Little Change in CBO Score of SGR Fix

On Tuesday, May 14, 2013, the Congressional Budget Office (CBO) released its May baseline projections, including a revised score for the cost of a 10-year freeze to physician payments under Medicare.  Medicare currently reimburses physicians under a Sustainable Growth Rate (SGR) formula, which is widely viewed as broken.  The SGR – or so-called “doc fix” – has plagued the health policy world for more than a decade.

CBO’s most recent score estimates that it would cost $139.1 billion to freeze physician payments for the next 10 years.  This estimate is only slightly higher than CBO’s February estimate of $138 billion.  (More information on the February estimate, as well as background information on the SGR, is available here.)

Within the last ten days both the Senate Finance Committee and the House Ways and Means Committees have held hearings regarding reforming the way Medicare pays physicians.  Unless Congress acts by the end of the year, physicians who treat Medicare beneficiaries will face an estimated 25 percent cut to their Medicare reimbursement.

CMS Announces Innovation Grants

Today, CMS announced they are making up to $1 billion available for Health Care Innovation Awards.  Additional information can be found here.  A CMS press release is available here.  CMS has also posted a list of frequently asked questions (FAQs), which are available here.

CMS notes that it is specifically seeking proposals in the following categories:

  • Models that are designed to rapidly reduce Medicare, Medicaid, and/or CHIP costs in outpatient and/or post-acute settings. In its FAQs, CMS indicated that priority areas include diagnostic services, outpatient radiology, high-cost physician-administered drugs, home based services, therapeutic services and post-acute services.
  • Models that improve care for populations with specialized needs. CMS notes that priority areas include treatment for those with Alzheimer’s disease, HIV/AIDS, serious behavioral health need, pediatric and adolescent populations, and those requiring long-term services and supports.
  • Models that test approaches for specific types of providers to transform their financial and clinical models.  CMS’ priority areas include models for specific physician specialties, including pediatricians who treat children with complex medical needs.
  • Models that improve the health of populations through activities focused on engaging beneficiaries, prevention, wellness, and comprehensive care that extend beyond the clinical service delivery setting.  Examples of some CMS-identified priority areas include models that integrate clinical care with community-based interventions, integration between behavioral health care and primary care, and models that develop population-based interventions.

Letters of intent are due between June 1 and June 28.  Applications are due between June 14th and August 15th.  Applications must include a “design of a payment model that is consistent with the new service delivery model” being proposed.

Dewonkify: Deem

The Word:  Deem

Definition:  When the House and Senate have not agreed to a budget resolution, they may “deem” legislation to act as a budget resolution in order to move forward with the budget and appropriations process.

Used in a Sentence:  “The House on Tuesday will pass a resolution that will deem the GOP-passed budget resolution as passed for the purpose of setting budget targets as members work on FY 2013 appropriations bills.” From The Hill, “House to ‘deem’ approval of 2013 budget on Tuesday,” By Pete Kasperowicz

How it Works:  The law governing the congressional budget process, the Congressional Budget Act of 1974, calls for the annual adoption of a budget resolution to establish levels of funding.  Section 302(a) requires that the aggregate amounts of spending in the annual budget resolution be allocated by committee; this is the overall number the House and Senate Appropriations Committees receive to fund the appropriations for that year. Section 302(b) requires the House and Senate Appropriations Committees to divide their allocations by subcommittee. Around Washington, this is literally known as the 302(b) allocation.  So, there is a problem when there is no agreed-upon budget resolution.  Complicating things, Members of either chamber may raise a “point of order” against legislation that would violate budget resolution policies.  In other words, if someone tries to bring up a spending bill, say the Labor, Health and Human Services, and Education Appropriations bill, without an agreed-upon budget resolution and therefore no 302(a) or 302(b) allocation, a Member could object on a point of order.

The deeming resolution is how Congress gets around these issues. The deeming resolution simply “deems” or provides the new spending allocations to the Appropriations Committee. According to the Congressional Research Service, “they also may set new aggregate budget levels, provide revised spending allocations to other House and Senate committees, or provide for other related purposes.  A deeming resolution may even declare that a budget resolution (in its entirety), passed earlier in the session by one chamber, is deemed to have the force and effect as if adopted by both chambers.”  A deeming resolution is a simple resolution requiring only the majority of votes in the chamber to pass and become effective.

History:  Since the Congressional Budget Act of 1974, Congress has failed more than a few times to finalize a budget and has used deeming resolutions to “deem” funding allocations.

As the impasse between the House and the Senate regarding how to finalize a fiscal year (FY) 2014 budget resolution continues, talk of the House or Senate deeming funding allocations is heating up once again.

FY 14 Appropriations Outlook: Stormy Weather Ahead

This week the House Appropriations Committee will start marking up the first fiscal year (FY) 2014 appropriations bill (the Military Construction–Veterans Affairs bill, to be exact).  This will formally kick off what will be a rocky appropriations season.

Let’s start with that fact that there is no agreed upon budget resolution, which means no agreed upon overall budget numbers, which for you real budget geeks out there means no 302(b) allocations (the numbers that the each appropriations subcommittee gets that sets the funding level for their bill).  Not to worry, Congress will likely find a way around the official requirements of all of this, most likely through “deeming” allocations.

Now add the fact that because there is no agreed upon budget the House and the Senate will work off of different overall funding levels for appropriations to the tune of about $91 billion. This is not chump change in a time of already austere funding levels, which are impacting programs that are already starting to really feel the impact of sequestration.

By all accounts, the House is basing its number on the $967 billion budget cap, which includes the sequester, while the Senate has said it is aiming to use a $1.058 trillion cap, and their budget reverses the sequester, as well as include revenue raisers.  This will present a challenge for the relatively non-controversial “Mil-Con” bill, but expect the big fireworks to come when Congress gets to the big bills like Defense and Labor-Health and Human Services-Education (LHHS).  That is if any of these bills get past subcommittee – Congress’ recent track record is not so good on that front.

As I said, hold on to your hat – stormy appropriations weather is in the forecast.

This Week is National Nurses Week

This week we celebrate National Nurses Week. Since 1991, National Nurses Week has been celebrated annually from May 6 through May 12, to coincide with the birthday of Florence Nightingale, the founder of modern nursing. National Nurses Week is the time of year to reflect on the important contributions that nurses make in providing safe, high-quality health care to their patients.

To mark the event, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius issued a press release commemorating National Nurses Week.

We celebrate and honor all nurses, especially our nursing clients: the American Nephrology Nurses Association, the American Nurses Association, the Association of Rehabilitation Nurses, the Dermatology Nurses Association, and the Oncology Nursing Society. Thank you for all that you do for patients and their caregivers!

UPDATE (May 7, 2013): Late Monday evening Representative Eddie Bernice Johnson (D-TX-30) introduced H.Res. 201, a resolution supporting the goals and ideals of National Nurses Week on May 6, 2013, through May 12, 2013. The bill had 45 bipartisan cosponsors when introduced.

CMS Releases Proposed IRF Payment Rule

On Thursday, May 2, 2013, the Centers for Medicare and Medicaid Services (CMS) released its proposed rule implementing fiscal year (FY) 2014 Medicare payment rates and policies for the inpatient rehabilitation facilities (IRFs) prospective payment system and changes to the IRF quality reporting system.  The proposed rule calls for aggregate payment increases to IRFs of 2 percent.

A copy of the proposed rule is available here and will be published in the Federal Register on May 8th.  A CMS fact sheet describing the proposed rule is available here.  CMS will be accepting comments on the proposed rule until July 1, 2013.

CMS Proposed Rule on Medicare Payments to SNFs

On Wednesday, May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule outlining fiscal year (FY) 2014 Medicare payments to skilled nursing facilities (SNFs).  Under the proposed rule, SNFs will see a 1.4 percent increase in their Medicare reimbursement compared to FY 2013 payment rates.

A copy of the proposed rule is available here and will be published in the Federal Register on May 6, 2013.  A CMS fact sheet on the proposed rule is available here.  Comments are due to CMS by July 1, 2013.

Dewonkify – Hold

The Word: Hold

Definition: An informal practice by which a Senator informs his or her floor leader that he or she does not wish a particular bill or other measure to reach the floor for consideration. The Majority Leader need not follow the Senator’s wishes, but is on notice that the opposing Senator may filibuster any motion to proceed to consider the measure.

Used in a Sentence:

Sen. Tom Harkin (D-Iowa) has placed a hold on one of President Obama’s top healthcare nominees.

Marilyn Tavenner had previously seemed poised for an easy, bipartisan confirmation as the administrator of the federal Medicare and Medicaid agency.

But Harkin placed a hold on Tavenner’s nomination Wednesday. Harkin’s office noted his frustration at the way the Obama administration plans to spend a $15 billion fund for prevention and public health programs.

From The Hill, “Harkin places hold on top healthcare nominee”

History: The hold is an informal custom of the Senate and not a part of the formalized rules.  The Congressional Research Service notes that “the origins of the practice are unclear and lost in the mists of history,” but “probably emerged from features long associated with the Senate, such as its emphasis on minority and individual interests, the informality and flexibility of its procedures, and a legislative culture that encourages accommodation for individual Senators’ policy and personal goals.”  Since the 1970s, however, the practice has been widely used by Senators to push their policy goals and extract concessions.

How it Works: The Senate usually proceeds to its business by a series of unanimous consent agreements.  A hold is essentially a threat by a member to his or her party leader that the senator intends to object to unanimous consent and use parliamentary procedures to stall consideration of a piece of legislation or a nomination if it is brought to the floor.

The Majority Leader can still place the item on the Senate calendar, but given the amount of business that must be considered in a relatively small number of working days, the threat of extended debate is usually enough to keep the item off the agenda, at least temporarily.

Oftentimes the senator placing the hold will remove the hold if certain concessions are made.  In fact, it is now not uncommon for members to place holds on bills they don’t necessarily oppose, simply as a means of negotiating another point or issue.

While Senator Harkin made public his intention to place a hold on the Tavenner nomination, holds are more often done in secret, earning them the nickname of the “silent filibuster.”

CMS Releases Proposed Rule on Hospice

On Monday, April 29, 2013, CMS released a proposed rule updating payment rates for hospices serving Medicare beneficiaries.  A copy of the fact sheet is available here and the 113-page proposed rule is available here.  The proposed rule will be published in the May 13th Federal Register.  Comments are due at the end of June.

Under the proposed rule, hospices would receive a 1.1 percent payment increase for fiscal year (FY) 2014.  The proposed rule also promulgates the ACA requirements that hospices that fail to meet certain quality standards will be subject to a two percent reduction in their reimbursement.

This proposed rule follows CMS’ Friday release of the inpatient prospective payment system (IPPS) and Long Term Care Hospital Prospective Payment System (LTCH PPS) – more information on that proposed rule is available here.  Stay tuned as DBR continues to provide updates as CMS releases its annual Medicare payment rules.

CMS Released Medicare Proposed Rule

Late Friday, April 26, 2013, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the hospital inpatient prospective payment system (IPPS) and long term care hospital (LTCH) PPS for fiscal year (FY) 2014 (which begins October 1, 2013).  A copy of the 1,424 page proposed rule is available here and is expected to be published in the Federal Register on May 10, 2013.  A CMS fact sheet on the proposed rule is available here.  Comments are due to CMS by 5:00 pm on June 25, 2013.

Under the proposed rule, in FY 2014, inpatient PPS rates would increase by 0.8 percent relative to FY 2013 rates.  FY 2014 LTCH payment rates would increase by 1.1 percent compared to FY 2013 payment rates.  The proposed rule also seeks to implement the document and coding offset provided under the American Taxpayer Relief Act of 2012 (more information on the legislation is available here) and seeks to implement the disproportionate share hospital (DSH) payment cuts provided under the Affordable Care Act (ACA).

This proposed rule contains policies related to the hospital acquired condition reduction program, which was created under the ACA to begin in FY 2015, and provides financial incentives to hospitals to prevent hospital-acquired conditions.  The proposed rule also provides additional policies for the hospital readmissions reduction program, including the addition of two new readmissions measures.