CLN Article

Regulatory Profiles

Essential Health Benefits Under Affordable Care Act in Flux

Even as the Supreme Court prepares to hear challenges to the Affordable Care Act next month, the department of Health and Human Services (HHS) is moving to give insurers and state governments more flexibility in the kind of benefits insurance exchanges must offer under the law. Physicians, hospitals, laboratories, and other healthcare stakeholders have monitored this area closely for signs as to which services will be paid for. According to a recent HHS announcement, stakeholders may get clues by looking to the largest plans already offered in their state.

By 2014, states must set up online markets for private coverage, with government assistance to help cover premiums for the tens of millions of uninsured Americans. If they do not, the federal government must step in and do it for them. However, how HHS will handle rules for what kind of benefits must be offered—such as wellness screenings—have been mired in controversy, and a recent Institute of Medicine report did little to clarify HHS's course.

In response, HHS announced that states will have the flexibility to select an existing health plan to set the "benchmark" for the items and services included in the essential health benefits package. States would choose one of the following health insurance plans as a benchmark: one of the three largest small group plans in the state; one of the three largest state employee health plans; one of the three largest federal employee health plan options; or the largest HMO plan offered in the state's commercial market. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.

The next big announcement in this area will be how HHS will limit cost sharing—a sore spot for the lab community which has long fought copays for lab testing.

The HHS essential health benefits bulletin is available on the Centers for Medicare and Medicaid Services website.

CMS Selects 32 ACO Pioneers

The Centers for Medicare and Medicaid Services (CMS) has chosen 32 organizations as members of the agency's Pioneer Accountable Care Organization (ACO) program, a special ACO subcategory designed for healthcare organizations that have already proven they can offer highly coordinated care.

The aim is to learn from these early adopters of the ACO model with an emphasis on coordinating with private payers while cutting costs. Long-term, CMS hopes that these new payment models will allow organizations to move away from a payment system based on volume under the fee-for-service model, towards one where each ACO is paid based on the value of care it provides. Under the CMS Shared Savings Program, ACOs can get a cut of any money they save the Medicare program compared to a benchmark as long as they meet quality mileposts along the way.

CMS will allow pioneer ACOs to move more rapidly from the Shared Savings Program model to a population-based payment model—within 2 years if the ACO meets its quality goals. In a population-based payment model, some or all of the ACO's fee-for-service payments will be replaced by a prospective per-beneficiary monthly payment.

The final list of participating Pioneer ACOs and more information about the Pioneer ACO Model is available from the Center for Medicare and Medicaid Innovations website.

CMS Launches In-Home Care Pilot

Up to 10,000 Medicare patients with chronic conditions will now be able to get most of the care they need at home under a new demonstration recently announced by the Centers for Medicare & Medicaid Services (CMS). The Independence at Home Demonstration greatly expands the scope of in-home services available to chronically ill Medicare beneficiaries, including a complete range of primary care services, such as lab testing.

Under the pilot, medical practices led by physicians or nurse practitioners will provide primary care home visits tailored to the needs of beneficiaries with multiple chronic conditions and functional limitations. Participating healthcare providers will receive incentive payments if they reduce Medicare expenditures by providing high-quality care while reducing costs. CMS will use quality measures to ensure beneficiaries experience high quality care.

Medical practices eligible to participate in the demonstration must have physicians or nurse practitioners with experience delivering home-based primary care. Up to 50 practices will be selected and each must serve at least 200 Medicare fee-for-service beneficiaries with multiple chronic conditions and functional limitations. Practices in the demonstration will be responsible for coordinating patient care with other health and social service professionals.

More information is available on the CMS website.

Joint Commission Proposes Goal Focused on 'Overuse'

A proposed National Patient Safety Goal (NPSG) for 2013 aims to minimize the overuse of tests, treatments, and procedures to reduce risk to patients. According to the proposal, the Joint Commission defines overuse as the use of a health service in circumstances where the likelihood of benefit is negligible and, therefore, the patient faces only the risk of harm. Research has documented that overuse occurs with significant frequency in the U.S., the organization noted.

Hospitals would be allowed to select the test, treatment, or procedure they want to evaluate, or choose one of the following five topics: early induction of labor; insertion of tympanostomy tubes; red blood cell transfusions; percutaneous coronary interventions; and diagnostic ionizing radiation.

The proposal is available on the Joint Commission website.