Appendix C

ACA Provisions with Implications for a Learning Health Care System*

QUALITY AND EFFECTIVENESS

Quality Measurement

• Extends the Physician Quality Reporting Initiative, a program that makes incentive payments to physicians who report quality measures data to Medicare.
• Requires the HHS Secretary to develop a National Strategy to Improve Health Care Quality to improve health outcomes and efficiency, identify areas for improvement, address gaps in comparative effectiveness information and data gathering, and improve research and dissemination of best practices. The national strategy must be updated annually, with the initial report submitted to Congress by January 1, 2011. A draft report was released on September 9, 2010.
• Requires AHRQ and CMS to develop quality measures that conform to the National Strategy, and requires the HHS Secretary to develop and periodically update provider-level outcome measures for hospitals and physicians, including 10 outcome measurements

___________________________________________________

*Reproduced with permission from the Institute of Medicine Roundtable on Value &Science-Driven Health Care. Available at http://www.iom.edu/vsrt (accessed February 27, 2012).

• for acute and chronic diseases by March 2012 and 10 outcome measurements for primary and preventive care by March 2013.
• Establishes the Medicaid Quality Measurement Program, which requires state Medicaid plans to report on state-specific health quality measures, as determined by the HHS Secretary, and requires the HHS Secretary to test, validate, and develop the quality measures, and to publish annual recommendations on changes to the core set of measures. The ACA appropriates $60 million per year for fiscal years 2010 through 2014 to the Medicaid Quality Measurement Program for a total appropriation of $300 million.
• Creates a quality measures reporting system for long-term care hospitals, inpatient rehabilitation facilities, cancer hospitals, and hospice programs.
• Creates an Interagency Working Group on Health Care Quality to coordinate quality activities across 23 federal departments.
• Creates a website, HealthCare.gov, to educate consumers about the Affordable Care Act, including insurance coverage options and information on health care quality and preventive care.

Comparative Effectiveness Research

• Establishes the Patient-Centered Outcomes Research Institute, a nonprofit Board consisting of the directors of AHRQ and NIH, as well as 19 members appointed by the U.S. Government Accountability Office (GAO), that will conduct research comparing the clinical effectiveness and appropriateness of medical treatments and procedures. The Institute’s research is aimed to assist patients, providers, purchasers, and policy makers in making informed health decisions.
• Directs the HHS Secretary to make standardized extracts of Medicare claims data available to qualified entities, as determined by the HHS Secretary, for analysis of provider and supplier performance on quality, efficiency, and effectiveness. Qualified entities must release their evaluations to the public, and reports must include descriptions of the metrics used.

Care Continuity

• Establishes the Community-Based Care Transitions Program to improve home-based chronic care management for Medicare beneficiaries with multiple chronic conditions.

• Creates the Community First Choice Option, which gives states the ability to offer home and community-based attendant services to certain Medicaid beneficiaries.
• Establishes the Community-Based Collaborative Care Network Program to support groups of providers that coordinate care for low-income and underinsured populations.
• Establishes interdisciplinary community health teams, created by grants and contracts to eligible organizations from the HHS Secretary, to facilitate collaboration between primary care providers and community-based prevention, patient education, and other resources.
• Creates the Federal Coordinated Health Care Office, a new office within the Centers for Medicare and Medicaid Services to improve coordination of care for dual eligibles.

Condition-Specific Care Improvement

• Creates a National Congenital Heart Disease Surveillance System to track epidemiological data on heart disease and identify areas for prevention and outreach.
• Establishes Centers of Excellence for Depression, a network of organizations that will develop and implement evidence-based treatment and prevention standards, foster communication with stakeholders, leverage community resources, and promote the use of electronic health records to coordinate and manage treatment of depressive disorders.
• Creates a National Diabetes Report Card, a biennial, publically-available report of aggregate prevention, quality of care, risk factors, and outcomes data for diabetic patients.

VALUE

Payment Reform

• Establishes a pilot program to test value-based purchasing programs in long-term care hospitals, inpatient rehabilitation facilities, cancer hospitals, and hospice programs.
• Prohibits Medicaid from paying costs associated with health care-acquired conditions.

Medicare-Specific Initiatives

• Establishes a national pilot program to improve patient care and reduce Medicare costs by bundling payments for episodes of care.
• Promotes value-based purchasing in Medicare by paying hospitals based on their performance on quality measures for common and high-cost conditions, including acute myocardial infarction, heart failure, pneumonia, surgeries, and health care–associated infections. Value-based incentive payments begin for discharges on or after October 1, 2012.
• Extends the Medicare Hospital Gainsharing Demonstration, which evaluates arrangements between hospitals and providers aimed at improving utilization of inpatient hospital resources.
• Modifies the Medicare physician fee schedule to incorporate payments that vary based on the quality of care provided, as measured by quality of care measures established by the HHS Secretary. The HHS Secretary must publish the quality measures and announce the effective date of payment modification by January 1, 2012. The modifier will be applicable to specific physicians and physician groups, as determined by HHS, beginning January 1, 2015, and will apply to all physicians and physician groups starting January 1, 2017.
• Reduces Medicare payments to hospitals for hospital-acquired conditions and preventable readmissions; imposes monetary penalty on hospitals with the worst rates of hospital-acquired conditions.
• Establishes an Independent Payment Advisory Board, a Board of 15 members appointed by the President and confirmed by the Senate that will recommend to Congress ways to slow the rate of growth in national health expenditures while preserving quality of care. Beginning January 15, 2014, in years when the CMS Chief Actuary projects Medicare spending growth to exceed the target growth rate for the year, the Board must submit to Congress and the President a proposal to reduce Medicare spending. The Board’s proposals will be binding unless Congress passes an alternative measure that achieves the same level of savings. In years when the Board is not required to submit a proposal, it must still submit an advisory report on the Medicare program. The Board must also produce an annual public report on systemwide health care costs, access to care, utilization, and quality, and an annual advisory report with recommendations to slow growth in health care costs while maintaining quality.

• Allows accountable care organizations (ACOs), groups of Medicare providers that voluntarily meet quality thresholds, to share in cost savings; establishes a demonstration project for pediatric ACOs.
• Creates an Independence at Home demonstration program to provide home primary care services for high-need Medicare patients and allow providers to share in cost savings.

State Initiatives

• Requires health plans to report their medical loss ratios and provide rebates to consumers if less than 85 percent of their premium (for large group market plans) and 80 percent (for individual and small group markets) is spent on clinical services and quality improvement. On November 22, 2010, HHS issued an interim final rule implementing the ACA’s medical loss ratio requirements, based on recommendations from the National Association of Insurance Commissioners (NAIC).
• Requires HHS and state health insurance commissions to establish a process for reviewing health plan premium increases; requires plans to justify increases; requires states to report on trends in premium increases and recommend whether plans should be excluded from Exchanges due to unjustified increases. The ACA appropriates $250 million to the HHS Secretary for grants to states of $1 million to $5 million between 2010 and 2014.

Fraud Elimination

• Seeks to reduce fraud in federal programs through enhanced oversight and screening by the HHS Office of the Inspector General for providers and suppliers participating in Medicare and by states for providers and suppliers participating in Medicaid, including licensure checks, criminal background checks, fingerprinting, unannounced site visits, and database checks. Establishes enrollment moratoria for providers and suppliers in categories at elevated risk of fraud, and requires providers and suppliers to establish claim submission compliance programs. The ACA appropriates a total of $350 million in fiscal years 2011 through 2020 to the Health Care Fraud and Abuse Control Fund for these and other fraud-fighting measures.

PUBLIC HEALTH/WELLNESS

Leadership

• Establishes the National Prevention, Health Promotion and Public Health Council to coordinate federal public health activities, fund prevention and public health programs, and develop evidence-based recommendations on the use of clinical and community preventive services.
• Establishes an Office of Women’s Health and an Office of Minority Health.
• Establishes a Regular Corps and a Ready Reserve Corps to serve in national emergencies.

Capacity

• Establishes a Prevention and Public Health Fund (PPHF) to invest in prevention and public health programs and slow the rate of growth in health care costs. The ACA appropriates $500 million to the PPHF in fiscal year 2010, $750 million in 2011, $1 billion in 2012, $1.25 billion in 2013, $1.5 billion in 2014, and $2 billion in 2015 and each fiscal year thereafter.
• Eliminates cost-sharing in Medicare and Medicaid for preventive services defined as effective by the Preventive Services Task Force.
• Provides access to annual wellness visits, comprehensive risk assessments, and personalized prevention plans for Medicare beneficiaries.
• Awards grants to states for programs that incentivize Medicaid beneficiary participation in tobacco cessation, weight control, and other health promotion programs to help prevent or manage chronic disease. The ACA appropriates $100 million for 5 years beginning in 2011.
• Creates a Medicaid demonstration program requiring states to reimburse qualified mental health care institutions for services to stabilize Medicaid beneficiaries experiencing an emergency psychiatric condition.
• Requires non-profit hospitals to conduct community needs assessments, taking into account input from the community served by the hospital, and adopt implementation strategies to meet identified needs.
• Promotes employer-based wellness programs through assessment, technical support on implementation, and grants to small employers.

• Increases funding for the National Health Service Corps, community health centers, school-based health centers, and nurse-managed clinics.
• Supports Aging and Disability Resource Centers aimed at streamlining access to long-term care for the elderly and people with physical, mental, or developmental disabilities.
• Creates an evidence-based national education campaign to increase awareness about breast cancer.

CROSS-CUTTING

Innovation

• Creates a new Center for Medicare & Medicaid Innovation (CMMI) within CMS to test and evaluate payment and service delivery models that reduce costs and maintain or improve quality of care. CMMI was formally established on November 16, 2010, with Richard Gilfillan, M.D., named as Acting Innovation Center Director. In Phase I of CMMI’s operation, CMMI will test payment and service delivery models for their effect on public expenditures and quality of care. Models to be evaluated include

— Promoting patient-centered medical homes in primary care

— Contracting directly with providers, services, and suppliers

— Utilizing geriatric assessments and comprehensive care plans to coordinate care for patients with multiple chronic conditions

— Promoting care coordination between providers and suppliers to transition away from fee-for-service reimbursement and toward salary-based payment

— Supporting care coordination for chronically ill patients through the use of health IT-enabled provider networks, including care coordinators, a chronic disease registry, and home tele-health technology

— Varying payment to physicians ordering advanced diagnostic imaging services according to the appropriateness of the service ordered

— Utilizing medication therapy management services

— Establishing community-based health teams by assisting primary care providers in chronic care management

— Assisting patients in making informed health care choices by paying providers for using patient decision-support tools

— Allowing states to test and evaluate integration of care for dual eligibles

— Allowing states to test and evaluate systems of all-payer payment reform

— Aligning evidence-based guidelines of cancer care with payment incentives for treatment planning and follow-up care

— Improving post-acute care through continuing-care hospitals, long-term care hospitals, home health, and skilled nursing care

— Funding home health providers of chronic care management services

— Developing a collaborative of health care institutions responsible for developing, documenting, and disseminating best practices, implementing best practices within institutions to demonstrate improved quality and efficiency, and proving assistance to other health care institutions on how to employ best practices and proven care methods

— Facilitating inpatient care of hospitalized patients through use of electronic monitoring by specialists

— Promoting efficiency and access to outpatient services though models that do not require a provider’s referral to the service

— Establishing payments to Healthcare Innovation Zones—teaching hospitals, groups of providers, and other clinical entities that, through their structure, deliver integrated and comprehensive health services while incorporating innovative methods for the clinical training of future health care professionals

In Phase II of CMMI’s operation, the HHS Secretary may expand the duration and scope of a model being tested, if the model meets certain criteria. Successful models will be implemented in Medicare, Medicaid, and CHIP. Beginning in 2012, the HHS Secretary is required to report to Congress every other year on CMMI’s activities. The ACA appropriates $5 million for CMMI’s design, implementation, and evaluation of models during fiscal year 2010. The law also appropriates funding for CMMI indefinitely, with a $10 billion appropriation for fiscal years 2011 through 2019, and $10 billion more for each subsequent 10 fiscal year period.

• Provides an Encouraging Investment in New Therapies tax credit to encourage investments in new therapies to prevent and diagnose acute and chronic diseases. The tax credit, which covers 50 percent of an eligible taxpayer’s investment on a therapeutic discovery project, is temporary for tax years 2009 and 2010 and is subject to a cap of $1 billion.
• Establishes the Cures Acceleration Network in the Office of the Director of NIH that will award grants and contracts to accelerate

• the development of products and therapies to cure certain high-need conditions.
• Directs the HHS Assistant Secretary for Preparedness and Response (ASPR) to award grants to pilot projects that design, implement, and evaluate new models for emergency care. Funds emergency medicine research, pediatric emergency medicine research, and directs the HHS Secretary to award grants to states to improve trauma center capacity.
• Authorizes the HHS Patient Safety Research Center (PSRC) to award grants and contracts to implement collaborative medication management services, where pharmacists and other providers would formulate treatment plans, prevent adverse drug interactions, and educate patients and caregivers on the management of chronic diseases.
• Establishes a formal licensing process for approving biosimilar therapeutics, with data exclusivity periods established to encourage creation of new biologics.
• Awards 5-year demonstration grants to states to develop, evaluate, and implement alternatives to current medical malpractice litigation, with preference given to states that consult relevant stakeholders and propose alternatives likely to reduce medical errors and improve patient safety.

Transparency

• Creates Physician Compare, a Web-accessible database of performance, effectiveness, safety, and other assessments of providers who participate in the Medicare Physician Quality Reporting Initiative.
• Requires disclosure of financial relationships between hospitals, providers, and manufacturers and distributors of drugs and devices.
• Requires Medicare and Medicaid nursing facilities to disclose ownership, expenditure, and certification information; creates a website allowing beneficiaries to compare facilities.
• Increases disclosure requirements for providers and suppliers enrolling in federal health programs.
• Requires states to keep accountings of state health insurance exchange expenditures, and authorizes audits by the HHS Secretary and Inspector General to prevent and detect fraud.

Data Resources

• Requires enhanced collection and reporting of data on race, ethnicity, sex, primary language, and disability status in all federally conducted or supported health care or public health programs. Such data will be used for statistical analysis, including analysis of geographic health disparities.
• Creates a database to share fraud data across federal and state health programs.

Information Technology

American Recovery and Reinvestment Act reforms:

• Formally establishes the Office of the National Coordinator for Health Information Technology to oversee development of a national health information network.
• Strengthens health information privacy and security standards.
• Authorizes grants to assist state and local governments and health care providers in adopting and using health IT.
• Provides financial incentives under Medicare and Medicaid to encourage hospitals, physicians, and health professionals to become meaningful users of health IT by using certified electronic health record technology in ways that allow the electronic exchange of information to improve health care quality.
• Encourages state Medicaid agencies to adopt a meaningful use incentive program similar to the federal program.

Workforce

• Establishes a National Health Care Workforce Commission of 15 members, appointed by the U.S. Government Accountability Office, to develop a national workforce strategy. The Commission will serve as a resource for Congress and the President, communicate and coordinate with the Departments of Health and Human Services, Labor, Veterans Affairs, Homeland Security, and Education, evaluate education and training activities in relation to demand, identify barriers to improved coordination between federal, state, and local levels, and encourage innovations to address population needs, changes in technology, and other environmental factors.
• Increases the nurse workforce though training programs, loan repayment, and retention grants.

• Redistributes unused Graduate Medical Education training positions toward primary care, general surgery, and medically underserved geographic areas.
• Provides bonus payments and grants for recruitment and training of providers to serve in rural and underserved areas.
• Supports development of training programs focused on prevention, public health, primary care, medical homes, team management of disease, and integration of mental and physical health services.

This page is blank