The Affordable Care Act and Medicare in …assets.cambridge.org/97811071/10557/frontmatter/...The...

The Affordable Care Act and Medicare in Comparative Context

Burdened with perennially rising costs and responsible for providing health insurance to more than one-sixth of all Americans, Medicare in its original form is fi scally and demographically unsustainable. In light of dramatic reforms under the Affordable Care Act, this book provides a comprehensive overview of the current state of Medicare. Eleanor D. Kinney explains how the ACA addresses systemic problems of cost and volume infl ation, quality assurance, and fraud. Recognizing the potential for more radical change in the future, Kinney also explores the potential of Medicare to become a single-payer system. Comparisons are made with national health systems in Canada and the United Kingdom, from which the United States can draw valuable lessons.

An approachable yet comprehensive account of Medicare and the ACA, this book will be invaluable for health care professionals and informed citizens.

Eleanor D. Kinney is an emeritus professor at Indiana University’s Robert H. McKinney School of Law and one of the nation’s leading experts on health law. She has served as a consultant to numerous health commissions, including President Clinton’s Task Force for Health Care Reform. Her most recent book is Protecting American Health Care Consumers (2002).

www.cambridge.org© in this web service Cambridge University Press

Cambridge University Press978-1-107-11055-7 - The Affordable Care Act and Medicare in Comparative ContextEleanor D. KinneyFrontmatterMore information

http://www.cambridge.org/9781107110557

http://www.cambridge.org


CAMBRIDGE BIOETHICS AND LAW

This series of books was founded by Cambridge University Press with Alexander McCall Smith as its fi rst editor in 2003. It focuses on the law’s complex and troubled relationship with medicine across both the developed and the developing world. Since the early 1990s, we have seen in many countries increasing resort to the courts by dissatisfi ed patients and a growing use of the courts to attempt to resolve intractable ethical dilemmas. At the same time, legislatures across the world have struggled to address the questions posed by both the successes and the failures of modern medicine, while international organizations such as the WHO and UNESCO now regularly address issues of medical law.

It follows that we would expect ethical and policy questions to be integral to the analysis of the legal issues discussed in this series. The series responds to the high profi le of medical law in universities, in legal and medical practice, as well as in public and political affairs. We seek to refl ect the evidence that many major health-related policy debates in the UK, Europe, and the international community involve a strong medical law dimension. With that in mind, we seek to address how legal analysis might have a transjurisdictional and international relevance. Organ retention, embryonic stem cell research, physician-assisted suicide, and the allocation of resources to fund health care are but a few examples among many. The emphasis of this series is thus on matters of public concern and/or practical signifi cance. We look for books that could make a difference to the development of medical law and enhance the role of medicolegal debate in policy circles. That is not to say that we lack interest in the important theoretical dimensions of the subject, but we aim to ensure that theoretical debate is grounded in the realities of how the law does and should interact with medicine and health care.

Series Editors

Professor Richard Ashcroft, Queen Mary , University of London Professor Margaret Brazier, University of Manchester Professor Graeme Laurie, University of Edinburgh

Professor Eric M. Meslin, Indiana University






The Affordable Care Act and Medicare in Comparative Context

ELEANOR D. KINNEY Indiana University






32 Avenue of the Americas, New York, NY 10013-2473, USA

Cambridge University Press is part of the University of Cambridge. It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence.

www.cambridge.org Information on this title: www.cambridge.org/9781107110557 © Eleanor D. Kinney 2015

This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2015 Printed in the United States of America A catalog record for this publication is available from the British Library .

Library of Congress Cataloging in Publication Data Kinney, Eleanor D., author. The Affordable Care Act and Medicare in comparative context / Eleanor D. Kinney. p. ; cm. -- (Cambridge bioethics and law) Includes bibliographical references and index. ISBN 978-1-107-11055-7 (hardback) I. Title. II. Series: Cambridge bioethics and law. [ DNLM : 1. United States. Patient Protection and Affordable Care Act. 2. Health Care Reform – United States. 3. Insurance, Health – United States. 4. Medicare. WA 540 AA 1] RA412.2 368.38′200973–dc23 2015002194

ISBN 978-1-107-11055-7 Hardback

Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or appropriate.






I dedicate this book to my wonderful husband,

Charles Malcolm Clark Jr., who has supported me with love

and sage advice in every endeavor worth pursuing.






ix

Contents

List of Figures page xviii

List of Tables xix

Acknowledgments xxiii

List of Acronyms xxv

1. Introduction 1

Part I. The Medicare Program

2. The Medicare Program 9 2.1. Enactment of the Medicare Program 9 2.2. Evolution of the Medicare Program 15

2.2.1. Fee-for-Service or “Original” Medicare 15 2.2.2. Medicare HMOs and Medicare Part C 16 2.2.3. The Medicare Prescription Drug Benefi t and

Medicare Part D 18 2.3. Design of the Medicare Program 19

2.3.1. Eligibility 19 2.3.2. Benefi ts 21 2.3.3. Coverage 24 2.3.4. Administration 24 2.3.5. Payment Methods 27 2.3.6. Financing 28

2.4. Contributions of the Medicare Program 28

3. Medicare Policy-Making Processes, Appeals, and Judicial Review 30 3.1. Policy Making under the Medicare Program 30

3.1.1. Predominant Medicare Policy-Making Process 32 3.1.2. Medicare Coverage Policy Making 37






Contentsx

3.1.3. Medicare Payment Policy Making 43 3.1.4. Medicare Fraud and Abuse Policy Making 45

3.2. Appeals 46 3.2.1. FFS Medicare Benefi ciary Appeals 46 3.2.2. Grievance Procedures and Appeals for Benefi ciaries in

MA Plans and PDPs 50 3.2.3. HHS Departmental Appeals Board (DAB) 50

3.3. Judicial Review of Medicare Program Policy and Decisions 51 3.3.1. Bar to Federal Question Jurisdiction under

the Social Security Act 52 3.3.2. Judicial Review of Medicare Coverage Policy 54 3.3.3. Statutory Preclusions of Judicial Review

of Medicare Payment Policy 56

4. Taming the Growth in Medicare Expenditures 59 4.1. The Challenge of Infl ation in Medicare Expenditures 60

4.1.1. Institutional Provider Payment 61 4.1.2. Physician and Other Fee-for-Service Provider Payment 70 4.1.3. Health Plan Payment 74

4.2. The Challenge of the Burgeoning Volume of Medicare Services 75 4.2.1. Retrospective Utilization Review for Institutional Providers 76 4.2.2. Volume Controls for Physicians and Other

Fee-for-Service Providers 78 4.3. Prospects for Success 78

5. Improving the Quality of Health Care Services 83 5.1. Enrollment in the Medicare Program 83

5.1.1. Survey and Certifi cation Process for Institutional Providers 84 5.1.2. Enrollment of Physicians and Nonphysician Practitioners 87

5.2. The Advent of Health Services Research 87 5.2.1. The Development of Standards of Care and

Quality Measures 90 5.2.2. Health Service Research on Outcomes of Care 91 5.2.3. Total Quality Management, Continuous Quality

Improvement, and Patient Safety 92 5.2.4. Small Area Analysis and Geographic Variation

in Medicare Spending 93 5.2.5. Social Determinants of Health 94 5.2.6. Translating Medical Research Progress into Better

Medical Practice 96






Contents xi

5.3. Federal Investment in Health Services Research 96 5.3.1. Early Programs in the Public Health Service 97 5.3.2. The Agency for Healthcare Research and Quality (AHRQ) 99 5.3.3. The Early HCFA Quality Initiatives 101 5.3.4. CMS Quality Improvement Initiative 102 5.3.5. The Clinical Translational Science Award Program 105

5.4. Health Information Technology Development 106 5.5. Prospects for Success 110

6. Curbing Fraud and Abuse in the Medicare Program 112 6.1. The Extent of the Problem 113

6.1.1. False Statements, False Claims, and Kickbacks 116 6.1.2. Physician Self-Referral 117

6.2. Legal Prohibitions Regarding Fraud and Abuse 122 6.2.1. False Claims and False Statements Prohibitions 122 6.2.2. Antikickback Prohibitions 123 6.2.3. Physician Self-Referral Prohibitions 125 6.2.4. Criminal Health Care Fraud 127

6.3. Remedies 127 6.3.1. Civil Monetary Penalties Act (CMPA) 128 6.3.2. False Claims Act 128 6.3.3. Health Insurance Portability

and Accountability Act of 1996 (HIPAA) 129 6.3.4. Exclusions from Federal Healthcare Programs 131 6.3.5. Administrative Review and Appeals 132

6.4. Prospects for Success 132

Part II. The Affordable Care Act and the Medicare Program

7. The Affordable Care Act 137 7.1. Organization of the U.S. Health Care Sector 138

7.1.1. Private Health Insurance Coverage 138 7.1.2. Public Health Insurance Program 140 7.1.3. The Uninsured 141

7.2. ACA Coverage Expansions and Protections 142 7.2.1. Title I – Quality, Affordable Health Care for All Americans 142 7.2.2. Title II – The Role of Public Programs 151 7.2.3. The Community Living Assistance Services and

Support Act 153 7.3. Other Provisions of the ACA 153

7.3.1. The ACA and Public Health 153






Contentsxii

7.3.2. The ACA and the Health Care Workforce 155 7.3.3. Remaining Titles of the ACA 157

7.4. Prospects for Success 157 7.4.1. Success of Insurance Market Reforms in Title I 160 7.4.2. Establishment of State and Federal Exchanges in Title I 160 7.4.3. Mandates to Participate in the Insurance Marketplaces 163 7.4.4. Medicaid Expansion and Reforms in Title II 164 7.4.5. Public Health Reforms in Title IV 165 7.4.6. Workforce Improvements in Title V 166

8. Title III: Improving the Quality and Effi ciency of Health Care 167 8.1. Transforming the Health Care Delivery System 167

8.1.1. Linking Payment to Quality Outcomes under the Medicare Program 168

8.1.2. Developing a National Strategy to Improve Health Care Quality 169

8.1.3. Developing New Patient Care Models 171 8.2. Improving Medicare for Patients and Providers 177

8.2.1. Ensuring Benefi ciary Access to Physician Care and Other Services 177

8.2.2. Rural Protections 179 8.2.3. Improving Payment Accuracy 179

8.3. Provisions Relating to Part C 181 8.4. Medicare Part D Improvements for Prescription Drug Plans

and MA-PD Plans 183 8.5. Ensuring Medicare Sustainability 186 8.6. Health Care Quality Improvements 187 8.7. Protecting and Improving Guaranteed Medicare Benefi ts 188 8.8. Prospects for Success 189

9. Major Initiative under Title III: Value-Based Purchasing of Health Care Services 190 9.1. The Concept of Value-Based Purchasing 190 9.2. Getting to Value-Based Purchasing 193

9.2.1. Inpatient Acute Care Hospitals 195 9.2.2. Physicians and Other Eligible Professionals 196 9.2.3. Other Institutional Providers 197

9.3. Value-Based Purchasing for Inpatient PPS Hospitals 199 9.3.1. Program Design 199 9.3.2. Implementation Issues 205






Contents xiii

9.4. Value-Based Purchasing for Physicians and Other Health Professionals 206 9.4.1. Improvements to the Physician Quality

Reporting System 206 9.4.2. Improvements to the Physician Feedback Program 211 9.4.3. Maintenance of Certifi cation Program (MOCP) 213 9.4.4. Implementation Issues 215

9.5. Value-Based Purchasing for Other Providers 216 9.6. Prospects for Success 216

10. Major Initiatives under Title III: Pilot Programs for Payment and Quality Reform 219 10.1. The Medicare Shared Savings Program 219

10.1.1. Development and Implementation of ACOs 220 10.1.2. Program Design 221 10.1.3. Administrative Issues 227 10.1.4. Current Models of ACOs 228

10.2. National Pilot Program for Payment Bundling 229 10.2.1. Getting to the Pilot on Payment Bundling 229 10.2.2. The Pilot Program 230 10.2.3. Administrative Issues 233

10.3. Community Health Teams to Support Medical Homes 234 10.3.1. Getting to the Medical Home Pilot 235 10.3.2. Demonstration Design 236

10.4. Prospects for Success 238 10.4.1. The Shared Savings Program 239 10.4.2. The National Pilot Program for Payment Bundling 242 10.4.3. The Medical Home Pilot Demonstration 243

11. Title VI: Improving Transparency and Program Integrity 244 11.1. Physician Ownership of Specialty Hospitals 244

11.1.1. The Rationale for the Prohibitions 245 11.1.2. Requirements to Qualify for Whole Hospital

or Rural Provider Exceptions 246 11.1.3. Exception to Prohibition on Expansion of Facility Capacity 248 11.1.4. Collection of Ownership and Investment Information 248 11.1.5. Enforcement 249

11.2. Transparency and Reporting Requirements for Physicians and Industry 249






Contentsxiv

11.2.1. The Problem of Confl icts of Interest 249 11.2.2. Transparency and Reporting of Physician Ownership

and/or Investment Interests 253 11.2.3. Disclosure Requirements for Physician Ownership

of Imaging Services 258 11.2.4. Reporting Requirements for Gifts of Prescription

Drug Samples 258 11.2.5. Transparency Requirements for Pharmacy Benefi t

Managers (PBMs) 258 11.3. Nursing Home Transparency and Improvement 259

11.3.1. Problems with Nursing Home Quality and Safety 260 11.4. Subtitle D – Patient-Centered Outcomes Research 263 11.5. Medicare, Medicaid, and SCHIP Program Integrity Provisions 264

11.5.1. Provider Screening and Other Enrollment Requirements under Medicare 264

11.5.2. Enhanced Medicare and Medicaid Program Integrity Provisions 265

11.5.3. Elimination of Duplication between HHS Data Banks 267 11.5.4. Miscellaneous Program Integrity Provisions 267 11.5.5. Expansion of the Recovery Audit Contractor

(RAC) Program 268 11.6. Prospects for Success 270

11.6.1. Physician Ownership and Transparency 270 11.6.2. Nursing Home Transparency and Improvement 271 11.6.3. Medicare, Medicaid, and CHIP Program

Integrity Provisions 272

12. Major Initiative under Title VI: The Patient-Centered Outcomes Research Institute 274 12.1. The Road to Comparative Effectiveness Research 275 12.2. Patient-Centered Outcomes Research Institute 278

12.2.1. Key Defi nitions 278 12.2.2. Purpose of the PCORI 279 12.2.3. Duties 279 12.2.4. Institutional Design, Governance, and Administration 283 12.2.5. Dissemination and Building Capacity for Research 285 12.2.6. Limitations on Use of Comparative Effectiveness

Research 287 12.2.7. Establishment and Funding of the Patient-Centered

Outcomes Research Trust Fund (PCORTF) 288






Contents xv

12.3. Prospects for Success 290 12.3.1. Challenges for Patients 293 12.3.2. Challenges for Physicians 294 12.3.3. Challenges for Payers 297 12.3.4. Challenges for Pharmaceutical and Medical

Device Manufacturers 298

Part III. The Future of Medicare in a Global Context

13. The Impact of the Affordable Care Act on the Medicare Program 305 13.1. Reforming the Medicare Program in the ACA 308 13.2. Medicare as a Single Payer for Universal Coverage 312

13.2.1. Necessary Steps 314 13.2.2. Remaining Issues for Resolution 317 13.2.3. Interest in a Single-Payer System 318

13.3. The Burden of Ideology in Health Reform 319

14. The Historical Foundations for Public Health Coverage in the United Kingdom, Canada, and the United States 322 14.1. Constitutional Arrangements 323

14.1.1. The Police Power and Federalism 324 14.1.2. Impact of Federalism and Location of the Police

Power over Health Policy 330 14.2. Economic Conditions Following World War II 333

14.2.1. United Kingdom 333 14.2.2. Canada 334 14.2.3. United States 335

14.3. The Rhetoric of Health Reform in the United Kingdom, Canada, and the United States 336

15. The Health Care Systems of the United Kingdom, Canada, and the United States 340 15.1. Health Care in the United Kingdom 340

15.1.1. Enactment of the National Health Service for England and Wales 341

15.1.2. Evolution of the National Health Service for England and Wales 343

15.2. Health Care in Canada 347 15.2.1. Canadian Health Care in the Postwar Period 348 15.2.2. Enactment and Evolution of Publicly Sponsored

Health Insurance 349






Contentsxvi

15.3. The Saga of Health Reform in the United States 354 15.3.1. American Health Care in the Postwar Period 354 15.3.2. Enactment of Public Health Insurance Programs

at the State and Federal Levels 355 15.3.3. American Health Care in the 1980s and 1990s 356 15.3.4. Health Reform in the Twenty-First Century 357

16. The United Kingdom, Canada, and the United States Compared 359 16.1. Comparative Health Sector Performance 359 16.2. Stakeholders and Their Infl uence 363

16.2.1. Physicians 364 16.2.2. Hospitals 371 16.2.3. Private Health Insurers 372 16.2.4. Pharmaceutical and Medical Device Manufacturers

and Suppliers 373 16.3. Mechanisms for Social Control of Stakeholders 374

16.3.1. Collegiality 374 16.3.2. Hierarchy 375 16.3.3. The Market 376

17. Convergence on Pragmatic Health Reform Strategies for Common Problems 379 17.1. Common Solutions for Common Problems 380

17.1.1. Enhancing Primary Care Delivery While Accommodating Integrated Specialty Care 382

17.1.2. Coordinating Health Care Services across Provider Sites 387

17.1.3. Getting Better Value for Payment 389 17.1.4. Addressing Health Disparities 391 17.1.5. Refocusing Health Care Delivery on Population Health 392

17.2. Common Tools for Health Reform 393 17.2.1. Health Services Research in Canada and the

United Kingdom 394 17.2.2. Adoption and Use of Information Technology 396 17.2.3. The Promise of Comparative Effectiveness Research 398

17.3. The Centrist Consensus 399

18. Entrepreneurship in Health Care 401 18.1. The Concept of Entrepreneurism 402

18.1.1. Conventional, For-Profi t Entrepreneurship 402






Contents xvii

18.1.2. Social Entrepreneurship 403 18.1.3. Institutional Entrepreneurship 405

18.2. Entrepreneurship in Health Care 406 18.2.1. Productive Entrepreneurship 409 18.2.2. Unproductive/Destructive Entrepreneurship in

Health Care 413 18.3. The Principle of Social Responsibility 416 18.4. Opportunities for Productive Entrepreneurship in the ACA 419

18.4.1. Opportunities in Title I 420 18.4.2. Opportunities in Title II 420 18.4.3. Opportunities in Title III 420 18.4.4. Opportunities in Title IV 421 18.4.5. Opportunities in Title V 421 18.4.6. Opportunities in Title VI 422

18.5. Entrepreneurship in the United Kingdom and Canada 424

Epilogue 427

Index 429






xviii

Figures

4.1. Growth in Medicare expenditures, 1970–2015 (dollars in billions) page 60 7.1. Percentage of uninsured adults (age 18–64) by state Medicaid

expansion decision 165 16.1. Ranking of the health systems of US-peer countries by

selected measures 362 17.1. Assessments of health care systems in Canada, the United States,

and the United Kingdom, selected years 1988–2002 381






xix

Tables

1.1. Pub. L. No. 111–148, Patient Protection and Affordable Care Act (ACA) (2010) page 2

2.1. Social Security Amendments of 1965 13 2.2. Per capita income, savings, and home equity of Medicare

benefi ciaries by selected demographic characteristics, 2013 (in 2013 dollars) 20

2.3. Functional contractors under FFS Medicare 26 2.4. The institutional and professional health care providers that serve

FFS Medicare benefi ciaries under Parts A and B of the Medicare program and that contract with Medicare Advantage (MA) plans to serve Medicare benefi ciaries 27

3.1. Regulatory objectives and strategies to assure the regulatory goal of paying for only reasonable and necessary items and services 31

3.2. Federal legislation enacting major changes in the Medicare program, 1965–2015 33

3.3. Five levels in the Medicare appeals process for benefi ciaries under FFS Medicare Parts A and B and for physicians and other Part B providers and suppliers 49

3.4. Divisions of the Departmental Appeals Board (DAB) 51 4.1. Subsection (d) hospitals 63 5.1. Medicare providers subject to the survey and certifi cation process

and citation of Conditions of Participation (CoP) 85 5.2. Statutory duties of the director of AHRQ 100 5.3. Activities pertaining to AHRQ comparative effectiveness research 100 6.1. Medicare fraudsters on FBI’s List of Ten Most Wanted

White-Collar Criminals 115 6.2. Federal health care fraud and abuse laws 123 6.3. Antikickback safe harbors and Stark Law exceptions 125






Tablesxx

6.4. HIPAA Title II – Preventing Health Care Fraud and Abuse 130 7.1. Number and percentage of people by health insurance status: 2013

(percentage in millions) 139 7.2. Title I – Quality, Affordable Health Care for All Americans 143 7.3. Benefi t categories for the “essential health benefi ts” for private

health plans under the ACA 147 7.4. Title II – Role of Public Programs 152 7.5. Title IV – Prevention of Chronic Disease and Improving

Public Health 154 7.6. Title V – Health Care Workforce 156 7.7. Subjects of regulations and guidance to implement Title I of the ACA 158 7.8. Federal ACA funding by program category as of April 2012 159 8.1. Title III – Improving the Quality and Effi ciency of Health Care 168 8.2. National quality strategy, aims and priorities 170 8.3. Subtitle A – Transforming the Health Care Delivery System,

Part III – Encouraging Development of New Patient Care Models 172 8.4. Subtitle B – Improving Medicare for Patients and Providers,

Part I – Ensuring Benefi ciary Access to Physician Care and Other Services 178

8.5. Subtitle B – Improving Medicare for Patients and Providers, Part II – Rural Protections 179

8.6. Subtitle C – Provisions Relating to Part C 181 8.7. Subtitle D – Medicare Part D Improvements for Prescription Drug

Plans and MA–PD Plans 185 8.8. Subtitle E – Ensuring Medicare Sustainability 187 8.9. Subtitle F – Health Care Quality Improvements 188 9.1. Subtitle A – Transforming the Health Care Delivery System,

Part I – Linking Payment to Quality Outcomes under the Medicare Program 191

9.2. AMA principles for Pay-for-Performance (PFP) 193 9.3. Final rules for updating PPSs and fee schedules and implementing

quality reporting and value-based purchasing for FY 2014 194 9.4. Hospital quality measures for inpatient hospital value-based

purchasing, FY 2014 and FY 2015 201 9.5. Domains and measures groups for the FY 2014 PQRS 209 9.6. Representative PQRS quality measures for FY 2014 210 9.7. American Board of Medical Specialties and its MOC programming

core competencies and learning process of the American Board of Medical Specialties 214

10.1. Exemplary specifi c quality measures for ACOs for FY 2015 224






Tables xxi

10.2. Determinations regarding ACOs for which administrative and judicial review are precluded 227

10.3. Applicable medical conditions and services for the National Pilot Program on Payment Bundling 231

10.4. Required quality measures for the National Pilot Program on Payment Bundling 233

10.5. Obligations of health teams 238 11.1. Title VI – Transparency and Program Integrity 245 11.2. Subtitle A – Physician Ownership and Other Transparency 245 11.3. Information to be reported on industry-physician fi nancial transactions 254 11.4. Information to be reported on industry-physician ownership interests 255 11.5. Items excluded from covered payments or other transfers of value 256 11.6. Required elements of nursing home compliance and ethics programs 262 11.7. Subtitle E – Medicare, Medicaid, and SCHIP Program Integrity

Provisions 265 12.1. Considerations for the PCORI in identifying research priorities and

a research project agenda 280 12.2. Institute Board of Governors 284 12.3. Schedule of appropriations to PCORTF 290 12.4. PCORI National Priorities 291 14.1. Seven key principles that guide the NHS set forth in the NHS

Constitution 337 15.1. Criteria for provincial health insurance plans under Canada’s

Medicare Act 351 16.1. Selected health sector statistics for Canada, the United Kingdom,

and the United States 360 16.2. Most effi cient health care system by country, Bloomberg News,

Bloomberg Best (and Worst), 2013 361 16.3. Common institutions and professionals delivering and fi nancing

care in a nation-state 364 16.4. Generalists and specialists as a share of all doctors, 2011 (or nearest year) 369 16.5. Occupancy rate of curative (acute) care beds, 2000 and 2011 (or

nearest year) 372 17.1. Characteristics of primary care in the Alma-Ata Declaration 384 17.2. Percentage of the population above sixty-fi ve and eighty years of age

in the United States, United Kingdom, and Canada, 2010 and 2050 388 18.1. Examples of entrepreneurship in health care pursuant to Baumol’s

Typology of Entrepreneurship 409 18.2. Rettig’s Mechanisms of Action: How New Medical Technology

Affects Health Care Costs 411






xxiii

Acknowledgments

There are many people who have made this book possible both recently and in the past. I thank my husband, children, and family for their constant loving support throughout my professorial career. I thank numerous colleagues who have commented on and critiqued my work on the Medicare program, administrative law, and health law and policy over the years. Several people warrant specifi c mention, Eric Meslin of Indiana University Center for Bioethics; Eric Wright now of Georgia State University, my colleague for twenty years at Indiana University’s Hall Center for Law and Health; Dr. David Orentlicher; Dr. Jeffrey Rivett, the famed historian of the National Health Service; Dr. John Clark of Indiana University Health; Bernard Dickens of the University of Toronto; Fran Miller of Boston University; and my colleagues and friends at Southern Illinois University and at the Beasley Institute for Law and Health Policy at Loyola University of Chicago School of Law. Many people helped me produce this book including my research assistants over the years and, in particularly, Allison Potenza, who worked with me most recently. I also want to thank Faith Long at Indiana University for proofreading and preparing the book for publication. I want to give special thanks to Miriam Murphy, the librarian at Indiana University McKinney School of Law, who found sources from here and abroad. I also want to thank my colleagues at Cambridge University Press who did such a great job preparing the book for publication. Finally, I would like to thank my students at Loyola University Chicago School of Law, Southern Illinois School of Law, and Indiana University McKinney School of Law, who challenged and enhanced my understanding of the Affordable Care Act and the Medicare program as well as reading and commenting on chapters of my book that had been their text. I am grateful.






xxv

Acronyms

AAMC American Association of Medical Colleges ACA Affordable Care Act ACE Acute Care Episode ACO Accountable Care Organization ACP American College of Physicians ACS American Cancer Society AHA American Hospital Association AHCPR Agency for Health Care Policy and Research AHRQ Agency for Healthcare Research and Quality ALJ Administrative Law Judge ALS Amyotrophic Lateral Sclerosis AMA American Medical Association APA Administrative Procedure Act APC Ambulatory Payment Classifi cation ARRA American Recovery and Reinvestment Act ASC Ambulatory Surgical Center ATRA American Taxpayer Relief Act of 2012 BBA Balanced Budget Act of 1997 BBRA Medicare, Medicaid, and SCHIP Balanced Budget

Refi nement Act of 1999 BHI Bureau of Health Insurance BIPA Medicare, Medicaid, and SCHIP Benefi ts Improvement and

Protection Act of 2000 CAM Complementary and Alternative Medicine CARE Continuity Assessment Record and Evaluation CBO Congressional Budget Offi ce CDC Centers for Disease Control and Prevention






Acronymsxxvi

CED Civil Enforcement Division CEO Chief Executive Offi cer CER Comparative Effectiveness Research CIHI Canadian Institute for Health Information CIHR Canadian Institutes of Health Research CME Continuing Medical Education CMI Center for Medicare and Medicaid Innovation CMP Competitive Medical Plans CMS Centers for Medicare and Medicaid Services CPC Current Procedure Codes CPT Current Procedural Terminology CQI Continuous Quality Improvement CRD Civil Remedies Division CT Scan Computerized Tomography Scan CTSA Clinical and Translational Science Award DAB Departmental Appeals Board DME Durable Medical Equipment DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and

Supplies DOJ Department of Justice DRG Diagnosis-Related Group DSH Disproportionate Share Hospital EHR Electronic Health Record EME Effi cacy and Mechanism Evaluation EMR Electronic Medical Record ERISA Employee Retirement Income Security Act of 1974 ESRD End-Stage Renal Disease FACA Federal Advisory Committee Act FBI Federal Bureau of Investigation FCA False Claims Act FDA Food and Drug Administration FFS Fee-for-Service FY Fiscal Year GAO U.S. General Accounting Offi ce or U.S. Government

Accountability Offi ce GDP Gross Domestic Product GNP Gross National Product GP General Practitioner GPCI Geographic Practice Cost Index






Acronyms xxvii

GPO Group Purchasing Organization HCA Hospital Corporation of America HCAHPS Hospital Consumer Assessment of Healthcare Providers and

Systems Survey HCE Health Care Expenditures HCFA Health Care Financing Administration HCPCS Healthcare Common Procedure Coding System HCQII Health Care Quality Improvement Initiative HCRQA Healthcare Research and Quality Act of 1999 HEAT Health Care Fraud Prevention and Enforcement

Action Team HEDIS Health Effectiveness Data and Information Set HEW Department of Health, Education, and Welfare HHS Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act of 1996 HIPPS Health Insurance Prospective Payment System HITECH Health Information Technology for Economic and

Clinical Health HMO Health Maintenance Organization HPSA Health Professions Shortage Area HQA Hospital Quality Alliance HQI Hospital Quality Initiative HS&DR Health Services & Delivery Research HTA Health Technology Assessment ICD International Classifi cation of Diseases ICD-10-CM/PCS International Classifi cation of Diseases, Clinical Modifi cation

and Procedural Classifi cation System IHSPR Institute of Health Services and Policy Research IOM Institute of Medicine IPAB Independent Payment Advisory Board IPPS Inpatient Prospective Payment System IQR Hospital Inpatient Quality Reporting program IRC Internal Revenue Code IRS Internal Revenue Service LEIE List of Excluded Individuals and Entities LTCH Long-term care hospitals MA Medicare Advantage MAC Medicare Administrative Contractor MAO Medicare Advantage Organization MA-PD Medicare Advantage Prescription Drug Plan






Acronymsxxviii

MCAC Medicare Coverage Advisory Committee MedCAC Medicare Evidence Development & Coverage Advisory

Committee MedPAC Medicare Payment Advisory Commission MIPPA Medicare Improvements for Patients and Providers

Act of 2008 MMA Medicare Modernization Act of 2003 MOC Maintenance of Certifi cation MS-DRGs Medical Severity–Diagnosis-Related Groups NCD National Coverage Determination NCHSR National Center for Health Services Research and

Development NDPB Non-Departmental Public Body NHS National Health Service NICE National Institute for Clinical Excellence (now known as

National Institute for Health and Clinical Excellence) NIH National Institutes of Health NIHR National Institute for Health Research NQF National Quality Forum OASIS Outcome and Assessment Information Set OBRA ’80 Omnibus Budget Reconciliation Act of 1980 OBRA ’81 Omnibus Budget Reconciliation Act of 1981 OBRA ’86 Omnibus Budget Reconciliation Act of 1986 OBRA ’87 Omnibus Budget Reconciliation Act of 1987 OBRA ’89 Omnibus Budget Reconciliation Act of 1989 OBRA ’90 Omnibus Budget Reconciliation Act of 1990 OBRA ’93 Omnibus Budget Reconciliation Act of 1993 OECD Organisation for Economic Co-operation and Development OIG Offi ce of the Inspector General OIRA Offi ce of Information and Regulatory Affairs ONC Offi ce of the National Coordinator for Health Information

Technology OPPS Outpatient Prospective Payment System PBM Pharmacy Benefi ts Management PCOR Patient-Centered Outcomes Research PCORI Patient-Centered Outcomes Research Institute PCORTF Patient-Centered Outcomes Research Trust Fund PDP Prescription Drug Plan PECOS Provider Enrollment, Chain and Ownership System PFP Pay for Performance






Acronyms xxix

PHR Public Health Research PORT Patient Outcome Research Teams PPO Preferred Provider Organization PPS Prospective Payment System PQRI Physician Quality Reporting Initiative PQRS Physician Quality Reporting System ProPAC Prospective Payment Assessment Commission PRRB Provider Reimbursement Review Board PSRO Professional Standards Review Organization QIC Qualifi ed Independent Contractor QRUR Physician Quality and Resource Use Reports RBRVS Resource-Based Relative Value Scale RVU Relative Value Units SCHIP State Children’s Health Insurance Program SGR Sustainable Growth Rate SNF Skilled Nursing Facility SSA Social Security Act SSRI Selective Serotonin Reuptake Inhibitors TAC Technical Advisory Committee TEFRA Tax Equity and Fiscal Responsibility Act of 1982 TENS Transcutaneous Electrical Nerve Stimulation TQM Total Quality Management VBPM Value-Based Payment Modifi er WHO World Health Organization






The Affordable Care Act and Medicare in …assets.cambridge.org/97811071/10557/frontmatter/...The...

Documents

Transcript of The Affordable Care Act and Medicare in …assets.cambridge.org/97811071/10557/frontmatter/...The...