/ en Fri, 25 Apr 2025 16:16:21 -0500 Thu, 13 Jun 24 08:35:50 -0500 /testimony/2024-06-13-aha-statement-energy-and-commerce-subcommittee-assessing-value-based-care <p class="text-align-center"><strong>Statement</strong></p><p class="text-align-center"><strong>of the</strong></p><p class="text-align-center"><strong>şÚÁĎŐýÄÜÁż Association</strong></p><p class="text-align-center"><strong>for the</strong></p><p class="text-align-center"><strong>Committee on Energy and Commerce</strong></p><p class="text-align-center"><strong>Subcommittee on Health</strong></p><p class="text-align-center"><strong>of the</strong></p><p class="text-align-center"><strong>U.S. House of Representatives</strong></p><p class="text-align-center"><strong>“Checking-In on CMMI: Assessing the Transition to Value-Based Care”</strong></p><p class="text-align-center"><strong>June 13, 2024</strong></p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the şÚÁĎŐýÄÜÁż Association (AHA) appreciates the opportunity to provide feedback on the transition to value-based care.</p><h2>THE ROLE OF ALTERNATIVE PAYMENT MODELS IN VALUE-BASED CARE</h2><p>Our members support the U.S. health care system moving toward the provision of more outcomes-based, coordinated care and are continuing to redesign delivery systems to increase value and better serve patients. The AHA appreciates the Centers for Medicare & Medicaid Services’ (CMS) continued efforts to develop innovative payment models to reward providers based on outcomes rather than patient volume. </p><p>Over the last 14 years, many of our hospital and health system members have participated in a variety of alternative payment models (APMs) developed by the Center for Medicare and Medicaid Innovation (CMMI). Some APMs have generated net savings for taxpayers while maintaining quality of care for patients.</p><p>While the movement to value holds tremendous promise, the transition has been slower than anticipated and more needs to be done to drive long-term system transformations. CMMI plays a critical role in ensuring that hospitals and providers are set up for success in the various models they deploy. But some of the CMMI models were designed with requirements that made implementation exceedingly difficult and success even more so.</p><p>There are principles that we believe should guide the development of APM design. These include:</p><ul><li><strong>Appropriate On-ramp and Glidepath to Risk.</strong> Model participants should have an adequate on-ramp and glidepath to transition to risk. They must have adequate time to implement care delivery changes (integrating new staff, changing clinical workflows, implementing new analytics tools, etc.) and review data prior to initiating the program.</li><li><strong>Adequate Risk Adjustment.</strong> Models should include adequate risk adjustment methodologies to account for social needs and clinical complexity. This will ensure models do not inappropriately penalize participants treating the sickest, most complicated and underserved patients.</li><li><strong>Voluntary Participation and Flexible Design.</strong> Model designs should be flexible, incorporating features such as voluntary participation, the ability to choose individual clinical episodes, the ability to add components/waivers and options for participants to leave the model(s).</li><li><strong>Balanced Risk Versus Reward.</strong> Models should also balance the risk versus reward in a way that encourages providers to take on additional risk but does not penalize those that need additional time and experience before they are able to do so. A glidepath approach should be implemented, gradually migrating from upside only to downside risk.</li><li><strong>Guardrails to Ensure Hospitals Do Not Compete Against Their Own Best Performance.</strong> Models should provide guardrails to ensure that participants are not penalized over time when they achieve optimal cost savings and outcomes performance. Participants must have incentives to remain in models for the long-term.</li><li><strong>Resources to Support Initial Investment.</strong> Upfront investment incentives should be provided to support organizations in their transition to value-based payment. For example, to be successful in such models, hospitals, health systems and provider groups must invest in additional staffing and infrastructure to support care delivery redesign and outcomes tracking.</li></ul><p>To ensure that these and other practical considerations are appropriately included in CMMI models, we believe the agency would benefit enormously from consulting an advisory group of hospital and health system leaders who are managing or have managed the kind of organizations that would be part of the models CMS is trying to build.</p><h2>TEAM PROPOSED PAYMENT MODEL</h2><p>On April 10, as part of the inpatient prospective payment system (PPS) proposed rule, the CMMI proposed a new mandatory payment model — Transforming Episode Accountability Model (TEAM) — that would bundle payment to acute care hospitals for five types of surgical episode categories: coronary artery bypass graft, lower extremity joint replacement, major bowel procedure, surgical hip/femur fracture treatment and spinal fusion. It would make acute care hospitals responsible for the quality and cost of all services provided during select surgical episodes, from the date of inpatient admission or outpatient procedure through 30-days post-discharge.</p><p>The AHA has significant concerns with the TEAM payment model. We are supportive of the Department of Health and Human Services Secretary’s goal of moving toward more accountable, coordinated care through new APMs. However, CMS is proposing to mandate a model that has significant design flaws, and as proposed places too much risk on providers with too little opportunity for reward in the form of shared savings, especially considering the significant upfront investments required. If CMS cannot make extensive changes to the model, it should not implement it at this time. To do so would make TEAM no more than a thinly disguised payment cut, as it fails to provide hospitals a fair opportunity to achieve enough savings to garner a reconciliation payment.</p><p>The proposal does not align with the principles we outlined above. For example, we have previously commented on the necessity for waivers to support care coordination, more gradual glidepaths to two-sided risk and reasonable discount factors to ensure financial viability. If anything, TEAM is a step backward with fewer waivers, shorter timelines to assume downside risk and more aggressive discount factors that make cost savings more challenging.</p><p>Moreover, the tremendous scope of this rule and its aggressive 60-day comment period made it challenging to fully evaluate and analyze the proposal and its significant impact on hospitals and health systems. The five types of surgical procedures proposed for inclusion in TEAM comprise over 11% of inpatient PPS payments in 2023 — a staggering amount that does not even include the outpatient payments that would be at risk as part of the model. While the AHA worked closely with our hospital and health system members to assess the potential impact of TEAM on the important work they do in caring for their patients and communities, the incredibly short comment period severely hampered our ability to provide comprehensive comments.</p><p>We strongly recommend that CMS make TEAM voluntary, lower the 3% discount factor and make several changes to problematic design elements.</p><h2>INCREASING ORGAN TRANSPLANT ACCESS PROPOSED MODEL</h2><p>Just four weeks after TEAM was proposed, CMS proposed another mandatory payment model for kidney transplants. The Increasing Organ Transplant Access (IOTA) model would test whether performance-based incentives or penalties for participating transplant hospitals would increase access to kidney transplants for patients with end-stage renal disease while preserving or enhancing quality of care, improving equitable access to kidney transplant care and reducing Medicare expenditures. The model would run for six years, beginning Jan. 1, 2025. Hospitals eligible for participation would include non-pediatric transplant facilities conducting at least 11 kidney transplants during a three-year baseline period. It is anticipated that 90 hospitals would be required to participate.</p><p>While we appreciate CMMI’s goals of increasing access to kidney transplants, we are again left questioning the model design elements and are concerned that the model as written may have unintended consequences by focusing so heavily on volume (namely sub-par matches). Also, as mentioned above, implementation of complex payment models requires significant time, resources and staffing on the part of hospital participants. But CMMI has proposed a start date of Jan. 1, 2025. Given the transformation that is already occurring nationally under provisions of the Organ Procurement and Transplantation Network Act, this aggressive timeline is untenable. Additionally, we are concerned that CMMI is again proposing mandatory participation. As mentioned in our principles, it is critical that organizations can assess whether models are appropriate to best serve the needs of their patients and communities. Therefore, participation should be voluntary.</p><h2>CONCLUSION</h2><p>Again, the AHA supports the health care system moving toward the provision of more accountable, coordinated care. We recognize the critical role CMMI plays in advancing innovative payment models. We have recommended principles that should guide the development of APM model design and are concerned that recent model proposals such as TEAM and IOTA are steps backwards. The AHA appreciates your efforts to examine these issues, and we look forward to working with you.</p> Thu, 13 Jun 2024 08:35:50 -0500 Hospital Value-based Purchasing /aha-transformation-talks/s2-ep6-leveraging-outcomes-based-data <div></div> <div> /* Banner_Title_Overlay_Bar */ .Banner_Title_Overlay_Bar { position: relative; display: block; overflow: hidden; max-width: 1170px; margin: 0px auto 25px auto; } .Banner_Title_Overlay_Bar h1 { position: absolute; bottom: 40px; color: #003087; /*background-color: rgba(255, 255, 255, .8);*/ width: 100%; padding: 20px 40px; font-size: 3em; /*box-shadow: 0 3px 8px -5px rgba(0, 0, 0, .6);*/ } @media (max-width:991px) { .Banner_Title_Overlay_Bar h1 { bottom: 0px; margin: 0px; font-size: 2.5em; } } @media (max-width:767px) { .Banner_Title_Overlay_Bar h1 { font-size: 2em; text-align: center; text-indent: 0px; padding: 10px 20px; } } @media (max-width:530px) { .Banner_Title_Overlay_Bar h1 { position: relative; background-color: #63666A22; } } /* Banner_Title_Overlay_Bar // */ /* center_body */ .center_body { /*margin-top:50px;*/ margin-bottom: 50px; 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padding: 0 5px; } /*.CenterCallout_a .CenterCallout_a_Wrapper p .CenterCallout_a .CenterCallout_a_Wrapper ul { display: none; }*/ } @media (max-width:991px) and (min-width:568px){ .CenterCallout_a CenterCallout_a_ul{ width: 75%; margin: auto; } } </div> <div> .Banner_Title_Overlay_Bar.TT_Banner img{ float: right; max-height: 250px; } .Banner_Title_Overlay_Bar.TT_Banner h1{ max-width:calc(100% - 225px); bottom:0px } @media (max-width:567px){ .Banner_Title_Overlay_Bar.TT_Banner h1{ display: inline-block; position: relative; max-width:calc(100% - 200px); } } @media (max-width:567px){ .Banner_Title_Overlay_Bar.TT_Banner h1{ display: inline-block; position: relative; max-width:100%; background-color: #f6f6f6 } .Banner_Title_Overlay_Bar.TT_Banner img{ float: none !important; margin: auto; display:block ; position: relative ; } } <header class="Banner_Title_Overlay_Bar TT_Banner"><img alt="Banner Image" src="/sites/default/files/2020-12/AHA_TT_thumbnail_300x173.jpg" /> <div> <h1 class="tth1">Leveraging Outcomes-based Data to Excel in a Value-based World</h1> </div> </header> </div> /* CntMenuSub */ .CntMenuSub{ margin:20px 0px; 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var path = url.split('/').slice(1, 2).join('/'); var pathreplace2 = path.replace(/-/g, " "); document.getElementById("CntMenuSubParentOnly").innerHTML =(pathreplace2); var y = document.getElementsByTagName("h1"); document.getElementById("CntMenuSubChildz").innerHTML = y[0].innerHTML; <div class="row"> <div class="col-md-6"> <div class="embed-responsive embed-responsive-16by9">View on YouTube.</div> <p>Sponsored by: <a href="https://www.3m.com/3M/en_US/health-information-systems-us/" target="_blank"> <img alt="3M Modal Logo" src="/sites/default/files/2022-09/Logo_3MModal_834x313.jpg" /> </a></p> </div> <div class="col-md-6 center_body"></p> <p class="center_Lead"></p>--> <p><strong>Today, it’s essential to provide nurses and other front-line caregivers with the tools to support clinical workflows while reducing cognitive burden associated with documentation and navigating digital health devices and platforms.</strong></p> <p>Simplifying clinical workflows and making caregivers’ jobs easier by deploying technologies like smart beds that can sense patients’ conditions and unified mobile communications and nurse call platforms can go a long way toward shaping whether nurses will be able to work smarter, not harder.</p> <p>Amid this shifting landscape, health care leaders are challenged to deliver a more connected, interoperable digital health ecosystem to collect information, improve nursing communications, and provide more time for patient engagement.</p> <li>xxxxxx</li> </ul>--> .TTreadmore{ font-weight: 700; margin-top:50px; } <p class="TTreadmore">Download the <a href="/system/files/media/file/2022/09/TTalks_S2-Ep06_Abstract_Handout.pdf" target="_blank">Episode Abstract</a> >></p> </div> </div> <div class="container-fluid row"> <div class="row"> <div class="col-md-12"> /* CalloutBorderWrapper - aka SponsorMarketoForm */ .CalloutBorderWrapper { background-color: ; padding: 5px 25px 20px 25px; border: solid 2px #307FE2; margin: 25px 100px 25px; } @media (max-width:640px){ .CalloutBorderWrapper { margin: 25px 0px 25px; } } .CalloutBorderWrapper h3 { margin: 10x 0 0 0; color: #555; font-size: .7em; text-transform: uppercase; font-weight: 400; letter-spacing: 3px; max-width: 200px; /* Custom for the copy length */ background-color: #fff; padding: 5px 15px; position: relative; top: -35px } .CalloutBorderWrapper h2 { color: #002855; } .CalloutBorderWrapper .CalloutBorderWrapperHolder { background-color: ; padding: 15px; display: inline-block; margin-bottom: 25px; } .CalloutBorderWrapperHolder form { margin: auto; } /* CalloutBorderWrapper - aka SponsorMarketoForm // */ <div class="cta--image-container CalloutBorderWrapper center_body"> <h3>Key Take Aways</h3> <p>Here is what our experts had to say:</p> .sp_CTA5_holder { margin-top:50px; border-bottom: solid 1px #555; padding-bottom: 50px; } .sp_CTA5_holder_last { border-bottom: solid 0px #555; } .sp_CTA5_holder >div{ overflow: auto; } .sp_CTA5_holder ul { list-style: none; /* Remove default bullets */ padding-left: 0px; margin-bottom: 25px; } .sp_CTA5_holder ul li { margin-bottom: 7px; line-height: 1.5em; } .sp_CTA5_holder ul li::before { content: " "; font-size: 1em; margin-right: 10px; display: inline-block; height: 12px; background-color: #d50032; width: 12px; position: relative; top: 0px; } .sp_CTA5_holder ul li { padding-left: 23px; text-indent: -23px; } .sp_CTA5_holder h2 { color: #002855; /*! line-height: 2em; */ font-size: 2.15em; margin: 0 0 15px 0; /*! font-size: 30px; */ } .sp_CTA5_holder h3 { color: #002855; line-height: 1em; font-size: 1.5em; margin-bottom: 25px; margin-top:5px; } .sp_CTA5_section{ margin-top: 25px } .sp_CTA5_ImgShadow { /*background-color:green;*/ /* just a visual */ text-align: center } .sp_CTA5_ImgShadow { padding-bottom:75px; /* must match the padding on the img*/ margin: 0px; } .sp_CTA5_ImgShadow img{ width: calc(100% - 35px - 15px); -webkit-box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); -moz-box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); position: relative; top: 75px; max-width: 490px; } @media (max-width:990px){ .sp_CTA5_ImgShadow img{ max-width: 350px;} } @media (max-width:990px){ .sp_CTA5_ImgShadow { padding-bottom:75px; /* must match the padding on the img*/ margin: 0px; margin-right: 40px } } <div class="sp_CTA5_section row"> <div class="col-sm-1"> </div> <div class="col-md-10"> <div><img alt="icon" src="/sites/default/files/2021-03/TT_Icon_Ep5_PatientJourney_150x150.png" /> <p>Address health disparities by collecting and using actionable data, including race, ethnicity, language and social determinants of health.</p> </div> <div><img alt="icon" src="/sites/default/files/2022-09/TT_Icon_S2Ep6_Partner_150x150.png" /> <p>Partner with community-based organizations to address societal factors influencing health outcomes.</p> </div> <div><img alt="icon" src="/sites/default/files/2021-02/TT_Icon_Ep3_Success_150x150.png" /> <p>Improve understanding of outcomes data across the care continuum, including post-acute care and other care settings.</p> </div> <img src="xxxx" alt="xxxx"> <p>xxxx</p> !--<ul> <li>xxxx</li> </ul>-- </div>--></div> <div class="col-sm-1"> </div> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-1"> </div> <div class="col-md-10 center_body"></p> <p class="center_Lead"></p>--> <h2>Speakers</h2> /* people */ .people { margin-top: 50px; } .people img:nth-child(1) { border-radius: 200px; -moz-border-radius: 200px; -webkit-border-radius: 200px; margin-bottom: 10px; max-width:200px; /* for Transformation Talks */ display:block; /* for Transformation Talks */ margin:auto; /* for Transformation Talks */ } .people img:nth-child(1):hover { opacity: .7 } @media (max-width:991px) { .people { margin: auto; } .people p { text-align: center } } .ci_profile { margin-bottom: 30px; display: block; } @media (max-width:991px) { .ci_profile { text-align: center } } .ci_profile p { margin: 0 0 7px 0 } .ci_profile_name { font-weight: 700; font-size: 20px; } p.ci_profile_name { font-size: 1.5em; } .ci_profile_title { font-style: italic; line-height: 1.3em } .ci_profile_company { font-size: 1em; } p.ci_profile_award { font-size: .8em; text-align:center; color:#55555599; font-weight: 700 } .ci_profile_social { width: auto; } .ci_profile_social i { padding-right: 25px; font-size: 20px } .ci_profile_social a:last-of-type i { padding-right: 0px; 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} } /* .people3 .rowEqual_768 // */ <div class="row people people4"> <div class="row rowEqual_768"> <div class="col-md-4 col-sm-4 ci_profile"><img alt="Baligh Yehia" src="/sites/default/files/2022-09/Baligh_Yehia_300x300.jpg" /> <p class="ci_profile_name">Baligh Yehia, MD, MPP, FACP</p> <p class="ci_profile_title">Senior Vice President, Ascension</p> <p class="ci_profile_company">President, Ascension Medical Group</p> <p class="ci_profile_award"> </p> <div class="ci_profile_social"> </div> </div> <div class="col-md-4 col-sm-4 ci_profile"><img alt="Eric Evenson" src="/sites/default/files/2022-09/Eric_Evenson_300x300.jpg" /> <p class="ci_profile_name">Eric Evenson</p> <p class="ci_profile_title">Director, Emerging Business</p> <p class="ci_profile_company">3M Health Information Systems</p> <p class="ci_profile_award"> </p> <div class="ci_profile_social"> </div> </div> <div class="col-md-4 col-sm-4 ci_profile"><img alt="Akinluwa (Akin) Demehin" src="/sites/default/files/2022-09/Akin_Demehin_300x300.jpg" /> <p class="ci_profile_name">Akinluwa (Akin) Demehin</p> <p class="ci_profile_title">Senior Director, Quality & Patient Safety Policy</p> <p class="ci_profile_company">şÚÁĎŐýÄÜÁż Association</p> <p class="ci_profile_award"> </p> <div class="ci_profile_social"> </div> </div> </div> </div> </div> <div class="col-md-1"> </div> </div> <div class="container-fluid CenterCallout_a"> <div class="row"> <div class="col-md-1"> </div> <div class="col-md-10 CenterCallout_a-Center"> <h4>Fuel Your Transformation</h4> <p>Health care leaders are more in need of innovative solutions than ever before. The <a href="/aha-transformation-talks">AHA Transformation Talks series</a> of video discussions among health care thought leaders offers insights to help hospital and health systems navigate health care’s new, disruptive environment and prepare for what’s next. Each 10-minute video in this series focuses on a transformational topic explored by the <a href="/environmentalscan" target="_blank">2021 AHA Environmental Scan</a> and SHSMD's <a href="https://www.shsmd.org/futurescan" target="_blank">Futurescan 2021-2026: Health Care Trends and Implications</a>. Explore the videos on this page for fresh ideas and best practices to guide you through this time of tremendous upheaval.</p> </div> <div class="col-md-1"> </div> </div> <div class="row"> <div class="col-md-1"> </div> <div class="col-md-10"> <div class="row rowEqual_768"> <div class="col-sm-4 CenterCallout_a_Holder CenterCallout_a-Center"> <div class="CenterCallout_a_Wrapper"><a href="/system/files/media/file/2022/09/TTalks_S2-Ep06_Abstract_Handout.pdf" target="_blank"><img alt="icon" class="CenterCallout_a_Icon" src="/sites/default/files/2020-11/Speech_Bubble_icon.png" /> </a> <h2 class="CenterCallout_a_SectionTitle"><a href="/system/files/media/file/2022/09/TTalks_S2-Ep06_Abstract_Handout.pdf" target="_blank">Abstract Overview</a></h2> <p>Read this abstract to learn about how current demands are impacting the health care workforce.</p> </div> </div> <div class="col-sm-4 CenterCallout_a_Holder CenterCallout_a-Center"> <div class="CenterCallout_a_Wrapper"><a href="https://insideangle.3m.com/his/podcast-post/how-value-based-care-does-and-doesnt-improve-health-equity/" target="_blank"><img alt="icon" class="CenterCallout_a_Icon" src="/sites/default/files/2020-12/Tools_icon.png" /> </a> <h2 class="CenterCallout_a_SectionTitle"><a href="https://insideangle.3m.com/his/podcast-post/how-value-based-care-does-and-doesnt-improve-health-equity/" target="_blank">Sponsor Podcast</a></h2> <p>How value-based care does (and doesn’t) improve health equity.</p> </div> </div> <div class="col-sm-4 CenterCallout_a_Holder CenterCallout_a-Center"> <div class="CenterCallout_a_Wrapper"><a href="/center/market-insights/leveraging-data/using-data-reduce-health-disparities-and-improve-health-equity" target="_blank"><img alt="icon" class="CenterCallout_a_Icon" src="/sites/default/files/2020-12/Documents3_icon.png" /> </a> <h2 class="CenterCallout_a_SectionTitle"><a href="/center/market-insights/leveraging-data/using-data-reduce-health-disparities-and-improve-health-equity" target="_blank">AHA Resources</a></h2> <p>Using Data to Reduce Health Disparities and Improve Health Equity.</p> </div> </div> <div class="CenterCallout_a_Wrapper"> <img alt="icon" class="CenterCallout_a_Icon" src="/sites/default/files/2020-12/Documents3_icon.png"> <h2 class="CenterCallout_a_SectionTitle">AHA Resources</h2> <p>xxxx</p> <ul> <li><a href="/">xxxx</a></li> <li><a href="/">xxxx</a></li> </ul> </div> </div>--></div> </div> <div class="col-md-1"> </div> </div> </div> <h3>Video Series Developed in Collaboration with:</h3> <a href="https://iprotean.com/"><img alt="iProtean VirtualEd" src="/sites/default/files/2022-04/Logo_iProtean_VirtualEd_834x313.jpg" /> </a> Thu, 15 Sep 2022 08:32:47 -0500 Hospital Value-based Purchasing <div class="col-md-10"> <h3><a href="/system/files/media/file/2022/09/readmissions-penalty-calculator-fy-2023-inpatient-final-rule_1.xlsx" target="_blank" title="Download the Hospital Readmissions Reduction Calculator Excel File.">Hospital Readmissions Reduction Program</a></h3> <h3><a href="/system/files/media/file/2022/09/medicare-operating-dsh-calculator-fy-2023-inpatient-pps-final-rule.xlsx" target="_blank" title="Download the Disproportionate Share Hospital Adjustment Calculator Excel File.">Disproportionate Share Hospital Adjustment</a></h3> <h3> </h3> </div> Tue, 06 Sep 2022 11:41:08 -0500 Hospital Value-based Purchasing /special-bulletin/2022-04-19-aha-summary-hospital-inpatient-pps-proposed-rule-fiscal-year-2023 <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) April 18 issued its hospital inpatient prospective payment system (PPS) and long-term care hospital (LTCH) PPS <a href="https://public-inspection.federalregister.gov/2022-08268.pdf" target="_blank">proposed rule</a> for fiscal year (FY) 2023. The rule proposes a 3.2% rate increase for inpatient PPS payments in FY 2023. However, when accounting for proposed changes to disproportionate share hospital (DSH) payments, outlier payments, the Medicare-dependent hospital (MDH) and low-volume adjustment (LVA) programs, and other policies, CMS estimates that inpatient PPS hospitals would actually see a net decrease of 0.3% from FY 2022 to FY 2023. Highlights of the proposals related to the LTCH PPS are covered in a separate Special Bulletin.</p> <div class="panel module-typeC"> <div class="panel-body"> <h3>  Key Highlights</h3> <p>   CMS’ proposed policies would:</p> <ul> <li>Increase inpatient PPS payment rates by 3.2% in FY 2023.</li> <li>Use FY 2018 and 2019 Worksheet S-10 data to determine the distribution of FY 2023 DSH uncompensated care payments. CMS also would use a three-year average of S-10 data for FY 2024 and beyond.</li> <li>Cut DSH payments by about $800 million, due partially to a decrease in the uninsured population.</li> <li>Decrease outlier payments by 1.8 percentage points. CMS states this is necessary to return to the target of paying 5.1% of inpatient PPS funds as outlier payments.</li> <li>End the Medicare-dependent hospital and low-volume adjustment programs, which expire on Sept. 30, 2022 under the law.</li> <li>Permanently apply a 5% cap on any decrease in a hospital’s area wage index. ď‚· Implement changes to the graduate medical education (GME) program, related to the calculation of full-time equivalent (FTE) caps.</li> <li>Apply measure suppressions to the Hospital Acquired-Condition (HAC) Reduction Program and most measures in the Hospital Value-based Purchasing (HVBP) program, resulting in neutral payment adjustments for FY 2023.</li> <li>Add 10 new measures to the inpatient quality reporting (IQR) program.</li> <li>Propose several policies intended to advance health equity.</li> <li>Seek several requests for information on measurement policy topics, maternal health, climate change and health equity, and payment adjustments for N95 respirators.</li> </ul> </div> </div> <h2>AHA TAKE</h2> <p>We are extremely concerned with CMS’ proposed payment update of only 3.2%, given the extraordinary inflationary environment and continued labor and supply cost pressures hospitals and health systems face.<strong> Even worse, hospitals would actually see a net decrease in payments from 2022 to 2023 under this proposal because of proposed cuts to DSH and other payments. This is simply unacceptable for hospitals and health systems, and their caregivers, that have been on the front lines of the COVID-19 pandemic for over two years now.</strong> While we have made great progress in the fight against this virus, our members continue to face a range of challenges that threaten their ability to continue caring for patients and providing essential services for their communities. See AHA’s full statement that was shared with the media <a href="/press-releases/2022-04-18-aha-statement-fy-2023-proposed-ipps-rule" target="_blank">here</a>.</p> <p>Highlights of the inpatient PPS rule follow.</p> <h2>FY 2023 IPPS PROPOSED CHANGES</h2> <h3>Inpatient PPS Payment Update</h3> <p>The proposed rule would increase inpatient PPS rates by a net of 3.2% in FY 2023, compared to FY 2022, after accounting for inflation and other adjustments required by law. Specifically, the update includes an initial market-basket update of 3.1%, less 0.4 percentage points for productivity required by the Affordable Care Act (ACA), and plus 0.5 percentage points to partially restore cuts made as a result of the American Taxpayer Relief Act (ATRA) of 2012.</p> <p>The ACA and ATRA adjustments would be applied to all hospitals. Additionally, hospitals not submitting quality data would be subject to a one-quarter reduction of the initial market basket and, thus, would receive an update of 2.43%. Hospitals that were not meaningful users of electronic health records (EHRs) in FY 2020 would be subject to a three-quarter reduction of the initial market basket and, thus, would receive an update of 0.88%. Hospitals that fail to meet both of these requirements would be subject to a market-basket update of 0.10%.</p> <p>The proposed increase in payment rates is offset by a 1.8 percentage point decrease in outlier payments, as well as other proposed policies and program expirations (e.g. DSH, LVA, MDH) resulting in a net decrease of $0.3 billion in FY 2023 compared to FY 2022.</p> <p>Table 1 below details the impact of proposed policies.</p> <img alt="Table 1L: Impacts of FY 2023 CMS Proposed Policies" data-entity-type="file" data-entity-uuid="3f39eb03-46c7-4386-b052-f4b4a6031e45" height="202" src="/sites/default/files/inline-images/table-1-image-4-19-22-ipps-bulletin.png" width="392" class="align-center"> <p>To approximate expected FY 2022 inpatient hospital utilization for rate-setting purposes, CMS proposes to use FY 2021 MedPAR claims and FY 2020 cost report data, as it ordinarily would have done. However, to account for the potential impact of COVID-19 on hospitalizations, CMS proposes several modifications to its calculations of MS-DRG relative weights and outlier fixed-loss amount.</p> <h3>Disproportionate Share Hospital (DSH) Payment Changes</h3> <p>Under the DSH program, hospitals receive 25% of the Medicare DSH funds they would have received under the former statutory formula (described as “empirically justified” DSH payments). For FY 2023, CMS estimates the empirically justified DSH payments to be $3.32 billion. The remaining 75% flows into a separate funding pool for DSH hospitals. This pool is updated as the percentage of uninsured individuals changes and is distributed based on the proportion of total uncompensated care each Medicare DSH hospital provides. For FY 2023, CMS estimates the 75% pool to be approximately $9.95 billion. After adjusting this pool for the percent of individuals without insurance, CMS estimates the uncompensated care amount to be approximately $6.54 billion. Total DSH payments are expected to decline by roughly $834 million compared to FY 2022.</p> <p>The agency proposes to use the two most recent years of audited data from Worksheet S-10 to determine the distribution of DSH uncompensated care payments for FY 2023. Specifically, CMS proposes using S-10 data from FY 2018 and 2019 cost reports. Additionally, for FY 2024 and beyond, CMS proposes to use a three-year average of the three most recent fiscal years for which audited data is available.</p> <p>In addition, beginning in FY 2023, CMS proposes to discontinue the use of low-income insured days as a proxy for uncompensated care for Indian Health Service and Tribal hospitals and establish a new supplemental payment.</p> <p>Finally, CMS proposes to revise the regulations related to the calculation of the Medicaid fraction of the Medicare DSH calculation. Specifically, CMS proposes to define “regarded as eligible” for Medicaid to include only patients who receive health insurance authorized by a section 1115 demonstration or patients who pay for all or substantially all of the cost of such health insurance with premium assistance authorized by a section 1115 demonstration where state expenditures are matched with federal Medicaid funds.</p> <h3>Area Wage Index</h3> <p>CMS makes several proposals in the rule around the area wage index, which adjusts payments to reflect differences in labor costs across geographic areas. First, the agency proposes to continue its low-wage-index hospital policy as established in the FY 2020 final rule. Specifically, for hospitals with a wage index value below the 25th percentile, the agency would continue to increase the hospital’s wage index by half the difference between the otherwise applicable wage index value for that hospital and the 25th percentile wage index value for all hospitals. As it has done previously, the agency would reduce the FY 2023 standardized amount for all hospitals to make this policy budget neutral.</p> <p>Second, to prevent large year-to-year variations in the wage index, CMS proposes to permanently apply a 5% cap on any decrease to a hospital’s wage index from the prior fiscal year. This would be applied in a budget-neutral manner.</p> <h3>Medicare Graduate Medical Education</h3> <p>Due to a court ruling related to the agency’s method of calculating direct GME payments to teaching hospitals when the weighted full-time equivalent (FTE) counts exceed the cap, CMS proposes to modify its policy related to FTE caps. Specifically, the proposed policy would address situations for applying the FTE cap when a hospital’s weighted FTE count is greater than its FTE cap, but would not reduce the weighting factor of residents that are beyond their initial residency period to an amount less than 0.5.</p> <p>CMS also proposes to allow an urban and a rural hospital participating in the same Rural Training Program (RTP) to enter into a RTP Medicare GME affiliation agreement, which would allow some flexibility to teaching hospitals that cross-train residents.</p> <h3>Medicare-dependent Hospital and Low-volume Adjustment Programs</h3> <p>Under statute, the low-volume hospital policy is set to revert to requirements that were in effect prior to FY 2011. Therefore, beginning in FY 2023, CMS proposes to revert and modify the definition of a low-volume hospital and the methodology for calculating the payment adjustment to statutory requirements. Additionally, the MDH program is set to expire at the end of FY 2022. As such, absent congressional action, hospitals that previously qualified for the MDH status will no longer have MDH status and will be paid based on IPPS federal rates beginning in FY 2023. The AHA is strongly <a href="/lettercomment/2022-04-11-aha-expresses-support-rural-hospital-support-act-s-4009" target="_blank">advocating</a> to make the enhanced low-volume policy and MDH program permanent.</p> <h3>Complication/Comorbidity and Major Complication/Comorbidity Analysis</h3> <p>In the FY 2022 IPPS proposed rule, CMS solicited comments on adopting a change to the severity level designation of the 3,490 “unspecified” diagnosis codes currently designated as either complication/comorbidity (CC) or major complication/comorbidity (MCC), where there are other codes available in that code subcategory that further specify the anatomic site, to a Non-CC for FY 2022. If approved, the change would have affected the severity level assignment for 4.8% of the ICD-10-CM diagnosis codes. Instead, for FY 2022 CMS finalized effective beginning with discharges on or after April 1, 2022, a new Medicare Code Editor (MCE) code edit for “unspecified” codes, to provide additional time for providers to be educated while not affecting the payment the provider is eligible to receive. For FY 2023, CMS is not proposing to change the designation of any ICD-10-CM diagnosis codes, including the unspecified codes that are subject to the “Unspecified Code” edit, as CMS continues its comprehensive CC/MCC analysis to allow stakeholders the time needed to become acclimated to the new edit.</p> <h3>Promoting Interoperability Program</h3> <p>CMS proposes a number of significant changes to the objectives and measures of the Promoting Interoperability Program starting with the calendar year (CY) 2023 reporting period:</p> <ul> <li>Increase the points associated with the Electronic Prescribing objective from 10 to 20 points, and make mandatory the query of prescription drug monitoring program measure, and expand it to include schedule II, III and IV drugs;</li> <li>Increase the points associated with the Public Health and Clinical Data Exchange objective from 10 to 25 points, and add a new required antimicrobial use and resistance surveillance measure;</li> <li>Reduce the points associated with the Health Information Exchange objective from 40 to 30 points, and add an optional attestation measure reflecting whether hospitals enable exchange under the Trusted Exchange Framework and Common Agreement (TEFCA);</li> <li>Reduce the points associated with the Provide Patients with Electronic Access to their Health Information from 40 to 25 points; and</li> <li>Adopt the same changes to the Promoting Interoperability Program’s electronic clinical quality measures (eCQM) measure set and required reporting proposed for the IQR program.</li> </ul> <h3>Hospital Quality Reporting and Value Programs</h3> <p>CMS proposes several significant policy changes intended to account for the impact of the COVID-19 PHE on its hospital quality reporting and value programs. The agency also proposes to add 10 new measures to the inpatient quality reporting (IQR) program, and to adopt several policies intended to advance health equity.</p> <ul> <li><u>Hospital Acquired-Condition (HAC) Reduction Program</u>. In last year’s inpatient PPS final rule, CMS adopted a COVID-19 measure suppression policy that permits the agency to not use quality measure data the agency believes have been distorted by the pandemic. Using this policy, CMS proposes to suppress all six measures in the HAC Reduction Program for FY 2023.<strong> As a result, no hospitals would be penalized under the HAC Reduction Program for FY 2023.</strong> However, CMS would continue to publicly report on hospital performance on the program’s healthcare associated infection (HAI) measures. CMS also proposes to suppress the program’s HAI measures for FY 2024, but would retain the claims-based Patient Safety Indicator (PSI) measure with technical changes intended to risk-adjust for COVID-19 diagnoses.<br>  </li> <li><u>Hospital Value-based Purchasing (HVBP) Program</u>. As it did for FY 2022, CMS proposes to suppress most of the HVBP program’s measures for FY 2023, including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures and five health care associated infection measures. As a result, CMS again believes it cannot calculate fair scores for hospitals nationally, and proposes that all hospitals would receive neutral payment adjustments under the VBP for FY 2023. Similar to last year, CMS also proposes to calculate and report HVBP measure scores publicly where feasible and appropriate.<br>  </li> <li>Hospital Readmissions Reduction Program (HRRP). For the FY 2024 HRRP, CMS proposes to resume scoring hospitals on the pneumonia readmissions measure that it suppressed for FY 2023. CMS would add the same COVID-19 diagnosis exclusion to the pneumonia measure that it adopted for the other five measures in the program. In addition, for all six measures in the HRRP, CMS proposes to include patient history of COVID-19 in the 12 months prior to the index hospitalization as a co-variate in the measures’ risk adjustment models.<br>  </li> <li><u>Inpatient Quality Reporting (IQR)</u>. CMS proposes to add 10 new measures to the IQR program. The measures and the period in which data collection and reporting would begin are listed below: <ul> <li>Hospital Commitment to Health Equity, a measure asking hospitals to attest to whether they are implementing certain health equity-related practices (CY 2023);</li> <li>Two “Social Drivers of Health” measures reflecting whether hospitals screen admitted patients for food insecurity, housing instability, transportation problems, utility needs and interpersonal safety (optional for CY 2023, required starting in CY 2024);</li> <li>Two perinatal care eCQMs reflecting the rates of Cesarean Births (CY 2023) and Severe Obstetric Complications (CY 2024)</li> <li>Two other eCQMs reflecting hospital performance on opioid-related adverse events and malnutrition (CY 2024) ;</li> <li>A patient-reported outcome performance measure (PRO-PM) reflecting functional recovery among elective total hip and knee replacement patients (optional July 1, 2023 – June 30, 2024, required July 1, 2024 – June 30, 2025);</li> <li>Updated versions of the Medicare Spending per Beneficiary and hip/knee complication measures currently used in the hospital VBP program (claims-based, starting with FY 2024 program years)</li> </ul> </li> </ul> <p>CMS also proposes refinements to its elective hip/knee replacement payment measure, and its excess days in acute care following acute myocardial infarction measure.</p> <p>Lastly, CMS proposes to increase the number of eCQMs required for reporting from four to six measures starting with the CY 2024 reporting period, which would affect payment in FY 2026. Hospitals would be required to report the proposed perinatal, and the previously adopted Safe Use of Opioids eCQM, while self-selecting three other eCQMs.</p> <ul> <li><u>Requests for Information</u>. The proposed rule includes several RFIs on several key measurement policy related topics -- guiding principles for health disparities measurement; approaches to advancing digital quality measurement; and how to use its policies and programs to address maternal health, including both quality measures and Medicare Conditions of Participation (CoPs).<br>  </li> <li><u>Proposed Maternal Quality Designation and Maternal Health RFI</u>. In conjunction with Vice President Harris’s Maternal Health Day of Action announcement in late 2021, CMS proposes to establish a publicly reported designation indicating hospital quality and safety for maternity care. Beginning in the fall of 2023, CMS would award this designation to hospitals that attest positively to both questions in the IQR’s previously adopted Maternal Morbidity Structural Measure. This measure asks whether a hospital (1) is currently participating in a structured state or national Perinatal Quality Improvement Collaborative and (2) implementing patient safety practices or bundles as part of these initiatives. CMS notes that it intends to propose in future rulemaking a more robust set of criteria for this designation, including other maternal health-related measures that may be finalized in the IQR program (such as the two proposed for adoption in this proposed rule).</li> </ul> <h3>Hospital Infectious Disease Data Reporting CoP for COVID-19 and Future PHEs</h3> <p>In 2020, CMS adopted a CoP requiring hospitals and critical access hospitals (CAHs) to submit certain data related to COVID-19 and other acute respiratory illnesses (i.e., influenza) to the Department of Health and Human Services (HHS). While the CoP was written to expire at the conclusion of the COVID-19 public health emergency (PHE), CMS suggests its need to monitor the impact of the pandemic could extend beyond the current PHE. In addition, the agency states that it and its federal partner agencies want a more permanent policy allowing it to collect data in the event of future PHEs involving infectious diseases.</p> <p>As a result, CMS proposes to revise the COVID-19 hospital data reporting CoP it adopted in 2020 so that hospital COVID-19-related reporting would continue after the conclusion of the current PHE through April 30, 2024, unless the HHS Secretary establishes an earlier end date. The broad data reporting categories proposed in the rule align with current reporting requirements. In addition, CMS proposes to establish a new CoP for future PHEs that would require hospitals and CAHs to report certain data to the Centers for Disease Control and Prevention in the event of a PHE declaration for an infectious disease.</p> <h3>Request for Information: Climate Change and Health Equity</h3> <p>As a byproduct of Executive Order 14008 on Tackling the Climate Crisis at Home and Abroad, the proposed rule includes a request for information (RFI) on how hospitals and other health care providers can better prepare for the impact of climate change on beneficiaries and consumers and how CMS can best support that work. The RFI specifically seeks comments on what HHS and CMS can do to help hospitals determine the impacts of climate change on their patients. Further, the agency seeks comment on how it can help providers better understand the threats of climate change on their health care operations, as well as what steps they can take to reduce emissions and track their progress.</p> <h3>Request for Information: Payment Adjustments for N95 Respirators</h3> <p>As a result of Executive Order 13987, “Organizing and Mobilizing the United States Government To Provide a Unified and Effective Response To Combat COVID–19 and To Provide United States Leadership on Global Health and Security,” CMS is seeking comments and feedback on the appropriateness of a payment adjustment to recognize the additional resource costs associated with acquiring NIOSH-approved surgical N95 respirators that are wholly domestically made. The agency is considering the payment adjustment for FY 2023 and beyond.</p> <h2>FURTHER QUESTIONS</h2> <p>CMS will accept comments on the IPPS proposed rule through June 17. The final rule will be published around Aug. 1, and the policies and payment rates will take effect Oct. 1. Watch for a more detailed analysis of the proposed rule in the coming weeks.</p> <p>If you have further questions, contact Shannon Wu, AHA senior associate director of policy, at 202-626-2963 or <a href="mailto:swu@aha.org">swu@aha.org</a>.</p> </div> <div class="col-md-4"> <p class="text-align-center"><strong><a class="btn btn-primary btn-wide" href="/system/files/media/file/2022/04/aha-summary-of-hospital-inpatient-pps-proposed-rule-for-fiscal-year-2023-bulletin-4-19-22.pdf">Download the PDF</a></strong></p> <p><a href="/system/files/media/file/2022/04/aha-summary-of-hospital-inpatient-pps-proposed-rule-for-fiscal-year-2023-bulletin-4-19-22.pdf" target="_blank"><img src="/sites/default/files/2022-04/image-aha-summary-of-hospital-inpatient-pps-proposed-rule-for-fiscal-year-2023-bulletin-4-19-22-510px.png"></a></p> <p> </p> </div> </div> </div> Tue, 19 Apr 2022 16:55:54 -0500 Hospital Value-based Purchasing /news/headline/2021-05-27-cms-proposes-delaying-certain-medicaid-value-based-drug-payment <p>The Centers for Medicare & Medicaid Services yesterday <a href="https://www.federalregister.gov/public-inspection/2021-11160/medicaid-program-establishing-minimum-standards-in-medicaid-state-drug-utilization-review-and">proposed</a> delaying Medicaid “best price” and “best price reporting” requirements for state value-based purchasing agreements with drug manufacturers until July 2022. The six-month delay also would apply to a requirement that drug makers include drugs sold in U.S. territories when calculating the best price. The requirements were included in a December 2020 CMS <a href="https://www.cms.gov/files/document/122120-cms-2482-f-medicaid-dur-ofr-master-webposting-508.pdf">final rule</a> on value-based drug payment. CMS will accept comments on the proposed rule through June 28. The Pharmaceutical Research and Manufacturers of America last week challenged portions of the final rule in federal court.</p> Thu, 27 May 2021 15:40:08 -0500 Hospital Value-based Purchasing /education-events/value-based-construction-next-evolution-health-care-facilities <div class="webreplay"> .webreplay{ border: solid 2px #777; padding: 15px 5px; margin: 0 0 10px 15px; } @media (min-width:360px){ .webreplay{ min-width: 290px; float: right; } } <h2><small>On-demand Webinar</small></h2> MktoForms2.loadForm("//sponsors.aha.org", "710-ZLL-651", 1247); </div> <p><strong>Value-Based Construction: The Next Evolution of Health Care Facilities </strong></p> <p><strong>Wednesday, June 23, 2021 </strong><br /> <em>1 - 2 p.m. Eastern; noon - 1 p.m. Central; 10 - 11 a.m. Pacific  </em></p> <p> </p> <p>Value-based health care continues to be key to enhancing health care across the nation. Improving outcomes and creating value for patients, providers and payers is an enormous paradigm shift, one that can change the fortunes of the American health care field and transform the lives of patients from coast to coast.  <br />  <br /> The next evolution of this paradigm shift is to extend the tenets of value-based care to health care facilities. Value-based construction (VBC), defined as applying value-based care principles to the way health care systems contract and complete construction work, can help control costs, maintain and improve facility performance, and deliver quality care through collaboration and data. </p> <p>Join Mark Kenneday, former ASHE president and Gordian’s director of healthcare market strategy and development, and Scott Creekmore Gordian’s vice president of healthcare as they explore a new approach that shifts away from the fee-for-service model of health care construction to a value-based model.  The approach focuses on a future where hospitals and health systems partner with contractors that help achieve their stewardship projects, where facilities costs are more transparent and budgets are firmer, and where they can consistently deliver the outcomes patients need. </p> <p paraeid="{b6667112-8aac-475a-8c39-cae1485c04e3}{173}" paraid="1773578828"><br /> <strong>Attendees Will Learn: </strong></p> <ul role="list"> <li aria-setsize="-1" data-aria-level="1" data-aria-posinset="1" data-font="Symbol" data-leveltext="ď‚·" data-listid="1" role="listitem"> <p paraeid="{c6db64f1-baef-45f1-b445-29434d0bea73}{7}" paraid="1797244649">A collaborative value-based approach to construction using data and software to create a more flexible and adaptable health care facility.  </p> </li> <li aria-setsize="-1" data-aria-level="1" data-aria-posinset="2" data-font="Symbol" data-leveltext="ď‚·" data-listid="1" role="listitem"> <p paraeid="{c6db64f1-baef-45f1-b445-29434d0bea73}{24}" paraid="1782204619">Alternatives to the fee-for-service model of construction.  </p> </li> <li aria-setsize="-1" data-aria-level="1" data-aria-posinset="3" data-font="Symbol" data-leveltext="ď‚·" data-listid="1" role="listitem"> <p paraeid="{c6db64f1-baef-45f1-b445-29434d0bea73}{37}" paraid="181667304">How verified construction procurement data can help control costs.  <br />  </p> </li> </ul> <p paraeid="{c6db64f1-baef-45f1-b445-29434d0bea73}{52}" paraid="1123075277"><strong>Speaker: </strong><br /> <br /> Mark Kenneday  <br /> <em>Director of Healthcare Market Strategy and Development   </em><br /> <strong>Gordian</strong><br /> <br /> Scott Creekmore<br /> <em>Vice President, Healthcare</em><br /> <strong>Gordian</strong></p> Mon, 03 May 2021 15:24:41 -0500 Hospital Value-based Purchasing /lettercomment/2020-07-20-aha-letter-cms-supporting-value-based-purchasing-vbp-drugs-covered <p>July 20, 2020</p> <p>The Honorable Seema Verma<br /> Administrator<br /> Centers for Medicare & Medicaid Services<br /> Hubert H. Humphrey Building<br /> 200 Independence Avenue, S.W., Room 445-G<br /> Washington, DC 20201</p> <p><strong><em>RE: Proposed Rule: CMS–2482–P, Medicaid Program: Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid (Vol. 85, No. 119), June 19, 2020</em></strong></p> <p>Dear Administrator Verma:</p> <p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the şÚÁĎŐýÄÜÁż Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed regulation related to supporting Medicaid drug value-based purchasing (VBP) arrangements and other changes to the Medicaid drug rebate program.</p> <p>If finalized, the proposed rule would grant states greater flexibility in developing VBP arrangements with drug manufacturers and health plans within the context of the Medicaid drug rebate program. In addition, the rule proposes to clarify certain issues related to how patient assistance programs should be accounted for in determining a drug manufacturers’ “best price” and how line extension drugs are defined within the context of Medicaid rebates.</p> <p>Lastly, the rule codifies several provisions required by legislation regarding the average manufacturer price of brand name drugs and safer prescribing of opioids. AHA’s comments will focus on the new VBP flexibility, patient assistance program clarification and line extension drug definition.</p> <p>The AHA strongly supports efforts to rein in the high cost of drugs. High and rising drug prices have created significant financial barriers for patients and the providers who care for them. The AHA supports innovations in drug purchasing arrangements, so long as these arrangements preserve or enhance patient access to critical medications and result in lower drug costs. However, we do not support financing arrangements that masquerade as innovation or increases in access but do nothing to reduce the underlying cost of drugs and, in fact, may increase drug spending over time.</p> <p>We appreciate CMS’s efforts to promote and encourage VBP arrangements to better align care and patient experience with reimbursement. Ideally, the core value of these arrangements focus on alignment, including eliminating waste; coordinating and streamlining care; and establishing risk/reward mechanisms to incentivize and encourage improvements in quality, patient experience and efficiency.</p> <p><strong>While we remain supportive of actions that would encourage VBP utilization generally, we must emphasize that the appropriate balance of risk and responsibility is critical.</strong></p> <p>The proposed rule provides a framework for state Medicaid programs, drug manufacturers, health plans and other stakeholders to consider appropriate models to achieve these objectives while not resulting in unintended negative consequences. These arrangements, while aspirational in ensuring best value for price, only will be effective in the long-term if they successfully provide increased value for patients. However, in this instance, it is unclear that the models discussed in the rule would achieve this value. In fact, they could enable drug manufacturers to rush drugs to market and increase — instead of reduce — costs without taking on any meaningful risk or committing to efforts that rein in unsustainable drug prices.</p> <p>In addition, these models place considerable burden on providers to track and report on outcomes, as well as to hold manufacturers accountable for returning any revenue in the event that a drug does not perform as promised.</p> <p>It is unclear how states will account for this burden, and we are deeply concerned that states would not be required to coordinate with providers before adopting such models. Should these data collection provisions be finalized, we expect the agency will ensure adequate mechanisms are in place to compensate providers in instances where drug manufacturers seek to access this data.</p> <p>Through the proposed rule, CMS seeks to encourage drug manufacturers to enter into VBP arrangements. Specifically, the proposed rule would define a VBP arrangement as one that aligns pricing and clinical outcome using evidence-based and outcomes-based measures. It would allow drug manufacturers to report multiple “best prices” for a therapy if the prices are tied to patient outcomes through VBP arrangements. In addition, the proposed rule would allow drug manufacturers to include VBP arrangements as part of a bundled sale. The agency determined that these two changes could remove existing barriers to VBP arrangements and therefore help facilitate broader adoption of VBP for pharmaceuticals.</p> <p>While we generally support VBP, we believe the specific proposals put forth in this rule <strong>require further consideration from the agency prior to finalization.</strong></p> <p>Specifically, we are concerned that the rebate provisions as drafted place intensive data collection and tracking requirements on providers. If finalized, providers would bear a significant portion of the burden of tracking patient outcomes, including those individuals who transition into and out of the Medicaid system, to determine if a rebate from the drug manufacturer is appropriate. In this instance, drug manufacturers may be encouraged to bring a drug to market with a “possible outcome,” but rely on providers to track whether or not that outcome is met. In addition to increasing provider burden, this model raises significant patient safety concerns by basing payment on prospective drug outcomes, not proven ones, with the potential for drug manufacturers to short-circuit the full review process.<sup><a href="#fn1">1</a></sup></p> <p><strong>We recommend the agency reexamine this approach. In its place, CMS should consider requiring drug manufacturers to demonstrate the outcome effectiveness of a drug prior to entrance into the market and receive payment based on that proven outcome. In instances where a drug proves to be more effective than initially demonstrated, the manufacturer should have the opportunity to demonstrate the increased benefit and reapply for payment that reflects the new outcome effectiveness.</strong></p> <p>The agency should also consider the fact that state Medicaid agencies and providers are at many different points along the transition to value, meaning that implementation of these provisions likely would result in the need to make significant changes to the care processes and policies currently in place to comply with existing regulatory structures.</p> <p>In addition, while states can choose to enter into VBP arrangements with drug manufacturers, CMS should carefully review the implications of these VBP arrangements on state Medicaid budgets as well as eligibility and enrollment policies. States are facing significant budget pressures resulting from the COVID-19-related economic recession. Considerable investment of Medicaid agency resources such as information technology systems and staff time will be required to effectively establish and manage these VBP arrangements yet state Medicaid programs currently are facing deep budget cuts.</p> <p>The adjustments made to the Medicaid rebate program to permit more flexibility for VBP arrangements could have the unintended effect of reducing state revenue by reducing the number of drugs for which state Medicaid agencies can claim rebates from drug manufacturers. CMS needs to better assess how these VBP arrangements may affect the state revenue derived from the Medicaid rebate program.</p> <p>Lastly, CMS needs to assess more fully how an individual’s participation in a VBP arrangement would be affected by that individual’s Medicaid eligibility status. Because Medicaid eligibility is largely based on income, an individual could lose their eligibility and access to covered treatment with a change in their income. This potential for enrollment churn could affect the proposed VBP arrangement that permits multiple “best prices,” since the manufacturer’s drug rebate to the state is individualized for each enrollee.</p> <p><strong>As CMS continues to pursue an increase in VBP opportunity, we urge the agency to consider the appropriate balance that must be struck to make these arrangements work effectively for the Medicaid program as well as throughout the health care delivery system.</strong></p> <p>The proposed rule also includes other important changes to the Medicaid drug rebate program. Specifically, the proposed rule addresses how patient assistance programs are to be counted in the manufacturers’ “best price” determination as well as propose a definition for line extension drugs for purposes of the Medicaid rebate formula.</p> <p>With regard to patient assistance programs, current regulations permit that the full value of patient assistance for non-Medicaid commercial plans be excluded from a manufacturers’ reported Medicaid “best price” as long as the full value of the assistance is passed on to the patient.</p> <p>Examples of patient assistance programs include drug discount cards, drug manufacturer coupons, copayment assistance, or patient rebate or refund programs. Concern has been raised regarding the role health plans and pharmacy benefit managers (PBMs) have played in managing patient assistance programs. In some cases, the health plans and PBMs have not passed on the full value of the assistance to the patient or consumer. CMS proposes to address these concerns by explicitly stating that a drug manufacturer’s patient assistance programs may only be excluded from the Medicaid “best price” reporting to the extent that the full value of the assistance is passed on to the patient.</p> <p><strong>The AHA supports CMS’s recommendation regarding how patient assistance programs should be accounted for in the Medicaid “best price” reporting.</strong></p> <p>In addition, CMS proposes a definition for line extension drugs for purposes of the Medicaid rebate program. The Affordable Care Act established an alternative rebate formula requiring that drug manufacturers pay a high rebate for line extension drugs by linking the line extension to the original drug. (A line extension drug is a new formulation of an existing drug such as an extended release formulation.) The agency, however, has never put forward a regulatory definition for line extension drugs. CMS has raised concerns that drug manufacturers were excluding some drugs from the definition of line extension drugs to avoid paying the higher rebate. To address this concern, CMS proposes to define a “new formulation” of a line extension drug as any change to the drug that contains at least one active ingredient in common with the original drug.</p> <p><strong>The AHA commends CMS’s efforts to improve the Medicaid drug rebate program through its proposed definition of line extension drugs.</strong></p> <p><strong>Lastly, we recommend that CMS extend the comment period beyond the current 30-day period. While the AHA supports CMS’s interest in promoting VBP arrangements to better align patient care with cost, stakeholders should have longer than 30 days to assess the implications of applying VBP arrangements for Medicaid drug coverage and purchasing.</strong></p> <p>These are new and complicated proposals that warrant more time for careful and thoughtful consideration.</p> <p>The AHA shares CMS’s goal to improve access to drug treatment for Medicaid beneficiaries that ensures safe and effective care. We look forward to working with CMS on these and other initiatives.</p> <p>Please contact me if you have questions, or feel free to have a member of your team contact Molly Collins, AHA’s director of policy, at <a href="tel:1-202-626-2326">(202) 626-2326</a> or <a href="mailto:mcollins@aha.org?subject=Question Regarding Proposed Rule: CMS–2482–P, Medicaid Program: Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid (Vol. 85, No. 119), June 19, 2020">mcollins@aha.org</a> or Mark Howell, AHA’s senior associate director of policy, at <a href="tel:1-202-626-2317">(202) 626-2317</a> or <a href="mailto:mhowell@aha.org?subject=Question Regarding Proposed Rule: CMS–2482–P, Medicaid Program: Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid (Vol. 85, No. 119), June 19, 2020">mhowell@aha.org</a>.</p> <p>Sincerely,</p> <p>/s/</p> <p>Ashley B. Thompson<br /> Senior Vice President of Public Policy Analysis & Development.</p> <hr /> <ol> <li id="fn1">Bach, Peter B. (July 6, 2020), <a href="https://www.healthaffairs.org/do/10.1377/hblog20200701.841730/full/" target="_blank">CMS’s Proposed Medicaid Best Price Loophole for Value-Based Purchasing of Drugs.</a> Health Affairs Blog.</li> </ol> Mon, 20 Jul 2020 13:32:16 -0500 Hospital Value-based Purchasing /special-bulletin/2020-06-19-cms-releases-proposed-rule-medicaid-drug-value-based-purchasing <div class="container"> <div class="row"> <div class="col-md-8"> <p class="text-align-center"><strong><a class="btn btn-primary btn-wide" href="/system/files/media/file/2020/06/cms-releases-proposed-rule-medicaid-drug-value-based-purchasing-arrangements-bulletn-6-19-20.pdf">Download the Special Bulletin:<br /> CMS Releases Proposed Rule on Medicaid Drug Value-based Purchasing Arrangements</a></strong></p> <p> </p> <p>The Centers for Medicare & Medicaid Services (CMS) June 17 released a <a href="https://www.govinfo.gov/content/pkg/FR-2020-06-19/pdf/2020-12970.pdf">proposed rule</a> that would grant states greater flexibility in developing value based purchasing arrangements with drug manufacturers and health plans within the context of the Medicaid Drug Rebate program. In addition, the rule proposes revisions to how drug manufacturers should calculate average manufacturer price (AMP) of brand name drugs and an approach to promoting safer prescribing of opioids and other medications, as required by legislation.</p> <p>The AHA will continue its review of the proposed rule and submit comments. <strong>Comments are due to CMS by July 20</strong>.</p> <p>Highlights of the proposed rule follow under key resources.</p> </div> <div class="col-md-4"> <div class="panel module-typeC"> <div class="panel-heading"> <h3 class="panel-title">Key Takeaways</h3> </div> <div class="panel-body"> <p>The proposed rule would:</p> <ul> <li>Provide states, drug manufacturers and health plans with flexibility to develop value-based purchasing arrangements.</li> <li>Require health plans to count drug manufacturers’ financial assistance programs in consumers’ deductibles.</li> <li>Provide guidance to state Medicaid programs and drug manufacturers on how to determine drug manufacturers’ financial assistance programs when calculating best practices and AMP.</li> <li>Implement congressional actions regarding how generic drugs are counted in a brand name drug’s AMP and standards for state drug utilization review programs.</li> </ul> </div> </div> </div> </div> </div> Fri, 19 Jun 2020 16:32:35 -0500 Hospital Value-based Purchasing /lettercomment/2019-09-09-aha-comments-cmss-cy-2020-home-health-prospective-payment-system-rate <p>AHA comments on Medicare and Medicaid Programs; CY 2020 Home Health Prospective Payment System Rate Update and CY 2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Home Infusion Therapy Requirements.</p> Mon, 09 Sep 2019 14:22:41 -0500 Hospital Value-based Purchasing <p>The Centers for Medicare & Medicaid Services (CMS) April 23 issued its hospital inpatient prospective payment system (PPS) and long-term care hospital (LTCH) PPS proposed rule for fiscal year (FY) 2020. The rule affects inpatient PPS hospitals, critical access hospitals (CAHs), LTCHs and PPS-exempt cancer hospitals. A summary of the proposals related to inpatient PPS hospitals, CAHs and PPS-exempt cancer hospitals is attached. The AHA issued a separate advisory on proposals related to the LTCH PPS. Comments on the proposed rule are due to CMS by June 24. The final rule will be published on or around Aug. 1 and take effect Oct. 1.</p> <p><strong>Our Take:</strong><br /> We are pleased that CMS has increased the new technology add-on payment rate, including for CAR-T therapies. Hospitals and health systems have been taking on this financial burden to ensure access to these life-saving treatments for patients, and while this proposal is not a permanent solution, it will help in the short-term. We also are strongly supportive of the proposed 90-day reporting period for attestation for the Promoting Interoperability Programs, a move that will reduce regulatory burden on hospitals. In addition, the AHA appreciates CMS’s recognition of the wage index’s shortcomings. At the same time, improving wage index values for some hospitals – while much needed – by cutting payments to other hospitals, particularly when Medicare already pays far less than the cost of care, is problematic. CMS has the ability to provide needed relief to low-wage areas without penalizing high-wage areas.</p> <p><strong>Key Takeaways:</strong><br /> CMS proposes policies to:</p> <ul> <li>Increase inpatient PPS payments by 3.2 percent in FY 2020.</li> <li>Use a single year of uncompensated care data from Worksheet S-10 to determine the distribution of Disproportionate Share Hospital uncompensated care payments for FY 2020.</li> <li>Increase the new technology add-on payment from 50 percent to 65 percent of the marginal cost of the case.</li> <li>Increase the wage index values for those hospitals with a wage index below the 25th percentile and decrease the wage index values for those hospitals with a wage index above the 75th percentile.</li> <li>No longer include wage index data from urban hospitals that reclassify as rural when calculating each state’s rural floor.</li> <li>Implement a reporting period of a minimum of any continuous 90 days for the calendar year 2021 reporting period for the Promoting Interoperability Programs.</li> <li>Replace the claims-only hospital-wide readmission measure in the Inpatient Quality Reporting program with a hybrid hospital-wide all-cause readmissions measure.</li> </ul> Wed, 15 May 2019 11:08:13 -0500 Hospital Value-based Purchasing