While this new IPAB may not recommend any changes in Medicare program eligibility, rationing of care, restricting benefits, raising revenues, or increasing beneficiary premiums or cost-sharing, it will be able to make any other recommendations to achieve annual targeted savings, improve beneficiary access to care, improve the health delivery system, and improve health outcomes.  If Congress does not act on the IPAB’s specific annual  recommendations (or enact other legislation that achieves similar savings) within certain timelines, the Secretary of the Department of Health and Human Services is required to implement the IPAB’s recommendations and such actions are not reviewable or reversible by either the President or the courts.

Given the broad authority granted to the IPAB, there has been significant opposition to its establishment, primarily from those concerned about delegating such broad policy authority to an unelected body, and from health care providers who are anxious that the primary way program savings can be achieved would be reductions in Medicare reimbursement rates to providers.  There have been several bills introduced to abolish the IPAB and two House of Representatives committee hearings about eliminating it.   On the other hand, President Obama has proposed expanding the authority of the IPAB even further, with a mandate to achieve even greater savings and adding authority to recommend value-based benefit designs and even greater enforcement of its recommendations.

The IPAB is not scheduled to begin its work until 2013 so it is unclear whether presidential appointments naming the fifteen board members will be made prior to the November 2012 elections.

Link to Original Source

Link to Original Source

Link to Original Source

This process of identifying measures to be used in quality improvement, public reporting, and payment reform activities across CMS programs that could also be used by private sector programs was required by section 3014 of the Patient Protection and  Affordable Care Act.  The Measure Applications Partnership is now seeking public comment about the proposed measures list before it finalizes a list to be submitted to  CMS by February 1, 2012.   CMS will still use its usual regulatory rulemaking process to adopt specific measures for specific programs.

Meanwhile, the Measure Applications Partnership will be focusing on finalizing its interim recommendations for selecting healthcare quality measures for dual Medicare-Medicaid eligible beneficiaries (by June 2012) and selecting measures for hospital care (by June 2012) and for post-acute care/long term care (by June 2012).

A Frequently Asked Questions(FAQ) about the Measure Applications Partnership is also available:

Link to Original Source

This is the highest amount of funding, and the most open-ended flexible initiative, to come from the CMMI, which was created by the Patient Protection and Affordable Care Act. However, successful applicants will need to demonstrate the ability to achieve satisfactory improvement in cost of care both at the program-level (net savings over the duration of each award) AND  and at the projected medical cost trend (reduction that results from building the sustainable new model continuing after the cooperative agreement period is complete).

It also explicitly includes workforce training and education as a element of the initiative.  The Funding Opportunity Announcement states:

• The health care workforce of the future will be highly focused on prevention, care coordination, care process re-engineering, dissemination of best practices, team-based care, community-based care, continuous quality improvement, and the use of data to support new care delivery models…there are many care coordination models that utilize less expensive but potentially highly effective individuals who are trained to interact with patients in a focused way to address preventive health and chronic conditions (e.g., community health workers). There is a shortage of such individuals today, even as we are moving toward a health care system based on effective care coordination and prevention. Additional examples could include but are not limited to: the use of personal and home care aides to help the elderly age at home; expanding the use of community-based paramedics to provide basic services to extend available primary care resources in rural communities; and the use of community-based nurse teams working with primary care practices to provide intensive care management for the most complex patients.

The objectives of the Healthcare Innovation Challenge are:

• Engage a broad set of innovation partners to identify and test new care delivery and payment models that originate in the field and that produce better care, better health, and reduced cost through improvement for identified target populations.
• Identify new models of workforce development and deployment and related training and education that support new models either directly or through new infrastructure activities.
• Support innovators who can rapidly deploy care improvement models (within six months of award) through new ventures or expansion of existing efforts to new populations of patients, in conjunction (where possible) with other public and private sector partners.

Awards will range from approximately $1 million to $30 million for a three-year period.  Applications are open to providers, payers, local government, public-private partnerships and multi-payer collaboratives.  Each grantee project will be monitored for measurable improvements in quality of care and savings generated.

The Health Care Innovation Challenge will encourage applicants to include new models of workforce development and deployment that efficiently support their service delivery model proposal.  Enhanced infrastructure to support more cost effective system-wide function is also a critical component of health care system transformation, and applicants are encouraged to include this as an element of their proposals.

Potential applicants must submit a letter of intent (LOI) by December 19, 2011 in order to be eligible for a funding award.  Full applications are due January 27, 2012 with a first round of awards anticipated by March 30, 2012.  A second round of awards would be made in August 2012 and would include as much of the remaining funding (if any) as the second round of applications warrant.

Innovation Center staff will be hosting an informational webinar on the Health Care Innovation Challenge for all interested individuals and organizations on Thursday, November 17, 2011 from 2:00-3:30pm ET.

Link to Original Source

Primary care is critical to promoting health, improving care, and reducing overall system costs, but it has been historically under-funded and under-valued in the United States. Without a significant enough investment across multiple payers, independent health plans– covering only their own members and offering support only for their segment of the total practice population– cannot provide enough resources to transform entire primary care practices and make expanded services available to all patients served by those practices.

The CPC initiative offers a way to break through this historical impasse by inviting payers to join with Medicare in investing in primary care in 5-7 selected localities across the country. The CPC initiative will test two models simultaneously: a service delivery model and a payment model. The service delivery model will test comprehensive primary care, which is characterized as having the following five functions:

1. Risk-stratified Care Management;
2. Access and Continuity;
3. Planned Care for Chronic Conditions and Preventative Care;
4. Patient and Caregiver Engagement;
5. Coordination of Care Across the Medical Neighborhood.

The payment model includes a monthly care management fee paid to the selected primary care practices on behalf of their fee-for-service Medicare beneficiaries and, in years 2-4 of the initiative, the potential to share in any savings to the Medicare program. Practices will also receive compensation from other payers participating in the initiative, including private insurance companies and other health plans, which will allow them to integrate multi-payer funding streams to strengthen their capacity to implement practice-wide quality improvement.

The Innovation Center is now accepting letters of intent from public and private health care payers for the Comprehensive Primary Care initiative. The first step is for public and private payers (including states) to indicate their interest to CMS, including the level and type of support for primary care practices being offered. Interested payers must submit a nonbinding letter of intent and a completed Geographic Service Area Worksheet by November 15, 2011.

Final applications, to be completed only after the letter of intent has been submitted, must be received on or before January 17, 2012. Once CMS evaluates these proposals and selects the markets, a second solicitation will be issued for primary care practices in those markets.

Link to Original Source

After the fourth year of the five-year demonstration, all ten of the participating physician groups (consisting of over 5,000 physicians providing health care service to over 220,000 Medicare fee-for-service beneficiaries) achieved quality improvement targets (on at least 29 of 32 measures related to diabetes, congestive heart failure, coronary artery disease and preventive care).  This continues the improvements in quality achieved and maintained since the first year of the demonstration.

However, only five of the ten physician groups earned incentive payments based on estimated savings in Medicare expenditures.  These five groups received a total of $31.7 million, or nearly 82%, of the $38.7 million savings that CMS estimated was saved through the demonstration in year four.  These five physician groups are the same five physician groups which earned incentive payments totaling $25.3 million (78% of the $32.3 million in savings CMS estimated) in year three.  A sixth physician group did earn an incentive payment after year two but has not earned any incentives in years three or four.  Four of the ten physician groups have yet to receive any incentive payments after four years.

The fact sheet also describes some of the quality improvement activities implemented by the ten physician groups during the demonstration, including:

• Patient registries
• Increased use of electronic health records
• Dashboard reports to providers
• Increased use of evidence-based guidelines and decision support
• Reports for patients
• Medication reconciliation
• Increased use of nurses on care team and as care managers
• Developing individual care plans
• Motivational education
• Coaching at hospital discharge and at other transition of care
• Care coordination
• Disease and case management
• Patient self-management
• Computerized telephonic monitoring
• Home-based monitoring
• Early/proactive physician follow up after discharge
• Community-based crisis intervention services
• Palliative care

However, since each of the ten participating physician groups has chosen a different set of these interventions, it is not clear which have been or will be the most effective (and in what combinations) in achieving the quality improvements and cost reductions.

Link to Original Source

The results reported in the fact sheet are summarized and discussed, including implications for designing Medicare Shared Savings Program ACOs, in this open access article from the New England Journal of Medicine.

Link to Original Source

The 32 measures being used in the Physician Group Practice demonstration are HEDIS measures, including ten measures related to patients with diabetes, ten for patients with congestive heart failure, seven for patients with coronary heart disease, and five preventive measures for all patients.  Only the diabetes measures are required for the first year, with the addition of the congestive heart failure and coronary heart disease measures in the second year, and all measures in the third year.

The report also details the complex weighting of the measures to calculate eligibility for any potential shared savings.  In the first year, the weighted quality measure scores count 30% towards shared savings, with the percentage increasing to 40% in the second year and to 50% in the third year.  This means that quality improvement will increasingly be the basis of any eligibility for shared savings as the demonstration proceeds.

The report also contains detailed technical specifications for sampling data, exclusions and other calculations.

Link to Original Source

Many of the design elements in the proposed Medicare Shared Savings Program ACOs, including Medicare fee-for-service beneficiary assignment, calculation of shared savings available, and quality measures required, are based on the design of this Physician Group Practice demonstration.

Some of the most significant differences in the proposed Medicare Shared Savings ACO design are that hospitals and other Medicare participants will participate in the ACO (in addition to physicians), there are significantly more quality measures to report (65 rather than 32), a two-sided risk model (including liability for losses, or higher than projected Medicare expenditures) is available, and the shared savings available to the ACO will be limited to 65% (in the two-sided model, with bonus for Federally Qualified Health Center or Rural Health Center participation) rather than 80%.

Link to Original Source

Link to Original Source

The care coordination focus area seems to be the most developed, with a Multi-Payer Advanced Primary Care Practice demonstrations to begin in eight states this summer, Medicaid state health home demonstrations being launched, applications just received for state demonstrations to integrate care for dual Medicare-Medicaid beneficiaries, and details of a Federally Qualified Health Center Advanced Primary Care Practice demonstration program being finalized.

And the Center announced its first initiatives:

1) A Multi-Payer Advanced Primary Care Practice Demonstration Project, with eight states (Maine, Vermont, Rhode Island, New York, Pennsylvania, North Carolina, Michigan and Minnesota) establishing up to 1,200 medical homes with payments from Medicare, Medicaid and private health plans, serving almost one million Medicare beneficiaries

2) A Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration with up to 500 community health centers providing patient-centered, coordinated care to 195,000 Medicare beneficiaries.

3) Launch of a Medicaid Health Home State Plan Option which allows Medicaid patients with at least two chronic conditions to designate a provider as a health home; states that implement this option will receive enhanced federal matching funds for their Medicaid program to support these health homes.

4) Availability of a demonstration project for up to 15 states to integrate and coordinate care for Medicare and Medicaid dual eligibles (low income seniors and persons with disabilities); up to $1 million is available to each of the 15 states.

While many of these initiatives were mandated by the PPACA, it is interesting that the Center seems to be using the terms “health homes”, “advanced primary care practice” and “medical homes” interchangeably and also seems to focused primarily on Medicare beneficiaries (for example, even in the FQHC demonstration, when most FQHCs see far more patients on Medicaid than Medicare).  It will also be interesting to see how the Center implements activities under its third goal since population level community health has not been a strong focus of Centers for Medicare and Medicaid Services initiatives and have been led by other operating divisions of the U.S. Department of Health and Human Services, namely, the Centers for Disease Control and Prevention.

With the historic enactment of national health care reform in March 2010, it can be a little overwhelming to understand all the details and implications of this huge structural shift in national health care policy.

As I continue to refine my own knowledge and understanding of the national health care reform law, I will share my analyses and presentations here.  I will be highlighting what I call the “patient-centeredness” and ”equity” elements of the legislation, two of the components of health care quality identified by the Institute of Medicine.

Text of Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act

Side-by Side Analysis of Equity Provisions in Final Senate and House Bills

California Pan-Ethnic Health Network Bulletin, Advancing Patient-Centeredness and Equity in Health Care Reform, July 2010

Plenary Presentation at California Pan-Ethnic Health Network “Building Quality and Equitable Health Care Systems”, June 2010

The federal government health care reform implementation website also has useful information and is available in Español (Spanish).

I also have compiled some of the publications and resources that I have found most useful in understanding the Patient Protection and Affordable Care Act.

Kaiser Family Foundation Summary of PPACA

Kaiser Family Foundation PPACA Implementation Timeline

Joint Center for Political and Economic Studies Advancing Health Equity for Racially and Ethnically Diverse Populations

Summit Health Institute for Research and Education Health Equity Activist Guide to the PPACA

Finally, I am compiling publications and resources on some of the key topics and issues emerging from the implementation of health care reform:

Medical Homes

Accountable Care Organizations

Comparative Effectiveness Research

Medical Homes: A Promising Model for Advancing Patient-Centeredness and Equity

One of the emerging models of health care delivery system re-design is the concept of a “medical home”.   In 2007, the American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association issued a Joint Principles defining patient-centered medical homes.

While the specific terminology and elements of a medical home (also being called a “health care home”, “primary care home” or “advanced primary care practice”) vary, the core idea is that everyone should have a partnership with a primary care provider who will provide access to comprehensive, coordinated, high quality health care.

Medical homes will be given a huge catalyst with the imminent widespread adoption of health information technology by physician practices, community health centers and hospitals.

I have compiled some key analyses and background resources on the concept of medical homes.

Robert Wood Johnson Foundation – Health Affairs Policy Brief on Medical Homes

Deloitte Health Care Solutions Issue Briefs on Medical Homes and “Medical Homes 2.0“

Center for Studying Health System Change Issue Brief on Medical Homes

Mathematica Issue Brief on Medical Homes

National Academy for State Health Policy Issue Brief on Medical Homes

The California Endowment Resource Guide on Health Homes

National Partnership for Women and Families Consumer Principles for Medical Homes

Some key articles are:

Link to Original Source

Link to Original Source