| Navigate this summary of provisions in the latest Senate health care reform legislation: |
Updated November 23, 2009
On Saturday November 21, 2009 the Senate voted 60-39 in a “cloture vote” to allow debate and the amending process to begin on H. R. 3590, its latest version of health care reform legislation. As expected, the vote was along party lines. Several Senate Democrats who voted in favor of beginning the debate said that they will not support the legislation in its current form. The debate will begin the week after Thanksgiving and likely last through much of December.
The Senate version of health care system reform legislation, “The Patient Protection and Affordable Care Act,” introduced on Thursday, November 19, by Senate Majority Leader Harry Reid (D-NV), merges health care reform bills passed earlier in the year by the Senate Finance Committee and the Senate Committee on Health, Education, Labor and Pensions (also known as the Senate HELP Committee).
According to the Congressional Budget Office’s analysis, the proposed legislation would cost $848 billion and would expand coverage to 94 percent of Americans.
Summary of the Physician-Related Provisions
Medicare Physician Payment Reform
This provision would only provide a one year fix replacing the 21.2 percent cut with a 0.5 percent positive update for 2010. Starting 2011, the scheduled cuts would be implemented.
Society’s position: The Society is concerned with another temporary fix, and supports the replacement of the Medicare’s sustainable growth rate (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.
Primary Care Bonus
Beginning in 2011, the provision would provide primary care practitioners, as well as general surgeons practicing in health professional shortage areas, with a 10 percent Medicare payment bonus for five years. Half of the cost of the bonuses would be offset through an across-the-board reduction in all other services.
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. We oppose any proposals that would provide additional payments to primary care physicians at the expense of specialists.
Potentially Misvalued Codes
This provision would require the Secretary of the U.S. Department of Health and Human Services (HHS) to identify “overvalued” physician services provided by Medicare. The Centers for Medicare & Medicaid Services (CMS) would be required to adjust payment for services “that have increased at an unusual annual rate without evidence supporting the clinical appropriateness of such growth.”
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.
Independent Medicare Advisory Board
This provision would create an independent, 15-member Medicare Advisory Board tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries. In years when Medicare costs are projected to be unsustainable, the Board’s proposals will take effect unless Congress passes an alternative measure that achieves the same level of savings. Congress would be allowed to consider an alternative provision on a fast-track basis. The Board would be prohibited from making proposals that ration care, raise taxes or Part B premiums, or change Medicare benefit, eligibility, or cost-sharing standards.
Society’s Position: The Society is concerned with any provision that would remove the oversight from those who have been elected to do so — especially when the expressed goal is to enact Medicare cuts annually. The Society is also concerned that the Medicare panel would not have the expertise required to make those kinds of decisions.
Physician Quality Reporting Initiative
This provision would extend bonus payments under the current PQRI program through 2014. It would create appeals and feedback processes for participating professionals in PQRI. It would establish a participation pathway for physicians completing a qualified Maintenance of Certification program with their specialty board of medicine. Beginning in 2014, physicians who do not submit measures to PQRI would be penalized under Medicare.
Society’s prosition: The Heart Rhythm Society has serious concerns with this provision. Before penalizing physicians for not reporting into the program, lawmakers need to ensure that all specialty of Medicine have access to measures relevant to their specialty.
National Strategy to Improve Health Care Quality
This section would require the Secretary of HHS (referred as the Secretary thereafter) to establish and update annually a national strategy to improve the delivery of health care services, patient health outcomes, and population health. This information would be published on a federal health care quality website not later than January 1, 2011.
Seventy-five million would be authorized over five years for the development of quality measures at Agency for Healthcare Research and Quality (AHRQ) and CMS. Quality measures developed under this section would be consistent with the national strategy. Once the measures are developed, the Secretary would have $20 million to support the endorsement and use of endorsed measures for use in Medicare, reporting performance information to the public, and in health care programs.
Society’s position: While the Society is very supportive of the use of quality measure as a quality improvement tool, lawmakers need to ensure that all physicians have access to appropriate measure reflecting their work.
Valued-Based Payment Modifier
This provision would direct the Secretary to develop and implement a budget-neutral payment system that would adjust Medicare physician payments based on the quality and cost of the care they deliver. Quality and cost measures would be risk-adjusted and geographically standardized. The Secretary would phase-in the new payment system over a 2-year period beginning in 2015.
Society’s position: the Society is concerned with this provision. Before penalizing physicians, lawmakers need to ensure that all physicians have access to measures that appropriately reflect their specialty.
Physician Resource Use Feedback Program
The provision would expand Medicare’s physician resource use feedback program to provide for development of individualized reports by 2012. Reports would compare the per capita utilization of physicians (or groups of physicians) to other physicians who see similar patients. Reports would be risk-adjusted and standardized to take into account local health care costs.
Society’s Position: The Society agrees that a more efficient use of resources is needed. The Society supports this provision, as long as it is for educational purpose only and that it will not affect payment to physicians (as it was originally proposed in the Senate Finance Committee’s legislation.)
Payment Bundling Pilot
This provision would direct the Secretary to develop a national, voluntary pilot program encouraging hospitals, doctors, and post-acute care providers to improve patient care and achieve savings for the Medicare program through bundled payment models. It would require the Secretary to establish this program by January 1, 2013 for a period of five years. Before January 1, 2016, the Secretary would also be required to submit a plan to Congress to expand the pilot program if doing so will improve patient care and reduce spending.
Society’s position: The Heart Rhythm Society supports a more efficient use of resources and is encouraged that potential bundled payments will be pilot-tested first. However, we will closely monitor this project to ensure patient’s access to heart rhythm specialist and that electrophysiology services rendered are adequately reimbursed.
CMS Innovation Center
The provision would establish within CMS a Center for Medicare & Medicaid Innovation. The purpose of the Center would be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care. Dedicated funding would be provided to allow for testing of models that require benefits not currently covered by Medicare. Successful models could be expanded nationally.
Society’s position: The Society appreciates that potential innovative payment system would be pilot tested and the results would be analyzed before potential national expansion. However, we will closely monitor this project to ensure patient’s access to heart rhythm specialists.
Physician Financial Relationship
This provision would require drug, device, biological and medical supply manufacturers to report transfers of value made to a physician, physician medical practice, a physician group practice, and/or a teaching hospital. Duplicative State or local laws would be preempted by Federal law, however, Federal preemption would not occur for State or local laws that are beyond the scope of this section.
Society’s position: The Society supports this provision — we believe 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. However, the Society would like to include a provision that provides 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.
Alternate Care Settings Pilot
Medicare shared savings program
This provision would reward Accountable Care Organizations (ACOs) that take responsibility for the costs and quality of care received by their patient panel over time. ACOs can include groups of health care providers (including physician groups, hospitals, nurse practitioners and physician assistants, and others). ACOs that would meet quality-of-care targets and reduce the costs of their patients relative to a spending benchmark would be rewarded with a share of the savings they achieve for the Medicare program.
Independence at home demonstration program
This provision would create a new demonstration program for chronically ill Medicare beneficiaries to test a payment incentive and service delivery system that utilizes physician and nurse practitioner directed home-based primary care teams aimed at reducing expenditures and improving health outcomes.
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.
Imaging-Use Rate Assumption Reform
The measure would increase the practice expense units for imaging services from a presumed utilization rate of 50 percent to 65 percent for 2010 through 2012, 70 percent in 2013, and 75 percent thereafter. It would exclude low-tech imaging such as ultrasound, x-rays and EKGs from this adjustment. It would also adjust the technical component discount on single session imaging studies on contiguous body parts from 25 percent to 50 percent.
Society’s position: The Society opposes this proposal. We are 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.
Comparative Effectiveness Research
This provision would establish a private, nonprofit entity (the Patient-Centered Outcomes Research Institute) governed by a public-private sector board appointed by the Comptroller General to identify priorities for and provide for the conduct of comparative outcomes research. It would require the Institute to ensure that subpopulations are appropriately accounted for in research designs, while prohibiting any findings to be construed as mandates on practice guidelines or coverage decisions and contains patient safeguards to protect against discriminatory coverage decisions by HHS based on age, disability, terminal illness, or an individual’s quality of life preference. It would provide funding for the Institute and authorize and provide funding for the Agency for Health Research and Quality to disseminate research findings of the Institute, as well as other government-funded research, to train researchers in comparative research methods and to build data capacity for comparative effectiveness research.
Society’s Position: The Society supports this provision as long as all the details from the “Patient-Outcomes Research Act of 2009” are included.
