Society Staff Meets with House Leadership to Discuss Health Care Reform Legislation
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Navigate this summary of provisions in the latest House health care reform legislation:
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Following a strategy similar to the Senate’s, the House of Representatives introduced two bills related to health care reform on October 29, 2009. The first bill, “The Medicare Physician Payment Act of 2009” (H.R. 3961), would repeal the Medicare physician payment update formula, also known as the sustainable growth rate (SGR) formula (averting the 21.5 percent cut) and would install a permanent “fix” starting in 2010. The second bill, “Affordable Health Care for America Act of 2009” (H.R. 3962), would reform the overall current health care system.
The Society joined other medical societies and met with House Speaker Nancy Pelosi (D-CA), Majority Leader Steny Hoyer (D-MD), Ways & Means Committee Chair Charles Rangel (D-NY), Ways & Means Health Subcommittee Chair Pete Stark (D-CA), Energy and Commerce Chair Henry Waxman (D-CA) and Energy & Commerce Health Subcommittee Chair Frank Pallone (D-NJ) to discuss the House strategy for passing both bills.
The House has previously signaled their commitment to physician groups to include a permanent fix as part of health care reform, by proposing a permanent fix in the health care reform legislation passed by the three committees of jurisdiction in the summer, and by explicitly exempting the physician fix from House “pay-go” rules (i.e., the revenues do not need to be raised to offset the cost of the bill). A permanent physician payment fix is estimated to cost as much $210 billion over 10 years. Because of the defeat of the Senate’s physician fix legislation (learn more) due to budgetary concerns, House leadership is now challenged with negotiating a compromise with the Senate on health care reform and may need to find revenues to offset the cost of the permanent fix.
The House is scheduled to begin debating the health care legislation on November 5 and hopes to finish the vote by November 11.
If you have any questions, please contact Isabelle Le Blanc, Coordinator, Legislative Affairs and Health Policy.
Summary of Physician-Related Provisions:
Medicare Physician Payment Act of 2009
Provision: The proposed legislation would replace the 21.5 percent fee schedule reduction in 2010 with an update based on the Medicare economic index. Beginning in 2011, the flawed Sustainable Growth Rate (SGR) formula would be replaced and would group services into two categories and establish separate target growth rates, including:
- Evaluation and management services (including office visits, primary care services, emergency services, consultation and home services), primary care and preventive services, which will increase based on the gross domestic product (GDP) +2 percentage points
- All other services will increase based on the GDP + 1 percentage point,/span>
Society’s position: The Society supports the replacement of the Medicare’s SGR formula with a stable mechanism for updating Medicare fees to continue to assure Medicare beneficiary access to high quality care. Fixing a bad formula should be part of any health care reform agenda. The Society will closely assess the newly proposed payment system to understand the potential impact on its members.
Affordable Health Care for America Act of 2009
Provision: The legislation would direct the Secretary of the U.S. Department of Health and Human Services (referred as the Secretary thereafter) to periodically review potentially misvalued services, such as those with fastest growth, codes that have experienced changes in practice expenses, codes for new technologies, codes that are often billed together or codes that have not been subject to review since the implementation of the Resource Based Relative Value System (i.e., Harvard-valued codes).
The Secretary would be entitled to use the existing structure, such as the American Medical Association/Specialty Society Resource-Based Relative Value Scale (RVS) Update Committee, or can choose to create its own process to receive recommendations on the review and appropriate adjustment of potentially misvalued services.
Society’s position: The Society opposes altering the current process by which services provided under Medicare are valued/re-valued. We believe that it is unnecessary and duplicative to establish another process to address suspected over-valued physician services. As part of the Resource Based Relative Value Scale (RBRVS), the American Medical Association (AMA) has already established the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The RUC provides recommendations to CMS for the valuation of new and revised codes as well as codes identified as misvalued under the Five Year Review of Work. The current process assures physician input from a variety of disciplines.
Primary Care Physician Bonus
Provision: The bill would increase the Medicare payment rate by 5 percent for primary care services of physicians specializing in primary care. Physicians specializing in primary care are defined both by specialty (e.g., family practitioners, internists, and others) and by share of a practice in primary care (at least 50 percent of allowed charges are for primary care services). Eligible practitioners practicing in health professions shortage areas receive an additional 5 percent.
Society’s position: The Society supports the efforts to improve access to primary care but policies should strive to maintain appropriate access to specialty care. However, we oppose any proposals that would provide additional payments to primary care physicians at the expense of specialists.
Physician Quality Reporting Initiative (PQRI)
Provision: The legislation proposes to extend the voluntary reporting in the PQRI program with annual 2 percent (of the total allowed charges) bonus payments for the years from 2009-2012. It would modify the program to create a mechanism that will provide timely feedback to health care professionals, upon request, and would create an appeal process beginning January 2011.
Society’s position: The Society supports the proposal that would refine the PQRI program, particularly allowing physician access to their data in timely manner, providing physicians with a reasonable appeal process.
Payment Bundling Pilot
Provision: This provision would direct CMS to develop a voluntary pilot program encouraging hospital, doctors and post acute care providers to achieve savings by making the most efficient use of global payments for episodes of care. This would essentially be an expansion and extension of the Medicare Acute Care Episode Demonstration project, which would permit hospital-physician gain-sharing.
Society’s position: The Heart Rhythm Society supports more efficient use of resources as long as patient access to quality care is not compromised. The Society is encouraged that potential bundled payments will first be pilot tested. Gain-sharing arrangements if properly structured to measure the effects of quality improvement and outcomes may be useful, but gain-sharing models or similar arrangements that focus on product standardization that could detrimentally limit or deny physicians the opportunity to select and utilize appropriate devices and supplies for particular patient cases are concerning.
Medicare Commission
Provision: Although the House bill does not set up an Independent Medicare Commission, it includes provisions for the Institutes of Medicine (IOM) to study and make recommendations to Medicare payment policies related to geographic variation and to promote high value health care. Similar to the Senate’s Independent Medicare Commission proposal, the Secretary of Health and Human Services will submit a proposal to Congress to implement the IOM recommendations. The plan must be certified to avoid an increase Medicare expenditures. It would be implemented starting in 2013, unless Congress votes to disapprove it.
Society’s position: The Society is concerned with any provision that would remove the oversight from those who have been elected to do so. We will review this new proposal to determine whether those developing the payment recommendations would have adequate expertise and whether this provision would simply be a means to cut provider payments
Comparative Effectiveness Research
Provision: The provision would create a new Center at the Agency for Healthcare Research and Quality, supported by a combination of public and private funding that will conduct, support and synthesize CER. The provision would establish an independent stakeholder commission that recommends research priorities, study methods, and ways to disseminate research to the Center. The Commission would have its own source of funding and be responsible for evaluating the processes of the Center and be authorized to make reports directly to Congress. This legislation would provide protections to prevent the Center and the Commission from mandating payment, coverage or reimbursement policies; protections would be provided to ensure that research findings are not construed to mandate coverage.
Society’s provision: The Society supports comparative effectiveness research, however, prefers a provision similar to the “Patient-Outcomes research Act of 2009” (link to the webpage) introduced earlier this year in the Senate.
Quality Measure Development
Provision: While soliciting stakeholders’ input (including hospital, physicians, health care quality alliances, health plans, employers, labor unions, federal agencies, pharmaceutical and device manufacturers, credentialing entities and nurses), this provision would direct the Secretary to establish national priorities for performance improvement. These priorities should reflect areas that contribute to a large burden of disease, have high potential to decrease morbidity and mortality and improve performance, address health disparities, and have the potential to produce the most rapid change based on current evidence. $2 million would be allocated to this provision annually until 2014.
Based on the national priorities for performance improvement established in this part, the Secretary would develop, test and update new patient-centered and population-based quality measures for the assessment of health care services. $25 million will be allocated annually until 2014 to the development of quality measures.
Society’s Position: The Society welcomes this proposal to further strengthen and improve quality measurement and development processes. The Society recommends that these resources be used to fill gaps in clinical research that will allow the arrhythmia community to build a better supply of evidence-based clinical practice guidelines, to fund clinical data registries and other innovative quality improvement activities, to develop valid risk adjustment mechanisms that will allow the Society to take full advantage of clinical outcomes data, and to conduct studies on whether currently used measures have any impact on quality and cost.
Financial Relationship with Industry
Provision: This provision would require manufacturers or distributors to electronically report any payments or other transfers of value above $5 made to a “covered recipient” (physician, physician group practice, other prescribers, pharmacy or pharmacist, health insurance issuer, group health plan, pharmacy benefit manager, hospital, medical school, sponsor of a continuing medical education program, patient advocacy or disease specific group, organization of health care professionals, biomedical researcher, group purchasing organization.) It would also require hospitals, manufacturers and group-purchasing organizations to report the nature of ownership arrangements by physicians. The information would be published annually on a public website.
The language includes penalties for non-reporting, ranging from $1,000 to $10,000 (but not exceeding $150,000). Payment less than $5 are not required to be reported.
Society’s position: The Society is pleased with the proposal about the financial relationship between physician and industry. The Society believes that while relationships between physicians and industry are an important component of advancing medical technologies and improving patient care, uniform procedures for transparent disclosure must be in place to minimize confusion and misrepresentation. The Society also encourages the House Leadership to adopt language that would provide physicians with the ability to correct inaccuracies in their report and provide background information on their relationships with industry prior to the public release of this information.
However, The Society is extremely concerned about the proposed restrictions on funding of continuing medical education courses. There is a legitimate place for ethical partnerships between industry and medical associations and this support has supported the advancement of cutting edge science, clinical innovation and continuing medical education.
Accountable Care Organization Pilot
Provision: The legislation would create an alternative payment model within fee-for-service Medicare to reward physician-led organizations that take responsibility for the costs and quality of care received by their patient panel over time. Accountable Care Organizations (ACOs) can include groups of physicians organized around a common delivery system (including a hospital), an independent practice association, a group practice, or other common practice organizations. ACOs can include nurse practitioners and physician assistants and other providers as designated by the ACO. ACOs that reduce the costs of their patients relative to a spending benchmark are rewarded with a share of the programmatic savings, conditional on meeting quality targets as well. CMS may allow ACOs to continue operating so long as they are reducing costs while maintaining quality or improving quality while maintaining costs.
Medical Home Pilot
Provision: The legislation would establish a medical home pilot program to assess the feasibility of reimbursing for qualified patient-centered medical homes. There are two models in the provision:
- the Independent Patient-Centered Medical Home, structured around a provider, is targeted at the top half of high-need Medicare beneficiaries with multiple chronic diseases
- the Community-Based Medical Home, which may include any eligible beneficiary, is targeted at a broader population of Medicare beneficiaries and allows for State-based or non-profit entities to provide care-management supervised by a beneficiary designated primary care provider. It provides approximately $1.8 billion for the pilot programs.
The Secretary is authorized to expand the program only if quality measures have been met and budget neutrality is demonstrated.
Society’s position: The Society supports the effort to allow groups of providers to voluntarily work together to improve quality and save costs. The Society supports exploration of alternative payment systems, including proposal for both an accountable care organization and medical home pilot programs. It is important to fully test alternative systems to understand their implications on quality of care and determine whether they achieve their stated goals.
Public Plan option
Provision: The bill would establish a public health insurance option available within the Exchange. The public option would obey the same rules that private plans obey and would have to survive on the premiums it receives. The Secretary will administer the public option and negotiate rates for providers that participate in the public option. An opt-out option would be available for Medicare Providers.
Society’s position: The Society does not have a specific position regarding the establishment of a public plan option; however, the Society opposes mandatory participation in the public plan and by Medicare providers to also participate in any public health insurance plan. The Society also opposes linking the payment mechanisms between Medicare and the public health insurance, even if the rates are slightly increased above Medicare rates.
Imaging-Use Rate Assumption Reform
Provision: The measure would increase the utilization rate for calculating payment for advance imaging equipment from 50 percent to 75 percent over four years.
Society’s position: The Society opposes this proposal. The Society is concerned that the decision is based on the absence of accurate empirical data. The Society would prefer a proposal directing CMS to work with physician organizations to conduct an accurate survey of equipment usage. If a valid, current survey demonstrates that the current equipment use rate diverges from actual use rates, a more accurate rate could then be transitioned into Medicare payment over a four-year period.
Part-D 'Donut Hole'
Provision: The bill would begin closing the so-called 'donut hole' in coverage under Medicare Part D in 2010 by providing a 50 percent discount for brand name drugs purchased by affected recipients. The 'donut hole' is the difference of the initial coverage limit and the catastrophic coverage threshold, as described in the Medicare Part D prescription drug program of the United States. After a Medicare beneficiary surpasses the prescription drug coverage limit, the Medicare beneficiary is financially responsible for the entire cost of prescription drugs until the expense reaches the catastrophic coverage threshold.
Society’s position: The Society supports the effort to eliminate the coverage gap in Medicare Part D, which is detrimental to the care of patients.
