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Presentation to Michigan anesthesia providers Apr 2010
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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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
Question.Does health care reform fix the 21.3% physician payment cut?
A. YesB. No
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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.
Anesthesia Business Consultants, LLC Confidential Presentation Materials
We Still Need a Permanent SGR Fix
Enough said.
It isn’t in the Health Care Reform law.
Anesthesia Business Consultants, LLC Confidential Presentation Materials
Anesthesia Business Consultants, LLC Confidential Presentation Materials
Disclaimer
• Selective overview• Statute = 1000 pages
– Congress may still modify– State lawsuits?
• Implementation details– Hordes of regulations coming– States have major responsibilities
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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%
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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.
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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.
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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.”
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
National AnesthesiaClinicalOutcomesRegistry
ProcessingAnesthesia Practice
Hospital ElectronicData
AnesthesiaInformationManagementSystems
BillingRecords
Paper AnesthesiaRecords
QM DataCollection
NACOR Data Sources
Anesthesia Business Consultants, LLC Confidential Presentation Materials
NACOR Data Flow
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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)?
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials
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
Anesthesia Business Consultants, LLC Confidential Presentation Materials