Healthcare Reform and Pain Management

Las Vegas—To adapt to the new healthcare environment, providers must embrace technology, quality measures, and collaboration. The rules are designed to make providers more accountable, lower the rapidly rising costs, and ensure patients receive the care they need, according to a session at the AAPM meeting titled What Health Care Reform Means to Pain Practitioners. Linda Van Horn, MBA, president and chief executive officer of 21st Century Edge, a healthcare consulting firm, began with an overview of the 3 main pieces of legislation that she believes will impact the healthcare industry. The American Recovery and Reinvestment Act, signed in February 2009, included the Health Information Technology for Economic and Clinical Health Act. On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA). And on March 30, 2010, the ACA was modified with the Health Care and Education Reconciliation Act. “In times of rapid change, our experience could be our worst enemy,” Ms. Van Horn said. “We’re making a quantum leap [with the healthcare reform legislation].” The first changes occurred on September 23, 2010, with the coverage of preventive services and immunizations, the elimination of preexisting condition exclusions for children, and the removal of restrictions on lifetime limits on coverage. Also, on December 30, 2010, a Web site was launched to provide users an opportunity to search for a physician by their specialty area, zip code, name, sex, and language. Ms. Van Horn also said that the Web site will eventually feature a comparison and ranking of physicians based on quality measures. In addition, from January 1, 2011, through December 31, 2016, the legislation provides a 10% bonus (paid monthly or quarterly) for primary care providers who charge ≥60% of total charges for office, nursing home, or home visits to Medicare. Primary care providers encompass family medicine, internal medicine, geriatrics, pediatric physicians, nurse practitioners, clinical nurse specialists, and physician assistants. During that same time period, general surgeons in Health Professional Shortage Areas are eligible for a 10% bonus (paid monthly or quarterly) for furnishing major procedures, defined as those with 10- to 90-day global periods. There are also incentives for adopting electronic health records (EHRs). For instance, the Medicare EHR incentive program allows providers who implement EHRs by 2012 to receive a maximum of $44,000 over a 5-year period: $18,000 in the first year, $12,000 in the second year, $8000 in the third year, $4000 in the fourth year, and $2000 in the fifth year. The payments are based on 75% of the Medicare Part B billings during a year; to be eligible for the $18,000 in the first year, the providers must accumulate $24,000 in Medicare charges. The Medicaid EHR incentive program is for nonhospital-based physicians who have ≥30% of their patient volume from Medicaid patients, although pediatricians are eligible if they have ≥20% of their patient volume from Medicaid patients. They can receive a maximum of $63,750 paid over 6 years. Physicians can receive the Medicare or Medicaid EHR incentive, but they are not eligible to earn both payments. Ms. Van Horn said the legislation also makes changes to the Health Insurance Portability and Accountability Act (HIPAA). For instance, EHRs must account for all disclosures of patient data, including treatment, payment, and healthcare operations, which were all previously exempt under HIPAA. Under the new HIPAA rules, patients must be notified of any privacy breach, and the media must be notified of any privacy breach involving >500 patients. Another quality measure is the value-based payment modifier, which provides differential payments to physicians based on their quality of care to Medicare beneficiaries. The modifier will begin in 2015 based on data recorded in 2014. In addition, the Physician Quality Reporting Initiative (PQRI) was implemented on January 1, 2011. If physicians report on quality measures, they are eligible to receive an incentive payment of 1.0% of their total estimated Medicare Part B physician fee schedule allowed charges for covered professional services. By January 1, 2016, physicians are required to report on PQRI measures or face a penalty equal to 2.0% of their Medicare Part B allowed charges. Ms. Van Horn also discussed accountable care organizations (ACOs) that focus on quality, costs, and efficiency. The proposed rules on ACOs were issued on March 31, 2011, but the final rules had not been determined as of late September, when Ms. Van Horn spoke. ACOs are scheduled to begin on January 1, 2012. Providers will be incentivized to work together to treat patients, and participants in ACOs will share in the savings they produce. To be eligible for cost-sharing, ACOs are required to demonstrate high-quality care. The proposed ACO rules include 65 quality measures in 5 domains: patient experience of care, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. Each of the domains will be equally weighted, according to Ms. Van Horn. The legislation includes other initiatives that encourage collaboration among providers. On January 1, 2013, the Department of Health and Human Services (DHHS) will begin a 5-year voluntary pilot program on bundling inpatient and outpatient hospital care. DHHS will select 10 chronic, acute, surgical, or medical conditions for the pilot program. DHHS defined an episode of care as providers receiving 1 payment for 3 days before a patient admission to 30 days after a patient is discharged from the hospital. According to Ms. Van Horn, bundling will help providers to work together and reward quality of care instead of volume of care. The legislation also created a nonelected Independent Payment Advisory Board (IPAB) that can recommend proposals to limit Medicare and healthcare spending growth. By January 1, 2014, the board will be required to submit advisory reports on Medicare spending to Congress. Ms. Van Horn said the board has the power to make binding Medicare policy and cost reduction decisions, but their private payer policy recommendations are nonbinding. She also mentioned that by July 1, 2014, the board will create a report pertaining to healthcare costs, patient access to care, and utilization and quality of care compared by region, types of care, and types of providers. The report will be submitted annually. In addition, on January 15, 2015, and every 2 years afterward, the board will submit recommendations on slowing health expenditures. The IPAB will also set reimbursement rates for physicians, according to Ms. Van Horn. She hypothesized that the IPAB will implement a new payment methodology based on packaging, bundling, quality, pay for performance, and episodes of care.