Medicare Demonstrations Medicare Demonstrations and Clinical - - PowerPoint PPT Presentation

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

• f 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