Health Reform Action Center

 

 Quality and Delivery System Reforms

The Affordable Care Act has put in place a wide variety of reforms set to improve the quality and delivery of health care; all with the goal of reducing its overall cost. The central thrust of these reforms is to move away from the current fee-for-service payment structure and work toward a more direct relationship between reimbursement and the provisions of care that improve health care outcomes.

Many of the quality and delivery system reforms are aimed at creating a health care system that is shaped predominantly by hospitals or large physician groups. As physicians organize themselves into increasingly larger groups, including ACA-supported patient-centered medical homes and accountable care organizations, they will invite in more sophisticated tools such as health information technology and acquire advanced management skills that will enable them to provide high quality care with increasing efficiency. Learn about where you fit in to each of the following initiatives below.

Accountable Care Organizations 

Strong Start 

CMMI Primary Care Projects 

Medicare Quality Measures 

Medicaid Quality Measures 

IPAB 

 

 Accountable Care Organizations

In an attempt to curb healthcare costs and broaden benefits, the ACA created Shared Savings Programs that calls for the creation of Accountable Care Organizations (ACOs). ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. The goal of coordinated care is to reduce Medicare costs by ensuring that patients receive the “right care at the right time”, avoiding unnecessary duplication of services and preventing medical errors.

Currently, the main thrust of Accountable Care Organizations is

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Strong Start

Funded by monies allotted to CMMI in the Affordable Care Act, ACOG joined the Department of Health and Human Services and the March of Dimes on Strong Start, a multi-faceted perinatal health campaign to reduce preterm births. Visit the Strong Start website.

Strong Start consists of two strategies. The first is a public-private partnership to reduce elective deliveries prior to 39 weeks through a public awareness campaign and quality improvement efforts. The campaign seeks to promote awareness, spread best practices and promote transparency through data collection.

The second is a funding opportunity to test innovative prenatal care approaches to reduce preterm births for women covered by Medicaid and at risk for preterm birth. CMMI offered grant funding for three evidenced-based maternity care service options:

  • Enhanced Prenatal Care through Centering/Group Visits - group prenatal care that incorporates peer-to-peer interaction in a facilitated setting for health assessment, education, and additional psycho-social support.
  • Enhanced Prenatal Care at Birth Centers - comprehensive prenatal care facilitated by teams of health professionals including peer counselors and doulas. Services include collaborative practice, intensive case management, counseling and psycho-social support.
  • Enhanced Prenatal Care at Maternity Care Homes - enhanced prenatal care including psychosocial support, education, and health promotion in addition to traditional prenatal care. Services provided will expand access to care, improve care coordination and provide a broader array of health services.

The window closed to apply for Strong Start funding on August 9, 2012.

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CMMI Primary Care Projects

The Affordable Care Act created the Comprehensive Primary Care (CPC) initiative, a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Run through CMS’ Center for Medicare and Medicaid Innovation (CMMI), Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients.

To date, over 500 primary care practices in 7 different localities are now participating in the CPC initiative, including the entire sate or localities in Arkansas, Colorado, New Jersey, New York, Ohio/Kentucky, Oklahoma and Oregon. Eligible practices in each market were invited to apply to participate and start delivering enhanced health care services in the fall of 2012. Practices were selected through a competitive application process based on their use of health information technology, ability to demonstrate recognition of advanced primary care delivery by accreditation bodies, service to patients covered by participating payers, participation in practice transformation and improvement activities, and diversity of geography, practice size and ownership structure.

The application process is closed for participation in the CPC initiative, but you can learn about more information about this effort to bolster the primary care workforce here.

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Medicare Quality Measures

The Affordable Care Act transformed the Medicare Physician Quality Reporting System (PQRS), created in 2006, from an experimental voluntary program that encouraged doctors to report on certain quality measures into a "pay for performance" infrastructure that will eventually result in reimbursement cuts to physicians that fail to participate. Congress and health policy experts are determined to relate physicians' pay to care that improves health care outcomes, not just the number of services a doctor provides.

The quality measures were developed by the National Committee for Quality Assurance (NCQA) and relevant medical societies. There are about 200 measures in today's program, including a number that are relevant to Ob-Gyns:

  • Do you give flu shots to your patients over age 50?
  • Do your patients get mammography screening?
  • Do your patients get antibiotic prophylaxis prior to surgery?
  • Do you order DXA for your patients over age 65?
  • Do you use HIT?
  • Do you counsel your patients to stop smoking?

Primarily due to small bonus payments, ob-gyn participation in this program has been very low, but a change from an incentive-based structure to one that penalizes non-participation places added emphasis to participation in PQRS. Currently, physicians who meet the mandated thresholds on quality measure reporting receive a 0.5% bonus to reimbursement rates in 2012, 2013, and 2014. Payments will be cut by 1.5% in 2015 and 2.0% in 2016 for physicians who don't participate, when all practices are required to participate.

To participate in the PQRS, individual eligible professionals may choose to report information on individual Physician Quality Reporting quality measures or measures groups using one of these four methods, reporting to:

  • to CMS on their Medicare Part B claims 
  • to a qualified Physician Quality Reporting registry
  • to CMS via a qualified electronic health record (EHR) product
  • or using the group practice reporting option (GPRO).

Eligible professionals who choose to report 2012 Physician Quality Reporting System individual measures should select at least three applicable measures to submit to attempt to qualify for a Physician Quality Reporting System incentive payment. Ob-Gyns can use this table for measures that an ob/gyn practice might be able to report. If fewer than three measures are reported, CMS will apply a measure-applicability validation process when determining incentive eligibility. There is also an option to report certain "measures groups" instead of reporting individual measures, but these groups would not be reportable for most ob/gyn practices.

For purposes of determining whether a group practice satisfactorily submits Physician Quality Reporting System quality measures data for 2012, each group practice selected to participate in the 2012 Physician Quality Reporting System GPRO will be required to report 29 quality measures. A practice must have at least 25 eligible providers to apply to CMS to participate using this option.

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Medicaid Quality Measures 

The Department of Health and Human Services (HHS) on Dec. 30, 2011, released the initial core set of 26 quality measures for adults enrolled in the Medicaid program. This initiative was established by the Affordable Care Act and complements the CHIP Quality Measures Program which also includes maternity care measures. The initial core set of measures, as well as future additions are to be used on a voluntary basis by state Medicaid agencies. States may institute reporting requirements on physicians treating Medicaid beneficiaries. To date ACOG Fellow Kim Gregory, MD serves on the Agency for Healthcare Research and Quality panel tasked with identifying measures. Women's health specific measures in the initial core set are:

  • Breast Cancer Screening,
  • Cervical Cancer Screening,
  • Chlamydia Screening in Women Ages 21 - 24,
  • Elective Delivery before 39 Weeks Gestation,
  • Antenatal Steroids,
  • Prenatal and Postpartum Care: Postpartum Care Rate

For a complete list of all initial core set measures, view the chart on pages 4 and 5 of the HHS release.

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IPAB 

The Affordable Care Act created the Independent Payment Advisory Board (IPAB) and charged it with keeping per capita Medicare spending in check, based on a growth-formula determined by the CMS Actuary. The Board is made up of 15 unelected officials, each with 6 year terms and a majority of whom must not be involved in providing health care. The Board has little Congressional oversight or judicial review, and no public accountability for its actions. Any Congressional changes to the Board’s recommendations must accomplish as least the same cost reduction goals and adhere to the same recommendation requirements. If Congress doesn’t act, the recommendations become law and are implemented on August 15 of each year.

  • The ACA outlined several different requirements to the types of cuts the Board can make, many of which skew toward putting a heavier burden on physicians:
  • IPAB isn’t allowed by to recommend payment increases where necessary.
  • The proposal cannot include rationing, raising revenues or premiums, increasing beneficiary cost-sharing, restricting benefits, or modifying eligibility criteria.
  • In its first five years, IPAB can only primarily recommend cuts to physicians; hospitals, nursing homes, and other providers are off the table.
  • Recommended cuts have to come from within Medicare, no outside sources of revenue.

Upon creation, IPAB is set develop its first recommendations in 2013, submit them in early in 2014, and take effect in 2015.

ACOG POSITION

ACOG strongly supports full repeal of IPAB as it can only lead to a decrease in physician reimbursement rates, especially during its first five years. IPAB will seriously undermine Congress’ role to provide transparency, fairness and stability in the health care delivery system. Medicare payment policy requires a broad and thorough analysis of providers and beneficiaries, and leaving these decisions regarding payment policy in the hands of an unelected, unaccountable governmental body with minimal Congressional oversight will negatively impact the availability of quality, efficient health care to Americans.

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Contact:

Government Affairs Staff 
Mailing Address:
PO Box 96920
Washington, DC 20090-6920
Phone (202) 863-2509
Fax (202) 488-3985
govtrel@acog.org