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

Implementation Briefs

Rating the Quality of Qualified Health Plans Sold in the Marketplace

Categories: Health Care Quality and Delivery System Reform, Health Information

Posted on January 7, 2014

On November 19, 2013, the Obama Administration published a Notice with comment that describes the overall Quality Rating System (QRS) framework for rating the quality of health plans (QHPs) sold in the health insurance Marketplace (another term for Exchanges). The purpose of the Notice is to solicit comments on the framework. Comments must be received by January 21, 2014. Comments are sought on both the proposed quality measures that QHP issuers would be expected to report, as well as on ways to preserve the integrity of QHP ratings and on areas for future measurement...

Transforming Health Care Delivery

Categories: Health Care Quality and Delivery System Reform, Health Information, Health Insurance, Long Term Care, Medicaid and CHIP, Medicare

Posted on January 16, 2013

Experts and stakeholders agree the current health care system is unsustainable. By 2020, health care spending will comprise almost 20% of the gross domestic product. Furthermore, an ever growing body of evidence clearly indicates that the system is not experiencing improvements in quality that are reflective of the cost growth. The Patient Protection and Affordable Care Act (ACA) takes significant strides towards the transformation of the American health care delivery system from a system that rewards volume to a system that rewards quality and value. The programs and initiatives...

Improving Care Coordination – Spurring Use of Health Information Technology in Long-Term Care

Categories: Health Care Quality and Delivery System Reform, Health Information, Long Term Care, Medicaid and CHIP, Medicare

Posted on November 14, 2012

Historically, the American health care system through its siloed delivery and reimbursement models has failed to support a patient-centered and coordinated delivery system. Fragmentation has resulted in a health care system where potentially avoidable hospital readmissions, duplicative testing, and medication errors are common. Widespread adoption and use of Health Information Technology (HIT) has the potential to decrease these occurrences by enabling providers to electronically exchange health information with other providers and their patients across settings of care to better coordinate patient care. Recognizing the potential benefit of widespread use of HIT, in 2009 Congress authorized...

Update: Medicare Quality Measurement and Reporting Programs

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicare

Posted on September 19, 2012

A February 2011 Implementation Brief titled “Medicare Quality Measurement and Reporting Programs” addressed Congress’ continuing efforts through the Affordable Care Act (ACA) to transition the Medicare program from a traditional volume-based fee for service purchaser of health care items and services to a value-based purchaser. The ACA took significant steps to move beyond financial and other incentives for quality measure development, measurement, and reporting to financial and other incentives for actual improvements in care delivery (e.g., value-based purchasing). Since the initial 2011 brief, the Centers for Medicare and Medicaid Services (CMS) has made significant progress in implementing Congress’ vision. That progress is described below.

Update: Financial Alignment Demonstrations for Dual Eligible Individuals

Categories: Health Care Quality and Delivery System Reform, Health Insurance, Long Term Care, Medicaid and CHIP, Medicare

Posted on July 18, 2012

The Affordable Care Act (ACA) included a number of provisions designed to improve the delivery of health and long-term care support services for individuals who are eligible for and enrolled in both the Medicare and Medicaid programs, commonly referred to as “dual eligible.” An earlier Health Reform GPS Implementation Brief outlined these changes. Among the provisions identified in the Brief was new demonstration authority provided to the Department of Health and Human Services (HHS) to permit states to waive certain provisions of Medicare law to better coordinate care for dual eligibles, new grant funding available to as many as 15 states to plan and implement integrated programs of care for dual eligibles, and the release of a July 11 State Medicaid Director (SMD) Letter providing preliminary guidance to states on demonstration models designed to improve care coordination for dual eligibles, including both capitated and fee-for-service models. This Brief provides an update on the financial alignment model outlined in the SMD letter, with a focus on subsequent guidance to states and health plans seeking to participate in capitated demonstrations. This demonstration is being followed closely at the federal level, and both...

Update: Financial Assistance Policies for Nonprofit Hospitals that Seek Federal Tax-Exempt Status

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Tax Policy

Posted on July 9, 2012

On June 22, 2012, the Internal Revenue Service and Treasury Department released for public view a notice of proposed rulemaking (NPRM) regarding the obligations of nonprofit hospitals seeking federal tax-exempt status. The NPRM deals with that portion of the ACA related to the obligation of nonprofit hospitals to maintain financial assistance and emergency medical care policies, as well as certain billing and collection policies, as a condition of federal tax exemption. The NPRM comment period will be for 90 days following Federal Register publication. The agencies have identified...

Administrative Simplification: Adoption of Operating Rules for Health Plan Eligibility and Health Care Claim Status Transactions

Categories: Health Care Quality and Delivery System Reform, Health Information, Health Insurance, Implementation Update

Posted on April 13, 2012

On July 8, 2011 the Secretary of the Department of Health and Human Services (HHS) issued an Interim Final Rule with Comment Period (IFR) regarding the operating rules for two types of HIPAA transactions: eligibility for a health plan and health care claim status. The rules are in response to Section 1104 of the Affordable Care Act (ACA), which directed the Secretary to adopt certain operating rules for transactions to enable electronic health information exchange and create greater uniformity in the transmission of health information. The ACA defines operating rules as...

Update: Release of Medicare Data for Performance Measurement

Categories: Health Care Quality and Delivery System Reform, Health Insurance, Implementation Update, Medicare

Posted on February 24, 2012

Health policy experts and lawmakers believe that measuring and publicly reporting information about the performance of physicians, hospitals, and other health care providers is critical to improving health care quality and controlling costs. Advancing health information access and transparency is a goal of the Patient Protection and Affordable Care Act (ACA) [1], which includes a number of provisions to incentivize quality measurement and reporting and to enable more informed consumer decision-making. Across the country, community organizations, such as the Alliances participating in the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative, have been demonstrating the power of using private payer and Medicaid medical claims data to measure and publicly report on provider performance. Their work could be further strengthened by access to Medicare claims data because it is the single largest pool of information about how health care is delivered in America. Combining Medicare data with data from other public and private payers such as Medicaid and employer sponsored plans, holds the potential to generate more complete and accurate provider performance measurement information, thereby further empowering consumer engagement and quality improvement.

The Center for Medicare and Medicaid Innovation: A Year’s Progress

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicaid and CHIP, Medicare

Posted on January 26, 2012

Improving the quality of care delivery and reducing explosive growth in healthcare costs is a cornerstone of The Patient Protection and Affordable Care Act (ACA). It reflects the shared understanding that the current silo-based approaches to care delivery that focus on settings of care (e.g., physician office, hospital) rather than care delivery across multiple providers and setting (e.g., episodic) are not working. Costs are increasing at an unsustainable pace, and evidence from leading researchers collectively points to serious deficiencies in health care quality and the disconnect between high spending and health care quality. To foster the development of more collaborative and...

Independent Payment Advisory Board (IPAB)

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicare

Posted on January 13, 2012

Section 3403 of the Affordable Care Act (ACA) established the Independent Payment Advisory Board (IPAB), a 15-member panel of appointed experts that will recommend cost-saving measures for Medicare. In the face of controversy about its structure and powers, legislation has been introduced in the 112th Congress to repeal its establishment.

Update: Medicare Shared Savings Program for Accountable Care Organizations

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicare

Posted on November 8, 2011

While a primary aim of the Affordable Care Act (ACA) was to increase access to affordable health insurance coverage, a critical, although less publicized, component of the law is a series of provisions designed to improve health care quality and efficiency and to advance the concept of “value-based purchasing.” The Agency for Health Care Research and Quality (AHRQ) defines the concept of value-based purchasing as holding “providers of health care accountable for both the cost and quality of care.” AHRQ notes that “value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. This strategy can be contrasted with more limited efforts to negotiate price discounts, which reduce costs but do little to ensure that quality of care is improved.”

Hospital Readmissions Reduction Program

Categories: Health Care Quality and Delivery System Reform, Health Insurance, Implementation Update, Medicare

Posted on November 1, 2011

Hospitals in the United States readmit an average of 20% of Medicare patients within thirty days of their initial discharge. These readmissions cost the Medicare program an estimated 12 billion dollars each year and may be an indicator of poor quality of care where the readmission was potentially preventable. In its June 2007 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) classified many hospital readmissions as potentially preventable. Based on these recommendations, Congress included the Hospital Readmissions Reduction Program (HRRP or Program) in the Affordable Care Act. CMS issued the final rule implementing the HRRP on August 18, 2011, although CMS will continue to clarify additional details of the program through future rulemaking.

Hospital Value-Based Purchasing Program

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicare

Posted on September 14, 2011

Historically, the Medicare program has passively purchased health care services for Medicare beneficiaries. Hospitals and other providers delivered services to Medicare beneficiaries and the Medicare program paid for the services without any indication of the quality or value of the care delivered. However, as costs have continued to escalate at an explosive pace without discernible improvements in the quality of care delivered, Congress and Medicare administrators have re-evaluated this passive payment methodology. Premised on the belief that the Medicare program must transition to be an active purchaser of high quality, cost-effective care, value-based purchasing uses financial incentives to both incentivize improved quality of care delivery and reduction of costs.

Release of Medicare Data for Performance Measurement

Categories: Centers for Medicare & Medicaid Services, Health Care Quality and Delivery System Reform, Health Information, Implementation Update, Medicare

Posted on July 6, 2011

Health policy experts and lawmakers believe that measuring and publicly reporting information about the performance of physicians, hospitals, and other health care providers is critical to improving health care quality and controlling costs. Advancing health information access and transparency is a goal of the Patient Protection and Affordable Care Act (ACA), which includes a number of provisions to incentivize quality measurement and reporting and to enable more informed consumer decision-making.

Medicaid Payment Adjustment for Health Care-Acquired Conditions

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicaid and CHIP, Medicare

Posted on June 8, 2011

A high number of deaths occur every year due to potentially preventable adverse events, including medical errors, in the hospital setting. The most commonly cited research on this topic was published by the Institute of Medicine (IOM) in 1999. The IOM report, "To Err is Human: Building a Safer Health System" stated that hospital acquired conditions (HACs) caused by medical errors are a leading cause of morbidity and mortality in the United States.[1] More recently, a 2007 study found that of 1.7 million infections acquired while a patient was receiving treatment in a hospital, 99,000 resulted in death in 2002.[2] In addition, there is also a significant cost burden associated with potentially preventable HACs. In 2000, the Centers for Disease Control and Prevention (CDC) published a report estimating the cost burden of HACs to be almost $5 billion.[3]

Update: Disclosure and Review of Unreasonable Premium Increases

Categories: Health Care Quality and Delivery System Reform, Health Insurance, Implementation Update

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.

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

Categories: Health Care Quality and Delivery System Reform, Health Insurance

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).

Medicare Accountable Care Organizations

Categories: Health Care Quality and Delivery System Reform, Medicare

Posted on April 20, 2011

An earlier Implementation Brief provided an overview of the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs), which was established by §3022 of the Affordable Care Act (ACA) by adding §1899 to the Social Security Act. On April 7, 2011, the federal Centers for Medicare and Medicaid Services (CMS) published a proposed rule implementing the MSSP. This proposed rule was accompanied by several additional policy documents:

Disclosure and Review of Unreasonable Premium Increases

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on April 14, 2011

Over the past decade, health insurance premiums have doubled (with particularly sharp increases in the small group and individual markets), making insurance coverage unattainable for millions of Americans. News stories have reported that some health insurers have sought to increase premium rates as much as 50 percent.

Primary Care Physician Workforce

Categories: Health Care Quality and Delivery System Reform, Workforce and Access

Posted on March 16, 2011

Strengthening and modernizing the health care workforce was a major goal of the Patient Protection and Affordable Care Act (ACA). The ACA contains dozens of provisions related to health care workforce issues, including strengthening primary care, national workforce policy development, increasing the supply of health care workers, and more. This Implementation Brief focuses on those provisions of the ACA that specifically target the strengthening of the primary care physician workforce.

Essential Community Providers

Categories: Health Care Quality and Delivery System Reform, Medicaid and CHIP

Posted on March 11, 2011

A recurring health reform theme over the years has been the “essential community provider.” Originated as an aspect of President Clinton’s health reform plan, the term has been used by policymakers and researchers alike to denote health care providers that through legal obligation or mission, organizational and service structure, and patient population characteristics, play a significant role in health care for patients and populations at disparate risk for inadequate access. Examples of patient populations reached by essential community providers include uninsured and underinsured persons, residents of medically underserved urban and rural communities that experience primary health care shortages, children with special health care needs and serious and chronic conditions, adults with mental illness and substance use disorders, disadvantaged patients who seek family planning and primary reproductive health services, seriously and chronically ill and disabled low-income populations including Medicare/Medicaid “dual enrollees,” homeless individuals, persons with HIV/AIDS, high risk pregnant women and newborns, and farm workers and their families.

State Health Insurance Exchange Navigators

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on February 28, 2011

One of the great challenges of our health care system for individuals and small employers is figuring out health insurance. Multiple products are available in the market, and they can differ enormously with respect to benefits and cost-sharing, coverage standards, who – and what – is in or out of provider networks, and how to make the best use of insurance coverage. Insurance agents and brokers – sometimes referred to as “producers” – provide an important service by helping people and small businesses make purchasing choices. But brokers and agents perform a specific task: their primary job is to sell insurance products. Thus, while their role is key to a functioning insurance market, brokers and agents may not be sources of impartial advice on how to select among competing plans, and they may not provide post-enrollment assistance in understanding and using coverage once purchased.

Chronic Disease Management

Categories: Health Care Quality and Delivery System Reform, Long Term Care, Medicaid and CHIP, Medicare, Public Health

Posted on February 23, 2011

More than 40% of the U.S. population has one or more chronic condition. Although the likelihood of having a chronic disease increases with age, approximately half of working-age Americans has at least one chronic condition. The prevalence of chronic diseases is increasing in both the elderly and non-elderly populations, with a significant increase in the number of people with multiple chronic diseases. Increased spending on chronic diseases in Medicare is a significant driver of the overall increase in Medicare spending over the last twenty years. Nevertheless, given the high cost of treating chronic diseases, the Affordable Care Act (ACA) includes many provisions to encourage chronic disease management as part of the overall emphasis on improving the efficiency of health care.

Medicare Quality Measurement and Reporting Programs

Categories: Health Care Quality and Delivery System Reform, Medicare

Posted on February 9, 2011

Health care quality represents a constantly recurring theme in U.S. health policy. Traditionally, the Medicare program has paid for health care services on a fee-for-service basis with the exception of inpatient hospital services, which are paid based on Diagnosis Related Groups (DRGs) under the prospective payment system (PPS), and the Medicare Advantage and Prescription Drug plans, which are paid on a capitated basis. All payment systems tend to incentivize something; in the case of fee-for-service, it is indiscriminant increases in volume of services provided, while in case-based or capitation systems it is indiscriminant reductions in volume. The challenge is to promote both quality and value while also apportioning financial risk appropriately. Because Medicare has relied principally on a fee-for-service approach to payment for physician and other services (and even while hospital payments are case-based under the PPS, it does not discourage multiple admissions and readmissions), the program has experienced incredible growth in the volume of services. At the same time, Medicare lacks a program-wide and deliberate approach to promoting quality and value.

Value-Based Health Care Purchasing: Essential Health Benefits and State Health Insurance Exchanges

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on January 25, 2011

Bringing down the overall cost of health care while improving its quality for all Americans represents one of the central goals of health reform. Although reducing the number of people without health insurance will provide relief by curtailing much of the estimated $50 billion in annual cost-shifting onto the insured, the longer term challenges are more complex, because they involve structural change in how health care is organized, delivered, and paid for. Specifically, improving health care quality while reducing costs means doing two things simultaneously: moving away from a fragmented system oriented toward what has been termed a “piecework” approach to health care; and introducing new approaches that reward greater clinical integration and efficiencies aimed at creating equally effective but lower-cost care. To achieve these results, the concept of “value-based purchasing” has received increased attention.

Teaching Health Centers

Categories: Health Care Quality and Delivery System Reform, Workforce and Access

Posted on January 5, 2011

Strengthening and modernizing the health care workforce was a major goal of the Affordable Care Act. The ACA contains dozens of provisions related to health care workforce issues, including strengthening primary care, national workforce policy development, increasing the supply of health care workers, education and training of the workforce, and other supports and improvements to the existing workforce. This Implementation Brief focuses on teaching health centers (THCs), a new type of health care entity created by the ACA.

Update: Health Insurance Reforms and “Grandfathered Plans”

Categories: Health Care Quality and Delivery System Reform, Health Insurance

Posted on November 17, 2010

The health reform law establishes minimum federal standards, preserving states’ ability to require more stringent standards for insured plans.

Appeals of Claims for Benefits

Categories: Health Care Quality and Delivery System Reform

Posted on August 29, 2010

The right to a fair and impartial appeal when a group health plan or health insurer denies a claim would seem to be a basic matter of fairness. Historically, however, this has not been the case. Patient protections vary tremendously depending on the type of health insurance and federal and state legal requirements.

Bundled Payments – Medicaid Demonstration Project

Categories: Health Care Quality and Delivery System Reform, Medicaid and CHIP

Posted on July 7, 2010

The health reform law requires the Secretary of HHS to establish a Medicaid demonstration project “to evaluate integrated care around a hospitalization.” Specifically, this project aims “to evaluate the use of bundled payments for the provision of integrated care for a Medicaid beneficiary . . . with respect to an episode of care that includes a hospitalization . . . and for concurrent physicians services provided during a hospitalization.”

Comparative Clinical Effectiveness Research

Categories: Health Care Quality and Delivery System Reform

Posted on July 1, 2010

The recently enacted Patient Protection and Affordable Care Act (PPACA) builds on federal efforts to support and direct research comparing patient treatments.

Medicaid Accountable Care Organization Demonstration Project

Categories: Health Care Quality and Delivery System Reform, Medicaid and CHIP

Posted on June 27, 2010

The law introduces ACOs on a voluntary basis by directing the Secretary of Health and Human Services to establish a “Pediatric Accountable Care Organization Demonstration Project.” This demonstration project would authorize a participating state to allow certain qualified Medicaid providers to organize themselves into an ACO for the purposes of receiving incentive payments “in the same manner as an accountable care organization is recognized and provided with incentive payments” under the health reform law’s Medicare ACO pilot program. The Medicaid ACO demonstration, akin to the Medicare ACO pilot, is aimed at reducing expenditure growth and improving health outcomes.

Center for Medicare and Medicaid Innovation

Categories: Health Care Quality and Delivery System Reform, Implementation Update, Medicaid and CHIP, Medicare

Posted on May 13, 2010

Health reform establishes a Center for Medicare and Medicaid Innovation (CMI) and empowering and directing the CMI to “test innovative payment and service delivery models to reduce program expenditures under the applicable titles [Medicare and Medicaid] while preserving or enhancing the quality of care furnished to individuals under such titles.”

Health Information Technology – Adoption Incentives

Categories: Health Care Quality and Delivery System Reform, Health Information

Posted on May 3, 2010

The health reform law makes no major revisions to provisions of the American Recovery and Reinvestment Act (ARRA) of 2009 to move the nation toward a national health information policy and create incentives for the adoption and meaningful use of health information technology (HIT). However, because the adoption and use of HIT is foundational to the implementation of many aspects of health reform, this entry summarizes the key provisions of the 2009 law.

The Community Health Centers and National Health Service Corps Fund

Categories: Health Care Quality and Delivery System Reform

Posted on April 15, 2010

Permanently authorizes, and provides funding for, the Community Health Centers program and the National Health Service Corps.