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CMS policy

Khaled J Saleh, William O Shaffer
In 2015, the US Congress passed legislation entitled the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act (MACRA), which led to the formation of two reimbursement paradigms: the merit-based incentive payment system (MIPS) and alternative payment models (APMs). The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs. As such, MACRA represents an unparalleled acceleration toward reimbursement models that recognize value rather than volume...
November 2016: Journal of the American Academy of Orthopaedic Surgeons
Sandra J Tanenbaum
The formulation of the triple aim responds to three problems facing the US health care system: high cost, low quality, and poor health status. The purpose of this article is to analyze the potential of the health care system to achieve the triple aim and, specifically, the attempt to improve population health by rewarding providers who contain costs. The first section of the article will consider the task of improving population health through the health care system. The second section of the article will discuss CMS's efforts to pay providers to achieve the triple aim, that is, to improve health care and population health while containing cost...
October 11, 2016: Journal of Health Politics, Policy and Law
R Carter Clement, Caitlin M Gray, Michael M Kheir, Peter B Derman, Rebecca M Speck, L Scott Levin, Lee A Fleisher
BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) recently imposed penalties against hospitals with above-average 30-day readmission rates following total joint arthroplasty (TJA). Hospitals must decide whether investments in readmission prevention are worthwhile. This study examines the financial incentives associated with unplanned readmissions before and after invocation of these penalties. METHODS: Financial data were reviewed for 2028 consecutive primary TJAs performed on Medicare beneficiaries over a 2-year period at an urban academic health system...
August 31, 2016: Journal of Arthroplasty
Laxmaiah Manchikanti, Alan D Kaye, Joshua A Hirsch
The Centers for Medicare and Medicaid Services (CMS) released the proposed 2017 Medicare physician fee schedule on July 7, 2016, addressing Medicare payments for physicians providing services either in an office or facility setting, which also includes payments for office expenses and quality provisions for physicians. This proposed rule occurs in the context of numerous policy changes, most notably related to the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and its Merit-Based Incentive Payment System (MIPS)...
September 2016: Pain Physician
Laxmaiah Manchikanti, Standiford Helm Ii, Ramsin M Benyamin, Joshua A Hirsch
UNLABELLED: The Merit-based Incentive Payment System (MIPS) was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to improve the health of all Americans by providing incentives and policies to improve patient health outcomes. MIPS combines 3 existing programs, Meaningful Use (MU), now called Advancing Care Information (ACI), contributing 25% of the composite score; Physician Quality Reporting System (PQRS), changed to Quality, contributing 50% of the composite score; and Value-based Payment (VBP) system to Resource Use or cost, contributing 10% of the composite score...
September 2016: Pain Physician
Monique C Chambers, Mouhanad M El-Othmani, Afshin A Anoushiravani, Zain Sayeed, Khaled J Saleh
Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve...
October 2016: Orthopedic Clinics of North America
Arpamas Seetasith, David Holdford, Anal Shah, Julie Patterson
BACKGROUND: A number of policy and labeling interventions aimed at reducing inappropriate prescribing of erythropoiesis-stimulating agents (ESAs) were implemented in the U.S. between 2006 and 2010. These interventions included the addition of an FDA Black Box Warning to ESA labeling, the implementation of a Risk Evaluation and Mitigation Strategy program, and the adoption of payment restrictions by the Centers for Medicare and Medicaid Services (CMS). The impact of these safety interventions on different types of ESA prescribing (on-label, off-label; evidence-based, not evidence-based) has not been investigated in a single study...
August 3, 2016: Research in Social & Administrative Pharmacy: RSAP
Camille Haycock, Michelle L Edwards, Christopher S Stanley
The Centers for Medicare & Medicaid Services (CMS) has released a proposed rule that details a consolidated pay-for-performance provider payment system within the Medicare Access and CHIP Reauthorization Act. This proposed rule establishes policy for the new provider Merit-Based Incentive System and Alternative Payment Models. While the rule is extremely complex, and not yet finalized, there are significant implications for nursing and advanced practice providers. This proposed rule intends to drastically change the current provider payment system and reward providers who demonstrate better quality outcomes at a lower cost...
October 2016: Nursing Administration Quarterly
David M Levine, Michael J Healey, Adam Wright, David W Bates, Jeffrey A Linder, Lipika Samal
BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) canceled Meaningful Use (MU), replacing it with Advancing Care Information, which preserves many MU elements. Therefore, transitioning from MU stage 1 to MU stage 2 has important implications for the new policy, yet the quality of care provided by physicians transitioning from MU1 to MU2 is unknown. METHODS: Retrospective longitudinal evaluation of the quality of care delivered by outpatient physicians at an academic medical center in the transition between MU1 and MU2...
August 26, 2016: Journal of the American Medical Informatics Association: JAMIA
Jennifer Tjia, Celeste A Lemay, Alice Bonner, Christina Compher, Kelli Paice, Terry Field, Kathleen Mazor, Jacob N Hunnicutt, Kate L Lapane, Jerry Gurwitz
OBJECTIVES: To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented. DESIGN: Mixed-methods study based on semistructured interviews. SETTING: U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX). PARTICIPANTS: Family members of nursing home residents (N = 41). MEASUREMENTS: Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation...
August 22, 2016: Journal of the American Geriatrics Society
(no author information available yet)
We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation...
August 22, 2016: Federal Register
Thomas Vaughn, A Clinton MacKinney, Keith J Mueller, Fred Ullrich, Xi Zhu
This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services (CMS) Accountable Care Organization (ACO) regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Overall, the regulatory changes are intended to (1) encourage ACOs to participate in two-sided risk contracts, (2) increase the likelihood that beneficiaries are assigned to the physician (and ACO) from whom they receive most of their primary care services, and (3) make it easier for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to participate in ACOs...
June 2016: Rural Policy Brief
Kevin F Erickson, Wolfgang C Winkelmayer, Glenn M Chertow, Jay Bhattacharya
OBJECTIVES: Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004, CMS reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment. STUDY DESIGN: Cohort study of patients starting dialysis in the United States in the 3 years before and the 3 years after payment reform...
2016: American Journal of Managed Care
(no author information available yet)
Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This final rule addresses changes to the Shared Savings Program, including: Modifications to the program's benchmarking methodology, when resetting (rebasing) the ACO's benchmark for a second or subsequent agreement period, to encourage ACOs' continued investment in care coordination and quality improvement; an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program; and policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined...
June 10, 2016: Federal Register
Karen J Maschke, Michael K Gusmano
We examine a recent dispute regarding the Centers for Medicare and Medicaid Services's (CMS) refusal to unconditionally pay for amyloid PET imaging for Medicare beneficiaries being assessed for Alzheimer's disease. CMS will only pay for amyloid PET imaging when patients are enrolled in clinical trials that meet certain criteria. The dispute reflects CMS's willingness in certain circumstances to require effectiveness evidence that differs from the Food and Drug Administration's standard for pre-market approval of a medical intervention and reveals how stakeholders with differing perspectives about evidentiary standards have played a role in attempting to shape the Medicare program's coverage policies...
June 10, 2016: Journal of Aging & Social Policy
Sung-Heui Bae
This integrative review synthesized evidence on the consequences of the Centers for Medicare & Medicaid Services (CMS) nonpayment policy on quality improvement initiatives and hospital-acquired conditions. Fourteen articles were included. This review presents strong evidence that the CMS policy has spurred quality improvement initiatives; however, the relationships between the CMS policy and hospital-acquired conditions are inconclusive. In future research, a comprehensive model of implementation of the CMS nonpayment policy would help us understand the effectiveness of this policy...
June 6, 2016: Journal of Nursing Care Quality
Catherine L Auriemma, Lucy Chen, Michael Olorunnisola, Aaron Delman, Christina A Nguyen, Elizabeth Cooney, Nicole B Gabler, Scott D Halpern
BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) recently instituted physician reimbursements for advance care planning (ACP) discussions with patients. AIM: To measure public support for similar programs. DESIGN: Cross-sectional online and in-person surveys. SETTING/PARTICIPANTS: English-speaking adults recruited at public parks in Philadelphia, Pennsylvania, from July to August 2013 and online through survey sampling international Web-based recruitment platform in July 2015...
June 1, 2016: American Journal of Hospice & Palliative Care
Debra Cascardo
It is time to add risk analysis and risk management to your policies and procedures manuals to comply with the HIPAA Security Rules. CMS is very serious about protecting patients' health information. There is no doubt that complying just with HIPAA security is a complex undertaking, because the rules themselves have multiple elements. Create a road map that not only sees the big picture but is detailed enough to address specific concerns unique to your practice, such as identifying the right individuals in your practice to lead the effort...
March 2016: Journal of Medical Practice Management: MPM
Abbie Begnaud, Thomas Hall, Tadashi Allen
Screening for lung cancer with low-dose CT has evolved rapidly in recent years since the National Lung Screening Trial (NLST) results. Subsequent professional and governmental organization guidelines have shaped policy and reimbursement for the service. Increasingly available guidance describes eligible patients and components necessary for a high-quality lung cancer screening program; however, practical instruction and implementation experience is not widely reported. We launched a lung cancer screening program in the face of reimbursement and guideline uncertainties at a large academic health center...
2016: American Society of Clinical Oncology Educational Book
Laxmaiah Manchikanti, Vidyasagar Pampati, Joshua A Hirsch
BACKGROUND: The increase in the utilization of various techniques in managing chronic pain, including interventional techniques, is a major concern for policy-makers and the public at large. Consequently, multiple regulations have been instituted to reduce health care expenditures in general and expenditures related to interventional techniques in particular. Previous investigations have shown significant increases of utilization of interventional techniques across the board with minor decreases noted in 2007, 2010, 2012 and 2013...
May 2016: Pain Physician
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