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>>  3.1 Encouraging Best Practices
  • The National Quality Forum should convene a group to create consensus metrics for commercial accountable care organizations (ACOs) and other integrated delivery systems. [page 86]
  • 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 >>
  • Promote shared decision-making in Medicare for high-cost conditions. Read More >>
  • Expand participation in CMS demonstrations and pilots by allowing rolling applications from providers. Read More >>
  • Disseminate information in both the public and private sectors on best practices for lowering hospital readmission rates. Read More >>
>>  3.2 Medicare/Medicaid Dual-Eligibles
  • Adopt a broad strategy to deliver Medicare and Medicaid services to dual-eligible individuals through a single program. [pages 97-101] [Medicare, Medicaid]
  • Transition the CMS Financial Alignment Demonstration for Medicare-Medicaid beneficiaries into a permanent dual-eligible aligned care initiative. Read More >>
  • Better coordinate care for beneficiaries eligible for both Medicare and Medicaid. Read More >>
  • CMS should insist on key beneficiary protections for the dually eligible throughout the implementation of state demonstrations. 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] Read More >>
>>  3.3 Quality Metrics
  • Align outcome-oriented performance measures across Medicare so that selection issues between Medicare Advantage (MA) and MCC can be detected. [page 21] [Medicare] 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 >>
  • Apply immediate payment incentives for participation in quality and value incentives to the existing FFS pay schedule. Read More >>
  • Develop robust quality metrics that are designed to gauge progress in achieving the goal of value-based payment models. Read More >>
>>  3.4 Patient and Consumer Engagement
  • 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 >>
  • For Medicare benefits, create an out-of-pocket maximum and reforms in copays similar to proposals by the Medicare Payment Advisory Commission (MedPAC) and other expert groups. 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 >>
  • Increase the use of bundled payments for hospital care and post-acute care to make it easier for patients and payers to compare and assess the total costs of care and quality for certain procedures and conditions (such as hip replacement surgery, appendectomy, or heart bypass surgery). [pages 24-25] [Medicare, Medicaid, Private Payers, FEHBP] Read More >>
  • Implement MedPAC's 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. Lift curbs on tiered cost-sharing in MA. An exceptions process should be developed. Read More >>
  • Allow MA plans to use tools that promote equality and value, such as using VBID incentives (insurance design that relies on clinical research and data on provider performance as the basis for offering incentives to consumers to use evidence-based treatments and services and to obtain care from providers with a demonstrated ability to deliver quality, efficient health care) to induce beneficiaries to choose high-performing networks, or varying their cost-sharing based on the clinical effectiveness and value of services. [page 17] [Medicare] Read More >>
>>  3.5 Price and Quality Transparency
  • Medicare Advantage: Replace the Medicare Plan Finder with a user-friendly, up-to-date Medicare open enrollment website that includes relevant pricing and benefit information for beneficiaries. Read More >>
  • Eliminate sustainable growth rate (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 >>
  • Provide better information on the benefits, safety, and cost of alternative high-cost medical treatment choices or technologies to inform decisions by patients and providers. [page 28] Read More >>
  • Implement MedPAC's 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 >>
  • Apply additional cost-sharing flexibility to the Medicare Shared Savings Program and the Pioneer Accountable Care Organization initiative to enable them to tier cost-sharing based on quality performance and the clinical effectiveness of services. [page 17] [Medicare] Read More >>
  • Direct CMS to study new ways to increase transparency of prices and quality. In the meantime, prohibit "gag clauses," require CMS to release Medicare and Medicaid data through a searchable database, and mandate public reporting of prices for routine services. [page 20] [Medicare, Medicaid]
>>  3.6 New Medicare Options for Beneficiaries
  • 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 >>
  • Offer Medicare beneficiaries a new "Medicare Essential" benefit option that provides more integrated, comprehensive benefits and better protection against catastrophic costs. Read More >>
  • Implement Medicare Health Rewards Program that provides small monetary incentives for Medicare beneficiaries to set and achieve health goals. Read More >>
  • Modify traditional Medicare benefits to allow tiered cost-sharing for providers, drugs, and services, provided that the modifications do not alter the overall actuarial value of Medicare for beneficiaries. [page 17] [Medicare] Read More >>
  • Consider one or more alternative Medicare benefit packages, either as a demonstration project or as alternative options for Medicare beneficiaries to choose. An alternative benefit package could merge Medicare Parts A, B, and D into a single benefit package, provide care coordination services, and offer lower cost-sharing to beneficiaries who use high-value providers and services; alternative packages could target certain high-cost beneficiaries in particular need of coordinated care. [page 20] [Medicare]
>>  3.7 Cost-Sharing and Premiums
  • Promote quality and value through an improved, enrollment-based version of accountable care organizations (ACOs) called "Medicare Networks," formed and governed by providers. Beneficiaries would have incentives to enroll, and normal fee schedule updates would be reserved for Medicare Network providers. Read More >>
  • Eliminate SGR and transition from FFS-based system to Medicare Comprehensive Care (MCC). Read More >>
  • Under a "Medicare Essential" plan (a new Medicare option that provides more comprehensive benefits and better protection against catastrophic costs), lower or eliminate deductibles and copayments for beneficiaries who register with a medical home or receive care from a care team. [page 27] [Medicare]
  • Implement MedPAC's recommendation to empower the Secretary of HHS to vary cost-sharing based on evidence of a particular treatment's effectiveness. Read More >>
  • Modify traditional Medicare benefits to allow tiered cost-sharing for providers, drugs, and services, provided that the modifications do not alter the overall actuarial value of Medicare for beneficiaries. [page 17] [Medicare] Read More >>
  • Consider one or more alternative Medicare benefit packages, either as a demonstration project or as alternative options for Medicare beneficiaries to choose. Read More >>
>>  3.8 Other Quality Improvement and Patient Engagement Proposals
  • 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 >>
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.