Two Aca-re­lated pi­lot pro­grams are com­ing un­der fire

Modern Healthcare - - CONTENTS - Jes­sica Zig­mond

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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.”

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