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Bundled payments top list of 2013 ACA measures

Friday December 28, 2012
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The year 2013 looks to be a relatively quiet one regarding implementation of the Affordable Care Act.

In 2012, the ACA survived a challenge in the Supreme Court and the prospect of being overturned by a Republican presidential administration. In 2014, core measures such as the mandate to buy health insurance, the operation of exchanges for purchasing individual insurance policies and the expansion of Medicaid go into effect.

In the coming year, ACA-related headlines likely will focus on the looming changes in '14. Healthcare providers and consumers may notice only a few changes.

Most notably, the Centers for Medicare & Medicaid Services will implement a three-year, national pilot program to encourage hospitals, physicians and other providers to work together to improve the coordination and quality of patient care in the Medicare program. Under payment bundling, providers will be paid a flat rate for an episode of care rather than receiving payments according to the current, fragmented system in which each service or test or bundles of items or services are billed separately to Medicare.

For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a "bundled" payment that provides incentives to deliver healthcare services more efficiently while maintaining or improving quality of care. It aligns the incentives of those delivering care, and savings are shared between providers and CMS.

Participants will use one of four models of bundled payments: acute care only; hospitals, physicians and post-acute care providers, the broadest of the four models; post-acute care only; and expansion of a previous Medicare pilot program, the Acute Care Episode demonstration, in which a single prospective payment covers services provided by hospitals and physicians during an inpatient stay that involves certain orthopedic and cardiovascular procedures.

"Bundled payments may encourage providers to focus on delivering high-quality, efficient care," according to a January 2012 report by the Commonwealth Fund (www.commonwealthfund.org/Blog/2012/Jan/Bundled-Payment-for-Care-Improvement.aspx). "But they may inadvertently create incentives for providers to stint on providing appropriate care. To prevent this, payment levels must be carefully calibrated to ensure providers’ financial viability while providing incentives to reduce costs and safeguards to ensure high quality.

"If appropriately designed, bundled payments could support the goals of health reform by encouraging providers to consider not only the services they deliver but the overall efficiency, effectiveness and coordination of care patients receive across providers and settings. This broader notion of healthcare delivery could lead to improved quality and the reduced cost growth necessary to enhance the long-term sustainability of the health system."

For much more information about the bundled care pilot program, visit http://innovations.cms.gov/initiatives/bundled-payments/index.html.

Medicaid funding

In other changes to healthcare brought on by the ACA in the coming year, state Medicaid programs will receive expanded funding for coverage of preventive services in 2013. The obvious goal is to increase the number of lower-income patients who seek preventive care.

In a related effort, the ACA will cover funding for state Medicaid programs to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services. The funding is an effort to help primary care practices accommodate the expected influx of 7 million new Medicaid patients, according to Congressional Budget Office projections, in 2014.


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