A project of the George Washington University's Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation

Health Care Quality and Delivery System Reform

CMS issues final rule on barring Medicaid match for certain medical conditions

Posted on June 6, 2011

The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) has issued a final rule restricting federal Medicaid match funding for payments to providers whose patients have certain preventable medical conditions. The rule is intended to “better align Medicare and Medicaid payment policies,” CMS said in a press release accompanying the rule. The rule implements Section 2702 of the Affordable Care Act (ACA), which requires the Secretary to adjust federal Medicaid payments for health care-acquired conditions (HCACs), similar to what is done in the Medicare program. The final rule extends the effective date by one year, from July 1, 2011 to July 2, 2012.

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Update: Disclosure and Review of Unreasonable Premium Increases

Posted on June 3, 2011

An earlier Implementation Brief provided an overview of the Disclosure and Review of Unreasonable Health Insurance Premium Rate Increases, which was established by §1003 of the Affordable Care Act (ACA) by adding §2794 to the Public Health Service Act (PHSA). On May 23, 2011, the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) published a final rule (with comment period) establishing a rate review program of “unreasonable” health insurance premium rate increases and implementing requirements for health insurance issuers regarding the disclosure and review of such unreasonable premium increases.

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CBO analyzes permanent prohibition on implementation of health reform

Posted on May 26, 2011

The Congressional Budget Office (CBO) has released a report to Congress analyzing the bugetary implications of legislation that permanently prevents the use of appropriated funds in Affordable Care Act (ACA) implementation. The analysis, submitted by CBO and the Joint Tax Commission (JCT) to Congressman Henry Waxman (D-CA) at his request, finds that the effects of a permanent prohibition on appropriated funds would largely depend on the Obama Administration’s interpretation of such a prohibition. CBO and JCT also found it difficult to measure the magnitude of effects on the deficit because any potential savings realized by reductions in spending might be offset by a significant loss in revenues resulting from the prohibition.

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New Pioneer ACO Model Announced by CMS

Posted on May 20, 2011

The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) have announced that the Center for Medicare and Medicaid Innovation (Innovation Center) will support a new type of Accountable Care Organization, called the Pioneer ACO Model. This type of ACO is designed to work in conjunction with both public and private payers and is estimated by the Medicare Chief Actuary to save up to $430 million over 3 years because of better care management and coordination.

“The Pioneer Model is an opportunity for those organizations that have already adopted significant care coordination processes to move further and faster into seamless, coordinated care by utilizing alternative payment mechanisms,” said Richard Gilfillan, M.D., director of the Innovation Center.

CMS will accept applications for Pioneer ACOs through July 18, 2011.

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NEJM article discusses how to rein in Medicare/Medicaid spending

Posted on May 19, 2011

In her New England Journal of Medicine article, “Hard Choices–Alternatives for Reining in Medicare and Medicaid Spending,” Dr. Meredith B. Rosenthal of the Harvard School of Public Health compares and contrasts the two most prominent proposals to reform health care: Paul Ryan’s “Roadmap for America’s Future” and the White House’s Affordable Care Act (ACA). She summarizes the main arguments supporting and opposing the two plans. The beauty of Ryan’s plan is that by fixing the federal government’s contribution to Medicare and Medicaid to a formula unrelated to the growth of overall health care costs, it would guarantee controlled federal spending growth. However, this would also shift financial risk to beneficiaries and state governments. The ACA alters the landscape for control federal health care spending by creating new institutions intended to facilitate progress toward reform and by directly altering payment formulas for Medicare and Medicaid. The downside of this cost savings portion of the ACA is that implementation of payment and delivery reforms is complex.

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CMS issues RFC on improving care for duals

Posted on May 16, 2011

The U.S. Department of Health and Human Services (HHS) has issued a Request for Comment (RFC) on opportunities for aligning benefits and incentives to improve overall care for individuals eligible for both Medicare and Medicaid.

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NEJM article compares and contrasts Paul Ryan’s “Roadmap for America’s Future” with the ACA

Posted on May 13, 2011

The New England Journal of Medicine’s perspective piece “Consensus and Conflict in Health System Reform–The Republican Budget Plan and the ACA” by Timothy Stoltzfus Jost, J.D., compares and contrasts Representative Paul Ryan’s (R-WI) “Roadmap for America’s Future” with the Affordable Care Act (ACA). In terms of their similarities, both plans would create a health care system in which many Americans purchase private health insurance using partially means-tested public subsidies through an exchange-based, information-rich competitive market, which is (more or less) open to all regardless of health status. Those who choose to remain uninsured would incur a penalty (or forgo a benefit), and those who purchased insurance would be responsible for significant costs. Jost also details five key differences between Roadmap and the ACA in the piece.

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Essential Health Benefits: Overview of the Department of Labor Report on Benefits Offered Under a “Typical” Employer Health Plan

Posted on May 11, 2011

The Affordable Care Act (ACA) requires that all health insurance issuers offering products in the individual and small-group markets, including both the state Exchange market as well as the non-Exchange market, provide coverage of certain “essential health benefits.” An earlier Implementation Brief explored the concept of “essential health benefits.” This Brief summarizes a new U.S. Department of Labor (DOL) report on benefits covered in a “typical” employer plan and identifies key implementation issues for the federal Department of Health and Human Services (HHS).

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FTC to host information gathering workshop on ACO antitrust issues

Posted on May 3, 2011

The Federal Trade Commission (FTC) will host a workshop on May 9 to gather information on enforcing U.S. antitrust laws as they relate to the formation of Accountable Care Organizations (ACOs). The Department of Justice (DOJ) and the FTC issued a joint policy statement on ACO antitrust enforcement March 31, for which the comment period expires at the end of May.

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CMS issues final rule on hospital value based purchasing

Posted on May 2, 2011

The Centers for Medicare and Medicaid Services (CMS) have issued the long-awaited final rule on the Medicare Hospital Value-Based Purchasing Program. The final rule reduces the number of quality measures tied to $850 million in Medicare hospital payments to 12 overall performance measures, down from the 17 measures put forth in the previous proposed rule. For more information on Medicare Value Based Purchasing Programs, click here.

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