The Affordable Care Act (ACA) included improvements to the Medicare programs. The guaranteed benefits under Medicare or Medicare Advantage have not changed. Instead, new benefits have been implemented that will provide cost savings for beneficiaries and increased focus on quality. The law also includes provisions aimed at delivering higher quality care at lower costs. New Medicare Benefits and Improvements •
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Annual Wellness Visit: Every Medicare beneficiary will receive this service during which the he can work with his physician to develop a personalized prevention plan. The plan will take a comprehensive approach to improving your health by better managing your condition and preventing disease. This will provide another opportunity for patients with liver disease to discuss how to best manage their condition with their primary physician as well what treatment he may be receiving from other physicians. This visit will be of no cost to the beneficiary. -‐ More information about the annual wellness visit and other preventive services covered by Medicare can be found here. -‐ As of January 2012, provisions were implemented for all patients to receive health risk assessments developed in coordination with their primary care physicians. Closing the Donut House: Since Medicare Part D prescription drug program was authorized, it has included a coverage gap, referred to as the “donut hole” in which Medicare stops paying the cost of the beneficiary’s drug coverage and the beneficiary is responsible for the full cost of the drugs. -‐ In 2010, all beneficiaries who reached the donut hole received a $250 rebate. -‐ Beneficiaries received a 50 percent discount on brand-‐name drugs, including biologics, and a 7 percent discount on generic drugs paid for out-‐of-‐pocket while in the donut hole in 2011. The discount will be gradually expanded to 75 percent by 2020, effectively closing the donut hole.
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org
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Improved Access to Primary Care Providers: Many patients report difficulties getting an appointment with a primary care physician as a result of the shortage of primary care physicians. This shortage is likely to be exacerbated as millions of Americans gain insurance coverage. To address this concern, the law provides 5 years worth of bonus payments to primary care physicians. Community-‐Based Care Transitions Program: The ACA created this 5 year program to provide funding to certain hospitals and select community-‐based entities that furnish evidence-‐based care transition services to Medicare beneficiaries at high risk for readmission, which includes patients suffering from forms of liver disease. Entities receiving funds will test models to improve patient transitions and their quality of care while documenting savings to the Medicare program. More information on the program can be found here.
New Care Delivery Models The ACA included provisions that would reform the delivery system that would improve the quality of care delivered to patients while reducing costs. A summary of these programs is below: • Medicare Shared Saving Program/Accountable Care Organizations (ACOs): On January 1, 2012, a shared savings program that promotes accountability for a patient population and coordinates items and services under Medicare Parts A and B was launched. Groups of providers and suppliers meeting the Secretary’s criteria can work together to coordinate care for Medicare FFS beneficiaries through ACOs; those ACOs meeting specified quality performance standards will be eligible to receive part of the shared savings. More information on the ACO program and where the ACOs have been established can be found here. • Pilot Program on Bundled Payments: The ACA established a national Medicare pilot program to develop and evaluate bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services and post-‐acute care services for an episode of care that begins 3 days prior to a hospitalization and spans 30 days following discharge. If the pilot program improves or does not reduce quality and reduces spending, a plan to expand the pilot will be developed. By October of this year, CMS plans on contacting interesting providers and providing information on bundled payment model definitions and other operational issues. CMS details the progress of this program’s development here.
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org
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Quality Reporting Programs: CMS is required to establish a hospital value-‐based purchasing program in Medicare to pay hospitals based on performance on quality measures and extend the Medicare physician quality reporting initiative. The legislation also extends the Physician Quality Reporting Initiative (PQRI) which requires physicians to report quality data. Plans to implement value-‐based purchasing programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers are also being developed. Creation of the Independent Medicare Advisory Board (IPAB): The Independent Medicare Advisory Board included as a mechanism to control costs in the Medicare program. CMS is required to determine whether the projected per capita growth rate for the program is set to exceed the target growth rate for a given year. When it is, the board is charged with developing a proposal with recommendations to reduce the growth in Medicare that must be implemented by the Secretary of Health and Human Services unless Congress enacts legislation that would alter the proposal. The recommendations of the board cannot ration health care, raise revenues, increase beneficiary premiums or cost sharing, or restrict the eligibility criteria for Medicare. The board may make recommendations to improve the health care delivery system, health outcomes, and beneficiary access to necessary and evidence-‐based items and services.
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American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org