Medicare, A View of the Program from the Inside Robert Bennett Physicians Regulatory Issues Team

1. Medicare, A View of the Program from the Inside Robert Bennett Physicians Regulatory Issues Team HBMA Fall Annual Conference September 12th, 2006 Las Vegas, NV

2. Agenda • Medicare 101 • Pay for Performance (P4P) • National Provider Identifier (NPI) • Medicare Administrative Contractor (MAC) • Part D experiences • Ways to access CMS

3. Medicare 101 • Centers for Medicare and Medicaid Services is BIG • Together the programs insure 1 in 4 Americans • Medicare • $345 Billion (2006) • Spends 1 in 3 health care dollars • Pays 1 billion claims per year to 1 million providers at an average cost of $1 per claim • Medicaid • $159 Billion • Is the money well spent? • US averages $6,423/person/year • 29 Industrialized nations average $1,764/person/year • The United Sates has 45.8 million uninsured, the other 29 industrialized nations have none. • Of 13 Industrial countries we rank 12th in delivering quality healthcare (Starfield JAMA July 26, 2000)

4. Medicare 101 • Part A • Hospital, Hospice, home health and SNF • CMS contracts with “fiscal intermediaries” to pay claims • Part B • Docs, Outpatient, Durable Medical Equipment (DME), Physical Therapy • CMS contracts with “carriers” to pay claims, DMERCs to pay • Part C • Medicare Advantage---much like a HMO • Part D • Prescription Drug Plan (PDP) • Parts A and B are merging into Medicare Administrative Contractors (MACs)

5. Agenda • Medicare 101 • Pay for Performance (P4P) • National Provider Identifier (NPI) • Medicare Administrative Contractor (MAC) • Part D experiences • Ways to access CMS

6. Why Pay for Performance?

7. Why Pay for Performance? International Health Spending per Capita 2002 U.S. ($5,267, 14.6%) Switzerland ($3,446, 11.2%) Turkey ($446, 6.6%) Canada ($2,931, 9.6%) U.K. ($2,160, 7.7%) Japan ($2,077, 7.8%) Mexico ($553, 6.1%) Poland ($654, 6.1%) Note: Because these data are based on Purchasing-Power Parity values, they will differ slightly from earlier values cited herein. Source: Adapted from Anderson, GF et al. (2005) Health Affairs And 16% of the population has no insurance at all

8. Why Pay for Performance? Age, Sex, Illness, Price adjusted TOTAL Medicare payment per non-capitated Medicare Enrollee, 1996 Source: Dartmouth Atlas of Health Care, 1999

9. Why Pay for Performance?

10. Why Pay for Performance? • 2006: You almost received a -4.5% decrease in Medicare’s Physician Fee Schedule, Congress ‘fixed’ it to 0% Feb 2006 with the Deficit Reduction Act. • 2007: -5.1% decrease in payment is slated for 2007 Physician Fee Schedule • Sustainable Growth Rate (SGR) formula (how Congress requires CMS to calculate physician payment) is ‘broken’ and requires annual ‘fixing’

11. CMS’ Strategies for P4P • Work through partnerships • Within CMS, Congress and MedPAC • With other agencies – Federal and State (AHRQ, FDA, NIH, CDC, VA, DoD, State Medicaid agencies) • With private sector partners – (Providers, professionals, and their associations, Quality alliances – AQA, HQA, NQF, IHI, SCIP, Accrediting bodies – JCAHO, NCQA, Vendors) • Measure quality and report comparative results • Develop and refine valid and reliable quality and efficiency measures • Comparative Reports to audiences via CMS’ “Compare” websites • Pay for performance – improve quality and avoid unnecessary costs • Reinforce CMS’ commitment to quality • Encourage avoidance of unnecessary costs • Provide greater financial support for those who are providing efficient care (higher quality per unit cost) • Encourage adoption of effective health information technology • Effective HIT contributes to higher quality, more efficient health care • Medicare Beneficiary Portal (Access to claims, deductibles, eligibility, enrollment, and personal data)

12. CMS’ P4P Demonstrations and Pilots • Hospital Quality Initiative (MMA 501(b)) • Part of HHS’ Nat. Quality Initiative • 10 quality measures, links reporting these measures to hospital discharge payment • Reporting is voluntary, those inpatient acute care hospitals that do not report will get a 0.4 percentage point reduction in their annual Medicare fee schedule update • 98.3% of eligible hospitals are complying • Heart attack (Acute Myocardial Infarction) • Was aspirin given to the patient upon arrival at the hospital? • Was aspirin prescribed when the patient was discharged? • Was a beta-blocker given to the patient upon arrival at the hospital? • Was a beta-blocker prescribed when the patient was discharged? • Was an ACE Inhibitor given to the patient with heart failure? • Heart failure • Did the patient get an assessment of his or her heart function? • Was an ACE Inhibitor given to the patient?  • Pneumonia • Was an antibiotic given to the patient within 4 hours of arrival? • Was the patient offered pneumococcal vaccination? • Was the patient's oxygen level assessed? • Thrombolytic agent within 30 minutes of arrival • PCI within 120 minutes of arrival • Smoking Cessation • Smoking Cessation • Comprehensive Discharge Instructions • Smoking Cessation • Appropriate Antibiotic • Blood culture before antibiotics • Surgical Infection Prevention • Prophylactic antibiotic within 1 hour of incision • Antibiotics D/Cd within 24 hours

13. CMS’ P4P Demonstrations and Pilots • Premier Hospital Quality Incentive Demonstration • improve the quality of inpatient care for Medicare beneficiaries by giving financial incentives to almost 300 hospitals for high quality • CMS is collecting data on 34 quality measures relating to five clinical conditions • performance publicly reported on CMS’s web site

14. CMS’ P4P Demonstrations and Pilots • Physician Group Practice Demonstration (BIPA 2000) • Ten 200+ physician practices nationwide • Practices can earn performance based payments after achieving savings in comparison to control group—began April 2005 • Medicare Care Management Performance Demo (MMA section 649) • Modeled on “Bridges to Excellence” Program • 3 year P4P demo for small/medium sized physician practices to promote health information technology adoption in AK, CA, MA, and UT • Medicare Health Care Quality Demonstration (MMA section 646) • 5 year demo to improve patient safety, reduce variations in utilization by using best practice guidelines

15. CMS’ P4P Demonstrations and Pilots • Physician-Hospital Collaboration Demo (PHCD) • MMA Section 646, announced Sept 6, 2006 • 3 year demo beginning 2007 to examine whether allowing hospitals to provide incentives for physicians to support better care can improve patient outcomes without increasing costs. • Hospital would be paid its usual inpatient rate for the patient’s care, but would pay to the physician a portion of the savings resulting from quality improvement and efficiency initiatives taken by the physician. • Payments only for documented, significant improvements in quality of care and savings in the overall costs of care. • Hospital must guarantee savings to Medicare (budget neutrality) • GAINSHARING@cms.hhs.gov. • http://www.cms.hhs.gov/DemoProjectsEvalRpts/

16. Physician Voluntary Reporting Program (PVRP) • Why should you participate in PVRP? • Represents the 1st step towards gathering info on the use of phy quality measures. • Phys who participate capture data about the quality of care provided to benes, which helps identify best practices • It starts with 16 quality measures, developed by physicians working with consensus organizations such as the AQA, NQF and the AMA Physician Consortium • Why now? • To assess your performance compared to other physicians through confidential reports. • As Congress contemplates revising the SGR there is interest in incorporating pay for reporting programs in such revision. • To make reporting straightforward, PVRP uses G codes (and when they become available, CPT II codes) on the claim form to pass data to CMS. Participation will give you the opportunity to ensure that your claims processor and office software can support this process. • Finally, your participation in PVRP now will help equip you with the experience to give CMS feedback on what works and what doesn’t in the new system.

17. Physician Voluntary Reporting Program (PVRP) • 16 Initial Measures • 7 measures for primary care measures • 2 for Emergency physicians • 2 for nephrologists • 5 for surgeons • Aspirin at arrival for acute myocardial infarction • Beta-blockers at arrival for acute myocardial infarction • Hemoglobin A1c control for diabetes • Low-density lipoprotein control for diabetes • High blood pressure control for diabetes • ACE inhibitors or ARBs for left ventricular systolic dysfunction • Beta-blockers for history of acute myocardial infarction • Falls assessment for elderly • Antidepressants for depression • Dialysis dose for ESRD • Hematocrit level for ESRD • Arteriovenous fistula for dialysis • Antibiotic prophylaxis for surgery • Thromboembolism prophylaxis for surgery • Internal mammary artery use for CABG • Pre-operative beta-blocker for isolated CABG

18. Physician Voluntary Reporting Program (PVRP)

19. Why Pay for Performance? • Medicare increasing focus on quality • P4P is here to stay - widespread support • Multiple demonstration projects underway / in development • Early results confirm improved quality outcomes using P4P • P4P can help preserve the Medicare trust fund

20. Agenda • Medicare 101 • Pay for Performance (P4P) • National Provider Identifier (NPI) • Medicare Administrative Contractor (MAC) • Part D experiences • Ways to access CMS

21. National Provider Identifier (NPI) background • Required by HIPAA Legislation - 1996 • Required for all electronic transactions • All HIPAA covered healthcare providers, whether they are individuals or organizations, must obtain an NPI for use to identify themselves in HIPAA standard transactions. • Once enumerated, a provider's NPI will not change. The NPI remains with the provider regardless of job or location changes. • HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans, must use only the NPI to identify covered healthcare providers in standard transactions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008. • Application online or in paper • Compliance Date is May 23, 2007, why wait? • NPI public use file?

22. National Provider Identifier (NPI) educational efforts • NPI Training Package • Consists of five powerpoint modules: General Information, Electronic File Interchange (EFI), Subparts, Data Dissemination and Medicare Implementation. • Modules currently available include: • Module 1: General Information • Module 2: Electronic File Interchange (EFI) • Module 3: Subparts • http://www.cms.hhs.gov/NationalProvIdentStand/04_education.asp#TopOfPage • CMS NPI Roundtable – September 26, 2006 2:00-3:30PM ET. • To participate, you may call 1-877-203-0044, pass code 4795739 • Where to go for questions: • If you bill a FI, NPIQuestionsfromFIBillers@cms.hhs.gov • If you bill a carrier, NPIQuestionsfromCarrierBillers@cms.hhs.gov • If you bill a DMERC, NPIQuestionsfromDMERCBillers@cms.hhs.gov • CMS NPI page www.cms.hhs.gov/NationalProvIdentStand • Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.

23. National Provider Identifier (NPI) cont • When applying for your NPI, CMS urges you to include your legacy identifiers, not only for Medicare but for all payers. If reporting a Medicaid number, include the associated State name. This information is critical for payers in the development of crosswalks to aid in the transition to the NPI. • The NPI is required prior to enrolling in Medicare • The 10-digit NPI replaces health provider identifiers in use today for all HIPAA standard transactions • Do not wait until May 23, 2007

24. Agenda • Medicare 101 • Pay for Performance (P4P) • National Provider Identifier (NPI) • Medicare Administrative Contractor (MAC) • Part D experiences • Ways to access CMS

25. Medicare Administrative Contractors (MACs) • Mandated by MMA Section 911 • Medicare Administrative Contractors (MACs) • Consolidate FIs and carriers • Single point of contact • Process both Part A and Part B claims • Reduce duplication of activities • Incentives for efficiency and quality service • All 23 contracts to be awarded by October 2011

26. Agenda • Medicare 101 • Pay for Performance (P4P) • National Provider Identifier (NPI) • Medicare Administrative Contractor (MAC) • Part D experiences • Ways to access CMS

27. Prescription Drug Benefit

28. Prescription Drug Benefit

29. Agenda • Medicare 101 • Pay for Performance (P4P) • National Provider Identifier (NPI) • Medicare Administrative Contractor (MAC) • Part D experiences • Ways to access CMS

30. Open Door Forums • Mandated by the Administrator and Secretary to give more access • 14 Open Doors: Physicians, Rural Health, Hospitals etc • Monthly conference calls which anyone can call in to CMS expert staff • Call Schedule and access numbers are on Open Door website accessible via www.cms.hhs.gov/opendoorforums • Does any other $800 Billion a year company put their CEO, COO on an unrestricted conference call with their customers? • Next Physician Open Door September 19, 2006 2pm EST

31. Practicing Physicians Advisory Council • Meets quarterly in Open Session Mandated by statute to advise the administrator on Practicing Physician issues • Recommendations go to Herb Kuhn(attends entire meeting) who runs the Medicare component of CMS • Anthony Senagore MD is Chair • ASP, RBRVS, Competitive Acquisition, Contractor Reform, Part D, NPI, etc • http://www.cms.hhs.gov/FACA/03_ppac.asp

32. Sign up for emails • http://www.cms.hhs.gov/apps/mailinglists/

33. Physician’s Regulatory Issues Team • Reviews Regs of concern to physicians • Represents the physician perspective on EMTALA, LEP, NPI, Recovery Audit Contractors, Fraud and Abuse, ASP, Rx Drug Benefit, Competitive Acquisition, etc. • Works on changing specific regs eg Anesthesia Post Op visit, PECOS, Podiatry physicals, MHTL, Anesthesia cart security How do you reach us? PRIT@cms.hhs.govwww.cms.hhs.gov/PRIT

34. Working at CMS on the PRIT PRIT@cms.hhs.gov robert.bennett@cms.hhs.gov 202-690-5907 http://www.cms.hhs.gov/physicians/prit/