Two Aca-related pilot programs are coming under fire
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HHS officials have no cause for alarm that the U.S. House of Representatives’ most recent repeal of the Patient Protection and Affordable Care Act will move beyond the House floor, but they may be worried that two pilot programs related to the law are drawing heavy criticism.
As House members debated and voted last week to overturn the reform law, HHS Secretary Kathleen Sebelius received one letter from the Government Accountability Office that questioned the legal basis of an $8 billion Medicare Advantage bonus plan, and another from Sen. Jay Rockefeller (DW.V.) that called for an end to a dual-eligible program that he helped draft.
In November 2010, the CMS indicated in a proposed rule for the law’s Medicare Advantage quality bonus program that bonus payments to Advantage plans would be waived and instead be determined under the terms of a national quality bonus payment demonstration project. Last week, GAO General Counsel Lynn Gibson wrote in a letter to Sebelius that HHS had failed to respond adequately to questions raised in a January GAO report.
“We remain concerned about the agency’s legal authority to undertake the demonstration,” Gibson wrote. She concluded the quality bonus demonstration has not met
two statutory requirements: to provide additional incentives to MA plans to increase the efficiency and economy of Medicare services; and to provide the CMS with the necessary information to determine if the demonstration’s changes in payment methods met that goal without compromising quality.
Brian Cook, a spokesman for the CMS, said in an e-mail that there is “longstanding precedent for this type of demonstration, with Republican and Democratic administrations using this authority in this way” and that the program will give MA plans incentives to improve quality for millions of seniors and people with disabilities.
Meanwhile, Rockefeller asked HHS to take “immediate steps” to halt the financial alignment initiative, an Affordable Care Act pilot program designed to test care-integration models that would improve outcomes and lower costs for those who qualify for both Medicare and Medicaid, or “dual eligibles.”
Rockefeller questioned the size and scope of the demonstration, noting that the CMS has indicated it will test two models—a capitated, managed-care model and a managed fee-forservice model—for up to 2 million dual-eligible enrollees. States, meanwhile, can seek approval to move an additional 1 million people in the demonstrations. “While it is clearly important to have an adequate sample size in order to evaluate demonstration programs, these changes appear to go far beyond what is necessary or appropriate in order to test new models of care,” Rockefeller wrote.
Chip Kahn, president and CEO of the Federation of American Hospitals, said that his group agreed with the senator’s concerns. “We think that these programs need to be tested to see whether on a larger scale they would provide the kind of savings from coordination that are being anticipated by the states,” Kahn said.
Cook said the CMS is “taking the input from Congress, MedPAC and other very seriously moving forward.”