Health Care Reform: Impact on the
Audiology Profession
2012
Health Care Reform
The Patient Protection and Affordable
Care Act (ACA)
Audiologists need to be successful in showing
the value of our services.
WHY?
HOW?
WHEN?
ACA
• “On March 23, 2010, President Obama signed
•
the Affordable Care Act. The law puts in
place comprehensive health insurance reforms
that will roll out over four years and
beyond,….”
Audiologists will be increasingly paid for
patient outcomes (value-based purchasing)
rather than number of tests or number of visits
ACA
• Medicare’s current fee-for-service payment
•
systems, which pays on the basis of quantity
and consumption of resources, does not support
this vision for quality health care.
Value-based purchasing (VBP) aligns
payment more directly to the quality and
efficiency of care provided by rewarding
providers for their measured performance
across the dimensions of quality.
ACA
• Congress and Presidential Administrations over
•
the last 20 years have moved Medicare from
prospective payment systems to value-based
health care purchasing initiatives (paying for
results) rather than the number of tests or
services, regardless of outcomes.
The ACA sends a strong signal that QUALITY
will be a central driver of health care reform
changes.
ACA
• $75 million annually appropriated by the
ACA for quality measure development
between 2010 and 2014.
ACA
• In an environment that rewards value and
quality, attention to outcomes measurement
and improvement will be essential to the
success of organizations across the health care
system.
(Sennett, C., MD, PhD. American Health & Drug
Benefits; 2010-2011)
ACA
• Milliman’s Health Care Reform Briefing
contends that “restructuring the payment
system can motivate providers to perform,
and payers and patients to pay for, only
those procedures consistent with the best
evidence and the needs of the patient.”
(Cornett, B. S. ASHA; 8/3/2010)
ACA
Opportunities for Quality Outcomes
Measurement and Reporting
• Value-based purchasing creates pressure to
perform
• Performance must be quantifiable
• Development of metrics to measure all
facets of health care performance will be a
key element of the reform process and is
funded by reform legislation
ACA
• More robust measures of clinical quality and
outcomes will emerge, including:



Health outcomes and functional status of
patients
Management and coordination of care across
episodes of care and provider settings
Care transitions for patients across the
continuum of providers, health care settings, and
health plans.
ACA
• Prohibition against discrimination of providers
•
by health plans
The provider non-discrimination provision
reads in part: “A group health plan…or
individual health insurance coverage shall not
discriminate with respect to participation under
the plan or coverage against any health care
provider who is acting within the scope of that
provider’s license or certification under
applicable State law.”
ACA – MPFS
Examples of Quality Outcomes Measurement
& Reporting Today:
• Older systems of quality measurement will
be expanded, such as the Physician Quality
Reporting System (PQRS) formerly the
Physician Quality Reporting Initiative
(PQRI) introduced by CMS. PQRS will
become a requirement, that is, quality
reporting will no longer be an option.
ACA - MPFS
• In 2010, private-practice audiologists enrolled
•
as Medicare providers began to participate in
the Medicare Physician Quality Reporting
System.
PQRS is a voluntary program designed to
improve the quality of care to Medicare
beneficiaries. Private-practice health care
professionals who participate in PQRS by
reporting on approved quality measures are
eligible for a 0.5% incentive payment from
2012-2014.
MPFS
• The final 2012 Medicare Physician Fee
Schedule contains five audiology measures.
• Starting in 2015, eligible providers who do
not satisfactorily report on quality measures
will be subject to penalty
ACA
• Accountable Care Organizations (ACOs)
are a method of integrating local group
physician practices with other members of
the health care system and rewarding them
for controlling costs and improving quality.
• Hospitals, primary care doctors, specialists
and possibly even nursing homes and home
care agencies would collaborate in an ACO,
which would coordinate care and payment
for care of participating patients.
ACA
• Some compare the concept to a construction
contract with the ACO having the role of a
general contractor and providers that of
subcontractors.
• The theory is that there will be increased
communication among providers leading to
better care and less duplication of services,
such as laboratory tests, that will reduce overall
health care costs.
(Thompson, M. Post-Star; 4-11-2010)
ACA
Accountable Care Organization
Instead of paying individually for each visit or
medical procedure, Medicare or Medicaid
would pay a set periodic payment, regardless
of the amount of services, to the ACO, which
would pass along proportionate payments to
participating providers.
ACA
1. An ACO may provide services with in-house
2.
staff, or contract with other provider
organizations. An ACO may prefer to
contract with a single hearing entity rather
than separately with multiple hearing
organizations.
Audiology services might be incorporated
into diagnostic or rehab contracts, by
independent audiology contracts, or through
ENT practices that are ACO participants.
ACA - ACO
• ASHA submitted comments in response to the
proposed ACO regulations issued on April 7, 2011.
ASHA urged CMS to require ACOs to:



Make audiology services accessible to patients. CMS
responded that market forces will determine the need for
the range of services offered.
Allocate an equitable portion of shared savings to
audiologists. CMS stated that it does not have legal
authority to dictate how shared savings are distributed.
Encourage the use of telehealth services provided by
audiologists. In response, CMS announced that it is
preparing a separate incentive package, not limited to
ACOs, which includes telehealth services beyond what is
currently reimbursed under fee-for-service Medicare.
ACA
Providers will be paid for managing outcomes
rather than volume of visits. With emphasis on
functional status, and the need to show
efficiency – for AR the International
Classification of Functioning, Disability, and
Health (ICF) may be useful for understanding
and measuring health outcomes.
• See Gagné, J. & Jennings, M. B. (2011, July 05).
Incorporating a Client-Centered Approach to Audiologic
Rehabilitation. The ASHA Leader.
ACA
The International Classification of
Functioning, Disability, and Health (ICF)
provides a framework for structuring clinical
care to address increasing demands for
efficiently achieving functional outcomes.
ACA
“Bundled” Payments
Under a “bundled” payment model, providers
receive a single payment for a defined set of
services.
ACA
• Bundled payment models disincentivize
the use of those providers whose services
increase utilization and cost without adding
perceived value.
• Clinicians will be chosen for the “bundle”
who can produce results efficiently, and can
perform collaboratively.
ACA
Bundled Payment Initiative
Under National Health Reform
CMS seeking applications Oct.2011 – March 2012
• Model 1: Acute hospital stay only
• Model 2: Hospital stay + post-acute care associated with
•
•
•
the stay
Model 3: Post-acute care only
Model 4: Inpatient stay including all physician services,
etc.
Distinct from National Pilot Program by 1/1/13
ACA
Bundled Payment Goals
• Decrease cost of an acute episode and
associated post-acute care
• Foster quality improvement
• Stimulate development of new evidencebased knowledge
• Applicant agrees to 2 to 3% discount of
inpatient and other payment rates.
Pre-ACA
In summary, the Congressional Research Service
(CRS) prepared a report (2006) for Congress on
pay-for-performance in health care, noting:
• “Many health care industry leaders and policy
makers have joined the call to pay health care
providers different amounts based on
variation in the quality of their services as
determined through their achievement on quality
performance measures.”
Not a New Concept
The 2006 CRS report Pay-for-Performance in Health
Care opens with:
If a physician make a large incision with an operating
knife and cure it, or if he open a tumor (over the eye)
with an operating knife, and saves the eye, he shall
receive ten shekels in money.
If a physician make a large incision with the operating
knife, and kill him, or open a tumor with the operating
knife, and cut out the eye, his hands shall be cut off.
— Code of Hammurabi, c. 1750 B.C.
www.asha.org