Volumne 12, Issue No. 1
February 4, 2014

MedPAC Supports Care Coordination, APRNs, & Home Infusions

Payment issues often drive choices in health care. Consequently, a very influential policy maker in Washington is the bipartisan Medicare Payment Advisory Commission, or MedPAC. In March and June of each year, MedPAC reports to Congress on the state of the Medicare program, and recommends payment rates and policies for Medicare providers, including hospitals and advanced practice registered nurses (APRNs).  The reports contain detailed research and suggestions on how Congress, the Department of Health and Human Services (HHS), and CMS (the Centers for Medicare and Medicaid Services) can ensure quality and access for Medicare beneficiaries, while limiting costs.  The 17 MedPAC commissioners are thought leaders in health policy, including Mary Naylor, PhD, RN, FAAN, an ANA member. ANA staff attend MedPAC meetings to advocate for the nursing profession, quality of care, and patient access. 

In its June 2012 Report to Congress, the Commission addresses several topics of importance to nursing: care coordination for Medicare beneficiaries; the need for state scope of practice reform to support APRNs and physician assistants; and home infusion therapy.  All MedPAC recommendations are subject to enactment by Congress or adoption by HHS or CMS.  Here is the full report.

Chapter 1 – Reforming Medicare’s benefit design.  MedPAC recommends redesigning Medicare’s current “fee-for-service” (FFS) system, “to give beneficiaries better protection against high out-of-pocket (OOP) spending and to create incentives for them to make better decisions about their use of discretionary care.”  For many years, MedPAC has considered how to move away from the FFS system of paying for every service and procedure, regardless of outcome, value, or cost.  Under the redesign, Medicare beneficiaries would still have an OOP maximum; cost-sharing could go down for services that deliver results at good value; and the current “aggregate cost-sharing liability” would stay the same.  However, beneficiaries would face new costs and fees — deductibles for Part A (hospital) and B (outpatient) services; copayments (dollar amounts) that vary by type of service, rather than coinsurance (percentages); and new fees for supplemental insurance.  MedPAC believes supplemental insurance, which nearly 90 percent of FFS beneficiaries receive through Medigap, employers, or Medicaid, “reduces incentives to weigh their decision about the use of care.”  It remains to be seen if Congress will take action to implement any of these suggestions.

Chapter 2 – Care coordination in fee-for-service Medicare.  In this chapter, MedPAC examines care coordination models – including many that rely upon nurses and APRNs — and discusses various approaches for Medicare to provide incentives to enhance care coordination services for beneficiaries. “Gaps exist in care coordination in fee-for-service (FFS) Medicare because of the fragmentation of service delivery, the lack of tools to help communicate across settings or providers, and the lack of a financial incentive to coordinate care.  These gaps are particularly important in Medicare because beneficiaries are more likely to have multiple chronic conditions than younger patients, requiring more interaction with the health care system.  The effects of poor care coordination include beneficiaries having to repeat medical histories and tests, receiving inconsistent medical instructions or information, experiencing poor transitions between sites of care, and using higher intensity settings when it is not necessary.”  The report notes that “recent Medicare demonstrations on care coordination and disease management models have not shown systematic improvements in beneficiary outcomes or reductions in Medicare spending. . . . Restructuring the way care is provided may be necessary to achieve good care coordination, but such restructuring is difficult in a FFS environment.”  The Commission believes accountable care organizations (ACOs) and other forms of “broad payment reform” such as bundled payment initiatives are needed, but “will take time to develop.  In the interim, it may be necessary to take intermediate steps to improve care coordination and provide explicit payments for the related activities that primary care clinicians do but that are not currently paid for under the FFS system.”  These could take the form of “billing codes in the physician fee schedule to direct resources toward care coordination activities”; “per member per month payments to a medical home or care management entity to manage a population of patients”; or “transitional care payments for patients being discharged from the hospital.”  CMS has proposed paying for transitional care management, as part of the Medicare Physician Fee Schedule proposed rule; the final rule is due out in November.

Chapter 3 – Care coordination programs for dual-eligible beneficiaries.  “In 2010, there were approximately 9.9 million dual-eligible beneficiaries—accounting for about 18 percent of Medicare FFS enrollment and 31 percent of Medicare FFS spending. They also account for about 15 percent of Medicaid enrollment and 40 percent of Medicaid spending. These individuals are high cost; require a mix of medical, long-term care, behavioral health, and social services; and have more limited financial resources than the general Medicare population.  Programs that help dual-eligible beneficiaries access and coordinate services could improve their quality of care and have the potential to reduce Medicare and Medicaid spending.”  MedPAC made several specific recommendations for new payment rules for the PACE program (Program of All-Inclusive Care for the Elderly), which “integrates Medicare and Medicaid benefits for the dual-eligible population who are 55 or older and nursing home certifiable” and provides services through a day center.  PACE would be open to all nursing-home certifiable Medicare patients, regardless of age, and adopt quality measures.  The Commission also supports CMS’ integrated care demonstrations for dual-eligible beneficiaries, both capitated models (with one fee per beneficiary, for all services), and managed FFS (limits on fees for individual services).

Chapter 5 – Serving rural Medicare beneficiaries.  The Affordable Care Act required MedPAC to review Medicare services in rural areas — “counties outside metropolitan statistical areas with 50,000 people.” The report notes that access and quality of care are similar in rural and urban areas.  But urban hospitals have better outcomes on most process measures and condition-specific 30-day mortality rates, because of their greater resources, especially to handle emergencies. “Nurse practitioners (NPs) and physician assistants (Pas) are important sources of care in rural areas. . . Variation in PA and nursing regulations exists across states that may limit Pas and advanced practice registered nurses’ ability to practice to the full extent of their education and training.  States that anticipate future physician shortages may consider reforming scope-of-practice regulations, as detailed in the recommendations by the Institute of Medicine, to facilitate NPs’ and PAs’ delivery of primary care in affected rural areas.”

Chapter 6 – Medicare coverage of and payment for home infusion therapy.  Per request by Congress, MedPAC studied the costs and potential benefits of providing intravenous administration of medications in the home versus alternate settings. MedPAC recognized that visiting nurses often play a key role, typically training patients and caregivers to administer drugs independently, subject to periodic nursing visits.  MedPAC concluded that the “cost implications for Medicare of expanded home infusion vary by drug.” While avoiding formal recommendations due to a lack of data, the report generally supports “filling in the gaps in current coverage” by Medicare, as well as a CMS demonstration project testing “the effects of providing an integrated home infusion benefit for beneficiaries needing infused antibiotics.”

Eileen Shannon Carlson, RN, JD

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