health care reform: payment and qualiy

Anesthesia Business Consultants, LLC Confidential Presentation Materials

Health Care Reform:Payment and Quality

Karin Bierstein, JD, MPHVice President for Strategic Planning & Practice Affairs, Anesthesia Business Consultants,

LLC

A Seminar on Business Management and Compliance Issues for Anesthesiologists

Birmingham, MichiganApril 21, 2010


Objectives

1. Understand the impact of the new health care reform law on anesthesiologists’ professional income

2. Identify the quality initiatives that may affect anesthesiologists

• Including the AQI


Question.Does health care reform fix the 21.3% physician payment cut?

A. YesB. No


21.3% Payment Cut – Postponed Again

• Continuing Extension Act of 2010 (signed into law April 15)

• Extends through May 31, 2010, the zero percent update (freeze)

• Retroactive to April 1st

• Medicare has now released claims held since April 1 for processing and payment.


We Still Need a Permanent SGR Fix

Enough said.

It isn’t in the Health Care Reform law.


Disclaimer

• Selective overview• Statute = 1000 pages

– Congress may still modify– State lawsuits?

• Implementation details– Hordes of regulations coming– States have major responsibilities


How the PPACA Became Law

• December 2009: Passed in the Senate

• March 21: Passed in the House of Representatives, which also passed the Health Care and Education Reconciliation Act

• March 23: PPACA Signed into law by President Obama

• March 25: Reconciliation Act passed in the Senate

• March 30: Reconciliation Act signed into law, making final changes to the PPACA


Patient Protection and Affordable Care Act (PPACA) – PAYMENT

• Medicare Cuts– Not in Medicare fee-for-service

payments to physicians– Medicare Advantage plans

• Reduction to equal ~ 100% of fee-for-service Medicare spending

– County-level adjustments– From 95% of in highest-cost quartile of

counties to 115% , in lowest-cost quartile

– Phased in over 3, 5 or 7 years

• Quality bonus payments – 2012, 1.5% - 2014, 5.0%


Hospitals will see cuts:

• $148.7 billion decrease in Medicare and disproportionate share hospital (DSH) payments over 10 years

• Hospital value-based purchasing program: – HHS shall establish a hospital value-

based purchasing program on or after Oct. 1, 2012

– Value-based purchasing demonstration programs for low-volume hospitals


PPACA Payment - IPAB• Independent Payment Advisory

Board– On ASA Key Issues Watch List– Annual recommendations to cut cost

growth in Medicare– If no Congressional action,

recommendations become law automatically

– Cannot be challenged in court– IPAB can also recommend

“constraints on growth” in private sector

• HHS review of mis-valued codes


Payment - Quality Incentives for Professionals

• PQRI bonus payment decreases starting in 2011– 2% cut starts in 2016

• MOC bonus 2011-2014– 0.5% to physicians who participate

• Quality Payment Modifier – Medicare to pay physicians

differentially based on quality and costs of care.

– Publish measures in 2012; phase in modifier from 2015 to 2017.


Bundled Payments

• National, voluntary bundled payment pilot program – CMS Acute Care Episode Demo;

Prometheus

• Global Medicare payment package for hospitals, doctors, and post-acute care providers

• Bundled payment models that span three days before and 30 days after a hospitalization

• Establish by January 1, 2013– for a period of five years.


Expanded Coverage for All

• 32 million uninsured will have coverage

• Medicaid payments will increase • Individual mandates begin in

2014– Penalty up to $2,250 / 2% of

household income

• Insurance more affordable for families and small businesses through tax credits and subsidies


PPACA – Health Insurance Reforms

• Within 6 months or less:– High risk pools for currently

uninsured– Adult children can keep coverage

to age 26– Policy can’t be canceled

(“rescinded”) because of illness– Lifetime caps are prohibited


PPACA – Health Insurance Reforms Cont’d

• September 2010 – restrictions on annual caps begin

• 2013 – annual caps prohibited• 2014 – exclusions for pre-

existing conditions prohibited• 2014 – denial of coverage &

higher premiums based on health status prohibited


Health Insurance Exchanges & “Fiction Fatigue”

• “Government-Run Health Care”• American Health Benefit

Exchanges• States must establish by 2014• To be administered by:

– Governmental agency, or– Non profit entity

• HHS will set standards, e.g. regulate certification criteria for health plans


The Anesthesia Quality Institute (AQI)

• Established as a separate corporation by ASA in 2009.

• Mission:– “Develop and maintain an ongoing

registry of case data that helps anesthesiologists assess and improve patient care. Organize the registry so that anesthesiology practice groups desire to submit their case information, and so that individual anesthesiologists, practice groups, researchers, and professional societies find the data useful for improving the quality of care.”


AQI Cont’d

• National Anesthesia Clinical Outcomes Registry (NACOR)

• A database designed and managed by the profession to document participants’ performance metrics and outcomes against benchmark data

• ± 5 practices already reporting their data


National AnesthesiaClinicalOutcomesRegistry

ProcessingAnesthesia Practice

Hospital ElectronicData

AnesthesiaInformationManagementSystems

BillingRecords

Paper AnesthesiaRecords

QM DataCollection

NACOR Data Sources


NACOR Data Flow


Question.Which item will the NACOR not collect?

A. Average managed care unit rate?

B. Acute pain management service?

C. Number of consults per year?D. Percentage of income from a

hospital contract?E. Name of hospital electronic

record system(s)?


Outcome measures from ASA Committee on Performance and Outcomes Measurement

• 1. Death• 2. Cardiac arrest• 3. Perioperative myocardial

infarction• 4. Anaphylaxis• 5. Malignant hyperthermia• 6. Transfusion reaction• 7. Stroke, cerebral vascular

accident, or coma following anesthesia

• 8. Visual loss


Outcome Measures Cont’d

• 9. Operation on incorrect site• 10. Operation on incorrect patient• 11. Medication error• 12. Unplanned ICU admission• 13. Intraoperative awareness• 14. Unrecognized difficult airway• 15. Reintubation• 16. Dental trauma• 17. Perioperative aspiration


Outcome Measures Cont’d

• 18. Vascular access complication, including vascular injury or pneumothorax

• 19. Pneumothorax following attempted vascular access or regional anesthesia

• 20. Infection following epidural or spinal anesthesia

• 21. Epidural hematoma following spinal or epidural anesthesia

• 22. High spinal• 23. Postdural puncture headache• 24. Major systemic local anesthetic

toxicity• 25. Peripheral neurologic deficit following

regional anesthesia• 26. Infection following peripheral nerve

block


Value of NACOR

• Personal benchmarking– Within the group or practice– Within a subspecialty– Nationally

• Government requirements• Quality Improvement• Hospital credentialing• Maintenance of Licensure• Maintenance of Certification• Clinical Research

health care reform: payment and qualiy

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