

79 79 ESRD Transition  CY 2013 will be third year  Blend is 75 percent PPS / 25 percent composite

80 80 ESRD Wage Index  Floor being reduced to 50 percent (from 55%)  Labor-related shares:  PPS – percent  CR percent  Tables on CMS website (Addenda A & B)

81 81 ESRD Outliers  For pediatric patients  Threshold drops from $71.64 to $50.15  MAP decreases from $45.44 to $43.63  For adult patients  Threshold drops from $ to $  MAP decreases from $78.00 to $61.06

82 82 Drug Issues  No change in drug add-on rate to CR ($20.33)  Daptomycin  Would allow separate payment  When used to treat non-ESRD-related condition  Thrombolytics  Would no longer be eligible for separate payment  Under the CR  Continue using ASP to set prices

83 83 ESRD Quality  Eleven new measures affecting PY 2015  Keeping five measures from PY 2014 for PY 2015  Performance score calculation essentially unchanged  Payment reductions for PY 2015  0.5% if < 10 points under minimum  1.0% if points under minimum  1.5% if points under minimum  2.0% if > 30 points under minimum  Refer to the rule for details  Do not underestimate requirements and scoring

84 84 Bad Debt  Implements provisions contained in the February “doc-fix” law  Affects all providers  Hospitals reduced to 65 percent (from 70%) in FY 2013  SNFs reduced as follows:  Non-dual eligibles from 70percent to 65 percent in FY 2013  Dual eligibles from 100% to 88% in FY 2013; 76% in FY 2014 and 65% in FY 2015  Impact is payment reduction of $330 million

85 85 Bad Debt  Hospital swing beds  For non-dual eligibles from 100% to 65% in FY 2013  For dual eligibles from 100% to 88% to 76% to 65%  For CAHs, ESRD facilities, CMHCs, FQHCs, RHCs, HMOs, HCPPs, and CMPs  88% in FY 2013  76% in FY 2014  65% in FY 2015  CMS says these reductions are “self-implementing”

86 86 Home Health Proposed PPS

87 87 Home Health PPS  Posted on  Published in Federal Register  Copy at:  13/pdf/ pdf  Comments due by

88 88 HHA Update  MB would be 2.5 percent (0.5% for non-quality)  ACA offset is – 1.0 percent  Adjustment effect for wage index update  Net is 1.5 percent  Code creep offset is an additional 1.32 percent based on FY 2012  Code creep is now estimated at 2.18 percent  When will CMS take this back???

89 89 HHA Update  Standardized amount would be $2, (current – $2,138.52)  Impact would be $20 million – update $300 million-updated wage index ($-70 million) Code offset ($-250 million)-other (-$10 million)  Labor-related share is percent -currently %  No change to outlier policy  New wage indexes on internet  Rural add-on remains percent

90 90 HHA Update Hospice Quality Reporting  For the FY 2014 payment determination: Report on 2 measures:  An NQF-endorsed measure that is related to pain management, NQF #0209: The percentage of patients who report being uncomfortable because of pain on the initial assessment (after admission to hospice services) who report pain was brought to a comfortable level within 48 hours.

91 91 HHA Update Hospice Quality Reporting  A structural measure that is not endorsed by NQF: Participation in a Quality Assessment and Performance Improvement (QAPI) program that includes at least three quality indicators related to patient care. Specifically, hospice programs are required to report whether or not they have a QAPI program that addresses at least three indicators related to patient care. In addition hospices are required to check off, from a list of topics, all patient care topics for which they have at least one QAPI indicator.

92 92 Proposed Physician and Other Part B Services for CY 2013

93 93 Physician Fee Schedule  For CY 2013  Posted July 6, 2012  Published in July 30, 2012 Federal Register  Copy at:  30/pdf/ pdf  Comments due September 4, 2012  Final rule on November 1, 2012  Includes many Part B issues

94 94 Update  Current law CF is $  CMS has not re-based  SGR projected to be minus 27 percent  No doubt waiting for Congress

95 95 Changes to RVUs  Interest rate assumption for practice expense  Cut from 11 percent to range of 5.5% -- 8%  Depending on loan size and maturity  Specific changes to PEs  Add 10 minutes to pacemaker follow-up  Add 15 minutes to the RT for GO424  Adding new categories of “misvalued codes”  Harvard-valued > $10 million  Services with “anomalous” time

96 96 Multiple Procedure Payment Reduction Expansion  To include cardiovascular & ophthalmic diagnostic services  TC only  25 percent reduction on same patient / same day  See Table 12

97 97 GPCIs  1.0 floor for work expires  See Addenda D & E for values  No changes this year

98 98 Telehealth  Add alcohol / substance abuse services  CPT codes G  Add preventive services  CPT codes GO442-7

99 99 Outpatient Therapy  Claims-based data strategy for 2013  Statutory mandate  Goal is to reform payment  Proposing to add codes to all claims  Non-payable G codes  To capture data on the beneficiary’s functional limitations: (a) at the outset of the therapy episode, (b) at specified points during treatment and (c) at discharge from the outpatient therapy episode of care.

100 100 Outpatient Therapy  Proposing modifiers for each G code  Describing impairment in 10 percent increments  Testing period for first six months of 2013  After , claims without appropriate codes / modifiers would be returned “unpaid”

101 101 Care Coordination  New HCPCS G codes for:  Non face-to-face services  Related to transitional care management  Furnished by physician / NPP  Within 30 days after discharge from hospital or SNF  Service elements include  Communication within 2 days post-discharge  Medical decision-making of at least moderate complexity  Face-to-face visit within 30 days prior or 14 days after the transition  Proposing an RVU of 1.28

102 102 New Preventive Services  New codes created for:  Alcohol misuse  Depression screening  Behavioral therapy for heart disease  Obesity counseling  RVUs for all are less than 0.5

103 103 Quality Reporting  CMS spends 239 pages discussing the PQRS Measures  For 2013 and individual measures  Value-Based Modifier  Mandated by Section 3007 of ACA  Affects payment on For some physicians On for all  Budget neutral

104 104 Other  Seeking comment on whether molecular pathology services should be paid under MPFS or CLFS  CRNA services to include anything allowed under state law  Ambulance services  Extend add-ons to (statutory)  Make clear that physician certification, by itself, is insufficient to support medical necessity for repetitive, scheduled trips

105 105 Other  AMP does not apply to drug on FDA shortage list  Mandatory face-to-face encounter for certain DME  No more than 90 days before order or 30 days after order  See Table 24 (p. 263) for list of affected items  Eliminate a limitation on contractors to do prepayment reviews  Allow NPPs to order portable x-rays

106 106 Middle Class Tax Relief And Job Creation Act of 2012

107 107 Middle Class Tax Relief And Job Creation Act of 2012  HR 3630  Part of a larger bill to extend payroll tax cut  Date of Enactment was February 22  P.L

108 108 Middle Class Tax Relief And Job Creation Act of 2012  Extension of Freeze on Medicare Physician Payment Rates. Extends current payment rates through December 31, The cost of this provision is $18 billion over eleven years  Extension of MMA section 508 reclassifications. The bill would extend these reclassifications through March 31, The cost of this provision is $100 million over eleven years  Extension of Medicare work geographic adjustment floor. This provision boosts payments for the work component of physician fees in areas where labor cost is lower than the national average. The provision would extend the existing 1.0 floor on the “physician work” index through December 31, The cost of this provision is $400 million over eleven years

109 109 Middle Class Tax Relief And Job Creation Act of 2012  Extension of exceptions process for Medicare therapy caps. Current law places annual per beneficiary payment limits on outpatient therapy services provided by non-hospital providers  Beneficiaries can get an exception to the cap for medically necessary therapy services. This provision extends the exceptions process through December 31, 2012  The provision also expands the cap on outpatient therapy services by applying both the cap and exceptions process to therapy services provided in hospital outpatient departments. Both the exceptions process and expansion of the therapy caps to the outpatient setting expire at the end of  The net cost of this provision is $700 million over eleven years

110 110 Middle Class Tax Relief And Job Creation Act of 2012  Extension of payment for technical component of certain physician pathology services. Extends the ability of independent laboratories to receive direct payments for the technical component for certain pathology services through June 30, The estimated cost of the provision is $100 million over eleven years  Extension of ambulance add-ons. Extends the add-on payment for ground and air ambulance services, including in super rural areas, through December 31, The cost of this provision is $100 million over eleven years  Extension of outpatient hold harmless provision. Extends the outpatient hold harmless provision through December 31, 2012, except for sole community hospitals with more than 100 beds who will no longer be held harmless. The cost of this provision is $100 million over eleven years

111 111 Middle Class Tax Relief And Job Creation Act of 2012  Extension of the qualifying individual (QI) program. Under current law, QI expires February 29, The provision would extend the QI program until December 31, The cost of this provision is $600 million over eleven years  Extension of Transitional Medical Assistance (TMA). Transitional Medical Assistance (TMA) allows low-income families to maintain their Medicaid coverage for up to one year as they transition from welfare to work. Under current law, TMA expires February 29, The provision extends TMA until December 31, The cost of this provision is $1.1 billion over eleven years

112 112 Middle Class Tax Relief And Job Creation Act of 2012  The bill fails to extend two Medicare provisions that were included in the Temporary Payroll Tax Cut Continuation Act enacted in December.  Mental Health Add-On: Medicare payments for certain mental health services have been increased to ameliorate a past payment reduction that disproportionately affected non-physician mental health providers. This provision expired on March 1, 2012  Payment for Bone Density Tests: Dual energy x-ray absorptiometry (DXA) is a test measuring bone mineral density to identify individuals who may have osteoporosis, or are at risk of osteoporosis. These tests currently receive a special Medicare payment amount, which expired on March 1, 2012

113 113 Middle Class Tax Relief And Job Creation Act of 2012  Reduction of Bad Debt Treated as an Allowable Cost. The provision would phase down bad debt reimbursement for all providers for all populations to 65 percent.  Providers currently receiving 100 percent reimbursement for their bad debt would have a three-year transition of 88 percent, 76 percent, and 65 percent, respectively.  Providers currently reimbursed at 70 percent for their bad debt would be reduced to 65 percent. This provision does not continue the existing accommodation for bad debt incurred by SNF providers on behalf of dual eligibles, which is currently reimbursed at 100 percent.  The savings from this policy are $6.9 billion over 11 years ( )

114 114 Middle Class Tax Relief And Job Creation Act of 2012  Prevention and Public Health Fund. The ACA established the Prevention and Public Health Fund to help shift the focus of the health care system to prevention rather than treatment.  The provision reduces the authorized amount for the Fund, for a reduction in spending of $5 billion. This does not account for further cuts anticipated in the sequestration that will go into effect beginning in FY  The savings from this policy are $5 billion over 11 years

115 115 Middle Class Tax Relief And Job Creation Act of 2012  Rebasing Medicaid State DSH Allotments. The Affordable Care Act (ACA) reduced DSH payments, starting in 2014, to reflect the expected decrease in uncompensated care as reform increases the number of patients with insurance. This policy would extend the DSH payment reductions for an additional year, through fiscal year  The savings from this policy are $4.1 billion over 11 years  Rebase Medicare Clinical Laboratory Payment Rates. This policy reduces clinical lab payment rates by 2 percent in  The savings from this policy are $2.7 billion over ten years

116 116 Where is Medicare Heading???

117 117 Where is Medicare Heading???  Accountable Care Organizations  Value-based purchasing  Bundling  Paying lowest price irrespective of setting  More immediate payment constraints

118 118 Questions


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