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Medicare Payment Improvement Act of 2009
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2010 · third_quarter · Medicare/Medicaid
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The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "promoting payment fairness in Medicare physician and practice expense payments; "new formulas for aligning Medicare reimbursement with value; "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; bonus payments for efficient providers; bonus payments for primary care providers; establishment and funding of comparative effectiveness research; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; and opposition to the establishment of a public option in Health Insurance Exchanges if it were to reimburse providers at Medicare rates. Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. These provisions were included in Sections 1159 and 1160 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3007 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. These provisions were included in Sections 1161 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3201 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act will reward Medicare Advantage plans that achieve a quality ranking of four stars or above based on a five-star rating system. The current star rating system was initiated in 2007 to allow the Centers for Medicare and Medicaid Services (CMS) and Medicare beneficiaries to assess health plans based on quality. It was not designed to be a payment system, but could be used as a means to apply bonus payments to high-performing Medicare Advantage plans. The current star rating system incorporates some of the longest-standing quality measurements (HEDIS and CAHPS) in the health care system and provides a credible, solid starting point for evaluating health plan quality. Marshfield Clinic believes that the incorporation of the quality incentive provisions into Medicare Advantage is a significant step in the evolution of Medicare payment. The current star rating system is a credible starting point, and we look forward to the opportunity to work to improve the system in ways that will sustain a strong incentive and reward for better health outcomes for Medicare beneficiaries. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Meaningful Use On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the it HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. These provisions were included in Sections 1157 and 1158 and 1194 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. These provisions were included in Sections 1401 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 6301 and 6302 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and as a candidate for appointment to the Medicaid and CHIP Payment and Access Commission (MACPAC) in 2010. Marshfield Clinic nominated Marilyn Follen for an open nurse position on the Board of Governors of the Patient-Centered Outcomes Research Institute. Marshfield Clinic also supported the nomination of Dr Jeff Thompson of the Gundersen Lutheran Health System on the same Board of Governors. On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also announced that she plans to convene a National Summit on Geographic Variation, cost, Access, and Value in Health Care later this year. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration. The Reconciliation Act of 2010, HR 4872, introduced by Rep. John Spratt included Section 1108 amending Section 3102 of the Patient Protection and Affordable Care Act, which increase the practice expense component of Medicare physician payment in localities that are below the mean of costs nationwide, effective January 1, 2010. HR 4213: The American Jobs and Closing Tax Loopholes Act introduced by rep. Charles Rangel included a 6-month ARRA FMAP extension that would provide much needed Medicaid relief for states ($305 Million for Wisconsin alone). HR 4213 also included provisions canceling the pending reductions in physician reimbursement under the SGR formula. Marshfield Clinic urged Wisconsin Senators to support the extension of federal funding.
Client expense: $90,000 · Firm income: Not reported
Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), SENATE
2010 · second_quarter · Medicare/Medicaid
The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "promoting payment fairness in Medicare physician and practice expense payments; "new formulas for aligning Medicare reimbursement with value; "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; bonus payments for efficient providers; bonus payments for primary care providers; establishment and funding of comparative effectiveness research; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; and opposition to the establishment of a public option in Health Insurance Exchanges if it were to reimburse providers at Medicare rates. Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. These provisions were included in Sections 1159 and 1160 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3007 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. These provisions were included in Sections 1161 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3201 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act will reward Medicare Advantage plans that achieve a quality ranking of four stars or above based on a five-star rating system. The current star rating system was initiated in 2007 to allow the Centers for Medicare and Medicaid Services (CMS) and Medicare beneficiaries to assess health plans based on quality. It was not designed to be a payment system, but could be used as a means to apply bonus payments to high-performing Medicare Advantage plans. The current star rating system incorporates some of the longest-standing quality measurements (HEDIS and CAHPS) in the health care system and provides a credible, solid starting point for evaluating health plan quality. Marshfield Clinic believes that the incorporation of the quality incentive provisions into Medicare Advantage is a significant step in the evolution of Medicare payment. The current star rating system is a credible starting point, and we look forward to the opportunity to work to improve the system in ways that will sustain a strong incentive and reward for better health outcomes for Medicare beneficiaries. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the it HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. These provisions were included in Sections 1157 and 1158 and 1194 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. These provisions were included in Sections 1401 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 6301 and 6302 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and as a candidate for appointment to the Medicaid and CHIP Payment and Access Commission (MACPAC) in 2010. Marshfield Clinic nominated Marilyn Follen for an open nurse position on the Board of Governors of the Patient-Centered Outcomes Research Institute. Marshfield Clinic also supported the nomination of Dr Jeff Thompson of the Gundersen Lutheran Health System on the same Board of Governors. On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also announced that she plans to convene a National Summit on Geographic Variation, cost, Access, and Value in Health Care later this year. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration. The Reconciliation Act of 2010, HR 4872, introduced by Rep. John Spratt included Section 1108 amending Section 3102 of the Patient Protection and Affordable Care Act, which increase the practice expense component of Medicare physician payment in localities that are below the mean of costs nationwide, effective January 1, 2010. HR 4213: The American Jobs and Closing Tax Loopholes Act introduced by rep. Charles Rangel included a 6-month ARRA FMAP extension that would provide much needed Medicaid relief for states ($305 Million for Wisconsin alone). HR 4213 also included provisions canceling the pending reductions in physician reimbursement under the SGR formula. Marshfield Clinic urged Wisconsin Senators to support the extension of federal funding.
Client expense: $130,000 · Firm income: Not reported
Government targets: Centers For Medicare and Medicaid Services (CMS), Council of Economic Advisers (CEA), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), SENATE
2010 · first_quarter · Medicare/Medicaid
Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; bonus payments for efficient providers; bonus payments for primary care providers; establishment and funding of comparative effectiveness research; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the PGP demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; and opposition to the establishment of a public option in Health Insurance Exchanges if it were to reimburse providers at Medicare rates. Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. These provisions were included in Sections 1159 and 1160 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3007 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. These provisions were included in Sections 1161 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3201 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the it HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. These provisions were included in Sections 1157 and 1158 and 1194 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. These provisions were included in Sections 1401 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 6301 and 6302 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. These provisions were included in Subtitle D of the House Bill, HR 3962, the Affordable Health Care for America Act, and in 6002 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and as a candidate for appointment to the Medicaid and CHIP Payment and Access Commission (MACPAC) in 2010. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. These provisions were included in Section 1123 of the House Bill, HR 3962, the Affordable Health Care for America Act. Medicare Payment Improvement Act of 2009, HR 2844. To amend title XVIII of the Social Security Act to create a value indexing mechanism for the physician work component of the Medicare physician fee schedule. Introduced by Rep. Ron Kind and Bruce Braley. Goal: To increase quality of health care in America and decrease cost. The Medicare Payment Improvement Act will fundamentally restructure the Medicare payment system by finally providing an incentive for physicians to provide high quality care. The bill eliminates a geographic adjuster (Work Geographic Practice Cost Index) from Medicare, and replaces it with a figure that measures Value. The value figure measures both quality of care and cost of care. Regions that provide high quality care at low cost will see their Medicare reimbursements increase. Regions that provide low quality care at high cost will see their reimbursements decrease. The current structure of Medicare is known as "fee-for-service," and incentivizes the number of services performed. The Braley bill shifts this to "value-based care," and incentivizes high quality care and low costs. This proposal will transition our current "quantity-based system" to a "quality-based system." Rep. Braley introduced HR 2201, the Medicare Equity & Accessibility Act. This bill would increase Medicare Part B reimbursement rates in Iowa, by placing a floor on the geographic adjuster (GPCI) that is part of the Part B formula. The bill would have the effect of increasing Part B reimbursements in Iowa and other rural states every time a health care provider sees a patient under Part B. Rep. Braley and others supporting the Medicare Payment Improvement Act including Reps. Kind, Inslee, and McCollum, who were representing a much broader 'Quality Coalition,' who have been pushing for a 'value index' in the Medicare Part B reimbursement equation to measure quality and efficiency of care. This provision includes the following: Quality-Based Care-- "Instruct IOM to study how to implement a 'value index' in the Medicare payment system. They will consider geographic differences, access to care, measures of quality, and the role of incentives to impact quality and efficient outcomes of care. "After a set two-year timeframe, IOM will make recommendations to the Secretary of HHS on how to specifically change the Medicare payment system to promote "high-value care," defined as the "efficient delivery of high quality, evidence-based, patient-centered care." "The Secretary will then submit a 'plan of implementation' to the Congress, to implement the recommendations of the IOM. "Congress will have a finite amount of time to pass a joint resolution of disapproval. If Congress fails to act, or if the recommendations are not expressly disapproved by both Chambers, then the recommendations of the IOM will be implemented, thereby reforming the Medicare payment system to incentivize high-value care. Addressing Geographic Disparity- "In addition, the deal resulted in substantive action to address geographic disparity in Medicare payments. IOM will do another study, completed within a year after enactment, to determine whether the data and assumptions used to determine the geographic adjusters (Geographic Practice Cost Indexes and Wage Index) are accurate, or based on flawed data. Many believe the factors that determine these indexes are based on flawed data. "Upon completion of the study (within one year), the Secretary will take immediate action to adjust the GPCIs and Wage Index to ensure they are based on accurate data. "A "Medicare Improvement Fund" is established, which will consist of $8 billion. From this fund, payments will immediately be made in 2012 and 2013, to ensure the money is there for regions who see an increase in their reimbursement due to the adjusted GPCIs and Wage Index. "In 2012 and 2013, a 'Hold Harmless' will exist to ensure that payments do not decrease in any region as a result of these more accurate measurements. The 'Hold Harmless' expires after 2013, to allow budget neutrality for all appropriate shifts that must be made due to correcting the data in the long-term. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration. The Reconciliation Act of 2010, HR 4872, introduced by Rep. John Spratt included Section 1108 amending Section 3102 of the Patient Protection and Affordable Care Act, which increase the practice expense component of Medicare physician payment in localities that are below the mean of costs nationwide, effective January 1, 2010.
Client expense: $150,000 · Firm income: Not reported
Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE
2009 · fourth_quarter · Health Issues
See page five for specific Health Care issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 3590 - Patient Protection and Affordable Care Act H. R. 3854 - Small Business Financing and Investment Act of 2009 H. R. 3961 - Medicare Physician Payment Reform Act of 2009 H. R. 3962 - Affordable Health Care for America Act H. R. 3326 - Department of Defense Appropriations Act, 2010 H. R. 3693 - Ensuring the Future Physician Workforce Act of 2009 H. R. 4371 - To amend title XVIII of the Social Security Act to continue using 2009 Medicare practice expense relative value units for certain cardiology services. S. 733 - National Trauma Center Stabilization Act of 2009 S. 1679 - Affordable Health Choices Act S. 1796 - America's Healthy Future Act of 2009 S. 1776 - Medicare Physician Fairness Act of 2009
Client expense: $8,403 · Firm income: Not reported
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE
2009 · fourth_quarter · Medicare/Medicaid
See page three for specific Medicare/Medicaid issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 3590 - Patient Protection and Affordable Care Act H. R. 3854 - Small Business Financing and Investment Act of 2009 H. R. 3961 - Medicare Physician Payment Reform Act of 2009 H. R. 3962 - Affordable Health Care for America Act H. R. 3326 - Department of Defense Appropriations Act, 2010 H. R. 3693 - Ensuring the Future Physician Workforce Act of 2009 H. R. 4371 - To amend title XVIII of the Social Security Act to continue using 2009 Medicare practice expense relative value units for certain cardiology services. S. 733 - National Trauma Center Stabilization Act of 2009 S. 1679 - Affordable Health Choices Act S. 1796 - America's Healthy Future Act of 2009 S. 1776 - Medicare Physician Fairness Act of 2009
Client expense: $8,403 · Firm income: Not reported
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE
2009 · fourth_quarter · Health Issues
See page five for specific Health Care issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 3590 - Patient Protection and Affordable Care Act H. R. 3854 - Small Business Financing and Investment Act of 2009 H. R. 3961 - Medicare Physician Payment Reform Act of 2009 H. R. 3962 - Affordable Health Care for America Act H. R. 3326 - Department of Defense Appropriations Act, 2010 H. R. 3693 - Ensuring the Future Physician Workforce Act of 2009 H. R. 4371 - To amend title XVIII of the Social Security Act to continue using 2009 Medicare practice expense relative value units for certain cardiology services. S. 733 - National Trauma Center Stabilization Act of 2009 S. 1679 - Affordable Health Choices Act S. 1796 - America's Healthy Future Act of 2009 S. 1776 - Medicare Physician Fairness Act of 2009
Client expense: $59,732 · Firm income: Not reported
2009 · fourth_quarter · Medicare/Medicaid
See page three for specific Medicare/Medicaid issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 3590 - Patient Protection and Affordable Care Act H. R. 3854 - Small Business Financing and Investment Act of 2009 H. R. 3961 - Medicare Physician Payment Reform Act of 2009 H. R. 3962 - Affordable Health Care for America Act H. R. 3326 - Department of Defense Appropriations Act, 2010 H. R. 3693 - Ensuring the Future Physician Workforce Act of 2009 H. R. 4371 - To amend title XVIII of the Social Security Act to continue using 2009 Medicare practice expense relative value units for certain cardiology services. S. 733 - National Trauma Center Stabilization Act of 2009 S. 1679 - Affordable Health Choices Act S. 1796 - America's Healthy Future Act of 2009 S. 1776 - Medicare Physician Fairness Act of 2009
Client expense: $59,732 · Firm income: Not reported
2009 · fourth_quarter · Medicare/Medicaid
Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; bonus payments for efficient providers; bonus payments for primary care providers; establishment and funding of comparative effectiveness research; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the PGP demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; and opposition to the establishment of a public option in Health Insurance Exchanges if it were to reimburse providers at Medicare rates. Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. These provisions were included in Sections 1159 and 1160 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3007 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. These provisions were included in Sections 1161 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3201 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the it HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. These provisions were included in Sections 1157 and 1158 and 1194 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. These provisions were included in Sections 1401 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 6301 and 6302 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. These provisions were included in Subtitle D of the House Bill, HR 3962, the Affordable Health Care for America Act, and in 6002 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and as a candidate for appointment to the Medicaid and CHIP Payment and Access Commission (MACPAC) in 2010. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. These provisions were included in Section 1123 of the House Bill, HR 3962, the Affordable Health Care for America Act. Medicare Payment Improvement Act of 2009, HR 2844. To amend title XVIII of the Social Security Act to create a value indexing mechanism for the physician work component of the Medicare physician fee schedule. Introduced by Rep. Ron Kind and Bruce Braley. Goal: To increase quality of health care in America and decrease cost. The Medicare Payment Improvement Act will fundamentally restructure the Medicare payment system by finally providing an incentive for physicians to provide high quality care. The bill eliminates a geographic adjuster (Work Geographic Practice Cost Index) from Medicare, and replaces it with a figure that measures Value. The value figure measures both quality of care and cost of care. Regions that provide high quality care at low cost will see their Medicare reimbursements increase. Regions that provide low quality care at high cost will see their reimbursements decrease. The current structure of Medicare is known as fee-for-service, and incentivizes the number of services performed. The Braley bill shifts this to value-based care, and incentivizes high quality care and low costs. This proposal will transition our current quantity-based system to a quality-based system. Rep. Braley introduced HR 2201, the Medicare Equity & Accessibility Act. This bill would increase Medicare Part B reimbursement rates in Iowa, by placing a floor on the geographic adjuster (GPCI) that is part of the Part B formula. The bill would have the effect of increasing Part B reimbursements in Iowa and other rural states every time a health care provider sees a patient under Part B. Rep. Braley and others supporting the Medicare Payment Improvement Act including Reps. Kind, Inslee, and McCollum, who were representing a much broader Quality Coalition, who have been pushing for a value index in the Medicare Part B reimbursement equation to measure quality and efficiency of care. This provision includes the following: Quality-Based Care-- Instruct IOM to study how to implement a value index in the Medicare payment system. They will consider geographic differences, access to care, measures of quality, and the role of incentives to impact quality and efficient outcomes of care. After a set two-year timeframe, IOM will make recommendations to the Secretary of HHS on how to specifically change the Medicare payment system to promote high-value care, defined as the efficient delivery of high quality, evidence-based, patient-centered care. The Secretary will then submit a plan of implementation to the Congress, to implement the recommendations of the IOM. Congress will have a finite amount of time to pass a joint resolution of disapproval. If Congress fails to act, or if the recommendations are not expressly disapproved by both Chambers, then the recommendations of the IOM will be implemented, thereby reforming the Medicare payment system to incentivize high-value care. Addressing Geographic Disparity In addition, the deal resulted in substantive action to address geographic disparity in Medicare payments. IOM will do another study, completed within a year after enactment, to determine whether the data and assumptions used to determine the geographic adjusters (Geographic Practice Cost Indexes and Wage Index) are accurate, or based on flawed data. Many believe the factors that determine these indexes are based on flawed data. Upon completion of the study (within one year), the Secretary will take immediate action to adjust the GPCIs and Wage Index to ensure they are based on accurate data. A Medicare Improvement Fund is established, which will consist of $8 billion. From this fund, payments will immediately be made in 2012 and 2013, to ensure the money is there for regions who see an increase in their reimbursement due to the adjusted GPCIs and Wage Index. In 2012 and 2013, a Hold Harmless will exist to ensure that payments do not decrease in any region as a result of these more accurate measurements. The Hold Harmless expires after 2013, to allow budget neutrality for all appropriate shifts that must be made due to correcting the data in the long-term. CMS Physician Group Practice Demonstration Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.
2009 · third_quarter · Medicare/Medicaid
See page three for specific Medicare/Medicaid issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H.R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 1679 - Affordable Health Choices Act
Client expense: $59,412 · Firm income: Not reported
2009 · third_quarter · Health Issues
See page five for specific Health Care issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 914 - Physician Workforce Enhancement Act of 2009 H. R. 1678 - Mitigating the Impact of Uncompensated Service and Time Act of 2009 H. R. 2 - Children's Health Insurance Program Reauthorization Act of 2009 H. R. 1016 - Veterans Health Care Budget Reform and Transparency Act of 2009 H. R. 84 - Veterans Timely Access to Health Care Act H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2891 - Access to Frontline Health Care Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 1377 - To amend title 38, United States Code, to expand veteran eligibility for reimbursement by the Secretary of Veterans Affairs for emergency treatment furnished in a non-Department facility, and for other purposes. H.R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 S. 733- National Trauma Center Stabilization Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 252 - Veterans Health Care Authorization Act of 2009 S. 597 - Women Veterans Health Care Improvement Act of 2009 S. 658 - Rural Veterans Health Care Improvement Act of 2009 S. 734 - Rural Veterans Health Care Access and Quality Act of 2009 S. 1679 - Affordable Health Choices Act
Client expense: $59,412 · Firm income: Not reported
2009 · third_quarter · Health Issues
See page five for specific Health Care issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 914 - Physician Workforce Enhancement Act of 2009 H. R. 1678 - Mitigating the Impact of Uncompensated Service and Time Act of 2009 H. R. 2 - Children's Health Insurance Program Reauthorization Act of 2009 H. R. 1016 - Veterans Health Care Budget Reform and Transparency Act of 2009 H. R. 84 - Veterans Timely Access to Health Care Act H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2891 - Access to Frontline Health Care Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 1377 - To amend title 38, United States Code, to expand veteran eligibility for reimbursement by the Secretary of Veterans Affairs for emergency treatment furnished in a non-Department facility, and for other purposes. H.R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 S. 733- National Trauma Center Stabilization Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 252 - Veterans Health Care Authorization Act of 2009 S. 597 - Women Veterans Health Care Improvement Act of 2009 S. 658 - Rural Veterans Health Care Improvement Act of 2009 S. 734 - Rural Veterans Health Care Access and Quality Act of 2009 S. 1679 - Affordable Health Choices Act
Client expense: $32,952 · Firm income: Not reported
2009 · third_quarter · Medicare/Medicaid
See page three for specific Medicare/Medicaid issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H.R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 1679 - Affordable Health Choices Act
Client expense: $32,952 · Firm income: Not reported
2009 · third_quarter · Medicare/Medicaid
See page three for specific Medicare/Medicaid issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H.R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 1679 - Affordable Health Choices Act
Client expense: $59,412 · Firm income: Not reported
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
2009 · third_quarter · Health Issues
See page five for specific Health Care issues. H. R. 3200 - America's Affordable Health Choices Act of 2009 H. R. 914 - Physician Workforce Enhancement Act of 2009 H. R. 1678 - Mitigating the Impact of Uncompensated Service and Time Act of 2009 H. R. 2 - Children's Health Insurance Program Reauthorization Act of 2009 H. R. 1016 - Veterans Health Care Budget Reform and Transparency Act of 2009 H. R. 84 - Veterans Timely Access to Health Care Act H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2891 - Access to Frontline Health Care Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 1377 - To amend title 38, United States Code, to expand veteran eligibility for reimbursement by the Secretary of Veterans Affairs for emergency treatment furnished in a non-Department facility, and for other purposes. H.R. 2718/S. 1110/S. 1380 - Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009 S. 733- National Trauma Center Stabilization Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 252 - Veterans Health Care Authorization Act of 2009 S. 597 - Women Veterans Health Care Improvement Act of 2009 S. 658 - Rural Veterans Health Care Improvement Act of 2009 S. 734 - Rural Veterans Health Care Access and Quality Act of 2009 S. 1679 - Affordable Health Choices Act
Client expense: $59,412 · Firm income: Not reported
2009 · third_quarter · Medicare/Medicaid
H.R. 2251/S. 973, Resident Physician Shortage Reduction Act of 2009: entire Bill H.R. 2844/S. 1249, Medicare Payment Improvement Act
Client expense: $220,000 · Firm income: Not reported
Government targets: Army, Dept of (Corps of Engineers), Education, Dept of, Energy, Dept of, Environmental Protection Agency (EPA), HOUSE OF REPRESENTATIVES, Natl Institute of Standards & Technology (NIST), Natl Oceanic & Atmospheric Administration (NOAA), Navy, Dept of, Office of Science & Technology Policy (OSTP), SENATE, Veterans Affairs, Dept of (VA)
2009 · third_quarter · Medicare/Medicaid
Senate Finance Chairman's Mark - America's Healthy Future Act (Baucus): role of public programs (Title I, Subtitle G), promoting disease prevention and wellness (Title II), linking payment to quality in Medicare (Title III, Subtitle A, Part I), development of new patient care models (Title III, Subtitle A, Part III), Medicare Advantange (Title III, Subtitle C) HR 3200 America's Affordable Health Choices Act (Waxman, Rangel, Miller)- accountable care organizations (Division B, Title III, Sec. 1301), medical homes (Division B, Title III, Section 1302), Medicare Advantage (Division B, Title I, Subtitle D), Special needs plans (Division B, Title I, Subtitle D, Sec. 1176 & 1177) S 1249 (Klobuchar) Medicare Payment Improvement Act of 2009 (entire bill) HR 2844 (Kind) Medicare Payment Improvement Act of 2009 (entire bill) S 1262 (Cantwell) Medical Efficiency and Delivery Improvement of Care Act of 2009 (Title III, Sec 3003) S 1133 (Wyden) Empowering Medicare Patient Choices Act (entire bill) HR 2580 (Blumenauer) Empowering Medicare Patient Choices Act (entire bill) S 1004 (Lincoln) RE-Aligning Care Act (entire bill) HR 2307 (Green) RE-Aligning Care Act (entire bill) S 1131 (Wyden) Independence at Home Act of 2009 (entire bill) HR 2560 (Markey) Independence at Home Act of 2009 (entire bill) S 1009 (Bennet) Medicare Care Transitions Program Act of 2009 (entire bill)
Client expense: $93,696 · Firm income: Not reported
2009 · third_quarter · Medicare/Medicaid
Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Program Marshfield Clinic has concerns about payment projections and policy changes outlined by the Centers for Medicare and Medicaid Services in its Advance Notice of Methodological Changes for Calendar Year 2010 for Medicare Advantage Capitation Rate and Part C and Part D Payment Policies, dated February 20, 2009. Our first concern is that the national per capita growth rate projected in CMSs Advance Notice deviates significantly from the growth rate health plans are experiencing. CMSs projection is based in large part on an unrealistic assumption that Medicare fee-for-service payments for physician services will be cut by 21% this year. However, since 2003, previously scheduled fee reductions have been overridden by Congress. Secondly, an across-the-board 3.74% reduction for risk score coding patterns for all health plans appears quite large. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. Medicare Payment Improvement Act of 2009 H.R.2844 : To amend title XVIII of the Social Security Act to create a value indexing mechanism for the physician work component of the Medicare physician fee schedule. Introduced by Rep. Ron Kind and Bruce Braley. Goal: To increase quality of health care in America and decrease cost. The Medicare Payment Improvement Act will fundamentally restructure the Medicare payment system by finally providing an incentive for physicians to provide high quality care. The bill eliminates a geographic adjuster (Work Geographic Practice Cost Index) from Medicare, and replaces it with a figure that measures Value. The value figure measures both quality of care and cost of care. Regions that provide high quality care at low cost will see their Medicare reimbursements increase. Regions that provide low quality care at high cost will see their reimbursements decrease. The current structure of Medicare is known as fee-for-service, and incentivizes the number of services performed. The Braley bill shifts this to value-based care, and incentivizes high quality care and low costs. This proposal will transition our current quantity-based system to a quality-based system. Rep. Braley introduced HR 2201, the Medicare Equity & Accessibility Act. This bill would increase Medicare Part B reimbursement rates in Iowa, by placing a floor on the geographic adjuster (GPCI) that is part of the Part B formula. The bill would have the effect of increasing Part B reimbursements in Iowa and other rural states every time a health care provider sees a patient under Part B. Rep. Braley and others supporting the Medicare Payment Improvement Act including Reps. Kind, Inslee, and McCollum, who were representing a much broader Quality Coalition, who have been pushing for a value index in the Medicare Part B reimbursement equation to measure quality and efficiency of care. This provision includes the following: Quality-Based Care-- Instruct IOM to study how to implement a value index in the Medicare payment system. They will consider geographic differences, access to care, measures of quality, and the role of incentives to impact quality and efficient outcomes of care. After a set two-year timeframe, IOM will make recommendations to the Secretary of HHS on how to specifically change the Medicare payment system to promote high-value care, defined as the efficient delivery of high quality, evidence-based, patient-centered care. The Secretary will then submit a plan of implementation to the Congress, to implement the recommendations of the IOM. Congress will have a finite amount of time to pass a joint resolution of disapproval. If Congress fails to act, or if the recommendations are not expressly disapproved by both Chambers, then the recommendations of the IOM will be implemented, thereby reforming the Medicare payment system to incentivize high-value care. Addressing Geographic Disparity In addition, the deal resulted in substantive action to address geographic disparity in Medicare payments. IOM will do another study, completed within a year after enactment, to determine whether the data and assumptions used to determine the geographic adjusters (Geographic Practice Cost Indexes and Wage Index) are accurate, or based on flawed data. Many believe the factors that determine these indexes are based on flawed data. Upon completion of the study (within one year), the Secretary will take immediate action to adjust the GPCIs and Wage Index to ensure they are based on accurate data. A Medicare Improvement Fund is established, which will consist of $8 billion. From this fund, payments will immediately be made in 2012 and 2013, to ensure the money is there for regions who see an increase in their reimbursement due to the adjusted GPCIs and Wage Index. In 2012 and 2013, a Hold Harmless will exist to ensure that payments do not decrease in any region as a result of these more accurate measurements. The Hold Harmless expires after 2013, to allow budget neutrality for all appropriate shifts that must be made due to correcting the data in the long-term. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments.
2009 · second_quarter · Medicare/Medicaid
H.R. 2919, Medicare Efficiency Incentive Act of 2009: entire bill. S. 1249, Medicare Payment Improvement Act of 2009: entire bill. S. 1262, Medical Efficiency and Delivery Improvement of Care Act of 2009: Section 3003: Value index under the Medicare physician fee schedule. H.R. 3074, Medicare Payment Fairness Act of 2009: entire bill. S. 295, Medicare Quality and Payment Reform Act of 2009: provisions relating to hospitals. H.R. 2251, Resident Physician Shortage Reduction Act of 2009: provisions relating to hospitals. H.R. 2350, Preserving Patient Access to Primary Care Act of 2009: provisions relating to hospitals. H.R. 1776, Quality FIRST Act of 2009: entire bill. H.R. 2844, Medicare Payment Improvement Act of 2009, entire bill. S. 1031, National Nursing Shortage Reform and Patient Advocacy Act, provisions relating to hospitals. H.R. 2525, Safeguarding our Hospitals' Futures Act of 2009, entire bill. S. 1108, Safeguarding our Hospitals' Futures Act of 2009, entire bill. H.R. 362, Rural Hospital Assistance Act of 2009: entire bill. H.R. 2891, Access to Frontline Health Care Act of 2009: entire bill. HELP Committee health reform proposal, The Affordable Health Choices Act: provisions relating to hospitals. House Tri-Committee health reform discussion draft: provisions relating to hospitals. S.318, Medicare Rural Health Access Improvement Act of 2009: provisions relating to hospitals. H.R. 1, The American Reinvestment and Recovery Act: provisions relating to hospitals including, HIT; comparative effectiveness. H.R. 2201, the Medicare Equity & Accessibility Act: provisions relating to hospitals. S. 1157, The Craig Thomas Rural Hospital and Provider Equity Act: provisions relating to hospitals. Other Issues: Medicare Geographic Disparity: Feingold-Klobuchar letter and McCollum-Obey letter. Capital IME payments to hospitals: Neal-Tiberi letter and Schumer-Roberts letter. Value-based purchasing as it relates to payments for hospitals. DSH payments to hospitals, including Sullivan, Bingaman, Inhofe letter. CMS proposed FY2010 rule, provisions relating to hospitals. Budget neutrality adjustment to rural floor of wage index: Congressmen Larsen, Pascrell, and LoBiondo Letter. Other issues continued: Graduate medical education as it relates to hospitals. Hospital physician self-referral issue. CMS final 2009 Medicare Outpatient Prospective Payment System rule: incident to policy. Monitored issues relating to GPO Safe Harbor. Issues relating to Medicare Administrative Contractors. Monitored issues relating to Medicare Recovery Audit Contractors. Monitored HHS Provider Conscience Regulation. Moratorium on Medicare regulation related to hospice budget neutrality adjustment factor. SGR fix--physician payment in Medicare.
2009 · second_quarter · Medicare/Medicaid
Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Program Marshfield Clinic has concerns about payment projections and policy changes outlined by the Centers for Medicare and Medicaid Services in its Advance Notice of Methodological Changes for Calendar Year 2010 for Medicare Advantage Capitation Rate and Part C and Part D Payment Policies, dated February 20, 2009. Our first concern is that the national per capita growth rate projected in CMSs Advance Notice deviates significantly from the growth rate health plans are experiencing. CMSs projection is based in large part on an unrealistic assumption that Medicare fee-for-service payments for physician services will be cut by 21% this year. However, since 2003, previously scheduled fee reductions have been overridden by Congress. Secondly, an across-the-board 3.74% reduction for risk score coding patterns for all health plans appears quite large. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments.
2009 · second_quarter · Health Issues
See page six for specific Health Care issues. H. R. 914 - Physician Workforce Enhancement Act of 2009 H. R. 1678 - Mitigating the Impact of Uncompensated Service and Time Act of 2009 H. R. 2 - Children's Health Insurance Program Reauthorization Act of 2009 H. R. 1016 - Veterans Health Care Budget Reform and Transparency Act of 2009 H. R. 84 - Veterans Timely Access to Health Care Act H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2891 - Access to Frontline Health Care Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 1377 - To amend title 38, United States Code, to expand veteran eligibility for reimbursement by the Secretary of Veterans Affairs for emergency treatment furnished in a non-Department facility, and for other purposes. S. 733- National Trauma Center Stabilization Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 252 - Veterans Health Care Authorization Act of 2009 S. 597 - Women Veterans Health Care Improvement Act of 2009 S. 658 - Rural Veterans Health Care Improvement Act of 2009 S. 734 - Rural Veterans Health Care Access and Quality Act of 2009 Affordable Health Choices Act
Client expense: $17,638 · Firm income: Not reported
2009 · second_quarter · Medicare/Medicaid
See page four for specific Medicare/Medicaid issues. H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act Affordable Health Choices Act
Client expense: $17,638 · Firm income: Not reported
2009 · second_quarter · Medicare/Medicaid
See page four for specific Medicare/Medicaid issues. H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act Affordable Health Choices Act
Client expense: $72,555 · Firm income: Not reported
2009 · second_quarter · Health Issues
See page six for specific Health Care issues. H. R. 914 - Physician Workforce Enhancement Act of 2009 H. R. 1678 - Mitigating the Impact of Uncompensated Service and Time Act of 2009 H. R. 2 - Children's Health Insurance Program Reauthorization Act of 2009 H. R. 1016 - Veterans Health Care Budget Reform and Transparency Act of 2009 H. R. 84 - Veterans Timely Access to Health Care Act H. R. 1213 - Screening Abdominal Aortic Aneurysms Very Efficiently Act of 2009 H. R. 2891 - Access to Frontline Health Care Act of 2009 H. R. 2350 - Preserving Patient Access to Primary Care Act of 2009 H. R. 2251/S. 973 - Resident Physician Shortage Reduction Act of 2009 H. R. 2844/S. 1249/H. R. 3074 - Medicare Payment Improvement Act of 2009 H. R. 1377 - To amend title 38, United States Code, to expand veteran eligibility for reimbursement by the Secretary of Veterans Affairs for emergency treatment furnished in a non-Department facility, and for other purposes. S. 733- National Trauma Center Stabilization Act of 2009 S. 330 - Medicare Prescription Drug Savings and Choice Act of 2009 S. 179 - Health Information Technology Act of 2009 S. 717 - 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act S. 252 - Veterans Health Care Authorization Act of 2009 S. 597 - Women Veterans Health Care Improvement Act of 2009 S. 658 - Rural Veterans Health Care Improvement Act of 2009 S. 734 - Rural Veterans Health Care Access and Quality Act of 2009 Affordable Health Choices Act
Client expense: $72,555 · Firm income: Not reported
2009 · second_quarter · Medicare/Medicaid
Medicare pay for value issues in health reform Support HR 2844 and S 1249, value indexing in Medicare payments
Client expense: $270,000 · Firm income: Not reported
Government targets: Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, SENATE
| Democratic |
| WA |
| Russell Feingold | Democratic | WI |
| Sherrod Brown | Democratic | OH |
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE
Client expense: $140,000 · Firm income: Not reported
Government targets: Agency for Healthcare Research & Quality (AHRQ), Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), SENATE
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: HOUSE OF REPRESENTATIVES, Medicare Payment Advisory Commission (MedPAC), SENATE
Client expense: $90,000 · Firm income: Not reported
Government targets: Agency for Healthcare Research & Quality (AHRQ), Centers For Medicare and Medicaid Services (CMS), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), Natl Economic Council (NEC), Natl Institutes of Health (NIH), Office of Management & Budget (OMB), SENATE, White House Office
Client expense: Not reported · Firm income: $10,000
Government targets: HOUSE OF REPRESENTATIVES, SENATE
Client expense: $90,000 · Firm income: Not reported
Government targets: Agency for Healthcare Research & Quality (AHRQ), Centers For Disease Control & Prevention (CDC), Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Natl Institutes of Health (NIH), Office of Management & Budget (OMB), SENATE
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)
Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)