Health Care on the Hill: Week of November 11, 2013

Wednesday, October 13, 2013

9:30 a.m.
ObamaCare Implementation: The Rollout of Healthcare.gov
House Oversight and Government Reform Committee Hearing
2154 Rayburn House Office Building

10:00 a.m.
Cyber Side-Effects: How Secure is the Personal Information Entered into the Flawed Healthcare.gov?
House Homeland Security Committee Hearing
311 Cannon House Office Building

10:00 a.m.
Budget Conference Committee Meeting
1100 Longworth House Office Building

Thursday, October 14, 2013

10:00 a.m.
The Effects of the Patient Protection and Affordable Care Act on Schools, Colleges, and Universities
House Education and the Workforce Committee Hearing
2175 Rayburn House Office Building

10:00 a.m.
Obamacare Implementation Problems: More than Just a Broken Website
House Energy and Commerce Subcommittee on Health Hearing
2322 Rayburn House Office Building

10:00 a.m.
Self-Insurance and Health Benefits: An Affordable Option for Small Business?
House Small Business Subcommittee on Health and Technology Hearing
2360 Rayburn House Office Building

Friday, November 15, 2013

10:00 a.m.
Reviewing FDA’s Implementation of FDASIA
House Energy and Commerce Subcommittee on Health Hearing
2322 Rayburn House Office Building

Senate Democrats Announce 2014 Schedule

Senate Democratic leadership released their 2014 schedule on Thursday. The Senate is slated to begin the second session of the 113th Congress on January 6, 2014 and an adjournment date has not been set.

The proposed schedule is listed below, but is subject to changes and adjustments. There will likely be additional state work time around the midterm elections.

January 6, 2014: Convene
January 20 – 24: State Work Period (Martin Luther King Jr. Day)
February 17 – 21: State Work Period (Presidents’ Day)
March 17 – 21: State Work Period
April 14 – 25: State Work Period (Passover and Easter)
May 26 – May 30: State Work Period (Memorial Day)
June 30 – July 4: State Work Period (Independence Day)
August 4 – September 5: State Work Period (Labor Day)

Administration Releases Additional Guidance on Third-Party Payers

Since the establishment of the health insurance exchanges, there has been the lingering question of whether some so-called third-party payers (such as hospitals, health care providers, and commercial payers) would be permitted to assist with an individual’s premiums and/or other cost-sharing obligations (like deductibles, copayments, etc.).

Today, November 4, 2013, the Center for Consumer Information & Insurance Oversight (CCIIO) released additional guidance on this issue suggesting that such assistance is not permissible.  According to the guidance, “HHS has significant concerns with this practice because it could skew the insurance risk pool and create an unlevel field” in the exchanges.  The guidance concludes by stating that “HHS intends to monitor this practice and to take appropriate action, if necessary.”

Dewonkify – Medicare Part B

Medicare is a federal program that provides health insurance coverage for people who are age 65 or older.  Individuals younger than 65 may qualify if they have certain disabilities or have End-Stage Renal Disease (ESRD).  Medicare is comprised of four parts — Parts A, B, C, and D.  Over the next few weeks, Capitol Health Record will dewonkify each of the four parts.

Definition:  Medicare Part B primarily pays for care provided by doctors and other health care professionals (like nurse practitioners), outpatient services, durable medical equipment (DME), home health, and some preventive services.

Used in a Sentence:  “The premiums for Medicare Part B will remain flat in 2014 and seniors have saved $8.3 billion on Part D prescriptions since the Affordable Care Act was enacted in 2010, the Department of Health and Human Services announced Monday. Medicare Part B covers medically necessary services, as well as preventive services.” From “Medicare Part B Premiums Won’t Go Up in 2014,” by Kelly Kennedy, USA Today, October 28, 2013

History:  Medicare Part B began in 1965 under the same legislation that enacted Medicare Part A and the Medicaid program.

Enrollment:  In 2012, 46.4 million Americans were enrolled in Medicare Part B.

Financing:  Medicare Part B is financed through general revenues and premiums collected from beneficiaries.  Because of the way it is financed, technically Medicare Part B can never be insolvent.  However, because the federal government pays 75 percent of the cost of Part B, many policymakers have begun to grow concerned about the increased cost of the program and have proposed ways to reduce these federal expenditures.

Sustainable Growth Rate (SGR):  Medicare Part B pays for services provided by physicians and other health care professionals using the SGR formula.  Unless Congress acts by the end of this year, physicians who treat Medicare beneficiaries will see their reimbursement cut by approximately 24 percent (the exact amount will be determined when the Centers for Medicare and Medicaid Services (CMS) releases its final rule implementing the Physician Fee Schedule).

Over the past decade, Congress has enacted more than 15 short-term fixes to address the SGR (see infographic).  In July the House Energy and Commerce Committee passed legislation to permanently address the SGR.  Last week, the House Ways and Means Committee and Senate Finance Committee jointly released a draft discussion guide which closely follows the Energy and Commerce proposal.

Premiums:  Medicare beneficiaries pay monthly premiums, which are adjusted each year and account for roughly 25 percent of Part B costs.  Currently most beneficiaries pay a monthly premium of $104.90 per month.  Individuals with higher incomes pay a higher monthly premium.  (More information on Medicare Part B premiums is available here.)  Individuals who lack other coverage (generally through a current or former employer) who delay signing up for Part B may be assessed a permanent late enrollment penalty.  (More information on the late enrollment penalty is available here.)

Out-of-Pocket Costs:  In addition to the monthly premium, beneficiaries have an annual deductible of $147 for 2013.  Beneficiaries also are assessed a copayment of 20 percent of the Medicare-approved cost of the service.  (More information is available here.) 

MedPAC To Meet This Week

The Medicare Payment Advisory Commission (MedPAC) will be meeting in Washington, DC this Thursday, November 7th, and Friday, November 8th, to discuss Medicare policies and recommendations. The agenda for the November meeting is available here.

MedPAC did not hold their scheduled meeting in October due to the government shutdown.

Health Care on the Hill: Week of November 4, 2013

Tuesday, November 5, 2013

10:00 a.m.
The Online Federal Health Insurance Marketplace: Enrollment Challenges and the Path Forward
Senate Health, Education, Labor, and Pensions Committee Hearing
430 Dirksen Senate Office Building
*CMS Administrator Marilyn Tavenner is expected to testify.

2:30 p.m.
Convention on the Rights of Persons with Disabilities
Senate Foreign Relations Committee Hearing
419 Dirksen Senate Office Building

Wednesday, November 6, 2013

10:00 a.m.
Health Insurance Exchanges: An Update from the Administration
Senate Finance Committee Hearing
215 Dirksen Senate Office Building
*HHS Secretary Kathleen Sebelius is expected to testify.

House of Representatives 2014 Work Calendar Released

Yesterday, House Majority Leader Eric Cantor released the 2014 House of Representatives calendar. The House of Representatives is scheduled to be in session 113 days next year.  The rest of the calendar is devoted to district work periods where lawmakers are back home working with constituents.  The number of calendar days in Washington, DC is on par with those of recent years.  In what is typical for an election year, the House will look to finish up its work around October 2, 2014 and then be back home until after the election.  Start scheduling those Hill days, fly-ins, and 2014 vacations…but the calendar, of course, is always subject to change.

Bicameral, Bipartisan SGR Proposal Released

On Thursday, October 31, 2013, the Senate Finance Committee and the House Ways and Means Committee released a draft discussion of their proposal to permanently fix the sustainable growth rate (SGR) formula, which Medicare uses to reimburse physicians and other health care professionals.  (More information on the SGR is available here.)  This discussion draft is similar to legislation that unanimously passed out of the House Energy and Commerce Committee in July 2013.  (More information on the Energy and Commerce legislation is available here.)

The discussion draft would prevent the imposition of the SGR cuts (estimated to be 24 percent for 2014), but does not call for any payment increases through 2023.  Beginning in 2024, health care professionals who participate in advanced alternative payment models (see below) would be eligible for a two percent update, while all other health care professionals would receive a one percent update.  The Energy and Commerce Committee legislation called for a 0.5 percent increase in reimbursement over 5 years.

The discussion draft also seeks to adjust reimbursement based in part on performance.  Beginning in 2017, penalties that would have been assessed under three quality incentive programs – the Physician Quality Reporting System (PQRS), the Value-Based Modifier, and the Electronic Health Record (EHR) Meaningful Use program – would be made available to health care professionals who have demonstrated ability to deliver high-quality healthcare.

In addition, the discussion draft encourages health care professionals to participate in alternative payment models (APMs) that involve two-sided risk and measure the quality of care provided (e.g., patient-centered medical homes, accountable care organizations (ACOs), etc.).  Providers who obtain a significant portion of their revenue from such APMs would be eligible for bonus payments.

Finally, the discussion draft contains provisions designed to encourage care coordination for individuals who have complex chronic care needs by developing new payment codes for these services beginning in 2015.  The discussion draft seeks to improve the accuracy of the valuation of services provided to beneficiaries and sets a target for the identification and revaluation of misvalued services.  Under the proposal, professionals would be required to consult with appropriate use criteria when ordering advanced imaging and electrocardiogram services.

Interestingly, like the Energy and Commerce Committee legislation, this discussion draft does not contain any offsets.  The Congressional Budget Office (CBO) previously estimated a ten year freeze to physician payments would cost $139.1 billion; the Energy and Commerce legislation was estimated by CBO to cost $175 billion over ten years.  While this discussion draft has not yet been officially scored by CBO, sponsors reportedly have been working to reduce the overall score of their proposal relative to the Energy and Commerce Committee’s legislation.

So far the discussion draft has received positive feedback from the House Energy and Commerce Committee.  The American Medical Association (AMA) and American Medical Group Association (AMGA) have issued statements indicating they are pleased the issue is moving forward and are currently reviewing the discussion draft.

Secretary Sebelius Testifies on ACA Implementation

After weeks of scrutiny, accusations, and calls for resignations by Republicans, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius testified before the House Energy and Commerce Committee today to defend the Affordable Care Act (a.k.a. “Obamacare”) after a month of significant enrollment challenges.  She faced questions on the cost and management decisions associated with the challenged healthcare.gov website, the enrollment portal for the federal health care exchanges.  Ironically, the website was down and inaccessible as she gave her testimony.

Sebelius’ testimony follows an October 24, 2013 House Energy and Commerce Committee hearing where federal contractors hired by the Centers for Medicare & Medicaid Services (CMS) and HHS to manage the website and paper enrollment processes pointed the finger at HHS when asked who is responsible for the website’s flaws and challenges.  Today, Sebelius did not point the finger at CMS or HHS staff, stating that she and CMS Administrator Marilyn Tavenner have been responsible for decisions to date.  CMS Administrator Tavenner provided similar testimony before the House Ways and Means Committee yesterday.

Sebelius faced questions on costs expended to date, stating that approximately $118 million has been spent on the healthcare.gov website and about $56 million on additional IT to support it.  She offered to get back to the Committee by mid-November 2013 with numbers concerning enrollment in the exchange marketplaces.

While both political parties expressed concern or outrage over the massive exchange website problems to date, Republicans largely defined the problems as an illustration of how flawed Obamacare is overall, while Democrats overwhelmingly characterized the problem as a short-term, fixable glitch.

Some Democratic lawmakers likened the problems to those faced during implementation of the Medicare Part D prescription drug benefit.  However, several on the Committee also sought to distinguish the implementation challenges from those of past programs and mention other problems beyond the website, including data privacy.  The federal data hub meant to link exchange applicant data to determine eligibility for subsidies has become a political target.  Whether personal information is protected and for how long it is stored by the federal government is something of great question, which has resulted in varying answers from the Administration.

The Senate is planning similar hearings next week, with CMS Administrator Tavenner testifying before the Senate Health, Education, Labor, and Pension (HELP) Committee on Tuesday, November 5, 2013, and HHS Secretary Sebelius testifying before the Senate Finance Committee on Wednesday, November 6, 2013.  Additional hearings and scrutiny over the next several months are anticipated in the lead-up to the January 1 enrollment date for the exchange marketplaces.

Dewonkify – Medicare Part A

Medicare is a federal program that provides health insurance coverage for people who are age 65 or older.  Individuals younger than 65 may qualify if they have certain disabilities or have End-Stage Renal Disease (ESRD).  Medicare is comprised of four parts — Parts A, B, C, and D.  Over the next few weeks, Capitol Health Record will dewonkify each of the four parts.

Definition:  Medicare Part A pays primarily for inpatient hospital stays, care in skilled nursing facilities, home health care, and hospice care.

Used in a Sentence: “Republicans have suggested a push to reduce the deficit with entitlement cuts, such as means testing for Medicare and a possible merger of Medicare parts A and B for hospitals and doctor services.” From “GOP Senators Ready Entitlement, Tax Proposals for Budget Conference” by Alan K. Ota, published in CQ (subscription required).We also have a program called the Seal of Recognition that may be worth your time and consideration.  You could submit your materials supporting the Trigen SureShot and our nursing team would evaluate the content to make sure it is consistent with the AORN Recommended Practices.  If approved, you would receive the AORN Seal of Recognition logo to use on your documents for one year (can be renewed annually).

History:  Medicare Part A began in 1965 and was enacted at the same time as Part B and Medicaid.  At the time, older Americans who did not have health care coverage through their employers, had to either purchase health insurance on their own (which could be expensive) or rely on their families to help pay for their medical care.  More information on the history of the Medicare program can be found here.

Financing:  Medicare Part A is financed through a payroll tax paid by employers and employees.  Part A currently pays out more in claims than it collects in revenue and is projected to become insolvent by the year 2026.  In 2012, total expenditures (costs) for the Medicare program were $574.2 billion and total income was $536.9 billion.  Each year the independent Medicare Trustees releases a report projecting the solvency of the program.  Information on the most recent Trustees’ report is available here.

Enrollment:  Currently 50.7 million Americans are enrolled in Medicare Part A.

Eligibility:  In order to be eligible for Medicare Part A, you (or your spouse) must have worked at least 10 years (40 quarters) in Medicare-covered employment.  Some individuals under age 65 may be eligible for Medicare Part A if they are entitled to Social Security (or railroad retirement) disability benefits for at least the previous 25 months or qualify for ESRD benefits.  More information on eligibility requirements can be found here.

Out-of-Pocket Costs:  Beneficiaries enrolled in Part A pay a deductible when they are admitted to the hospital.  The amount of the deductible varies from year to year and is calculated to be $1,216 in 2014.  This deductible covers beneficiaries’ costs for the first 60 days of care within a benefit period.  Beneficiaries pay additional fees for hospitalizations longer than 60 days (for more information, see here).

Premiums:  About 99 percent of individuals who have Part A do not pay a premium.  However, some individuals may be able to enroll in Part A and pay a monthly premium:  individuals (and spouses) with fewer than 30 quarters (7.5 years) of Medicare-covered employment pay a premium of $426 and individuals (and spouses) with between 30 and 39 quarters of Medicare-covered employment pay $234.  (More information is available here.)