Medicare Demonstrations Medicare Demonstrations and Clinical Integration and Clinical Integration Mark Wynn Mark Wynn Director, Division of Payment Policy Director, Division of Payment Policy Demonstrations, CMS Demonstrations, CMS
Overview of Presentation Overview of Presentation � Medicare Demonstrations � Medicare Demonstrations � Acute Care Episode Demonstration � Acute Care Episode Demonstration � Gainsharing Demonstrations � Gainsharing Demonstrations � Physician Group Practice Demonstration � Physician Group Practice Demonstration
Scale of Medicare Demonstrations Scale of Medicare Demonstrations � About 25 demonstrations implemented � About 25 demonstrations implemented � About 12 demonstrations under � About 12 demonstrations under development development � Focus on careful evaluations to guide � Focus on careful evaluations to guide future policies future policies
Historic Examples of Medicare Historic Examples of Medicare Demonstrations Demonstrations � DRGs � DRGs � Medicare managed care � Medicare managed care � Community Access Hospitals in rural � Community Access Hospitals in rural areas areas � PPS for skilled nursing facilities � PPS for skilled nursing facilities � Bidding for Durable Medical Equipment � Bidding for Durable Medical Equipment � Disease management � Disease management � Value Based Purchasing � Value Based Purchasing
Medicare Considerations Medicare Considerations � Trust funds train wreck, urgent need to � Trust funds train wreck, urgent need to increase efficiency increase efficiency � Secretary Leavitt emphasis on Medicare � Secretary Leavitt emphasis on Medicare as a purchaser of quality services as a purchaser of quality services � Misaligned Medicare incentives, hospital � Misaligned Medicare incentives, hospital PPS pays per discharge, physicians paid PPS pays per discharge, physicians paid a la carte a la carte
Acute Care Episode (ACE) Acute Care Episode (ACE) Demonstration Demonstration � Will make global payments (A & B) for � Will make global payments (A & B) for select inpatient episodes of care select inpatient episodes of care � Up to 15 PHO sites in MAC region 4 (TX, � Up to 15 PHO sites in MAC region 4 (TX, CO, OK, NM) CO, OK, NM) � Competitive bidding on basis of price and � Competitive bidding on basis of price and quality quality � Share savings with Medicare beneficiaries, � Share savings with Medicare beneficiaries, up to the Part B premium amount up to the Part B premium amount
ACE Approach ACE Approach � Start with CABG, knee+ hip replacement � Start with CABG, knee+ hip replacement � Expand to post acute care in future years � Expand to post acute care in future years � Sites may use gainsharing (optional) � Sites may use gainsharing (optional)
Gainsharing Demonstrations Gainsharing Demonstrations � Two similar demonstrations, authorized by � Two similar demonstrations, authorized by DRA sec. 5007 and MMA sec. 646 DRA sec. 5007 and MMA sec. 646 � Gainsharing incentive payments paid by � Gainsharing incentive payments paid by hospitals to physicians as a share of hospitals to physicians as a share of savings incurred from collaborative efforts savings incurred from collaborative efforts between hospitals and physicians to between hospitals and physicians to improve quality and efficiency improve quality and efficiency
Gainsharing Approaches Gainsharing Approaches � CMS seeks a broad, quality focused � CMS seeks a broad, quality focused approach approach � Efficient use of ER and ICU � Efficient use of ER and ICU � Reduce duplicate or marginal tests � Reduce duplicate or marginal tests � Length of stay � Length of stay � Innovative technologies � Innovative technologies � Care coordination and discharge planning � Care coordination and discharge planning
Thorough Evaluation Thorough Evaluation � Quality � Quality � Internal cost savings � Internal cost savings � Medicare payments/savings � Medicare payments/savings � Reasonable payments to physicians � Reasonable payments to physicians � Needed modifications to policy or design � Needed modifications to policy or design
Physician Group Practice Demo Physician Group Practice Demo � Authorized by BIPA of 2000, sec. 412 � Authorized by BIPA of 2000, sec. 412 � Large � Large PGPs PGPs of 200+ Drs of 200+ Drs � PGP shares in Medicare savings � PGP shares in Medicare savings compared with control group compared with control group � Incentives also based on quality measures � Incentives also based on quality measures � Operates in 10 large physician groups � Operates in 10 large physician groups
PGP Objectives PGP Objectives � Prevent hospitalizations through care � Prevent hospitalizations through care management management � Promote efficient and high quality care � Promote efficient and high quality care � Reward PGP for high quality care � Reward PGP for high quality care � Initial rewards to two � Initial rewards to two PGPs PGPs paid in 2007 paid in 2007
Issues Issues � What works? � What works? � How to expand to program � How to expand to program � Interest groups and policy debates � Interest groups and policy debates � Relation of cost and quality � Relation of cost and quality � Time lags of measurement and incentives � Time lags of measurement and incentives
Thank You Thank You Mark Wynn Mark Wynn Mark.Wynn@CMS.HHS.Gov Mark.Wynn@CMS.HHS.Gov
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