Archive for July, 2012

An Overview of the Hospital Value-Based Purchasing Program

Section 3001(a) of the Affordable Care Act (ACA) includes a new section 1886(o) to the Social Security Act and amended 42 U.S.C. § 1395ww to establish the hospital value-based purchasing (VBP) Program.

Under the VBP Program, beginning October 2012 hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS), as these funds will be used to pay for the performance bonuses under VBP Program. By 2015, hospitals that continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement. Continue reading →

Vaccination Recommendations for Teens

The Office of Adolescent Health (OAH) recently published immunization recommendations for adolescents.  According to the OAH, at the age of 11 or 12 all adolescents should receive the following three important vaccines (as well as an annual flu shot):

  • Tetanus, diphtheria, and pertussis vaccine (1 dose): a booster to protect against these three infectious diseases (pertussis is also called “whooping cough”);
  • Meningococcal conjugate vaccine (2 doses) (MCV4 or MenACWY): an immunization to protect against meningococcal disease (such as meningitis or sepsis, a blood infection);
  • Human papillomavirus (HPV) vaccine (3 doses) (Cervarix or Gardasil): an immunization recommended for both boys (Gardasil only) and girls (both Cervarix or Gardasil) to protect against many HPV-related cancers;
  • Influenza (flu) vaccine (each year): a vaccine (either the flu shot or nasal spray) that is recommended yearly for everyone over 6 months of age to protect against different strains of seasonal influenza.

Additional information about vaccinations, as well as an interactive chart, can be found on the OAH’s Website.

How To Form An ACO

An accountable care organization (ACO) is a Medicare shared savings program that promotes accountability for a patient population, coordinates items and services under Medicare parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient services.  In early July 2012 the United States Department of Health and Human Services (HHS) announced the approval of 89 new ACOs, joining the 27 previously approved ACOs participating in the Medicare shared savings program. The new ACOs did not include those already participating in the Pioneer ACO Model or the Physician Group Practice Transition Demonstration.

The statutory authority for ACOs is set forth in 42 U.S.C. § 1395jjj: “Not later than January 1, 2012, the Secretary shall establish a shared savings program (in this section referred to as the ‘‘program’’) that promotes accountability for a patient population and coordinates items and services under parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery.” Continue reading →

Hospital Value-Based Purchasing Program (Scoring)

Section 3001(a) of the Affordable Care Act added a new section 1886(o) to the Social Security Act and amended 42 U.S.C. § 1395ww to establish the hospital value-based purchasing (VBP) program.

For Fiscal Year (FY) 2013, a hospital’s performance in the VBP program will be based on how it scores in the 12 Clinical Process of Care measures and eight Patient Experience of Care dimensions of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The hospital’s Total Performance Score will be composed: (1) 70% from the 12 clinical process of care measures; and (2) 30% from the 8 patient experience of care dimensions. Continue reading →

Hospital Value-Based Purchasing Program (Eligibility)

Pursuant to the Affordable Care Act (ACA), the Centers for Medicare & Medicaid Services (CMS) established a minimum numbers of cases, measures, and surveys for hospitals to be eligible to participate in the Hospital Value-Based Purchasing (VBP) Program. 

Minimum Cases and Measures:  For Fiscal Year (FY) 2013, CMS has established specific minimum reporting requirements for number of cases, measures, and surveys. A hospital’s performance in the Hospital VBP Program will be based on its performance on 12 Clinical Process of Care measures and eight Patient Experience of Care dimensions of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, including:

  1. A minimum of 10 cases per measure and at least four applicable measures during the performance period are required to receive a Clinical Process of Care score.  
  2. At least 100 completed HCAHPS surveys during the performance period (to receive a Patient Experience of Care score). Continue reading →

Getting Ready for Value-Based Purchasing (HCAHPS Survey)

Section 3001(a) of the Affordable Care Act added a new section 1886(o) to the Social Security Act and amended 42 U.S.C. § 1395ww to establish the hospital value-based purchasing program (VBP).  Under VBP, beginning October 2012 hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS), as these funds will be used to pay for the performance bonuses. By 2015, hospitals that continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement.

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey performance will account for 30 percent of hospital VBP Total Performance Score in fiscal years 2013 and 2013.  The HCAHPS survey, the first national, standardized, publicly reported survey of patients’ perspectives of hospital care, is a survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.  Click on the following links for examples of the standard HCAHPS survey and the expanded HCAHPS survey.

The Medicare Self-Referral Disclosure Protocol

Section 6409 of the Affordable Care Act (ACA) established the Medicare voluntary self-referral disclosure protocol (“SRDP”) for providers of services and suppliers to self-disclose actual or potential violations of federal law governing the limitation on certain physician referrals (42 U.S.C. § 1395nn). These prohibitions include:

(1) a physician from making referrals for certain designated health services (“DHS”) payable by Medicare to an “entity” with which he or she (or an immediate family member) has a direct or indirect financial relationship (an ownership/investment interest or a compensation arrangement), unless an exception applies; and

(2) the entity from presenting or causing a claim to be presented to Medicare (or billing another individual, entity, or third party payor) for those referred services.

The SRDP requires health care providers or suppliers to submit all information necessary for CMS to analyze the actual or potential violation.  In return, CMS can reduce the amount due and owing for violations. The SRDP is intended to facilitate the resolution of only matters that, in the disclosing party’s reasonable assessment, are actual or potential violations of the physician self-referral law. Continue reading →

Improving Coverage Under the Affordable Care Act

While the success of the Affordable Care Act remains to be seen, there is no shortage of ways in which the Federal Government hopes to improve coverage.

The following is a sampling of some statutory provisions (42 U.S.C. sections 300gg-1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12) designed to make American health better.

  1. Guaranteed issuance of coverage in the individual and group market
  2. Guaranteed renewability of coverage
  3. Prohibition of preexisting condition exclusions or other discrimination based on health status
  4. Prohibiting discrimination against individual participants and beneficiaries based on health status
  5. Parity in mental health and substance use disorder benefits
  6. Comprehensive health insurance coverage
  7. Prohibition on excessive waiting periods
  8. Coverage for individuals participating in approved clinical trials
  9. Disclosure of information
  10. No lifetime or annual limits
  11. Prohibition on rescissions

The Financial Impact of the Supreme Court’s Decision

The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) recently estimated the direct spending and revenue effects of H.R. 6079, the Repeal of Obamacare Act, as passed by the House of Representatives on July 11, 2012. Estimates by the CBO reflect the spending and revenue projections by CBO in March 2012, adjusted after the Supreme Court decision in National Federal of Independent Business v. Sebelius and the implications therefrom.

In repealing the Affordable Care Act (ACA), H.R. 6079 would restore provisions of law modified by that legislation as if the ACA had never been enacted. Continue reading →

Expanding Insurance for Dependants

Last week the Federal Government issued proposed regulations for Federal Employee Health Benefits (FEHB) Program enrollees.

Expanding upon the Affordable Care Act’s insurance provision for dependents until the age of 26 (42 U.S.C. § 300gg-14(a)), the proposed regulations will afford the same coverage for FEHB-enrollee children of same-sex domestic partners.

The regulations also allow children of same-sex domestic partners to be covered family members under the Federal Employees Dental and Vision Insurance Program (FEDVIP). Continue reading →

 

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