Lisa M. Palacios RN, MSN
Clinical Nurse Liaison
Liaison Manager
Boston Home Infusion
September 10, 2013
Objectives
 Identify the contributing factors that
are influencing change in the health
care industry.
 Describe 3 constructive pathways or
means to manage the proposed and
expected changes in health and home
care as we go forward.
“Change is the law of life. And
those who look only to the
past or present are certain to
miss the future.”
~JFK
The Alphabet Soup of
Health Care
 ACA
 CBO
 ACO
 CMS
 CBA
 OMG!!
ACA
Affordable Care Act.
The Patient Protection and Affordable Care Act
(PPACA) commonly called Obamacare or the
Affordable Care Act (ACA), is a United States federal
statute signed into law by President Barack Obama on
March 23, 2010. Together with the Health Care and
Education Reconciliation Act, it represents the most
significant government expansion and regulatory
overhaul of the country's healthcare system since the
passage of Medicare and Medicaid in 1965.
CBO
Congressional Budget Office
The Congressional Budget Office (CBO) is a
federal agency within the legislative branch of the
United States government that provides economic
data to Congress. The CBO was created as a
nonpartisan agency by the Congressional Budget
and Impoundment Control Act of 1974.
ACO
Accountable Care Organization
An Accountable Care Organization (ACO) is a healthcare organization
characterized by a payment and care delivery model that seeks to tie
provider reimbursements to quality metrics and reductions in the total
cost of care for an assigned population of patients. A group of
coordinated health care providers forms an ACO, which then provides
care to a defined group of patients. The ACO may use a range of
payment models (capitation, fee-for service with asymmetric or
symmetric shared savings, etc.). The ACO is accountable to the patients
and the third-party payer for the quality, appropriateness and efficiency
of the health care provided. According to the Centers for Medicare and
Medicaid Services (CMS) an ACO is "an organization of health care
providers that agrees to be accountable for the quality, cost and overall
care of Medicare beneficiaries who are enrolled in the traditional feefor-service program who are assigned to it."
CMS
Center Medicare Services
The Centers for Medicare & Medicaid Services (CMS), previously
known as the Health Care Financing Administration (HCFA), is a
federal agency within the United States Department of Health and
Human Services (DHHS) that administers the Medicare program and
works in partnership with state governments to administer Medicaid,
the State Children's Health Insurance Program (SCHIP) and health
insurance portability standards. In addition to these programs, CMS
has other responsibilities, including the administrative simplification
standards from the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), quality standards in long term care facilities
(more commonly referred to as nursing homes) through its survey and
certification process and clinical laboratory quality standards under the
Clinical Laboratory Improvement Amendments.
CBA
Competitive Bidding Area
The service area that a provider who won
the competitive bid must provide
products and services to regardless of
their physical location.
Friend or Enemy?
 AFFORDABLE CARE ACT
 ACCOUNTABLE CARE ORGANIZATIONS
 COMPETITIVE BIDDING
HEALTH CARE REFORM
Aka
THE PATIENT
PROTECTION
AFFORDABLE CARE ACT
The Affordable Care Act provides Americans with better
health security by putting in place comprehensive health
insurance reforms that will:
 Expand coverage.
 Hold insurance companies accountable.
 Lower health care costs.
 Guarantee more choice.
 Enhance the quality of care for all Americans.
The Affordable Care Act
The Patient Protection and
Affordable Care Act
The Health Care and Education
Reconciliation Act of 2010
Eligibility
 The Affordable Care Act fills in current gaps in coverage for the poorest
Americans by creating a minimum Medicaid income eligibility level
across the country.
 Beginning in January 2014, individuals under 65 years of age with
income below 133 % of the federal poverty level (FPL) will be eligible
for Medicaid.
 Low-income adults without children will be guaranteed coverage
through Medicaid in every state without need for a waiver.
 Parents of children will be eligible at a uniform income level across all
states. Medicaid and Children's Health Insurance Program (CHIP)
eligibility and enrollment will be much simpler and will be coordinated
with the newly created Affordable Insurance Exchanges.
Financing
 Coverage for the newly eligible adults will be fully funded
by the federal government for three years, beginning in
2014, phasing down to 90% by 2020.
 Authorization for the Children's Health Insurance Program
(CHIP) is extended through 2019 and funding is currently
authorized through 2015.
 Additional federal funding for state Medicaid programs is
also available for primary care, preventive care, community
based long-term services and supports and new
demonstrations to improve quality and re-engineer
delivery systems.
Information Technology
Systems & Data
 CMS developed and codified a policy and financing structure to
provide states with tools needed to achieve the immediate and
substantial investment in information technology systems.
 Medicaid systems will be in place in time for the January 1, 2014
launch date of the new Affordable Insurance Exchanges as well
as the expansion of Medicaid eligibility.
 Assures a simple and seamless enrollment experience for
consumers who qualify for Medicaid or CHIP or who are
shopping for health insurance in the Affordable Insurance
Exchanges.
Coordination with Affordable
Insurance Exchanges
 The Affordable Care Act creates a system of coverage
between Medicaid, the Children's Health Insurance
Program (CHIP) and Affordable Insurance Exchanges.
 Single application.
 Eligibility determined for all insurance affordability
programs through one simple process.
Affordable Insurance
Exchange
 The ObamaCare Health Insurance Exchange (HIX) opens Oct 1st, 2013.
 The ObamaCare health insurance exchanges, or ObamaCare exchanges, are State, Federal or
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joint-run online marketplaces.
Americans can use the "Affordable" Insurance Exchange online marketplaces to buy health
insurance from private health care providers who will compete to cover them. Shoppers can
use a price calculator to find the best deal for them and their family. These programs are for
folks above the poverty line that do not qualify for Medicaid.
The health insurance exchanges are estimated to provide up to 29 million people with
affordable health insurance by 2019.
States can build a health insurance exchange(HIX) on their own, partner with one or more
other states, or have the federal government build and run the insurance exchange for them.
The states can apply for funds from the federal government for assistance with the exchange.
There are four tiers of plans you or your employer can purchase on the exchange. They range
from lower quality but more affordable "Bronze plans", to "Silver plans" to a more expensive
plan with better coverage called a "Gold plan". There is also a "Platinum plan" which is the
highest quality and cost plan. Lower premium plans will have higher deductibles.
Affordable Insurance
Exchange (Part 2)
All plans sold on and off the ObamaCare Health Care Exchange must
include:
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Ambulatory patient services.
Emergency services.
Hospitalization.
Maternity and newborn care.
Mental health and substance use disorder services, including
behavioral health treatment.
Prescription drugs.
Rehabilitative and habilitative services and devices.
Laboratory services.
Preventive and wellness services and chronic disease management.
Pediatric services, including oral and vision care.
Benchmark Benefit Plans
Assures that the coverage gained through the Medicaid eligibility expansion includes mental
health services and prescription drugs.
 Prescription Drugs.
 Tobacco Cessation Services for Pregnant Women.
 Family Planning.
 Hospice Care for Children.
 Tobacco Cessation.
 Preventive and Obesity-Related Services.
 State Option to Provide Health Homes for Enrollees with Chronic Conditions.
Community-Based Long-Term
Services & Supports
The Affordable Care Act includes a number of program and funding improvements to help
ensure that people can receive long-term care services and supports in their home or the
community. The law improves existing tools and creates new options and financial
incentives for states to provide home and community-based services and supports.
 Home and Community-Based Services State Plan Option.
 Community First Choice.
 State Balancing Incentive Payments Program.
 Money Follows the Person (MFP).
 Demonstration Grant for Testing Experience and Functional Assessment.
 Tools (TEFT).
Quality of Care & Delivery
Systems
The Affordable Care Act seeks to improve the quality of care and the manner in which that
care is delivered, while at the same time reducing costs. Delivery System Improvements:
The law provides enhanced federal funding to states to establish health homes to
integrate care for people with chronic illnesses. It establishes the Center for Medicare and
Medicaid Innovation to focus on producing better experiences of care and better health
outcomes at lower costs through improvement.
 Health Homes.
 Provider-Preventable Conditions Including Health Care-Acquired Conditions.
 Quality Improvement.
 Adult Quality Measures.
 Prevention.
 TEFT.
Prevention of Chronic Disease
Prevention of Chronic Disease and Improving Public Health
of the Affordable Care Act promotes prevention, wellness
and public health and supports health promotion efforts at
the local, state and federal levels. Several provisions under
Title IV expand access to health care services that help
Medicaid beneficiaries prevent and manage chronic
disease.
 Preventive and Obesity-Related Services.
 Tobacco Cessation for Pregnant Women.
 Incentives for the Prevention of Chronic Disease.
Preventive and ObesityRelated Services
Two provisions Sections 4004(i) and
4106 encourage states to expand
and promote coverage of evidencebased preventative services for
adults.
Children's Health Insurance
Program
 The Affordable Care Act extends funding for the Children's Health
Insurance Program (CHIP) through FY 2015 and continues the
authority for the program through 2019.
 January 2014, all individuals under 65 years of age with income below
133 % of the federal poverty level (FPL) ($14,500 for an individual and
$29,7000 fix a family of four in 2011) many of whom have children
enrolled in CHIP, will be eligible for Medicaid.
 Children currently covered by CHIP with family incomes between 100
– 133 % FPL will transition to Medicaid but states will retain their
ability to claim the enhanced CHIP matching rate. The law provides
for a 23% point increase in the CHIP federal matching rate beginning
in October.
Dual Eligibles
The Affordable Care Act creates a new office within the Centers for
Medicare & Medicaid Services, the Medicare-Medicaid Coordination
Office, to coordinate care for individuals who are eligible for both
Medicaid and Medicare ("dual eligibles" or Medicare-Medicaid
enrollees).
The office is charged with making the two programs work together more
effectively to improve care and lower costs.
The office is focused on improving quality and access to care for
Medicare-Medicaid enrollees, simplifying processes and eliminating
regulatory conflicts and cost-shifting that occurs between the Medicare
and Medicaid programs, states and the federal government.
• Integrating Care for Medicare-Medicaid Enrollees.
• Medicare Data.
• State Demonstrations.
• Waiver Period.
Provider Payments
 Improving Payments for Primary Care Services.
 Q & A: Increased Medicaid Payments for Primary Care Physicians.
 Combined State Plan Reimbursement Template for Medicaid PCP
Payment Increases .
 Disproportionate Share Hospital (DSH) Payment.
 Medicaid Emergency Psychiatric Demonstration Project.
 Improvements to the Medicaid and CHIP Payment and Access
Commission.
(MACPAC).
Program Transparency
The Affordable Care Act promotes transparency
about Medicaid policies and programs,
including establishing meaningful
opportunities for public involvement in the
development of state and federal Medicaid
waivers.
Program Integrity
The Affordable Care Act includes numerous provisions designed to increase
program integrity in Medicaid, including terminating providers from
Medicaid that have been terminated in other programs, suspending Medicaid
payments based on pending investigations of credible allegations of fraud and
preventing inappropriate payment of claims under Medicaid.
Areas of interest under this provision:
 Provider Participation
 Pending Investigations of Credible Allegations of Fraud
 National Correct Coding Initiative (NCCI)
 Recovery Audit Contractors (RACs)
 Home Health
FACE TO FACE
 The Affordable Care Act (ACA) established a face-to-face
encounter requirement for certification of eligibility for
Medicare home health services, by requiring the certifying
physician to document that he or she, or a non physician
practitioner working with the physician has seen the patient.
 The encounter must occur within the 90 days prior to the start of
care, or within the 30 days after the start of care.
 Documentation of such an encounter must be present on
certifications for patients with starts of care on or after January 1,
2011.
Health Homes
 CMS expects state health home providers to operate
under a "whole-person" philosophy. Health Homes
providers will integrate and coordinate all primary,
acute, behavioral health and long-term services and
supports to treat the whole person.
 Not a physical house. Concentric clearing house with
multiple services available to track and care for the
patient.
 None in Massachusetts.
Who is Eligible for a Health Home?
 2 or more chronic conditions.
 One chronic condition and are at risk for a second.
 One serious and persistent mental health condition.
 Chronic conditions listed in the statute include mental health, substance
abuse, asthma, diabetes, heart disease and being overweight. Additional
chronic conditions, such as HIVIAIDS may be considered by CMS for approval.
 States can target health home services geographically.
 States cannot exclude people with both Medicaid and Medicare from health
home services.
Health Home Services
 Comprehensive care management.
 Care coordination.
 Health promotion.
 Comprehensive transitional care/follow-up.
 Patient & family support.
 Referral to community & social support services.
Health Home Providers
States have flexibility to determine eligible health home providers.
Health home providers can be:
 A designated provider : May be a physician, clinical/group practice,
rural health clinic, community health center, community mental health
center, home health agency, pediatrician, OB/GYN or other provider.
 A team of health professionals: May include physicians, nurse care
coordinators, nutritionists, social workers, behavioral health
professionals. They can be free-standing, virtual, hospital-based or a
community mental health center.
 A health team: May include medical specialists, nurses, pharmacists,
nutritionists, dieticians, social workers, behavioral health providers,
chiropractics, licensed complementary and alternative practitioners.
“The root of the skepticism
is the resistance to the
process of change itself”
~ Unknown
HEALTH CARE REFORM....
WILL IT WORK??
PROS
 Increased coverage. Thirty-two million Americans who would not have been
covered by health insurance either now have coverage or will get the coverage
they need starting in 2014.
 3.1 million Americans ages 19 through 25 who may be added to their parents'
plans. Many of these youth are working but still cannot afford to pay for health
benefits.
 Patients with pre-existing conditions will no longer be able to be denied
coverage by insurance companies. Insurance companies will no longer be able
to drop plan members once they get sick.
 People who can't afford health insurance will have the Federal government
paying states to add this group to the state's Medicaid program.
PROS (Part 2)
 Reduced healthcare costs. According to the Congressional Budget Office(CBO), the cost
of healthcare could be reduced. Since the Act makes sure 95 percent of citizens have
health insurance, preventative healthcare will be more accessible. The newly insured will
no longer have to wait until their ailments become so extreme that they are forced to visit
the hospital emergency room, a more costly care avenue.
 Reduced budget gaps. The Congressional Budget Office (CBO) estimates that the PPACA
will reduce the national budget deficit by $143 billion by 2019 because of the Act's
associated taxes and fees. In addition, the CBO believes that the Medicare "donut hole"
gap in coverage will be eliminated by 2020.
 Higher taxes, lower deductions. Americans who don't pay for insurance and don't qualify
for Medicaid will be assessed a tax of $95 (or 1 percent of income, whichever is higher) in
2014. The tax will increase substantially to $325 (or 2 percent of income) in 2015, and $695
(or 2.5 percent of income) in 2016. Individuals with annual incomes above $200,000 and
couples with incomes above $250,000 will pay higher taxes to help cover costs of the
program. And, in 2014, families can only deduct medical expenses that exceed one
percent of income, rather than today's 7.5 percent of income.
CONS
 Shortage of healthcare professionals. A new study by the
National Monitor predicts that the implementation of the
PPACA, coupled with the nation's aging provider population,
could lead to a shortage of 52,000 primary care physicians by
2025. This could leave millions of Americans without access to
healthcare. The study also noted that office visits to primary care
physicians will likely increase from 462 million to 565 million by
2025, further straining the system. Take into account the aging
nurse pool as well and a problem exists.
 Higher drug costs. Pharmaceutical companies will pay an extra
$84.8 billion in fees over the next ten years to pay for closing the
"donut hole" in Medicare. This could raise drug costs if they pass
these fees on to consumers.
“If you don‘t like something, change
it; if you can't change it, change the
way you think about it.”
~Mary Engelbreit
ACO
ACCOUNTABLE CARE
ORGANIZATION
Accountable Care Organizations (ACOs)
are groups of doctors, hospitals and
other health care providers, who come
together voluntarily to give coordinated
high quality care to their Medicare
patients. They were mandated by the
ACA.
MEDICARE ACOs
 Medicare Shared Savings Program.
 Advanced Payment ACO Model.
 Pioneer ACO Model.
Medicare Shared Savings Program
- A program that helps Medicare fee-for-service program providers
become an ACO.
 Fee-for-service (FFS) is a payment model where services are
unbundled and paid for separately. In health care, it gives a negative
incentive for physicians to provide more treatments because payment
is dependent on the quantity of care, rather than quality of care.
Similarly, when patients are shielded from paying (cost-sharing) by
health insurance coverage, they are incentivized to welcome any
medical service that might do some good. FFS is the dominant
physician payment method in the United States,.. it raises costs,
discourages the efficiencies of integrated care and a variety of reform
efforts have been attempted, recommended, or initiated to reduce its
influence (such as moving towards bundled and capitation). In
capitation, physicians are discouraged from performing procedures,
including necessary ones, because they are not paid anything extra for
performing them.
The Shared Savings Program
The Shared Savings Program is designed to improve
beneficiary outcomes and increase value of care
by:
 Promoting accountability for the care of Medicare FFS
beneficiaries.
 Requiring coordinated care for all services provided
under Medicare FFS.
 Encouraging investment in infrastructure and
redesigned care processes.
Advance Payment ACO Model
A supplementary incentive program for selected participants in the Shared
Savings Program.
 The Advance Payment Model is designed for physician-based and rural
providers who have come together voluntarily to give coordinated high quality
care to the Medicare patients they serve.
 Designed for smaller ACO's without the capital to fund care coordination
infrastructure.
 Upfront and monthly payments....advance on the shared savings projected
 Up front fixed payment
 Up front variable payment
 Monthly payment
35 Advanced Payment ACO's in US - Massachusetts...Harbor Medical Weymouth.
Pioneer ACO Model
A program designed for early adopters of coordinated care:
 The Pioneer ACO Model is designed for health care organizations and
providers that are already experienced in coordinating care for patients across
care settings.
 Allow these provider groups to move more rapidly from a shared savings
payment model to a population-based payment model.
 Consistent with, but separate from, the Medicare Shared Services Program.
 Work in coordination with private payers by aligning provider incentives,
which will improve quality and health outcomes for patients across the ACO,
and achieve cost savings for Medicare, employers and patients.
 Provide more coordinated care to beneficiaries at a lower cost to Medicare.
Massachusetts ACO's
 Partners Health Care.
 Atrius Healthcare.
 Beth Israel Deaconess Physicians Organization.
 Mt Auburn Cambridge Independent Practice Associates
(MACIPA).
 Steward Health Care.
How do they Differ?
 The payment models being tested in the first two
years of the Pioneer ACO Model are a shared savings
payment policy with generally higher levels of shared
savings and risk for Pioneer ACOs than levels currently
proposed in the Medicare Shared Savings Program.
 In year three of the program, participating ACOs that
have shown a specified level of savings over the first
two years will be eligible to move a substantial portion
of their payments to a population-based model.
What is Population-based
Payment?

A provider entity agrees to accept
responsibility for the health of group of
patients in exchange for a set amount
of money.
 Global Payment or Total Cost of Care
payment.
Bundling
 Bundling involves moving the financial responsibility of the
hospital-discharged patient to the hospital itself. It essentially
partners the hospital with the Post-Acute providers currently
receiving their discharged patients by making hospitals
responsible for the care costs of these patients.
 All Part A hospital patients will eventually be Bundled, as
Medicare essentially eliminates payment coverage for patients
readmitted to the hospital within 30 days of discharge under the
Bundling model.
 Patient choice will remain intact, but the lowered cost of care
produced by successfully managed care transition programs will
redefine "reasonable and necessary" care levels.
Care Transition Teams
 Care Transitions Programs were created to reduce health care costs by
decreasing a patient's preventable readmissions to the hospital.
 Overall goal of the CTT is to provide patients with the coordination and
training necessary to properly utilize existing medical services in the
community.
 Intermediate risk patients who are medically complex, but socially
stable.
 Concentrate their efforts on stabilizing the patient medically.
 Care Transition intervention is ideally limited to a maximum of 90
days.
How does it work?
 The CTT first visits a potential care transitions patient in the hospital.
 When patient is discharged, the CTT visits him or her at home within 48 hours.
Patient sets his or her own health goals and develops a relationship with the
team. Medicine reconciliation is also done.
 Medical equipment assessment and a psychosocial assessment are done.
 A primary care appointment for the patient is made within seven days of
discharge.
 The nurse also will attend the appointment with the patient and help facilitate
the necessary transportation.
 Over the next 30 days the CTT works directly with the patient.
How does it work (Part 2)
 Weekly home visits enable the nurse is to educate patients on issues
such as care for chronic conditions.
 After the first 30 days, the nurse will transition the patient to the health
coaches, who will continue to provide education while coordinating
appointments and transportation.
 During the next sixty days, the patient will ideally develop skills to take
control of his or her own healthcare. He will learn to make
appointments and arrange transportation while simultaneously
gaining the skills to properly manage chronic conditions.
 Pt now has relationship with and have medical needs met by the PCP,
eliminating the need for frequent hospitalization.
 ER visits and readmissions are often lowered significantly. Costs are
lowered.
ACO
GOOD???
BAD???
UGLY???
Pros
 Shared risk means shared responsibility.
 Wider scope of data aggregation.
 Better population health control.
 More options for patients.
 Greater financial security for solo practitioners.
Pros (Part 2)
 Ensure patient safety and care coordination.
 Cut costs across the board.
 Promote health information exchange (HIE).
 Patients receive more comprehensive care, feel taken care
of and have access to more choices and greater benefits.
 Receive more tailored services, since providers will only be
reimbursed for medically necessary tests and procedures.
 Interdisciplinary care teams can increase the accuracy of
diagnoses and support a patient with multiple conditions.
CONS
 IT infrastructure required is costly.
 Shared risk also means shared decision making.
 Individual priorities and visions can cause potential difficulties when it comes
to choosing a new direction or allocating the bill.
 Increased exchange of information and more providers utilizing a patient's
chart, data security and patient privacy can be compromised.
 Providers will need to coordinate with each other to ensure that HIPAA
regulations are being strictly followed as data is shared back and forth to
prevent improper use of information.
 Providers will also need to ensure that patients don't feel juggled among
providers in the name of comprehensive care.
A Success Story
Mr. X was diagnosed this spring with a potentially deadly
heart ailment. Since then, his doctor and other medical
professionals have spent hours explaining the disorder and
discussing ways he can try to live with it. Whenever he has
a question, someone from the hospital or VNA gets right
back to him with an answer. Every week or two, a nurse
comes to his home to take his blood pressure, ask about his
pain and check for complications.
He believes that without such support, he would be
struggling more. “I definitely would have returned to the
hospital more often" he said.
How does this affect home care?
Bill Dombi, Vice President for Law at the National
Association of Home Care and Hospice (NAHC) for the
last 25 years states:
"Home Health is still going forward, homecare will be bigger,
stronger, and more a mainstream part of healthcare in the
future. The new model will be based on integrated care with
one purpose: keeping people at home rather than anywhere
else; if they happen to leave the home to go to the hospital, it's
getting them back home sooner. Ten years from now,
homecare will still be around but it will be different; it will not
be what we see today, it will be a much, much bigger realm of
homecare services; it may not even be called Home Health
anymore."
Here to Stay?
 With 32 Pioneer ACO's in existence and
over 400 ACO's of varying structure,
both commercial and Medicare based,
ACOs are here to stay. The jury is still
out as to how much revenue they will
generate, how much savings they will
incur and how effective they will be in
consolidating patient care. . .
COMPETITIVE BIDDING
The DMEPOS Competitive bidding program was
mandated by Congress though the Medicare
Prescription Drug Improvement and
Modernization Act of 2003 to replace the current
fee schedule for selected Durable Medical
Equipment Prosthetics Orthotics and Supplies
(DMEPOS) items with a competitive bid. The
intent was to reduce beneficiary out-of-pocket
expenses and save Medicare money while ensuring
the beneficiary access to quality items and
services.
How does it work?
 Competitive bidding area established.
 Providers submit a sealed bill.
 Providers evaluated on financial eligibility, stability, bid
price and compliance with applicable standards.
 Medicare doesn't reveal the standards they are judging
providers on.
 "Winners" are expected to provide service while absorbing
a 45% cut in fee structure.
Product Categories
 Oxygen supplies and equipment.
 Standard (power and manual) wheelchairs, scooters, and related accessories.
 Enteral nutrition, equipment and supplies.
 CPAP devices, resp. assistive devices, related supplies and accessories.
 Hospital beds.
 Walkers.
 Support Surfaces (mattress and overlays).
 Negative Pressure Wound Therapy pumps and related supplies.
In Other Words..
Competitive bidding is a new Medicare program that
will make it challenging for beneficiaries to obtain the
medically necessary equipment and services they need
for daily living. Medicare traditionally has contracted
with many home medical equipment (HME) providers
throughout the country. However, the competitive
bidding program will decrease the number of
providers available to supply equipment and services.
Medicare will accept new providers based on a bidding
process. Those providers who offer the lowest bids for
equipment and service will receive contracts from
Medicare.
GOOD IDEA?????
We don't think so...
Decide for yourself
What's wrong
with
Competitive
Bidding??
It's an arbitrary pricing scheme with no transparency
or appeal process…
 Artificially low pricing and low ball bids factored in
result in "mean" lower than submitted bid.
 No appeals process.
 CMS refuses to release methodology used to assess bid
winners.
 Winning providers can back out of contracts.
It's bad for small businesses and will destroy thousands
of jobs…
 93% providers not awarded contracts.
 42% will go out of business.
 100,000 people lose their job.
 Creates a less competitive market.
It will hurt Medicare recipients: seniors and people with
disabilities…
 No local providers.
 Delay in service.
 Dissolve long-term provider -patient relationship.
 Multiple vendors.
 Decrease in product quality.
 Limited coverage for new technologies.
 Medicare help line offers little problem-solving help.
Joe, a wheelchair user from the Dallas area with
Limb Girdle Muscular Dystrophy, was told by his
doctor that he needed a hospital bed. He called
the contract winner located closest to him, one
hour and a half away from his home. When he
found that there would be a delay in receiving a
new bed, he decided to take matters into his own
hands. Worrying for his safety, he ordered a bed
from Craig's List, paying for it out of his own
pocket. He told us that he was fortunate that he
could afford the bed on his own, but he worried
others who could not and would have to wait.
Paul is a concerned husband who cares for his wife,
Mary, who relies on oxygen to treat her COPD. Since
the CBP started in their city, Mary's new provider visits
much less often than the old provider, now visiting
once every six months instead of once every three. At
one point, an entire year had passed before a provider
visited .Paul was forced to make concentrator
adjustments on his own by doctor's order, which made
him feel uncomfortable. He admits that he is not
trained to monitor the meter and to know when
adjustments are necessary. In the past, his provider's
regular visit made the couple feel safe and secure living
in their apartment, but now they are uncertain about
the future in their home.
Multiple wheelchair users in Kansas City waited months
to receive new wheelchair batteries. They expressed
concerns that available providers were located far away
from where they lived and the providers nearby would
not serve them because they had not purchased their
chairs from those providers. Deanna, a physical
therapist who assists beneficiaries with equipment,
was concerned that the bid winners were not certified
seating specialists or experienced wheelchair
providers. She believes that the lack of access to
quality care is costing more in the long run, because
people are treated for pressure sores as a result of poor
seating.
Shirley is a senior who lives on her own in a Kentucky
mobile home. She relies on oxygen to treat her lung
disease and a walker to safely maneuver around her
home. After competitive bidding went into effect, she
was instructed by her provider that in case of a power
outage, she will need to check into a hotel or drive to a
relative's house to get power for her oxygen
concentrator. In the past, a provider would be available
24 hours and seven days a week to deliver portable
oxygen tanks and check on her well being during a
power outage. She knows that if the power goes out
now, she will struggle to maneuver her cumbersome
concentrator to her vehicle, lift it into the car and drive
safely to a hotel she is unable to afford.
It will cost taxpayers more……
 No local service = More ER visits and
more hospital stays.
 More hospital stays = More Medicare
costs.
 More Medicare costs = More money from
taxpayers.
Is there an
alternative?
Market Pricing Program
 It uses an auction system to establish market-based prices
around the country.
 The MPP would conduct a new auction to set specific pricing for
similarly sized bidding areas.
 The winners are bound to the bid they submit.
 The price would be set based on the higher "clearing price" that
is traditionally used in auctions.
 More medical equipment providers can compete. In the majority
of cases a Medicare- approved provider could still participate
even though they didn't win the bid prior.
How is it better?
 Cost saving to Medicare.
 Realistic market access.
 Expert Design, Implementation, and Monitoring-Plus Transparency.
 Bidding Integrity and Price Determination.
 Bidder Accountability and Small Businesses.
 Products.
 Timetable.
WHAT CAN YOU
DO???
THE ANSWER IS
PLENTY!!!
FIGHT BACK!
 Make your voice heard. Get involved!
 Call the Medicare beneficiary hotline to voice your




concerns and complaints.
Call your congressional rep and encourage him to put
pressure on Congress to sign HR 1717.
Educate yourself on the various groups advocating for
the repeal of competitive bidding. Many have liaisons
at the governmental level to make our voices heard.
Share your story.
Share your patients story.
FIGHT BACK!
 Get involved. Either locally, statewide or nationally. Be an advocate.
 Educate yourself.
 Join organizations that collectively advocate for better health care as a
whole.
 Think outside the box every time you are presented a difficult situation.
 Re-allocate the resources you have to better serve the purpose.
 Flood the congressional switchboard with your concerns.
Resources
 www.contactingthecongress.org
 www.house.gov/representatives
 www.senate.gov/general_contact_information/senator
 www.whitehouse.gov/contact
 www.medicare.gov
 www.homesne.org
 1-800-633-4227…..1-800-MEDICARE