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>>  1.1 Medicare's Sustainable Growth Rate (SGR)
  • Promote quality and value through an improved, enrollment-based version of accountable care organizations (ACOs) called "Medicare Networks," formed and governed by providers. Read More >>
  • Eliminate SGR and transition from FFS-based system to Medicare Comprehensive Care (MCC). Read More >>
  • Repeal and reform the SGR mechanism. Limit cost of reform to $245 billion over 10 years. Read More >>
  • Repeal and replace the SGR with a Medicare physician payment policy that provides incentives to improve health outcomes and participate in care system innovation. Read More >>
  • Eliminate the SGR formula and move from fee-for-service payment toward pay-for-value. Read More >>
  • Transition away from SGR and toward value-based systems of health care delivery and provider reimbursement (including patient safety initiatives, patient-centered medical homes, ACOs, episodic bundling and global payments, and value-based payment updates to Medicare's fee schedule). [page 12] [Medicare]
  • Reform the Sustainable Growth Rate (SGR) to move Medicare physician payment away from fee-for-service to a system that encourages coordinated care and quality; in the short-term, impose a modest reduction in reimbursement rates below a freeze and allow CMS to make certain budget-neutral adjustments aimed at improving care quality [page 19] [Medicare] Read More >>
>>  1.2 Medicare Payment Rates
  • Promote quality and value through an improved, enrollment-based version of accountable care organizations (ACOs) called "Medicare Networks," formed and governed by providers. Read More >>
  • Eliminate SGR and transition from FFS-based system to Medicare Comprehensive Care (MCC). Read More >>
  • Use competitive bidding for all health care products: (1) expand competitive bidding by 2014 for durable medical equipment, prosthetics, orthotics, and supplies nationwide; (2) extend competitive bidding by 2015 to medical devices, lab tests, advanced imagine services, and all other health care products; (3) extend competitively bid prices to Medicaid and all other government health programs. [page 4] [Medicare, Medicaid] Read More >>
  • Repeal and replace the SGR with a Medicare physician payment policy that provides incentives to improve health outcomes and participate in care system innovation. Read More >>
  • Eliminate the SGR formula and move from FFS payment toward pay-for-value. Read More >>
  • Accelerate efforts by private payers and Medicare to provide incentives to physicians and hospitals for meeting performance benchmarks compared to their peers, while accounting for case mix and socioeconomic status of their underlying populations; include benchmarks that continually drive improvement. [page 5] [Medicare, Medicaid, Private Payers, FEHBP] Read More >>
>>  1.3 Value-Based Purchasing
  • Promote quality and value through an improved, enrollment-based version of accountable care organizations (ACOs) called "Medicare Networks," formed and governed by providers. Read More >>
  • Eliminate sustainable growth rate (SGR) and transition from fee-for-service-based system to Medicare Comprehensive Care (MCC). Read More >>
  • By 2014, require all Medicaid managed care programs to use competitive bidding. Read More >>
  • Eliminate the SGR and move from FFS payment toward pay-for-value. Read More >>
  • Develop robust quality metrics that are designed to gauge progress in achieving the goal of value-based payment models. Read More >>
>>  1.4 Alternatives to Fee-For-Service Payment
  • Promote quality and value through an improved, enrollment-based version of accountable care organizations (ACOs) called "Medicare Networks," formed and governed by providers. Read More >>
  • Eliminate SGR and transition from FFS-based system to Medicare Comprehensive Care (MCC). Read More >>
  • Form "accountable care states" with global targets for all health care spending by both public and private payers. Read More >>
  • Repeal and replace the SGR with a Medicare physician payment policy that provides incentives to improve health outcomes and participate in care system innovation. Read More >>
  • Expand participation in CMS demonstrations and pilots by allowing rolling applications from providers. Read More >>
  • Within Medicare, adopt bundled payments for select conditions and procedures that encompass a set of well-defined services and have a relatively clear beginning and end point. [page 8] [Medicare] Read More >>
  • Establish a system where many providers are paid a fixed amount for a bundle of services or all of a patient's care; expand the Medicare Acute Care Episode (ACE) Demonstration program, and pay more and more providers under this type of model over time. [page 20] [Medicare]
>>  1.5 Medicare Advantage
  • Establish a standardized minimum benefit for Medicare Advantage (MA) plans—including all services covered by traditional Medicare, a cost-sharing limit to protect against catastrophic expenses, and slightly lower cost-sharing—and pay plans using a competitive pricing system. Read More >>
  • Require that MA per capita payment increase match that of Medicare Comprehensive Care (MCC) plans (GDP + 0%), or less if Medicare costs grow more slowly. [pages 20-21] [Medicare]
  • Require that MA per capita payment increase match that of Medicare Comprehensive Care (MCC) provider organizations (GDP + 0%), or less if Medicare costs grow more slowly. [pages 20-21] [Medicare]
  • Use competitive bidding for MA by basing the benchmark for private plans on their average bid by 2014. [page 6] [Medicare] Read More >>
  • With a "Medicare Essential" plan (a new Medicare option that provides more integrated, comprehensive benefits and better protection against catastrophic costs) in place, recalibrate MA plan payments based on the costs of a new Medicare Essential option; offer high-quality, low-cost MA plans and their enrollees shared savings to encourage plans to operate more efficiently and encourage beneficiaries to select the best plan for them. [page 27] [Medicare]
  • Implement the Medicare Payment Advisory Committee's (MedPAC) recommendation to empower the U.S. Secretary of Health and Human Services to vary cost-sharing based on evidence of a particular treatment's effectiveness. Read More >>
  • Disseminate best practices for global payment models, including those from MA and Medicaid managed care, to further support movement to global payments, including alignment of quality measures across the public and private sectors. [page 11] [Medicare, Medicaid, Private Payers, FEHBP] Read More >>
  • Consider making MA payments based on a "competitive bidding" system rather than a fixed rate, but only if such a system can be designed in a way that reduces costs without damaging quality. [page 20] [Medicare]
>>  1.6 Supporting Primary Care
  • Implement a standard program for person-focused Medicaid that includes support for capitated Medicaid managed care organizations as well as state-directed reforms that focus on particular components of care. Read More >>
  • Better coordinate care for beneficiaries eligible for both Medicare and Medicaid. Read More >>
  • Change payment of primary care to reward care management, coordination, and a team-based systemic approach to caring for patients under Medicare, Medicaid, other public programs, and private plans participating in health insurance exchanges. [pages 23-24] [Medicare, Medicaid, Private Payers, FEHBP] Read More >>
  • Eliminate the SGR formula and move from fee-for-service (FFS) payment toward pay-for-value. Read More >>
  • Expand Medicare, Medicaid, and private patient-centered medical home pilots to include more patients and providers. [page 7] [Medicare, Medicaid, Private Payers] Read More >>
  • Direct CMS to develop an improved physician-payment formula for the Medicare program that promotes participation in new models (such as accountable care organizations [ACOs] and patient-centered medical homes), encourages care coordination across multiple providers, prioritizes primary care, and reduces Medicare costs. This would be enforced by the potential to reinstate a rebased sustainable growth rate (SGR) if a new formula is not implemented. [page 19] [Medicare]
>>  1.7 Promoting High-Quality Care
  • Promote quality and value through an improved, enrollment-based version of accountable care organizations (ACOs) called "Medicare Networks," formed and governed by providers. Read More >>
  • Eliminate SGR and transition from FFS-based system to Medicare Comprehensive Care (MCC). Read More >>
  • Require health insurance exchanges and state employee plans to offer tiered insurance plans that designate providers with high quality and low costs for patients (at least one tiered product at the bronze and silver levels by 2016). Read More >>
  • Create new payment incentives and support for comprehensive primary care teams that focus on the highest-cost Medicare and Medicaid patients; extend incentives to the Federal Employees Health Benefits (FEHB) Program, the military health coverage programs (TRICARE and the Civilian Health and Medical Program of the Uniformed Services), the Veterans Health Administration, and other federal programs. [page 24] [Medicare, Medicaid, Private Payers, FEHBP] Read More >>
  • Apply immediate payment incentives for participation in quality and value incentives to the existing FFS pay schedule. Read More >>
  • Accelerate efforts by private payers and Medicare to provide incentives to physicians and hospitals for meeting performance benchmarks compared to their peers, while accounting for case mix and socioeconomic status of their underlying populations; include benchmarks that continually drive improvement. [page 5] [Medicare, Medicaid, Private Payers, FEHBP] Read More >>
  • Expand penalties for unnecessary hospital readmissions and avoidable complications ("never events"); expand the Hospital Readmissions Reduction Program to include more medical conditions and higher penalties on more types of providers. Work to calibrate penalties to adjust for patient demographics, types of condition, and timing of readmission. [pages 19-20] [Medicare]
>>  1.8 Prescription Drugs
  • Require all Medicare Advantage plans to include Part D prescription drug coverage by 2015. [page 45] [Medicare] Read More >>
  • Form "accountable care states" with global targets for all health care spending by both public and private payers. Read More >>
  • Incentivize state governments to increase generic drug utilization in Medicaid by allowing states to share in the savings generated when generic substitution increases. Read More >>
  • Use comparative evidence to set reimbursement rates at the time of coverage. Read More >>
  • Restore drug rebates for those on Medicaid by requiring them for dual eligibles who receive drug coverage through Medicare Part D; require manufacturers of these drugs to be responsible for the same 23.1 percent above average manufacturer price (AMP) rebate as in Medicaid, with the same additional rebate for price increases that exceeded the rate of inflation. [page 27] [Medicare, Medicaid]
>>  1.9 Graduate Medical Education
  • Graduate Medical Education (GME): Reduce the indirect medical education (IME) percentage add-on to inpatient hospital admissions from 5.5 percent to 3.5 percent. Read More >>
  • Form "accountable care states" with global targets for all health care spending by both public and private payers. Read More >>
  • - Modify scholarship and medical loan forgiveness programs to address the most acute workforce needs, including provider shortages in primary care specialties and in medically underserved geographic areas. [page 22] Read More >>
>>  1.10 Other Payment Reforms
  • Medicare Advantage: Implement a reinsurance system for Medicare Advantage (MA) by 2016, similar to system in place for Medicare Part D. [page 45] [Medicare] Read More >>
  • Use common performance measures and the MCC payment reforms to create a more straightforward pathway for Medicare to join in state-based financing reforms that have a "critical mass" of participants in a state including private plans, state/employee retiree plans, and Medicaid plans. [p. 32] [Medicare, Medicaid, Private]
  • Expand Medicare and Medicaid's ban on physician self-referrals by closing loopholes for in-office imaging, pathology laboratories, and radiation therapy (exception should apply to physicians who use alternatives to FFS payment). Read More >>
  • Accelerate payment policy innovations across federal and state public programs to stimulate change across the country and support local care system innovation. [page 25] [Medicare, Medicaid] Read More >>
  • Require Medicare to cover participation in the Diabetes Prevention Program (DPP) for eligible people with prediabetes. Read More >>
  • Give the Independent Payment Advisory Board (IPAB) expanded authority to change benefit design and reform cost-sharing rules and prevent IPAB from being restricted through special interest carve-outs. [page 21] [Medicare] Read More >>
Source: Katie Horton, J.D., M.P.H., R.N., Mary-Beth Malcarney, J.D., M.P.H., and Naomi Seiler J.D., George Washington University Department of Health Policy.