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Clinton Presidential Records
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Health Care Task Force
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Health Care Working Group Drafts [Folder 2] : [Health Initiatives and Benefits]
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HEALTH RESEARCH INITIATIVES
Health Care Reform encourages cost-conscious choices on the part of consumers and
providers by employing explicit financial incentives. At the same time advances in basic
medical science, medications development, technology, and refinements in the organization,
structure, and delivery of personal and public health services hold the promise of enhanced
system efficiency, increased longevity, and improved quality of life. Continued and
expanded investments in health research are integral features of the cost containment and
quality improvement under health care reform. Abe-important will be assessing-ihe-costs of
adeptnig inlo piaeliee new proeedwes-and-technologies-as-well-as-eonsidering-to-the-extent
possible cost cffcctiveness-as-part-ef-elinical-trialsr
New funding for health research is focused in two areas:
prevention research related to biomedical and behavioral research to promote
health and prevent the onset of disease.
health services research related to quality and outcomes measures, access and
financing, efficiency and cost effectiveness, consumer choice and decisionmaking research, primary care, and evaluation of health care reform.
PRIORITY AREAS FOR PREVENTION RESEARCH
The National Institutes of Health will support prevention research under current
authority of section 301(a) in priority areas including:
Child health - Including perinatal health, birth defects and diseases of
childhood, unintentional injuries, learning and cognitive development, and
adolescent health
Chronic and recurrent illnesses - Including research on Alzheimer's disease,
cancer, cardiovascular diseases, bone and joint diseases, and other chronic
diseases and conditions.
Reproductive health - Research areas include contraceptive development and
use, sexually transmitted diseases, adolescent pregnancy, and pregnancyrelated complications.
Mental health - Including research on mental disorders in children and
adolescents, child abuse and neglect, women's mental health, mental disorders
in the elderly and their caregivers, severe mental disorders, and violence.
�Substance abuse - Research will target vulnerable populations, including highrisk youth, and will study medications development, and preventing
dependence on tobacco, alcohol, and drugs.
Infectious diseases - Focusing on new and emerging infectious diseases,
vaccine development, and fundamental vaccine research, as well as, on
infectious diseases currently taking health and societal tolls, such as:
HIV infection and AIDS - Research on behavior, vaccines, transmission
of HIV, and prevention of disease progression to AIDS.
Tuberculosis - Includes research on new vaccines to prevent TB, early
diagnosis, and preventing disease progression.
Health and Wellness Promotion including:
Nutrition [section 301(B)(3)] - Includes defining optimal diets, dietary
links to disease, and obesity.
Physical activity - Includes an emphasis on fitness for all ages, and
fitness and aging.
Environmental health - Includes an emphasis on identifying health
hazards and their effects, and disorder-specific research.
Prevention Research and Infrastructure Resource Development - Basic science
development providing foundations for prevention efforts across a range of
diseases and disorders, including behavioral and social approaches, and
genetics.
Resource development will include support for prevention research training
and enhancement of statistical and epidemiologic techniques.
COORDINATION AND FUNDING OF PREVENTION RESEARCH
An additional investment of $1.5 billion annually will be required to fund new
research activities in the above priority categories. The NIH Institutes, Centers,and
Divisions will distribute the funds using three mechanisms: grants, contracts, and NIH
intramural research.
�The NIH Associate Director for Prevention will coordinate the prevention research
programs of the national research institutes under current authority of section 402 (7), and
will report annually to the NIH Director and the Secretary on the status and progress of
prevention research activities.
In consultation with the national research institutes, the NIH Associate Director will
develop an ongoing plan for prevention research activities conducted by the NIH.
Prevention research findings will be translated into, or appropriately integrated with,
personal health services and public health programs to maximize the impact of prevention
research on disease reduction and improved health status.
PRIORITY AREAS FOR HEALTH SERVICES RESEARCH
This research will provide the knowledge to increase the cost effectiveness,
appropriateness and quality of care in a reformed health care system. The health services
research program includes research designed to improve the effectiveness and appropriateness
of clinical practice through several interrelated activities, including:
effectiveness research
quality and outcomes research
development and dissemination of clinical practice guidelines
research and evaluation related to administrative simplification under health
care reform
research on consumer choice and information resources
evaluation of health care reform.
A new generation of health services research that will answer critical questions on the
effectiveness of treatments for common clinical conditions will be initiated. The patient
outcomes research and the development of clinical practice guidelines will be a central part
of the health services research agenda.
�Examples of specific areas of health services research are:
Effectiveness research which examines the appropriateness and effectiveness of
alternative strategies for the prevention, diagnosis, treatment, and management
of clinical conditions, in terms of patient outcomes. The Medical Treatment
Effectiveness Program research focuses on conditions that meet one of more of
the following criteria:
Large number of individuals are affected
- .
There is uncertainty or controversy regarding effectiveness of
treatment.
Associatedrisksand/or costs of treatment are high
Patient outcomes research teams (PORTs) are 5-year grants that include
elements of formal literature synthesis, data acquisition and analysis,
development of clinical recommendations, dissemination of findings, and
evaluation of the effects of findings on change in clinical practice.
Clinical practice guidelines development promotes the quality, appropriateness,
and effectiveness of health care. The guidelines also represent standards of
quality, performance measures, and medical review criteria through which
health care providers may assess or review the provision of health care. These
guidelines are used to assist in determining how diseases, disorders, and other
health conditions can most effectively and appropriately be prevented,
diagnosed, treated, and managed clinically.
Research and evaluation regarding computerized medical records and
information systems will contribute to the administrative simplification goals of
health reform.
Studies will be undertaken on the impact of barriers to access, utilization, and
continuity of health care services on health care reform.
Research and analytic work will be necessary to devise, implement, maintain,
and evaluate a system of health care budgets, at the national, state, and
alliance levels.
Expanded research onriskadjustment is required to facilitate efficient
measurement and quantification of personal health care needs. Such research
is essential to Federal and state management of health alliance structures and
financing mechanisms.
�Long-term care research and demonstrations with new program models for
financing and administration will be undertaken.
Service system organization and structural research will include examination of
the relationship of continuity, accessibility, and comprehensiveness of primary
care to cost, quality, and access in health care which is critical for planning
and organizing more effective and efficient services.
EVALUATION OF HEALTH CARE REFORM
The introduction of comprehensive health care system reform will affect every aspect
of American health care delivery. Studying the intended and unintended effects of these
changes is a fundamental public responsibility. To support heath care reform and the Health
Security Act, evaluation research will include:
Short-term research - Evaluate the responsiveness of the system to health care
reform, including its effects on institutions, health care professionals, and
specific population groups.
Long-term monitoring - Examine the effects of reforms on cost, quality and
access. Longitudinal studies using databases developed through the
augmentation of national and regional surveys and analyses of secondary data
are needed.
Demonstrations and evaluations - Address critical issues in health care reform,
such as quality assurance and medical liability.
CONSUMER CHOICE AND DECISION-MAKING RESEARCH
Priority will be placed on research for improving information resources that enable
purchasers to make health care choices based on their relative value and quality. This
research would improve consumer decision making and result in more cost-effective service
delivery and health plan selection. The research efforts will include:
Consumer awareness of benefit plans, availability of supplemental coverage,
cost-sharing, and utilization.
Effects of consumer knowledge on the selection of health plans including the
relationship between health status and choice of plan.
Types of information and form of media most effective in assisting consumers
in selecting efficient health plans and providers, including information on costs
and quality of care.
�Impact of improved information on consumer satisfaction, access to care,
quality of care and the cost of services.
Patient choice and decision-making related to treatment alternatives.
COORDINATION AND FUNDING OF HEALTH SERVICES RESEARCH
An additional $300 million will support the health services research program
described above (funding for the Quality Management Improvement Program and the
information system activities are included in the Quality Management and Improvement
section and the Infonnation Systems section).
Administrative responsibility for the health care reform research activities described
above will reside in the Agency for Health Care Policy and Research in the Public Health
Service and the Office for Research and Demonstrations in the Health Care Financing
Administration. The research activities will be conducted through the intramural and
extramural programs using the mechanisms of grants, contracts, and cooperative agreements.
�PJ
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�WORKING GROUP DRAFT
PRIVILEGED AND CO^JriDEJ'mAL
ADMINISTRATIVE SIMPLIFICATION
The National Health Board enters into contracts for the development and
implementation of:
Standard forms to record enrollment, clinical encounters and insurance
reimbursement.
Automation of insurance transactions and industry-wide adoption of standard
forms.
Simplified coordination of benefits.
The creation of "standard and unique" identification numbers for all health care
providers, health plans, employers and enrolled consumers.
Steps to streamline the administration of the M^icafe program.
STANDARD FORMS
In consultation with providers, plans, employer groups, and others, an advisory committee
to the National Health Board adopts standard forms used for insurance reimbursement, health
plan enrollment and to record clinical encounters.
The advisory committee determines the standard information requirements and data
definitions for forms by July 1, 1994. All health plans and alliances adopt content
requirements by December 31, 1994.
B), January 1, 1995, all health plans adopt a single, standard form for reimbursement
according to the following classes of providers:
x „ v
The UB-92 for institutional providers
The Standard Health Insurance Claim Form ^CFA-hpO) for all noninstitutional providers except pharmacies and dentists
HCFA 1500 for dentists
The Universal Drug Claim Form developed by the National Council on
Prescription Drug Programs for pharmacies that seek reimbursement.
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�WORKING GROUP DRAFT
PRIVILEGED AND CeWPtBBNTlTttr
The standard claim form serves the secondary purpose of collecting information required for state
monitoring, accountability and the measurement of quality outcomes.
All health plans and employers also adopt a national, standard enrollment form. In conjunction
with standard claim reimbursement and encounter information, enrollment data is used for monitoring
accountability and performance.
INSURANCE TRANSACTIONS
The National Health Board oversees the development of standards for the automation of insurance
transactions, including claims payments and status reports, remittance advice, eligibility, coordination
of benefits and utilization management.
Standard coding and content requirements eliminate multiple, conflicting requirements on health
provider, for information, formats and definitions.
The National Health Board identifies and consolidates existing standards in the health care
industry), working from prototypes developed by the American National Standards Institute.
The Board reviews standards in consultation with groups such as the Workgroup for Electronic
Data Interchange, the American National Standards Institute, the National Institute of Standards and
Technology.
By July 1, 1994, the National Health Board designates national standards that providers, plans,
alliances and employers adopt as a condition of participation in the health system. The Board
establishes requirements related to content, definitions and a strategy for implementation no less than
six months before the requirement for standardized transactions takes effect.
All government health programs, including the Department of Defense, CHAMPUS, Department of
Veterans Affairs, Medicare and Medicaid adopt national standards immediately. All private payers,
including purchasers of health insurance through regional and corporate alliances, adopt national
standards for electronic transactions after January 1, 1995.
109
�WORKING GROUP DRAFT
PRIVILEGED AND'COOTIDENTIAL
Major public and private payers, hospitals, major employers and corporate alliances, as
well as clinics and group practices of 20 o mr professionals automate the core transaction set
r oe
by July 1, 1995. States may deny payments to plans that have not automated transactions by
that date.
To speed implementation, the National Health Board provides technical assistance to health
alliances and plans.
UNIQUE IDENTIFICATION NUMBERS
The National Health Board undertakes a process to determine, adopt and enforce unique
identification numbers for consumers in health plans.
STREAMLINING MEDICARE
The Medicare program participates in the implementation of standard forms, uniform-in
billing, electronic claims submission, remittance notices, coordination of benefits, unique
identification numbers and streamlining of utilization review as required under health reform.
In addition, the Medicare Program consolidates current roster of 83 insurance companies
that act as contractors; it contracts separately for different functions (e.g. claims processing
using a common system across contractors, provider profiling, provider relations, audit, fraud
and abuse prevention).
Medicare eliminates extra billing for Part B providers such as durable medical equipment
providers, orthotic and prosthetic suppliers and ambulances.
Medicare streamlines claims processes further by:
Deleting information related to Medicare as a secondary payer from claim form
and incorporating into national eligibility file.
The Department of Health and Human Services develops and mandate modelcoordination of benefits rules immediately for Medicare,:workers'
compensation, auto insurance and other nonalliance health coverage.
�WORKING GROUP DRAFT
PRIVILEGED AND CONTIDE^AL
Additional coordination of benefits reform occurs when the national enrollment
file is developed and operational (January 1, 1996) After the enrollment file is
operational, insurers are required to forward coordination of benefits claims to
appropriate insurers, through the enrollment file if necessary.
Deleting Medigap reporting requirement from the claim form; supplemental
insurance becomes part of the national eligibility file.
The Health Care Financing Administration also:
Incorporates evaluations from physicians and their representatives into annual
performance evaluations of carriers, expanding the current five-state pilot
project nationally.
Eliminates complexities caused by dual funding sources and rules for Medicare
Part A and Part B claims.
Efforts already underway by HCFA eliminate some complexities. In 1996, the
Health Care Financing Administration begins to implement national, standard,
integrated claims processing system for all Medicare claims, with the goal of
full implementation by 1998.
Streamlines the process for settling cost reports, working through the
Medicare-Technical Advisory Group on Hospital Administrative Issues.
Eliminates the requirement for physicians to sign an acknowledgement of
awareness of penalties associated with falsifying claims information on an
annual basis and replaces with a single acknowledgement when granted hospital
privileges.
Eliminates prebilling requirement for attestation by physician of diagnoses and
major procedures performed in the hospital.
[HHS position: Streamlines the prebilling requirement for attestation by
physicians through work of the Medicare Technical Advisory Group on Hospital
Administrative Issues.]
�_ WORKING GROUP DRAFT
PRIVILEGED AND €OMFIDENTIAL
Simplifies the "Important Letter to Medicare Patients" in consultation with the
Medicare-Technical Advisory Group.
Repeals legislation requiring review of at least ten surgical procedures.
Improves upkeep of data in "Common Working File."
Notifies health care provides 120 days in advance pf apy major change ki
billing procedures/y|||^^£
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Consistent with the 4th Scope of Work, the ^RO prograrrw^fco^^e (omojie'^^
toward analysis and improvement of patterns of health care and outcomes, anc
away from individual case review, as appropriate.
The National Health Board explores developing standards for a single annual inspection of
health care institutions to replace multiple inspections performed by federal, state, local and
private accreditation, survey and certification agencies.
112
��WORKING GROUP DRAFT
PRIVILEGED AND OOHFIDDNTIAL
QUALITY MANAGEMENT AND IMPROVEMENT
Health reform transforms the current prescriptive quality
assurance program into a quality-management system focused on
performance measures and continuous improvement.
Quality assurance programs in the current system rely on
external checks, forms and process manuals. Insurance c a r r i e r s ,
peer review organizations, state and federal inspection agencies
audit the work being done in hospitals, doctors' o f f i c e s and
laboratories, and penalize the providers i f they f a i l to follow
rules. Patients play a minor role, lacking r e l i a b l e information
upon which to compare the quality of health plans, providers or
treatments.
Under the American Health Security Act, in addition to
appropriate structural and process mechanisms, emphasis i s placed
on outcomes and customer-focused continuous quality improvement.
NATIONAL QUALITY MANAGEMENT PROGRAM
The National Quality Management Program develops the quality
information system and establishes standards for State, Alliance
and plan level quality management programs. An advisory council
under the National Health Board, appointed by the President
oversees the program.
The council consists of 15 members who are representative of
the population, including representatives of consumer groups,
health plans, states, purchasers of care and experts in quality of
care and related f i e l d s of health service research.
The advisory council to the National Quality Management
Program:
Develops a core set of quality measures and standard
consumer survey questionnaires, and updates them over
time to r e f l e c t changing goals and improving methods for
quality improvement in health care. (Surveys are
carried out by the entity responsible for overall
information systems.)
Develops sampling strategies to ensure that performance
reports r e f l e c t populations d i f f i c u l t to reach with
t r a d i t i o n a l consumer-sampling methods, including
consumers who f a i l to enroll in a health plan or resign
from plans.
9 5
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�WORKING GROUP DRAFT
PRIVILEGED AND rONT^DENTIAti
Sets national goals for performance on selected quality
measures.
Establishes minimal standards of access and quality for
plans for selected measures.
Supports research and technology assessment to develop
r e l i a b l e tools for measuring health outcomes.
Evaluates the impact of health reform on the quality of
care.
Reports annually on performance of the health care
system.
Reviews and recommends changes to the quality measures
annually and establishes a five-year p r i o r i t y l i s t for
measures to be included i n the future.
Uses the national network of regional centers to obtain
quality related access u t i l i z a t i o n and management data.
(See section on "Information Systems and Administrative
Simplification," Tab 16.)
PERFORMANCE REPORTS
The National Quality Management Program under the National
Health Board develops a core set of measures of performance that
apply to a l l health plans, institutions and practitioners. I t
publishes annual performance reports outlining the r e s u l t s of
those measures for each health plan, creating a public system of
accountability for quality and providing consumers with meaningful
information.
I t also provides annual reports to the states on the
comparative performance of health plans and state quality
programs. Quality reports include information on the performance
of a l l i a n c e s and health plans on as many as 50 measures of access
to care, appropriateness of care, health outcomes and s a t i s f a c t i o n
with care.
I t provides the r e s u l t s of a smaller number of quality
measures for health care i n s t i t u t i o n s , doctors and other
practitioners i f the available information i s s t a t i s t i c a l l y
meaningful. State performance reports include trends, performance
on national quality measures and on goals for national performance
on access, appropriateness and health outcomes.
96
�WORKING GROUP DRAFT
PRIVILEGED AND •eONFIDENTIAfc
The following c r i t e r i a determine the selection of national
measures of quality performance:
The measures r e f l e c t important aspects of care in terms
of prevalence of i l l n e s s , morbidity, mortality or cost.
The set i s representative of the range of services
provided to consumers by the e n t i t i e s i n question.
Measures are r e l i a b l e and v a l i d and data needed for
calculation can be obtained without undue burden.
Performance on measures included i n the set vary widely
among the e n t i t i e s on the performance report.
When the measures are rates of process of care, these
processes are linked by strong s c i e n t i f i c evidence to
health outcomes.
When the measures are outcomes of care, performance l i e s
within the control of providers and adequate r i s k
adjustment can be accomplished.
STATE ROLE
As part of the Quality Management Program, states assume
responsibility to:
Develop and implement plans to meet enrollment, access
and quality standards established by the federal
government.
Assure that plans and providers meet essential national
standards through licensure and c e r t i f i c a t i o n
procedures.
Monitor the extent to which plans make the f u l l range of
benefits covered in the guaranteed package accessible to
a l l population groups.
Prepare comparative reports on the performance of
a l l i a n c e s , plans, providers and practitioners within the
State.
Establish i n each a l l i a n c e a premium check-off system at
enrollment where an annual amount— up to $2 per
e n r o l l e e — can be designated for the purpose of
supporting a consumer advocacy program.
97
�WORKING GROUP DRAFT
PRIVILEGED AND CONTIDENTIAL
Establish a program of technical assistance. E l i g i b l e
organizations may include nonprofit foundations, publicprivate partnerships, consortia led by academic medical
centers, or other forms.
Technical assistance may include a variety of
a c t i v i t i e s such as: fostering collaboration among
health plans and providers; disseminating
information about successful quality-improvement
programs, practice guidelines and research
findings; and providing educational courses and
other forums for providers to exchange information
on the evaluative sciences and quality improvement
activities.
Technical assistance i s targeted at improving
quality management practices and not designed to
regulate or interfere with the administration of
plans and providers.
A per capita levy on insurance premiums, with the
amount established by the National Health Board,
funds the technical assistance program.
Providers and health plans are not required to use
technical assistance resources as a condition of
participation i n the new health care system,
although health plans are accountable for improving
performance on national quality measures.
ROLE OF ALLIANCES
As part of the quality management program, health a l l i a n c e s :
Resolve consumer complaints, grievances and requests to
leave a health plan.
Disseminate to consumers information related to quality
and access to aid i n their selection of plans.
Prepare comparative reports on the quality of health
plans, providers and practitioners within the a l l i a n c e .
Conduct education programs to a s s i s t consumers i n using
quality and other information i n choosing health plans.
98
�WORKING GROUP DRAFT
PRIVILEGED AND CONFIDENTIAL
ROLE OF HEALTH PLANS
As p a r t of t h e q u a l i t y management program, h e a l t h plans:
Measure and disclose performance on q u a l i t y measures.
Maintain and improve t h e q u a l i t y of care d e l i v e r e d by
providers and p r a c t i t i o n e r s .
Meet n a t i o n a l , uniform Conditions o f P a r t i c i p a t i o n
established f o r h e a l t h plans t h e by t h e National Health
Board (See "Health Plans," Tab 9 ) .
DEVELOPING INFORMATION FOR QUALITY MANAGEMENT
An e l e c t r o n i c network containing uniform enrollment,
f i n a n c i a l and u t i l i z a t i o n data i s created, as o u t l i n e d i n t h e
section on Information Systems. As p a r t of t h e o v e r a l l
i n f o r m a t i o n systems framework, q u a l i t y management data i s reported
through t h e network and includes information r e l a t e d t o
enrollment, c l i n i c a l encounters, consumer s a t i s f a c t i o n , and
q u a l i t y measures. Regional centers are l i n k e d e l e c t r o n i c a l l y w i t h
s t a t e q u a l i t y programs, h e a l t h a l l i a n c e s and plans, p r o v i d i n g upto-date q u a l i t y and u t i l i z a t i o n information by plan and provider,
as w e l l as comparative information on other h e a l t h plans and
s t a t e s . Regional centers a u d i t samples of data provided by plans
and providers t o ensure i n t e g r i t y .
To supplement r o u t i n e l y c o l l e c t e d information, h e a l t h plans
gather c l i n i c a l data s p e c i f i e d by t h e n a t i o n a l q u a l i t y management
program from samples of medical records.
To assure coordination w i t h other data a c t i v i t i e s , t h e consumer
s a t i s f a c t i o n surveys are conducted as described i n t h e section on
Information Systems. Consumer surveys, i n combination w i t h other
data captured i n t h e information system, w i l l gauge access t o
care, use of h e a l t h services, outcomes and s a t i s f a c t i o n .
BOLSTERING THE KNOWLEDGE BASE FOR IMPROVING QUALITY OF CARE
To enhance t h e p r a c t i c e of medicine and promulgate
information about best p r a c t i c e s and e f f e c t i v e treatment
approaches, t h e National Q u a l i t y Management Program:
Develops p r a c t i c e guidelines t h a t a s s i s t providers i n
achieving q u a l i t y standards t h a t underpin n a t i o n a l
measures of q u a l i t y .
99
�WORKING GROUP DRAFT
PRIVILEGED AND -GONFIDENTIAL
Designs sample surveys t o include representation o f
populations considered t o be at r i s k f o r inadequate
h e a l t h care.
Develops methodology standards f o r p r a c t i c e g u i d e l i n e s ,
an evaluation and voluntary c e r t i f i c a t i o n process f o r
guidelines developed by the p r i v a t e sector.
Operates a clearinghouse and dissemination
practice guidelines.
program f o r
Disseminates information documenting c l i n i c a l l y
i n e f f e c t i v e procedures and treatments.
Establishes s c i e n t i f i c standards and procedures f o r
evaluating the c l i n i c a l appropriateness of protocols
used t o manage h e a l t h service u t i l i z a t i o n .
Finances research on t o p i c s c e n t r a l t o q u a l i t y
management and improvement, i n c l u d i n g dissemination
methods, and ways of measuring q u a l i t y .
With the advice of the n a t i o n a l q u a l i t y advisory
committee, and i n coordination w i t h the h e a l t h services
research community, establishes p r i o r i t i e s f o r h e a l t h
services research and evaluation r e l a t e d t o Q u a l i t y
Management. Such p r i o r i t i e s w i l l t a r g e t diagnoses w i t h
the highest l e v e l of u n c e r t a i n t y i n treatment decisions,
widest v a r i a t i o n i n p r a c t i c e p a t t e r n s , and/or
s i g n i f i c a n t costs and incidence.
STREAMLINING REGULATORY ACTIVITIES
Minimum standards f o r Health Care I n s t i t u t i o n s . The n a t i o n a l
q u a l i t y management program develops uniform standards f o r
l i c e n s i n g of h e a l t h care i n s t i t u t i o n s t h a t focus on e s s e n t i a l
performance requirements r e l a t e d t o p a t i e n t care. As they are
developed, those standards replace current r e g u l a t i o n s except i n
areas of f i r e s a f e t y , s a n i t a t i o n and p a t i e n t r i g h t s .
Current standards are r e t a i n e d u n t i l new ones are t e s t e d ,
promulgated, evaluated and implemented. I n the i n t e r i m ,
government agencies responsible f o r l i c e n s i n g and c e r t i f y i n g
h e a l t h care i n s t i t u t i o n s are required t o coordinate inspections,
minimize paperwork and reduce the number o f inspections.
100
�PRIVILEGED AND •CONriDENTIAL"
WORKING GROUP DRAFT
When t h e new standards are i n place, agencies charged w i t h
c e r t i f y i n g h e a l t h i n s t i t u t i o n s w i l l pay p a r t i c u l a r a t t e n t i o n t o
i n s t i t u t i o n s w i t h problematic records, i n response t o complaints
and randomly selected v a l i d a t i o n s i t e s .
By January 1, 1996, t h e n a t i o n a l q u a l i t y management program
completes demonstration p r o j e c t s f o r new performance standards and
r e v i s e standards according t o the f i n d i n g s .
Demonstration
p r o j e c t s must evaluate t h e impact o f these standards i n assuring
q u a l i t y o f care, reducing cost and burden on p r o v i d e r s .
Medicare Peer Review Organizations. The peer review o r g a n i z a t i o n
system under Medicare continues u n t i l t h e new q u a l i t y system i s
implemented and t h e Secretary o f the Department of Health and
Human Services determines t h a t Medicare enrollees are protected
adequately through National Q u a l i t y Management Program. PROs w i l l
end a t t h a t time.
( During the i n t e r i m , the PRO program i s streamlinec
Requiretaents fiar physician a t t e s t a t i o n
procedures i/s srreamlined/^ndNannua:
for inacauyate re^orts^ars replaiKjed/jij
when_qr^nred_hospital p r i v i l e g e s ^ J ( S e e " A d m i n i s t r a t i v e
^Sa^npTif^icati^oi^
The C l i n i c a l Laboratory Improvement Act. Regulation o f
c l i n i c a l l a b o r a t o r y t e s t i n g are re-focused t o emphasize q u a l i t y
p r o t e c t i o n w h i l e reducing a d m i n i s t r a t i v e burdens.
BUDGET
As p a r t o f t h e PHS i n f r a s t r u c t u r e budget, $300 m i l l i o n i n FY 1996
funds w i l l be used t o develop t h e a n a l y t i c and support f u n c t i o n s
necessary t o provide t e c h n i c a l assistance, analyze data and r e p o r t
on plan performance. Funds f o r the operating costs o f t h e
National Q u a l i t y Management Program w i l l be included i n t h e
operating costs o f t h e h e a l t h care reform program.
101
�10
WORKING GROUP DRAFT
0
PRIVILEGED AND i.U*ll •li.iaJ'll iJLl
INFORMATION SYSTEMS
Timely and r e l i a b l e information represents a c r i t i c a l
element i n e f f o r t s to reform the health care system and to
protect and improve the health of the Nation.
Health care reform establishes a new framework for health
information. Using standard forms, uniform health data
sets, electronic networks, national standards for electronic
data transmission, consumer surveys and public health
surveillance, the information framework supports:
o
The development of clear and useful information for
consumers.
o
Measurement of health status.
o
Monitoring and evaluation of the health care system.
o
Issuance of Health Security Cards.
o
Development of links among health care records to
improve patient care.
o
Analysis of patterns of health care.
o
Streamlined and simplified administration with
associated cost savings; improved policy development
and budget management.
o
I d e n t i f i c a t i o n of fraudulent a c t i v i t i e s .
The new information system features:
o
Strong privacy, c o n f i d e n t i a l i t y and security
protections.
o
Strong public/private partnerships and shared
responsibilities.
o
C l i n i c a l and administrative data
o
Appropriate l i n k s to the National
Infrastructure programs.
o
Electronic networks to insure timely a v a i l a b i l i t y of
r e l i a b l e information.
standards.
Information
DETERMINED TO BEAN
ADMINISTRATIVE MARKIN
INITIALS: DME:Q&&
�WORKING GROUP DRAFT
PRIVILEGED AND tiOMFiDliWTlAL
DATA AND INFORMATION SYSTEM FRAMEWORK FOR HEALTH REFORM
Every American i s e n r o l l e d i n t h e h e a l t h care plan of choice
and receives a h e a l t h s e c u r i t y card t o assure access t o
needed h e a l t h services throughout t h e United States.
Much l i k e ATM cards, t h e h e a l t h s e c u r i t y card f a c i l i t a t e s
access t o i n f o r m a t i o n about h e a l t h coverage through an
i n t e g r a t e d n a t i o n a l e l e c t r o n i c data network. The card
i t s e l f contains a minimal amount of i n f o r m a t i o n .
The National Health Board [HHS p o s i t i o n : HHS i s responsible
f o r t h i s ] , i n c o n s u l t a t i o n w i t h State and p r i v a t e e n t i t i e s
and other r e l e v a n t organizations, develops and implements
uniform n a t i o n a l standards f o r a d m i n i s t r a t i v e , c l i n i c a l ,
f i n a n c i a l and other h e a l t h care r e l a t e d i n f o r m a t i o n .
Standards include:
o
Uniform minimum h e a l t h data sets w i t h standard data
items and d e f i n i t i o n s .
o
E l e c t r o n i c data interchange standards f o r t r a n s f e r o f
the i n f o r m a t i o n .
A comprehensive h e a l t h care i n f o r m a t i o n p r i v a c y framework i s
e s t a b l i s h e d , i n c l u d i n g mechanisms f o r management and
o v e r s i g h t o f privacy and s e c u r i t y . P r i n c i p l e s of t h e
framework include:
o
Uniform p r i v a c y and c o n f i d e n t i a l i t y r i g h t s w i t h s p e c i a l
emphasis on p r o t e c t i o n of h i g h l y s e n s i t i v e data.
o
D e f i n i t i o n s of f a i r i n f o r m a t i o n p r a c t i c e s .
o
Appropriate
o
Enforcement mechanisms and p e n a l t i e s .
o
Coordination w i t h t h e p o l i c i e s established under t h e
National Information I n f r a s t r u c t u r e programs.
s e c u r i t y measures and technology.
The Board [HHS p o s i t i o n : HHS i s responsible f o r t h i s ]
establishes unique i d e n t i f i e r numbers f o r plans, providers
and p a t i e n t s . To ensure t h a t a l l views and concerns are
heard and addressed, t h e d e c i s i o n regarding t h e choice o f
i n d i v i d u a l i d e n t i f i c a t i o n numbers i s made through p u b l i c
hearings and a formal n o t i c e and comment process. The Board
[HHS p o s i t i o n : HHS i s responsible f o r t h i s ] has a u t h o r i t y
t o designate t h e Social Security Number as a unique
i d e n t i f i e r f o r persons i f t h a t o p t i o n i s selected.
�WORKING GROUP DI
PRIVILEGED AND SOHFIDEHTIAL
INFORMATION SYSTEMS
Health plans maintain.uniform documentation, i n electronic
form, of all^ c l i n i c a r encounters With health providers.
Records kay be based on insurance claims or c l i n i c a l
encounter^\(depending on^the type of health delivery
system).
The record system may be plan or community-based, or
shared among several plans.
Encounter records conform to the uniform minimum
administrative and c l i n i c a l data sets developed by the
Board [HHS position: HHS i s responsible for t h i s ] , and
are transmitted as appropriate to the national network
(see discussion below).
Emphasis i s placed on the goal of electronic records
and electronic data interchange with associated
economic e f f i c i e n c i e s . A phase-in period, with
incentives, i s planned to achieve t h i s goal. During
the phase-in period, standard forms may be used.
Current information systems technology readily supports
the^capture, retention and electronic data interchange
of encbunter records as a byproduct of the provision of
care and\with favorable benefit cost e f f i c i e n c i e s .
1
Development of regional encounter data systems i n t h i s
fashion wilU also support analysis of u t i l i z a t i o n and
treatment patterns, as well as quality and outcome
monitoring/as a basis for improving health care.
Analysis of//treatment patterns and creation of
normative data on ttye f u l l rang^ of medical, persdnal
and publi^Ahealth variables requires such large numbers
of e$coui>tjers as tp preclude traditional; sampling
\j
Withint-his framework, plans are encouraged to innovate to
«t^fequirements.
I t i s not the intent of health care reform to mandate
e x p l i c i t approaches to t h i s requirement.
Rather,
f l e x i b l e , l o c a l solutions to l o c a l needs and conditions
w i l l be fostered.
This requirement does not c a l l for implementation of a
very costly, f u l l - s c a l e computerized patient record.
I t c a l l s for using today's technology to capture, use
and access information.
�WORKING GROUP DRAFT
PRIVILEGED AND fiONriDDHTIAL-
The framework promotes t h e formation o f community based
h e a l t h i n f o r m a t i o n systems t h a t improve t h e q u a l i t y o f
care and reduce cost by minimizing d u p l i c a t e
procedures, t e s t s and adverse drug i n t e r a c t i o n s .
Plans, p r o v i d e r s , s t a t e s and h e a l t h a l l i a n c e s receive
f e d e r a l t e c h n i c a l assistance t o enable t i m e l y
conformance w i t h these requirements and t o s e l e c t cost
effective technical solutions.
Federal assistance i s compatible w i t h moving t h e h e a l t h
care system toward t h e p o i n t - o f - s e r v i c e i n f o r m a t i o n
system v i s i o n described below.
A POINT-OF-SERVICE INFORMATION SYSTEM
The long-term i n f o r m a t i o n s t r a t e g y / f o r h e a l t h reform
envisions t h e c r e a t i o n o f a h e a l t n care "Point-of-Service"
i n f o r m a t i o n system t h a t bringsyvalue-based h e a l t h
i n f o r m a t i o n t o bear on decisions by consumers, \
p r a c t i t i o n e r s , payers and p o l i c y makers^.. I n a p o i n t - o f service-informati-on-syst'em, / c T i n i c a l , a d m i n i s t r a t i v e and
payment data are exchanged e l e c t r o n i c a l l y among employers,
h e a l t h plans, physicians o f f i c e , h o s p i t a l s , l a b o r a t o r i e s ,
pharmacies, and other providers. Like c u r r e n t / c r e d i t card
and automatic t e l l e r machineXgystems, t h e sys'tem:
C o l l e c t s i n f o r m a t i o n as a bv
care.
t of the delivery of
o
o
7
Protects t h e privacy, c o n f i d e n t i a l i t y and s e c u r i t y o f
the i n f o r m a t i o n .
Provides immediate access t o i n f o r m a t i o n f o r
appropriate uses.
The n a t i o n a l system w i l l evolve from today's plan, dommunity
and r e g i o n a l h e a l t h i n f o r m a t i o n systems.
Accelerato —
development o f p o i n t - o f - s e r v i c e i n f o r m a t i o n systems
a d d i t i o n a l funding from t h e f e d e r a l government t o support
technology development and r e g i o n a l demonstration p r o j e c t ^
i n plans, communities, a l l i a n c e s and f e d e r a l f a c i l i t i e
1
)ERAL, ALLIANCE, PLAN AND STATE DATA NETWORK
An electronic network of regional centers conta
enrollment, financial, and utilization data is
network receives standardized enrollment, encou
related data from plans for aggregation, analys
feedback to plans, alliances, states and the Fed
Government. Tl^ LIU^^U^-.'
—Tjtzr
�WORKING GROUP DRAFT
PRIVILEGED AND OOHriDCMTIMj
The network supports the various analytic needs budget monitoring, measuring utilization, access, and
state accountability, assessing quality - of States,
health plans, health alliances and the federal
government. ^(j ^
^
Federal funds/^inancttS^the network, which i s b u i l t on
c o l l a b o r a t i o n w i t h p r i v a t e sector, State and e x i s t i n g
f e d e r a l programs.
Required data i s entered once and i s a byproduct o f
r o u t i n e a d m i n i s t r a t i o n and p r o v i s i o n o f care a t t h e
p l a n and a l l i a n c e l e v e l .
Health plans maintain uniform e l e c t r o n i c records o f a l l
encounters/claims.
Plans t r a n s m i t encounter data, i n t h e form o f a uniform
minimum data s e t , t o t h e network on a r e g u l a r basis.
Uniform encounter data s e t i s designed t o meet a
v a r i e t y o f data needs.
A n a t i o n a l enrollment i n f o r m a t i o n system i s maintained.
Health a l l i a n c e s / p l a n s c o l l e c t and maintain d e t a i l e d
l o c a l enrollment f i l e s and submit a p o r t i o n o f those
f i l e s t o t h e network on a r e g u l a r basis.
Creation of t h e network does not i n h i b i t plans and h e a l t h
a l l i a n c e s from being innovative i n meeting t h e i n f o r m a t i o n
needs discussed above.
CONSUMER SURVEYS AND PUBLIC HEALTH SURVEILLANCE
Consumer surveys o f s a t i s f a c t i o n , access t o care and r e l a t e d
measures are conducted on a plan-by-plan and State-by-State
basis.
HHS c a r r i e s out t h e consumer surveys i n accordance w i t h
the o v e r a l l q u a l i t y measures and standard survey
questionnaires developed by t h e Advisory Council t o t h e
N a t i o n a l Q u a l i t y Management Program.
I n a d d i t i o n t o economic e f f i c i e n c i e s , c e n t r a l i z e d
a d m i n i s t r a t i o n o f t h e consumer surveys assures t h e
u n i f o r m i t y and c o m p a r a b i l i t y of survey i n f o r m a t i o n and
provides t h e basis f o r o b j e c t i v e n a t i o n a l . State and
r e g i o n a l norms and comparisons.
�tf
WORKING GROUP D
F
PRIVILEGED AND COHriDENTIAL
National population based surveys are conducted by HHS to
monitor the /implementation of health care reform and assess
i t s impact 6n the general population, potentially vulnerable
populations. States and the health care system.
(^^ITIIKA
/ u b l i c health surveillance and data systems w i l l continue to
be needed'monitor the health status of the population and to
identify and address emerging threats to the public health.
Public health data systems involving the federal government,
States, and l o c a l governments are strengthened and more
closely integrated within the o v e r a l l information systems
framework.
GOVERNANCE
A National Health Data Advisory Council i s established. The
Council, reports to the Board [HHS position: the Secretary
of HHS does t h i s ] and oversees the information and data
a c t i v i t i e s , including standard setting and privacy
protections, of the federal government under health care
reform. Membership includes consumers, users and providers
of data developed by plans, a l l i a n c e s , States and the
federal government.
BUDGET
As part of the PHS infrastructure budget, $200 m i l l i o n w i l l
be necessary to carry out the consumer survey program.
Funds to e s t a b l i s h and operate the information system and
networks w i l l be included i n the operating costs of the
health care reform program.
�REMAINING HHS POLICY ISSUES
We have already provided separate pieces d i r e c t l y to White House
Health Staff Reform s t a f f on the following PHS issues: Quality
Management, Public Health Service I n i t i a t i v e s , Health Research
I n i t i a t i v e s , Information Systems, Creating a New Health
Workforce, and Undeserved Populations. We assume these agreed
upon changes to the draft are being made. In addition, we are
attaching a separate drop in piece on drug benefits which has
been approved by Chris Jennings. Moreover, the Administration
group which i s now meeting w i l l address several changes in the
transition section and the National Health Board of the draft
upon which we have commented previously. TAB A contains these
agreed upon write-ups. (Note the Underserved write-up i s being
revised by PHS)
Attached are continuing HHS policy concerns about the draft in
additional areas. The f i r s t paper restates our continuing
concerns about several issues concerning the Medicare program,
these were communicated e a r l i e r as an attachment to the memo from
the Secretary to the F i r s t Lady. Policy issues also remain in
the areas of Medicaid, Medicaid Maintenance of Effort, Capacity
of Health Plans, Authority of Health Plans, Premium Guarantees,
Cost-Sharing Subsidies, Nursing Home Inspections, Budgets, Fraud
and Abuse, Antitrust, The Indian health Service, and FEHBP. The
l a s t suggests a n c i l l a r y p o l i c i e s concerning annuitants and
employees abroad which need to be included in the document to
replace the sentence that FEHBP w i l l be simply abolished, leaving
i t unclear what w i l l happen to these groups. TAB B contains
these not yet agreed upon write-ups. (One other write-up w i l l
follow shortly on the level of premium subsidies in fee-forservice plans).
TAB C contains a l i s t of r e l a t i v e l y minor edits and
changes that do not raise policy issues.
suggested
�MMRNU
EOADM
To:
I r a Magaziner
Judy Feder
Carolyn Getz
Greg Lawler
From:
Chris Jenninc
Date:
July 26, 1993
RE:
Medicare drug benefit draft paper
:=====:
The attached i s a working group draft submitted by HHS on
the Medicare outpatient prescription drug benefit. These
recommendations were discussed previously and I see no problems
with the content.
Unfortunately, HHS thought these suggestions had been
incorporated into the original comments sent to the Department
when, i n fact, they had not. The Department assumed I had given
them to you and vice versa. I apologize for the confusion.
Please review the enclosed. I t i s important that we
incorporate the Department's suggestions into the current version
of the l e g i s l a t i v e specifications.
I f you have any questions, please c a l l me at x2645.
Thanks.
�c
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DETERMINED TO BEAN,
ADMINISTRATIVE MARKING
INITIALSiJiiZ^ HATF
fe/D-
WORKING GROUP DRAFT
PRIVILEGED ANDe8NriPCNTIAL •
MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
Beginning In January, 1996, tho Medicare program expands to cover outpatient
prescription drugs,
Any Medicare beneficiary who elects to enroll in the Part B program (as 97
percent of the Medicare population currently do) Is automatically enrolled In the new
prescription drug benefit.
As with other Part B benefits, the Medicare prescription drug benefit is funded by
both general revenues and beneficiary premiums. The Part 5 premium would be
increased to cover the new benefit. Beneficiary premiums currently finance 26
percent of Part B ooets, Thus, beneficiaries would pay 25 percent of the oost of the
new drug benefit. Other rules related to enrollment in Medicare Part B also apply to
the prescription drug benefit.
i
DEDUCTIBLES, COINSURANCE AND CAPS
A $250 annual deductible applies to the new drug benefit. Once the deductible
has been met, a 20,percent coinsurance per preecription applies. In addition, a
$1,000 annual out-of-pocket cap is in effect for each Medicare beneficiary.
Both the annual deductible and out-of-pocket cap are indexed each year to
assure that the same percentage of beneficiaries continue to receive benefits as did
with the Initial $260 deductible and $1000 oap.
COVERAGE
The Medicare drug benefit covers ail FDA approved drugs, biologicals and
Insulin for their medically accepted indications as found In at least one of tne three
national compendia, which are the American Medical Association Drug Evaluations,
the American Hospital Formulary Service, and the United States Pharmacopeia.
The Medicare drug benefit Includes coverage of home IV drugs, In addition, the
current limited coverage of outpatient drugs under Medicare such as
immunosuppressive drugs are incorporated into the drug benefit.
The Secretary of Health and Human Servicee has the discretion not to ©over
certain pharmaceutical products listed in Section 1927(d) of the Social Security Act.
Examples include fertility drugs, medications used to treat anorexia and drugs used
for cosmetic purposes. However, bsnzodiazeplnas and barbiturates would be
covered under the Medicare drug benefit.
July 23, 1983 5:03pm
i
�17-/3-93 n5:?7 F FO OIF
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Tht Secretary has the authority to establish maximum quantities per prescription
or limit the number of refills In order to discourage waste.
The Secretary has the authority to subject medications to requirements for prior
approval, meaning thai physicians or pharmacists could be required to obtain prior
approval before prescribing or dispensing a particular medication. Particular druge
become subject to prior approval based on evidence that they are subject to clinical
misuse or Inappropriate uee or because the Secretary determines that they are not
oost effective.
All new drugs approved by the FDA are covered under the benefit. In the case of
new drugs that the Secretary determines are excessively or inappropriately priced,
the Secretary has the authority to establish a price for Medicare's purposes based on
negotiations with manufacturers. If a manufacturer refuses to negotiate or the
Secretary Is unable to negotiate a price thai the Secretary determines to be
reasonable, the Secretary would have the authority to exclude the drug from
coverage under Medicare.
COST CONTAINMENT
As a condition of participation in Medicare and Medicaid, drug manufacturers
must sign rebate agreements with the Secretary. Rebates are required for nonInnovator multiple source drugs (generic) but will be less than those currently
required under the Medicaid rebate program.
For single source and Innovator multiple source drugs, manufacturers pay a
rebate to Medicare for each drug based on the difference between the average
manufacturer price (AMP) to the retail dass of trade and the weighted average of the
prices of the drug In the non-retail marketplace, or 15 percent of the AMP, whichever
Is greater.
For single source and innovator multiple source drugs, an additional rebate is
required on a drug-by-drug basis for manufacturers who Increase prices at a higher
rate than Inflation. The baseline indexed price will be the AMP for the prescription
between April and (June, 1993.
Rebates are paid to the Secretary on a quarterly basis
In the case of dual eligibles, to prevent manufacturers from paying rebates to
Medicare and Medicaid, Medicare be the recipient of the rebate.
The Secretary has the authority to conduct verification surveys of the AMP.
A manufacturer is considered the entity holding legal title to or possession of the
July 23, 1993 5:03pm
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new drug code (NDC) for the covered outpatient drug.
The new program provides incentives to encourage the uee of generic drugs.
Only generic versions of brand-name drugs are covered unless the physician
indicates that a brand name medication is neoessary. The Secretary aleo has the
authority to eubjeot a brand-name product to a prior approval requirement if a generic
substitute Is available.
REIMIUR8EMENT
For brand name drugs, reimbursement win be the lower of the 90th percentile of
usual and customary charges In a previous period, or the estimated acquisition cost
(EAC) plus a dispensing fee.
For generic drugs, payment is the lower of the pharmacist's usual and customary
charge or the median of all generic prices (times the number of units dispensed) plus
a dispensing fee. a
t
For participating pharmaclee, the dispensing fee ie $5, Indexed to the Consumer
Price Index (CPI). Participating pharmacies are required to accept assignment on all
prescriptions. Non-participating pharmacists receive $2 less per prescription.
CHANGES IN PRIVATE INSURANCE REQUIREMENTS
Private Insurance plans provided by former employers are required to either
reduce the amount-of the premium charged to Medicare beneficiaries to account for
the coverage of prescription drugs, or Increase coverage of other health services by
the actuarial value of the prescription drug benefit under the private plan.
SUBSIDIES
Low-lnoome Medicare beneficiaries receive the same financial assistance for outof-pocket costs associated with the drug benefit as provided for other eost-sharing
amounts.
REVIEWS
The Medicare DUR program parallels the program established in OBRA 1990 for
Medicaid. Participating pharmacists are required to offer to counsel Medicare
recipients on the use of medications.
The Secretary establishes a national syetem of Electronic Claims Management as
the primary method for determining eligibility, processing and adjudicating olaime,
and providing information to the pharmacist about the patient's drug uee under the
Medicare drug program.
July 23, 1993 5:03pm
�tn-?.:-^ M-.ti m F M O F
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MEDICARE OUTPATIENT PRESCRIPTION DRUG BCNEPIT
1. Propoaad ehftnae: Strike "subscribes to" and insert "elects to enroll in*. Strike
•coverage" and insert "program."
Rationale; Terminology clarification.
2. Proposed ohanoe: Strike entire third paragraph and insert "As with other Part B
benefits, the Medicare prescription drug benefit Is funded by both general
revenues and beneficiary premiums. The Part B premium would be Increased to
cover the new benefit. Benefldary premiums currently finance 25% of Part B
costs. Thus, beneficiaries would pay 25% of the cost of the new drug benefit.
Other rules related to enrollment In Medicare Part B also apply to the prescription
drug benefit."
Rationale: Beneficiaries will not pay the same amount for new coverage as they
do for current coverage, They will pay the same percentage - 25%.
DEDUCTIBLES CP-PAYMENTS A P CAPS
N
1. Proposed ohanoe: Change "the same NUMBER of beneflclariea"to"the same
PERCENTAGE.pf beneficiaries.''
Rationale: Use of "number* would lead to benefit reaching a smaller percentage
of beneficiaries over time.
2. Proposed chanoa: Strike "co-paymenf and insert "coinsurance."
Rationale. Copayment usually refers to a fixed amount while coinsurance refers
to a fixed percentage.
.
^A
/
3. Proposed chan9e: Index the $1000 out-of-pocket cap In the same manner aa the
S250 annual d^duotlble.
Rationale: Assures the same percentage of benefldaries over time.
4. PrgpPSrt Chflnofr Insert 'Once the deductible Is met" before "beneficlariee aleo
pay 20 percent...".
BlllfiDAlfi: Beneficiaries only pay the 20 percent colnsuranoe after the deductible
has been reached.
,
July 23, 1003 6:03pm
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MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
1, Propoacd chanoe: Reference to compendia should read "as found in at least one
of the three national compendia, which are..."
Rationale: Current language requires that the medically accepted indication for a
drug or biological be listed In all three compendia.
y
2. Proposed change: Ineulln ehould be covered under the new benefit.
Rationale: Insulin needs to be explicitly listed sinoe it is neither a drug or
biological, Including insulin is oonsistent with the Medicare Catastrophic
Coverage Aot of 1988 (MCCA).
/
3. prpposed eh anas: A home IV therapy benefit should be covered under the new
drug benefit. Drugs provided through the home IV benefit would be eubject to the
new benefit's deductible and co-payment. Current limited coverage of home IV
therapy under the DME benefit would be eliminated.
Rationale: Including home IV therapy Is consistent with the MCCA and eliminates
quality assurance concerns under the DME program, According to HCFA
actuaries, the cost of the home IV benefit will total $263 million for CY 1995.
/ 4. Pfooosed chanoe: Current coverage of immunosuppressive drugs, blood clotting
factors and osteoporosis drugs should be covered under this new benefit.
Rationale: Medicare currently covers immunosuppressive drugs for the first year
after a covered transplant. After the first year of immunosuppressive therapy, the
beneficiary would then be covered under the new drug benefit. Covering the
beneficiary under the new benefit from the outset would be administratively
simpler. Medicare also currently covers blood clotting drugs for hemophiliacs
and osteoporosis drugs.
5. Proposed change: The Secretary would have the discretion to exclude from
coverage drugs listed in Section 1927(d) of the .Social Security Act, except for
benzodiazepines and barbiturates.
Rationale: Under Medicaid, the statutory exclusions are permissive; states may
or may not cover the drugs listed in the categories. Applying the statutory
exclusion to Medicare implies mandatory exclusion of the listed drugs.
c
July 23, 1993 5:03pm
%
�n-... n5:?[ P FO OP
7?Vq?
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pn7/]n
MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
6. ProooMd ehanaa: Add a provfaion that give* the Secretary the authority to
•etablleh maximum quantitiw per prescription and limits on the number of refills.
Rationale: This provision will discourage wasteful dispensing of pharmaceuticals.
7. Proposed chanpe: Either physidans and PHARMACISTS may be required to
obtain approval before prescribing and/or dispensing a particular medication.
Rationale: In the Medicaid program, pharmacists rather than physicians generally
request prior approval before dispensing a pharmaceutical product.
8. Proposed change: In the case of new drugs that the Secretary determines are
excessively or Inappropriately priced, the Secretary has the authority to establish
a price for Medicare's purposes based on negotiations with the manufacturers. If
a manufacturer refuses to negotiate or the Secretary is unable to negotiate a
price that the Secretary determines to be reasonable, the Secretary would have
the authority to exclude the drug from coverage under Medicare.
Rationale: Mandating that ALL of a manufacturer's drug products not be
reimbursed by any federal program is too punitive and as such will never be
enforced. In addition, a manufacturer may agree to negotiate but not negotiate In
good faith.
COST CONTAINMENT
*
•
>
1. Proposed change: As a condition of participation in Medicare AND MEDICAID,
drug manufacturers must elgn rebate agreements with the Secretary to be
reimbursed for covered drugs under Medicare..
Rationale: This provision increases likelihood that manufacturers will elgn rebate
agreements when both Medicare jod Medicaid participation Included.
2. Proposed ohan9e: Include rebates for generic as well as brand name drugs.
The rebates for generic drugs would be at a lower level than is currently
mandated under the Medicaid program (currently 10% of AMP, 11% of AMP in
1W4). The reductions In savings would be offset by stricter enforcement of state
laws mandating generic substitution. Medicare's generic rebate percentage
would equal the revised Medicaid percentage.
Bfliiflfl^fi; Mandating generic drug rebates is consistent with the current
July 23, 1993 5:03pm
3
�nS:?7 F FO O F
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PflR/ll
MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
Medicaid druo'^abate program. Not mandating generic drug rebates would
reduce the Total rebates that could be coiiected by the Federal government. Not
Including generic rebates could aleo make the manufacturing of generic drugs
too attractive relative to the manufacturing of innovator drugs.
3. Propoaed chanoe: Delete reference to carriers or intermediaries.
Rationale: Having drug claims processors also administer the rebate program
raise* conflict of interest and confldentiallty Issues.
4. Proposed change: The rebate formula should use a weighted average of the
prioes offered O the manufacturer of a given drug In the non-retail market rather
y
than the median price of the drug in the non-retail market.
Rationale: Using the median rather than the weighted average may result in
eigniflcantiy reduced rebates. For example, If a few HMOs and hoapitals receive
substantial discounts from drug manufacturers but the majority of other providers
receive minor discounts, the median will be skewed towards tne lower discounts.
9. Proposed change: Change "average price charged' to 'average manufacturers
prioe."
Rationale: Consistency of terminology.
6. Proposed chanoe: The baseline index price will be the average manufacturers
price (AMP) for the prescriptionfromApril through June 1993.
A spun of seweial inomhs Is d
tost accurate estimate of price.
7. Proposed chanoe: A provision for dual eligibles must be Included with Medicare
serving as recipient of the rebate when Medicare la the primary payor.
Mfiflfllfi: Avoids situations in which drug
rers would
PrgP9>Ml Chflngq: Add a provision which allows the Secretary to conduct
verification surveys of the AMP.
RiliPnalB: Drug manufacturers provide the Secretary with the AMP. Oversight Is
July 23, 1993 5:03pm
4
'
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m-?.vq.i n,:?f
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F FO OF
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MEDICARE OUTPATIEffT PRESCRIPTION DRUG BENEFIT
required to determine thet the informgon euBBlledj^ocurete. Thle provleion Is
coneietent with the Medl^hri^pregram.
8
p ^ ^ d ^hRnoe^AmanuTacturer Ie coneidered the ^
h o l i n g ^ »
i f ^ S S e i S ^ t h e new drug number (NDC) number for the covered outpat.ent
drug.
/
/
BUlflMlfl; Th'* Provision clarifies the responsible manufatW
SSalstent Wtti the Medicaid rebate agreement. ^
1
0,
E l f i
j
i f l l f i
i£^^
"0^
i c
Thia definition Is
•"bstitutw."
FUtlonale: Not dear what high quality means In relation to generic druge or
Shetiw this reference Is meaningful given current FDA practice.
MIMPUPSEMENT
1
1. p gpf aftri chance: Insert "In a previous period'after "charges."
r
BaHQMl* More precise.
2. pmnn^ change Change 'aetud acquisition cost" to 'estimated acquisition
cost."
Rationale- Actual acquisition cost is very difficult to administer, requiring a survey
SfSSsltlon costs of pharmadsts. Estimated acquisition cost could be simply
calculated as a percentage of average wholesale price (AWP).
3. proposed change: Separate discussion of dispensing fees from costs of drugs.
Ret[onaie: Clarity.
MEDICARE HMCfc
1. prpposed change: Omit this section.
Rationale: Since outpatient drugs are added to the benefil package, HMOs
would be required to provide such benefits.
CHAMQSS IN PP'VAT^ INSURANCE REQUIREMENTS
July 23, 1993 5:03pm
6
�M-K-M 05:/? F FM O F
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MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
1. PropoBed chanoe: This provision should be limited to polioiee paid for by former
empJoyere.
Rationale: The new benefit's Impact on Medigap policies would be dealt with
through toes ratio requirements. NAIC would have to revise the standard benefit
package to account for the new benefit.
fiUJUlQlEft
1. Proooeed chanoe: Reptaoe this provision with "Low income beneficiaries receive
the eame financial protection for out-of-pocket costs associated with the drug
benefit as provided for other Medicare cost-sharing amounts."
Rationale: This provision clarifies the provision's intent. Also, financial assistance
implies a cash payment.
REVIEWS
1. Proposed change: Strike "and medical history" and insert "use."
2. Rationale-. The pharmacist will not have access to the patient's entire medical
hietory,
July 23, 1993 5:03pm
Q
�PRIVILEGED AND CONFIDEHTIAE*
WORKING G O P DRAFT
RU
CREATING A NEW HEALTH WORKFORCE
Health care reform workforce programs: shift the balance in the graduate training of
physicians from specialties in excess supply to primary care; substantially increase the
training of nurse practitioners and physician assistants; recruit and support the education of
under-represented minority and disadvantaged students; support State health workforce
analytic and planning programs; and adjust Medicare payment formulas to increase
reimbursement for primary care.
DEVELOPMENT AND SUPPORT FOR GRADUATE MEDICAL EDUCATION
A new system to manage physician specialty training will be established under new
legislative authority.
Total number of physician post-graduate training positions: After a five year phase in
period, at least 50% of new physicians will be trained in primary care rather than in
specialties now in excess supply. Primary care includes family medicine, general internal .
medicine, and general pediatrics.
To achieve the goal of bringing primary care and specialty training into balance, the
number of primary care residency positions will be gradually increased by about 7% a year,
over a five year period. During this same period, the overall number of specialty training
positions will be decreased by approximately 10 percent a year. The number of first year
residency positions available will continue to exceed the number of graduates of U.S.
medical schools.
The new system also encourages the site and content of physician training to more
closely reflect actual community medical practice.
Determination of approved nuipber^'residency positions: The number of training
positions in each specialty will-be set on a national basis by the Secretary of HHS, acting on
the recommendations oLttieNational Council on Graduate Medical Education, and allocated
to regional councHsr^egional councils are responsible for/the distribution of positions to
specific programs withinVeach area.
The national council inclirdes-m'edical educators, practicing physicians, consumers,
health plan and alliance executives, and others and is appointed by the Secretary.
ii3
DETERMINED TO BEAN
ADMINISTRATIVE MARKING
INITIALS: A k A - DATE:
�WORKING GROUP DRAFT
PRIVILEGED AND e6NFIDENTIAfc
The national council recommends the total number of positions for each medical
specialty, based on the national need for new physicians in specific specialties. The national
council then apportions the residency positions to the regions taking into account:
•
Current regional distribution and quality of training programs
•
Need to maintain access to a range of primary care and specialty training
positions for under-represented minorities
•
Other factors relating to specific specialties and training programs
In developing its recommendations, the national council seeks the views of
professional medical, hospital, and educational associations and other appropriate
organizations and entities.
Positions are allocated for each postgraduate year because the point at which residents
enter subspecialty training varies among specialties, i.e., family medicine training begins in
the first postgraduate year, while training in internal medicine subspecialties begins in the
fourth postgraduate year of training.
Residency training programs that do not participate in the allocation process will not
be eligible for support from the pooled payment system.
Allocation of residency positions: Ten regional councils would be established for the
purpose of distributing the residency training positions to individual residency training
programs.
The regional councils include representatives of academic institutions training
physicians in the region, alliance and health plan representatives, consumers, and others as
appropriate. Members would be appointed by the Secretary.
The regional councils receive applications from training institutions in each area for
residency positions in each specialty. Positions are allocated to accredited residency training
programs based on such factors as:
•
Program quality
•
The relevance of the training program curricula to the future practice of
physicians
•
Participation of 4nffer-represented minorities
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�WORKING GROUP DRAFT
PRIVILEGED AND CONTIDENTfAL
•
Participation in locally-coordinated educational programs
•
Other relevant factors
The Secretary reviews regional council decisions and retains therightto amend
allocations for good cause.
To assure continuity, allocations to programs are available for periods of up to 3
years, and are made at least one year in advance of the residency training year.
Funding for Residency Training: Funds to support graduate medical education is pooled
from all insurers to reflect the benefits that all patients and plans received from graduate
medical education and training.
Direct medical education payments
•
Payments are provided to the residency training program for each approved
residency training position.
•
Payments are based on a formula which considers the national average resident
salary and the costs of faculty supervision and related teaching expenses.
Funding Sources:
Funds from two sources would be pooled:
•
Medicare contributes to the direct medical education fund based its percentage
of hospital bed days.
•
Other payers contribute through a surcharge on private health plan premiums.
Currently, Medicare pays explicitly for graduate medical education (GME), based on
historical costs. In FY 1992, Medicare payments for GME totalled $1.5 billion. Other
payers support GME implicitly, through higher hospital charges.
Estimated cost: The fund would require an estimated $6.0 billion from all payers.
115
�WORKING GROUP DRAFT
PRIVILEGED AND CONTIDEimAL
Allocation of payments: Funding for residents are provided directly to those training
programs which receive approved residency training positions. This encourages the
development of non-hospital-based programs, which provide a greater portion of their
training in ambulatory and primary care settings such as HMOs and community clinics than
do most hospital-based programs.
Transition payments: Transition payments are provided to teaching hospitals which are
required to reduce the size of their residency training programs, to offset a portion of the
costs associated with hiring replacement staff and maintaining services. Payments will be
phased out over a five year period, will begin at the rate of 150 percent of current national
average direct medical education payment for an equivalent position, and will decrease by
25 percent a year thereafter.
RE-TRAINING PHYSICIANS IN PRIMARY CARE
In order to further expand the availability of primary care physicians, support is
provided for the development of programs to re-train mid-career specialists to serve as
primary care physicians. Areas to be explored include the use of incentives, the type and
length of effective retraining programs and the development of certification criteria.
COMMUNITY-BASED TRAINING OF PRIMARY CARE PHYSICIANS
Health reform supports community-based undergraduate and graduate medical
training, continuing education and faculty development in primary care, broadening the
impact of existing public support, which is limited to programs at the pre-doctoral and
residency levels in family medicine (section 747) and general internal pediatrics (section
748).
SUPPORT FOR TRAINING OF MINORITIES AND DISADVANTAGED PERSONS
To increase the diversity of the health care workforce, support is provided to
programs that increase the number of health professionals among racial minority groups and
disadvantaged persons. The goal of these programs is to double the level of underrepresented minorities enrolled in the first year of medical school to a level of 3,000 students
by the year 2000.
116
�WORKING GROUP DRAFT
PRIVILEGED AND CQNTIDE?mAL
Strategies include:
•
Continuing financial assistance for under-represented minorities and
disadvantaged students entering health professions training programs under
sections 724 and 736.
•
Increasing support for recruitment and retention of under-represented minority
and disadvantaged students in medicine, dentistry, nursing, public health, and
other health professions under section 1707.
•
Maintaining efforts to foster interest in health careers among under-represented
minorities at the pre-professional levels.
•
Supporting programs to increase the number of minority faculty ion the health
professions, minority health services researchers and minority basic scientists.
TRAINING FOR NURSE PRACTITIONERS, NURSE MIDWIVES, AND PHYSICIAN
ASSISTANTS
Expanded training: Current funding for training of nurse practitioners, under section
822, and physician assistants, under section 750 will be amended to:
•
Increase current funding levels to double the number of graduates produced
annually, giving priority to the expansion of existing programs, and
•
Establish long-term goals and a funding strategy to maintain the supply of
practitioners
A similar program is implemented to support nurse midwives.
Barriers to practice: To remove inappropriate barriers to practice, the Secretary of the
Department of Health and Human Services develops and encourages the adoption of model
professional practice statutes for advanced practice nurses and physician assistants, either
under a new general authority for special projects or by amendment of sections 822 or 750.
117
�WORKING GROUP DRAFT
PRIVILEGED AND CONTIDEffnAL
RURAL HEALTH PROVIDER GRANTS
A rural health provider grant program supports a wide range of activities, including new
community training programs for rural practitioners, the development of rural-oriented health
education curricula, and the improvement of medical communications technology.
PRIORITY PROJECTS
A health professions special projects and demonstration training authority is established
to support the transition to the new health system, including support for the following new
projects:
•
Training of providers in mental health, substance abuse treatment and
prevention, geriatrics, and developmental disabilities:
•
Training for school-based health providers in immunization, reduction of
substance abuse, dealing with teen pregnancy, control of violence, and linking
students and families with the community health system.
•
Students in baccalaureate-level nurse training programs preparing for careers
in teaching, community health service, and specialized clinical care.
•
Training related to managed care, cost-effective practice management,
continuous quality improvement practices, and provision of culturally sensitive
care.
Programs also support Priority Health Training Programs designed to improve the
supply, distribution, and quality of providers, including those in areas with inadequate health
systems: rural areas under section 778, inner-city areas under new authority.
Support expands for:
•
Service-linked regional educational networks; e.g., AHECs (section 746),
geriatric education centers (section 777).
•
Health administration (section 771), public health training positions (section
761), special projects (section 762) and preventive medicine (section 763).
•
Professional nurse clinician and nurse anesthetist training positions and nursing
special projects (sections 820, 821, 822, 830 and 831).
118
�WORKING GROUP DRAFT
PRIVILEGED AND CONTIDErJTIAL-
Primary care loans are provided for students in dentistry, nursing and targeted allied
health professions; e.g., occupational health and physician therapy.
FUNDING FOR PRIMARY CARE TRAINING
An additional annual investment of $200 million funds workforce related programs
specified above.
INCENTIVES FOR PHYSICIANS TO PROVIDE PRIMARY CARE
In addition to refocusing federal support for physician education to focus on primary care,
the Medicare programs increases its rates of reimbursement for primary care physicians.
RATE INCREASES
Eliminate office consultations as a separate service and use the savings to increase
fees for all office visits: Office consultations are eliminated as a separate category of
service; codes for office visits also cover consultations. The relative values for office
consultations are redistributed to office visits without increasing total spending.
Because office consultations currently pay more than office visits, the change has the
effect of increasing fees for office visits. Because primary care physicians perform
consultations less often than sub-specialists perform them, it increases payments for primary
care without increasing Medicare spending.
Increase the relative value of allowances for office visits to reflect time spent before
and after visits: Currently, the relative values for procedures, including medical visits,
account for physician time spent immediately prior to an office visit for preparation and
immediately after an office visit for chart work, patient instructions, etc. Increasing the
work component under primary care services by 10 percent increases spending for those
services; the increase is offset by reducing relative values for all services.
Establish a resource-based method to pay for the physician overhead component of
the physician fee-schedule: The Secretary develops a methodology and data sets for
implementing a resource-based system for determining practice expense relative value units
for each physician's service.
119
�WORKING GROUP DRAFT
PRIVILEGED AND•IOM IDLNUAL
The current physician-fee schedule includes a work component that accounts for the
physician's activities and a practice expense component that accounts for overhead (other
than malpractice). The work component is based on resources used; the practice expense
component is based on historic charges.
Because primary care services are office-based, actual overhead costs are higher than for
surgical services. Under the current system, however, surgical services are assigned a
higher overhead fee than primary care services. Collecting data on actual overhead costs and
developing an allocation method for assigning overhead to individual procedures increases the
relative value of primary care services and decreases it for many non-primary care services.
Provide a separate expenditure target rate of growth for primary care: Establish a
third category for primary care services, expanding the existing two categories which cover
surgical services and all other services.
Provide a higher expenditure target rate of growth for the separate primary care
services target: Increasing the target for primary care services decreases the target for other
services.
Bonus payments: Eliminating the 10 percent bonus payment for non-primary care
services in rural and urban Health Professional Shortage Areas shifts additional resources to
increase the bonus payment to 20 percent for primary care services in those areas.
120
�PRIVILEGED AND eONTIDENTIAk
WORKING GROUP DRAFT
ACADEMIC HEALTH CENTERS
Academic health centers perform broad community functions that must be sustained
under health reform. Special measures are included to:
•
preserve the unique roles of academic health centers in teaching and research;
•
ensure access to specialized services appropriately concentrated in academic
health centers; and
•
guarantee availability of specialty services to underserved rural and urban
areas.
ENSURING SUPPORT FOR TEACHING'AND,RESE-AReH~MISSIONS
\
An all payer funding podUs-established to support the higher costs incurre^ by
academic health centersjlue^to the institutional costs of research, development of ne^v
medical technology, treatment of sicker patients, and provision of specialized patient care.
The national funding pool is created by combining monies from a surcharge on \
private premiums with a Medicare contribution. It is allocated to academic health centers
and affiliated teaching hospitals through afixedpercentage add-on to hospital payments.
Funding Formula: A new separate payment is provided to academic health centers,
including affiliated teaching hospitals. The payment will reimburse hospitals for costs /
curred over and above the cost of routine patient care. Only those institutional costs^which
are not captured by the general patient care revenues, and which can be analyticallyjustified,
< re included in the formula.
This approach represents a revision of the current Medicare indirect'medical
cation (IME) payment formula, to factor in the impact of universal-health insurance
covferage under health care reform. The revised system reduces^M^tficare payments to
teachmg. hospitals for the costs of caring for the uninsured-and disproportionate share of poor
patients, since such payments are no longer needed-once there is universal access to care.
Costs: In Fiscal Year 1992, Medicare's IME payments were $3.6 billion, including the costs
of bad debt, charity care, and other costs not related to medical education. As these costs
are eliminated, Medicare IME costs will be reduced accordingly and Medicare payments will
reflect the program's proportionate share of total remaining costs. All private payers will
121
�WORKING GROUP DRAFT
PRIVILEGED AND CONTIDENTIAL
also contribute explicitly to the national fund on a proportionate basis, in lieu of payments
currently made implicitly through higher charges.
The pooling of existing payments into a single national fund ensures that the costs of
maintaining the viability of academic health centers as centers of excellence are shared
equitably by all payers.
FINANCING CLINICAL RESEARCH
The American Health Security Act expands investment in clinical investigations and
research related to the delivery of health services and outcomes. Health plans also are
required to provide coverage for routine patient care associated with approved clinical trials.
(See "Guaranteed Comprehensive Benefits," Tab 4).
ENSURING ACCESS TO ACADEMIC HEALTH CENTERS
To ensure that all patients receive the specialized services available through academic
health centers when appropriate:
A / ^ o f " / C f^> ^
•
The Department of Health and Human Services, in cooperation with states and
health alliances, identifies rare diseases, specialized procedures and treatments
for which health plans will be required to establish contractual relationships
will academic health centers.
•
Health alliances monitor contractual relationships between health plans and
academic health centers to assure appropriate coverage for severity of illness
and to prevent anti-competitive pricing.
•
Health alliances oversee quality management and patient grievance mechanisms
to ensure appropriate detection, referral, morbidity and mortality of illnesses
eligible for referral and specialized treatment.
•
Health alliances provide consumers with information regarding potential
eligibility for clinical dials of relevant investigational treatments.
122
�WORKING GROUP DRAFT
PRIVILEGED AND CONriDENTIAL
ENSURING RURAL AND URBAN ACCESS TO ACADEMIC HEALTH CENTERS
To secure appropriate access to academic health centers for patients in rural and urban
areas with inadequate health care systems:
•
Grants to academic health centers assist in the development of an information
and referral infrastructure to support rural health networks.
•
Grants to establish health-care networks in inner-city areas build on existing
urban charity hospitals and affiliated neighborhood clinics.
•
Health alliances institute additional protections to ensure access by rural and
urban underserved populations to special services.
123
�0*
INDIVIDUAL ELECTION AT AGE
65 TO REMAIN IN HEALTH ALLIANCES
I n d i v i d u a l e l e c t i o n a t age 65 t o remain i n h e a l t h a l l i a n c e s p. 162
The book would: (1) allow Medicare b e n e f i c i a r i e s t o e n r o l l i n any
a l l i a n c e plan; (2) have Medicare pay a f i x e d c o n t r i b u t i o n t o
a l l i a n c e s equal t o the costs t h a t Medicare would be projected t o
bear under the new budget c o n s t r a i n t f o r the same b e n e f i c i a r y
population i n the a l l i a n c e ; (3) have plans negotiate rates w i t h
a l l i a n c e s f o r Medicare-eligibles
whereas
HHS p r e f e r s : (1) allow i n d i v i d u a l s t o remain i n the risk-based
plan i n which they are already e n r o l l e d a f t e r reaching age 65;
(2) Medicare payment would be 95% of the average per capita cost;
(3) the premium amount f o r those over age 65 should be the same
as the under 65 population, but age-adjusted.
Rationale f o r HHS
position:
(1) HHS believes t h a t adverse s e l e c t i o n would occur i f the
i n d i v i d u a l o p t - i n applies t o a l l plans. The a v a i l a b l e evidence
i s t h a t Medicare r i s k contractors are enjoying s i g n i f i c a n t
favorable s e l e c t i o n . I f r i s k contractors w i t h t h e i r mechanisms
t o c o n t r o l u t i l i z a t i o n r i s k s e l e c t , the i n c e n t i v e t o r i s k select
f o r f e e - f o r - s e r v i c e plans (which have no mechanisms t o c o n t r o l
u t i l i z a t i o n ) w i l l be even greater. Since plans would have
information on the p r i o r use of services f o r current enrollees,
they would be i n a p e r f e c t p o s i t i o n t o take steps t o encourage
only the healthy b e n e f i c i a r i e s t o o p t - i n , thus leaving Medicare
f e e - f o r - s e r v i c e w i t h the bad r i s k s .
HHS i s w i l l i n g t o accept the p o s s i b i l i t y of adverse s e l e c t i o n f o r
a risk-based plan since the a l t e r n a t i v e i s t o force a b e n e f i c i a r y
t o leave a health care d e l i v e r y system t o which they have grown
accustomed ( i f HHS does not have a r i s k contract w i t h the p l a n ) .
B e n e f i c i a r i e s previously e n r o l l e d i n f e e - f o r - s e r v i c e plans,
however, do not have a comparable problem when they become
e n t i t l e d t o Medicare since they can continue t o receive services
from the same providers i n Medicare.
Note t h a t we could allow o p t - i n t o f e e - f o r - s e r v i c e plans once
they Secretary determines t h a t a health status adjuster s e n s i t i v e
enough t o p r o t e c t against the r i s k of favorable s e l e c t i o n by feef o r - s e r v i c e plans i s a v a i l a b l e .
(2) HHS believes t h a t Medicare should pay r i s k plans i n the
A l l i a n c e the same way i t pays r i s k plans t h a t contract w i t h
Medicare — at 95% of the average per capita cost. Even a t 95%,
we have been overpaying because h e a l t h i e r than average persons
have been e n r o l l i n g i n r i s k plans. I f we pay plans i n the
�Alliance at even higher rates, clearly that w i l l be placing an
unfair burden on the Medicare Trust Fund.
(3) We believe that the premium for the over 65 population should
be the same as for the under 65 population, but age-adjusted.
Otherwise, plans who do not wish to serve Medicare beneficiaries
w i l l charge higher than necessary premiums. I t would be unfair
to subject beneficiaries to a sudden change in premiums at age
65.
�DEPARTMENT OF DEFENSE
Department o f Defense-p.175
Appropriations and Reimbursement—the book has m i l i t a r y plans
r e c e i v i n g c a p i t a t e d payments from Medicare f o r services t o
Medicare b e n e f i c i a r i e s e n r o l l e d i n m i l i t a r y plans whereas
Medicare s t r o n g l y p r e f e r s t h a t , consistent w i t h c u r r e n t p o l i c y ,
DoD pays f o r services provided t o d u a l - e l i g i b l e s i n m i l i t a r y
facilities.
Rationale f o r HHS p o s i t i o n :
HHS s t r o n g l y objects t o s h i f t i n g costs from DoD t o Medicare f o r
services provided t o d u a l l y - e l i g i b l e i n d i v i d u a l s i n m i l i t a r y
f a c i l i t i e s . Currently, approximately $1 b i l l i o n i s spent
annually f o r the care of dual e l i g i b l e s i n m i l i t a r y f a c i l i t i e s .
S h i f t i n g these expenditures t o the Medicare program would f u r t h e r
s t r a i n t h e already weak Medicare Hospital Insurance (Part A)
Trust Fund. Also, because one-quarter of the Supplemental
Medical Insurance (Part B) Trust Fund i s funded by Medicare
b e n e f i c i a r i e s , t h i s c o s t - s h i f t i n g would r e s u l t i n increased
premiums f o r a l l b e n e f i c i a r i e s .
�VETERANS AFFAIRS
Veterans A f f a i r s - p . 177
Appropriations and Reimbursement—the book has Medicare
reimbursing VA h e a l t h plans and centers f o r services t o higher
income veterans e l i g i b l e f o r Medicare whereas HHS s t r o n g l y
objects t o Medicare paying f o r services provided by VA h e a l t h
plans and centers.
Rationale f o r HHS
position:
HHS s t r o n g l y objects t o having Medicare pay f o r services provided
i n VA f a c i l i t i e s . The cost f o r the care of veterans i n VA
f a c i l i t i e s belongs t o the VA; cost s h i f t i n g t o the Medicare
program i s i n a p p r o p r i a t e and i s a f u r t h e r burden on the already
s t r a i n e d Medicare t r u s t funds.
�INFORMATION SYSTEMS
I n f o r m a t i o n Systems-p. 103
I n t h e s e c t i o n s on Basic Data and Framework and I n f o r m a t i o n
Systems (pp. 104 and 105) t h e book would have t h e Board
r e s p o n s i b l e whereas HHS b e l i e v e s t h a t HHS should be r e s p o n s i b l e .
I n t h e s e c t i o n on Governance (p.107), t h e book has t h e C o u n c i l
r e p o r t i n g t o t h e Board whereas t h e HHS would p r e f e r t h a t t h e
Council r e p o r t t o the Secretary.
R a t i o n a l e f o r HHS p o s i t i o n :
HHS b e l i e v e s t h a t t h e d u t i e s o f t h e Board should be narrowed.
HHS i s b e s t a b l e t o p e r f o r m these f u n c t i o n s . No new bureaucracy
i s needed, See a l s o r a t i o n a l e f o r HHS p o s i t i o n on t h e N a t i o n a l
Health Board/National A d m i n i s t r a t i o n .
�MEDICARE
In the section on Medicare Managed Care on p. 163:
Medigap Reform — the book does not address t h i s issue.
HHS
wants t o p r o h i b i t Medigap insurers from h e a l t h screening or
u n d e r w r i t i n g during the annual coordinated open enrollment
period. Also, Medigap insurers would no longer be able t o ager a t e premiums.
Rationale
f o r HHS p o s i t i o n :
Medicare managed care plans compete f o r enrollees w i t h Medigap
i n s u r e r s . This competition c u r r e n t l y does not take place on a
l e v e l p l a y i n g f i e l d . While managed care plans are p r o h i b i t e d
from h e a l t h screening, Medigap insurers are free t o do so. While
managed care plans charge one premium regardless of age, many
Medigap insurers age-rate t h e i r premiums. These reforms w i l l
provide f o r a f a i r e r competition.
note: please insert i n the book after the paragraph on
coordinated open enrollment not before.
�\
Health Reform Plan;
HHS
Rationale
F e d e r a l Administratrpn-p. 40
I n the n a t i o n a l h e a l t h board s e c t i o n :
Oversee s t a t e systems-Vthe book has t h e board oversee s t a t e
systems whereas HHS would p r e f e r t o oversee s t a t e systems
R a t i o n a l e f o r HHS
positron:
HHS has c o n s i d e r a b l e e x p e r i e n c e i n w o r k i n g w i t h s t a t e s (e.g.,
M e d i c a i d and p u b l i c h e a I t t ^ p r o g r a m s ) .
O v e r s i g h t o f s t a t e systems
i s a key o p e r a t i o n a l r e s p o n s i b i l i t y t h a t w i l l r e q u i r e d i v e r s e
e x p e r t i s e , s i g n i f i c a n t p e r s o n n e l r e s o u r c e s , and a b i l i t y t o
c o o r d i n a t e across h e a l t h programs.
Q u a l i t y s y s t e m — t h e book has t h e board e s t a b l i s h and manage t h e
g u a l i t y system whereas HHS wou^d p r e f e r t o do so (p. 4 1 ) .
R a t i o n a l e f o r HHS
position:
\
HHS i s c u r r e n t l y d e v e l o p i n g s t a t e \ o f t h e a r t q u a l i t y systems i n
t h e Medicare program and i n t h e P u b l i c H e a l t h S e r v i c e .
These
programs w i l l p r o v i d e t h e f o u n d a t i d n f o r q u a l i t y assessment i n
t h e new h e a l t h system. L i k e s t a t e o v e r s i g h t , e s t a b l i s h i n g and
m o n i t o r i n g q u a l i t y assessment i s a key o p e r a t i o n a l r e s p o n s i b i l i t y
t h a t w i l l r e q u i r e diverse expertise, s i g n i f i c a n t personnel
r e s o u r c e s , and a b i l i t y t o c o o r d i n a t e across h e a l t h programs.
S t a t e p l a n s — t h e book has t h e board r e v i e w s t a t e p l a n s whereas
HHS would p r e f e r t o do so (p. 44)
R a t i o n a l e f o r HHS
position:
The S e c r e t a r y o f HHS i s g i v e n t h e r e s p o n s i b i l i t y f o r e n s u r i n g
t h a t a l l i n d i v i d u a l s have access t o t h e f e d e r a l l y guaranteed
package o f h e a l t h b e n e f i t s . T h i s r e s p o n s i b i l i t y s h o u l d n o t be
fragmented between two d i f f e r e n t f e d e r a l a u t h o r i t i e s (a board and
an agency). One f e d e r a l a u t h o r i t y s h o u l d revrew and approve
s t a t e p l a n s , oversee s t a t e i m p l e m e n t a t i o n , and^enforce f e d e r a l
r e q u i r e m e n t s . D i v i d i n g these f u n c t i o n s between\two a u t h o r i t i e s
i s u n l i k e l y t o f a c i l i t a t e smooth and e f f e c t i v e i m p l e m e n t a t i o n .
�'\
MEDICARE INTEGRATION
Medicare Integration-p.160
In the Medicare section:
Assurances—the book does not include assurances that beneficiary
out of pocket expenses (premiums and cost sharing), i n at least
one fee for service plan, would be no higher than under
traditional Medicare for current or better benefits. I f an
enhanced benefit package i s a l l that i s provided, out of pocket
costs s t i l l cannot be any greater than under Medicare.
Rationale for HHS position:
The Medicare population has been given assurances that they w i l l
not be made any worse off. I t i s absolutely essential that t h i s
assurance be included i n the plan.
��w
WORKING GROUP DRAFT
PRIVILEGED AND GONROENTIAL
MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
Beginning in January, 1996, the Medicare program expands to cover outpatient
prescription drugs.
Any Medicare beneficiary who elects to enroll in the Part B program (as 97 percent
of the Medicare population currently do) is automatically enrolled in the new
prescription drug benefit.
As with other Part B benefits, the Medicare prescription drug benefit is funded by
both general revenues and beneficiary premiums. The Part B premium would be
increased to cover the new benefit. Beneficiary premiums currently finance 25 percent
of Part B costs. Thus, beneficiaries would pay 25 percent of the cost of the new drug
benefit. Other rules related to enrollment in Medicare Part B also apply to the
prescription drug benefit.
DEDUCTIBLES, COINSURANCE AND CAPS
A $250 annual deductible applies to the new drug benefit. Once the deductible
has been met, a 20 percent coinsurance per prescription applies. In addition, a
$1,000 annual out-of-pocket cap is in effect for each Medicare beneficiary.
Both the annual deductible and out-of-pocket cap are indexed each year to assure
that the same percentage of beneficiaries continue to receive benefits as did with the
initial $250 deductible and $1000 cap.
COVERAGE
The Medicare drug benefit covers all FDA approved drugs, biologicals and insulin
for their medically accepted indications as found in at least one of the three national
compendia, which are the American Medical Association Drug Evaluations, the
American Hospital Formulary Service, and the United States Pharmacopeia.
The Medicare drug benefit includes coverage of home IV drugs. In addition, the
current limited coverage of outpatient drugs under Medicare such as
immunosuppressive drugs are incorporated into the drug benefit.
The Secretary of Health and Human Services has the discretion not to cover
certain pharmaceutical products listed in Section 1927(d) of the Social Security Act.
Examples include fertility drugs, medications used to treat anorexia and drugs used for
cosmetic purposes. However, benzodiazepines and barbiturates would be covered
under the Medicare drug benefit.
August 4, 1993 6:13pm
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DETERMINED TO BEAN
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INITIALSiJ&O- D A T E : i ^ &
�The Secretary has the authority to establish maximum quantities per prescription
or limit the number of refills in order to discourage waste.
The Secretary has the authority to subject medications to requirements for prior
approval, meaning that physicians or pharmacists could be required to obtain prior
approval before prescribing or dispensing a particular medication. Particular drugs
become subject to prior approval based on evidence that they are subject to clinical
misuse or inappropriate use or because the Secretary determines that they are not
cost effective.
All new drugs approved by the FDA are covered under the benefit. In the case of
new drugs that the Secretary determines are excessively or inappropriately priced, the
Secretary has the authority to establish a price for Medicare's purposes based on
negotiations with manufacturers. If a manufacturer refuses to negotiate or the
Secretary is unable to negotiate a price that the Secretary determines to be
reasonable, the Secretary would have the authority to exclude the drug from coverage
under Medicare.
COST CONTAINMENT
As a condition of participation in Medicare and Medicaid, drug manufacturers must
sign rebate agreements with the Secretary. Rebates are required for non-innovator
multiple source drugs (generic) but will be less than those currently required under the
Medicaid rebate program. Generic drugs pay a fixed 10 percent rebate of average
manufacturer's price (AMP) until 1994 when the amount increases to 11 percent.
For single source and innovator multiple source drugs, manufacturers pay a
rebate to Medicare for each drug based on the difference between the average
manufacturer price (AMP) to the retail class of trade and the weighted average of the
prices of the drug in the non-retail marketplace, or 15 percent of the AMP, whichever
is greater.
For single source and innovator multiple source drugs, an additional rebate is
required on a drug-by-drug basis for manufacturers who increase prices at a higher
rate than inflation. The baseline indexed price will be the AMP for the prescription
between April and June, 1993.
Rebates are paid to the Secretary on a quarterly basis.
In the case of dual eligibles, to prevent manufacturers from paying rebates to
Medicare and Medicaid, Medicare be the recipient of the rebate.
The Secretary has the authority to conduct verification surveys of the AMP.
August 4, 1993 6:13pm
2
�A manufacturer is considered the entity holding legal title to or possession of the
new drug code (NDC) for the covered outpatient drug.
The new program provides incentives to encourage the use of generic drugs.
Only generic versions of brand-name drugs are covered unless the physician indicates
that a brand name medication is necessary. The Secretary also has the authority to
subject a brand-name product to a prior approval requirement if a generic substitute is
available.
REIMBURSEMENT
For brand name drugs, reimbursement will be the lower of the 90th percentile of
usual and customary charges in a previous period, or the estimated acquisition cost
(EAC) plus a dispensing fee.
For generic drugs, payment is the lower of the pharmacist's usual and customary
charge or the median of all generic prices (times the number of units dispensed) plus
a dispensing fee.
For participating pharmacies, the dispensing fee is $5, indexed to the Consumer
Price Index (CPI). Participating pharmacies are required to accept assignment on all
prescriptions. Non-participating pharmacists receive $2 less per prescription.
CHANGES IN PRIVATE INSURANCE REQUIREMENTS
Private insurance plans provided by former employers are required to either
reduce the amount of the premium charged to Medicare beneficiaries to account for
the coverage of prescription drugs, or increase coverage of other health services by
the actuarial value of the prescription drug benefit under the private plan.
SUBSIDIES
Low-income Medicare beneficiaries receive the same financial assistance for outof-pocket costs associated with the drug benefit as provided for other cost-sharing
amounts.
REVIEWS
The Medicare DUR program parallels the program established in OBRA 1990 for
Medicaid. Participating pharmacists are required to offer to counsel Medicare
recipients on the use of medications.
The Secretary establishes a national system of Electronic Claims Management as
the primary method for determining eligibility, processing and adjudicating claims, and
providing information to the pharmacist about the patient's drug use under the
Medicare drug program.
August 4, 1993 6:13pm
3
�MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
1. Proposed change: Strike "subscribes to" and insert "elects to enroll in". Strike
"coverage" and insert "program."
Rationale: Terminology clarification.
2. Proposed change: Strike entire third paragraph and insert "As with other Part B
benefits, the Medicare prescription drug benefit is funded by both general
revenues and beneficiary premiums. The Part B premium would be increased to
cover the new benefit. Beneficiary premiums currently finance 25% of Part B
costs. Thus, beneficiaries would pay 25% of the cost of the new drug benefit.
Other rules related to enrollment in Medicare Part B also apply to the prescription
drug benefit."
Rationale: Beneficiaries will not pay the same amount for new coverage as they
do for current coverage. They will pay the same percentage - 25%.
DEDUCTIBLES. CO-PAYMENTS AND CAPS
1. Proposed change: Change "the same NUMBER of beneficiaries" to "the same
PERCENTAGE of beneficiaries."
Rationale: Use of "number" would lead to benefit reaching a smaller percentage
of beneficiaries over time.
2. Proposed change: Strike "co-payment" and insert "coinsurance."
Rationale: Copayment usually refers to a fixed amount while coinsurance refers
to a fixed percentage.
3. Proposed change: Index the $1000 out-of-pocket cap in the same manner as the
$250 annual deductible.
Rationale: Assures the same percentage of beneficiaries over time.
4. Proposed chanoe: Insert "Once the deductible is met" before "beneficiaries also
pay 20 percent...".
Rationale: Beneficiaries only pay the 20 percent coinsurance after the deductible
has been reached.
August 2, 1993 4:19pm
1
�MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
COVERAGE
1.
Proposed change: Reference to compendia should read "as found in at least one
of the three national compendia, which are..."
Rationale: Current language requires that the medically accepted indication for a
drug or biological be listed in all three compendia.
2.
Proposed chanoe: Insulin should be covered under the new benefit.
Rationale: Insulin needs to be explicitly listed since it is neither a drug or
biological. Including insulin is consistent with the Medicare Catastrophic
Coverage Act of 1988 (MCCA).
3.
Proposed change: A home IV therapy benefit should be covered under the new
drug benefit. Drugs provided through the home IV benefit would be subject to the
new benefit's deductible and co-payment. Current limited coverage of home IV
therapy under the DME benefit would be eliminated.
Rationale: Including home IV therapy is consistent with the MCCA and eliminates
quality assurance concerns under the DME program. According to HCFA
actuaries, the cost of the home IV benefit will total $263 million for CY 1995.
4.
Proposed change: Current coverage of immunosuppressive drugs, blood clotting
factors and osteoporosis drugs should be covered under this new benefit.
Rationale: Medicare currently covers immunosuppressive drugs for the first year
after a covered transplant. After the first year of immunosuppressive therapy, the
beneficiary would then be covered under the new drug benefit. Covering the
beneficiary under the new benefit from the outset would be administratively
simpler. Medicare also currently covers blood clotting drugs for hemophiliacs
and osteoporosis drugs.
5.
Proposed change: The Secretary would have the discretion to exclude from
coverage drugs listed in Section 1927(d) of the Social Security Act, except for
benzodiazepines and barbiturates.
Rationale: Under Medicaid, the statutory exclusions are permissive; states may
or may not cover the drugs listed in the categories. Applying the statutory
exclusion to Medicare implies mandatory exclusion of the listed drugs.
August 2, 1993 4:19pm
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�MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
6.
Proposed change: Add a provision that gives the Secretary the authority to
establish maximum quantities per prescription and limits on the number of refills.
Rationale: This provision will discourage wasteful dispensing of pharmaceuticals.
7.
Proposed change: Either physicians and PHARMACISTS may be required to
obtain approval before prescribing and/or dispensing a particular medication.
Rationale: In the Medicaid program, pharmacists rather than physicians generally
request prior approval before dispensing a pharmaceutical product.
8.
Proposed change: In the case of new drugs that the Secretary determines are
excessively or inappropriately priced, the Secretary has the authority to establish
a price for Medicare's purposes based on negotiations with the manufacturers. If
a manufacturer refuses to negotiate or the Secretary is unable to negotiate a
price that the Secretary determines to be reasonable, the Secretary would have
the authority to exclude the drug from coverage under Medicare.
Rationale: Mandating that ALL of a manufacturer's drug products not be
reimbursed by any federal program is too punitive and as such will never be
enforced. In addition, a manufacturer may agree to negotiate but not negotiate in
good faith.
COST CONTAINMENT
1.
Proposed change: As a condition of participation in Medicare AND MEDICAID,
drug manufacturers must sign rebate agreements with the Secretary to be
reimbursed for covered drugs under Medicare.
Rationale: This provision increases likelihood that manufacturers will sign rebate
agreements when both Medicare and Medicaid participation included.
2.
Proposed chanoe: Include rebates for generic as well as brand name drugs.
The rebates for generic drugs would be at a lower level than is currently
mandated under the Medicaid program (currently 10% of AMP, 11% of AMP in
1994). The reductions in savings would be offset by stricter enforcement of state
laws mandating generic substitution. Medicare's generic rebate percentage
would equal the revised Medicaid percentage.
Rationale: Mandating generic drug rebates is consistent with the current
August 2, 1993 4:19pm
3
�MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
Medicaid drug rebate program. Not mandating generic drug rebates would
reduce the total rebates that could be collected by the Federal government. Not
including generic rebates could also make the manufacturing of generic drugs
too attractive relative to the manufacturing of innovator drugs.
3. Proposed change: Delete reference to carriers or intermediaries.
Rationale: Having drug claims processors also administer the rebate program
raises conflict of interest and confidentiality issues.
4. Proposed change: The rebate formula should use a weighted average of the
prices offered by the manufacturer of a given drug in the non-retail market rather
than the median price of the drug in the non-retail market.
Rationale: Using the median rather than the weighted average may result in
significantly reduced rebates. For example, if a few HMOs and hospitals receive
substantial discounts from drug manufacturers but the majority of other providers
receive minor discounts, the median will be skewed towards the lower discounts.
5. Proposed change: Change "average price charged" to "average manufacturers
price."
Rationale: Consistency of terminology.
6. Proposed change: The baseline index price will be the average manufacturers
price (AMP) for the prescription from April through June 1993.
Rationale: A span of several months is desirable to calculate the AMP to get the
most accurate estimate of price.
7. Proposed chanoe: A provision for dual eligibles must be included with Medicare
serving as recipient of the rebate when Medicare is the primary payor.
Rationale: Avoids situations in which drug manufacturers would pay double
rebates.
8. Proposed chanoe: Add a provision which allows the Secretary to conduct
verification surveys of the AMP.
Rationale: Drug manufacturers provide the Secretary with the AMP. Oversight is
August 2, 1993 4:19pm
4
�MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
required to determine that the information supplied is accurate. This provision is
consistent with the Medicaid rebate program.
9.
Proposed change: A manufacturer is considered the entity holding legal title to
or possession of the new drug number (NDC) number for the covered outpatient
drug.
Rationale: This provision clarifies the responsible manufacturer. This definition is
consistent with the Medicaid rebate agreement.
10. Proposed change: Strike "high quality" before "generic
substitutes."
Rationale: Not clear what high quality means in relation to generic drugs or
whether this reference is meaningful given current FDA practice.
REIMBURSEMENT
1.
Proposed change: Insert "in a previous period" after "charges."
Rationale: More precise.
2.
Proposed change: Change "actual acquisition cost" to "estimated acquisition
cost."
Rationale: Actual acquisition cost is very difficult to administer, requiring a survey
of acquisition costs of pharmacists. Estimated acquisition cost could be simply
calculated as a percentage of average wholesale price (AWP).
3.
Proposed chanoe: Separate discussion of dispensing fees from costs of drugs.
Rationale: Clarity.
MEDICARE HMOS
1.
Proposed change: Omit this section.
Rationale: Since outpatient drugs are added to the benefit package, HMOs
would be required to provide such benefits.
CHANGES IN PRIVATE INSURANCE REQUIREMENTS
August 2, 1993 4:19pm
5
�MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
1. Proposed change: This provision should be limited to policies paid for by former
employers.
Rationale: The new benefit's impact on Medigap policies would be dealt with
through loss ratio requirements. NAIC would have to revise the standard benefit
package to account for the new benefit.
SUBSIDIES
1. Proposed change: Replace this provision with "Low income beneficiaries receive
the same financial protection for out-of-pocket costs associated with the drug
benefit as provided for other Medicare cost-sharing amounts."
Rationale: This provision clarifies the provision's intent. Also, financial assistance
implies a cash payment.
REVIEWS
1. Proposed change: Strike "and medical history" and insert "use."
2. Rationale: The pharmacist will not have access to the patient's entire medical
history.
August 2, 1993 4:19pm
�WORKING GROUP DRAFT
PRIVILEGED AND COHriDENTIAL
QUALITY MANAGEMENT AND IMPROVEMENT
Health reform transforms the current prescriptive quality
assurance program into a quality-management system focused on
performance measures and continuous improvement.
Quality assurance programs in the current system rely on
external checks, forms and process manuals. Insurance c a r r i e r s ,
peer review organizations, state and federal inspection agencies
audit the work being done in hospitals, doctors' o f f i c e s and
laboratories, and penalize the providers i f they f a i l to follow
rules. Patients play a minor role, lacking r e l i a b l e information
upon which to compare the quality of health plans, providers or
treatments.
Under the American Health Security Act, in addition to
appropriate structural and process mechanisms, emphasis i s placed
on outcomes and customer-focused continuous quality improvement.
NATIONAL QUALITY MANAGEMENT PROGRAM
The National Quality Management Program develops the quality
information system and establishes standards for State, Alliance
and plan level quality management programs. An advisory council
under the National Health Board, appointed by the President
oversees the program.
The council consists of 15 members who are representative of
the population, including representatives of consumer groups,
health plans, states, purchasers of care and experts in quality of
care and related f i e l d s of health service research.
The advisory council to the National Quality Management
Program:
Develops a core set of quality measures and standard
consumer survey questionnaires, and updates them over
time to r e f l e c t changing goals and improving methods for
quality improvement in health care. (Surveys are
carried out by the entity responsible for overall
information systems.)
Develops sampling strategies to ensure that performance
reports r e f l e c t populations d i f f i c u l t to reach with
t r a d i t i o n a l consumer-sampling methods, including
consumers who f a i l to enroll in a health plan or resign
from plans.
9 5
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�PRIVILEGED AND QOHFIDENTIAL
WORKING GROUP DRAFT
Sets n a t i o n a l goals f o r performance on selected q u a l i t y
measures.
Establishes minimal standards of access and q u a l i t y f o r
plans f o r selected measures.
Supports research and technology assessment t o develop
r e l i a b l e t o o l s f o r measuring h e a l t h outcomes.
Evaluates the impact of h e a l t h reform on the q u a l i t y of
care.
Reports annually on performance o f the h e a l t h care
system.
Reviews and recommends changes t o the q u a l i t y measures
annually and establishes a five-year p r i o r i t y l i s t f o r
measures t o be included i n the f u t u r e .
Uses the n a t i o n a l network o f r e g i o n a l centers t o obtain
q u a l i t y r e l a t e d access u t i l i z a t i o n and management data.
(See section on "Information Systems and A d m i n i s t r a t i v e
S i m p l i f i c a t i o n , " Tab 16.)
PERFORMANCE REPORTS
The National Q u a l i t y Management Program under the National
Health Board develops a core set of measures of performance t h a t
apply t o a l l h e a l t h plans, i n s t i t u t i o n s and p r a c t i t i o n e r s . I t
publishes annual performance reports o u t l i n i n g the r e s u l t s o f
those measures f o r each h e a l t h plan, c r e a t i n g a p u b l i c system of
a c c o u n t a b i l i t y f o r q u a l i t y and p r o v i d i n g consumers w i t h meaningful
information.
I t also provides annual r e p o r t s t o the states on t h e
comparative performance o f h e a l t h plans and s t a t e q u a l i t y
programs. Q u a l i t y r e p o r t s include information on the performance
of a l l i a n c e s and h e a l t h plans on as many as 50 measures o f access
t o care, appropriateness o f care, h e a l t h outcomes and s a t i s f a c t i o n
w i t h care.
I t provides the r e s u l t s of a smaller number of q u a l i t y
measures f o r h e a l t h care i n s t i t u t i o n s , doctors and other
p r a c t i t i o n e r s i f the a v a i l a b l e information i s s t a t i s t i c a l l y
meaningful. State performance reports include trends, performance
on n a t i o n a l q u a l i t y measures and on goals f o r n a t i o n a l performance
on access, appropriateness and h e a l t h outcomes.
96
�PRIVILEGED AND CONriDENTIAL
WORKING GROUP DRAFT
The f o l l o w i n g c r i t e r i a determine the s e l e c t i o n o f n a t i o n a l
measures o f q u a l i t y performance:
The measures r e f l e c t important aspects o f care i n terms
of prevalence o f i l l n e s s , m o r b i d i t y , m o r t a l i t y or cost.
The s e t i s representative o f the range of services
provided t o consumers by the e n t i t i e s i n question.
Measures are r e l i a b l e and v a l i d and data needed f o r
c a l c u l a t i o n can be obtained without undue burden.
Performance on measures included i n the set vary widely
among the e n t i t i e s on the performance r e p o r t .
When the measures are rates o f process o f care, these
processes are l i n k e d by strong s c i e n t i f i c evidence t o
h e a l t h outcomes.
When the measures are outcomes o f care, performance l i e s
w i t h i n the c o n t r o l o f providers and adequate r i s k
adjustment can be accomplished.
STATE ROLE
As p a r t o f the Q u a l i t y Management Program, s t a t e s assume
responsibility to:
Develop and implement plans t o meet enrollment, access
and q u a l i t y standards established by the f e d e r a l
government.
Assure t h a t plans and providers meet e s s e n t i a l n a t i o n a l
standards through licensure and c e r t i f i c a t i o n
procedures.
Monitor the extent t o which plans make the f u l l range of
b e n e f i t s covered i n the guaranteed package accessible t o
a l l population groups.
Prepare comparative r e p o r t s on the performance o f
a l l i a n c e s , plans, providers and p r a c t i t i o n e r s w i t h i n the
State.
E s t a b l i s h i n each a l l i a n c e a premium check-off system a t
enrollment where an annual amount— up t o $2 per
e n r o l l e e — can be designated f o r the purpose o f
supporting a consumer advocacy program.
97
�WORKING GROUP DRAFT
PRIVILEGED AND €t»Wf IUEMT1AL
Establish a program o f t e c h n i c a l assistance.
Eligible
organizations may include n o n p r o f i t foundations, p u b l i c p r i v a t e partnerships, consortia led by academic medical
centers, or other forms.
Technical assistance may include a v a r i e t y o f
a c t i v i t i e s such as: f o s t e r i n g c o l l a b o r a t i o n among
h e a l t h plans and providers; disseminating
information about successful quality-improvement
programs, p r a c t i c e guidelines and research
f i n d i n g s ; and p r o v i d i n g educational courses and
other forums f o r providers t o exchange information
on t h e evaluative sciences and q u a l i t y improvement
activities.
Technical assistance i s targeted a t improving
q u a l i t y management p r a c t i c e s and not designed t o
regulate or i n t e r f e r e w i t h the a d m i n i s t r a t i o n of
plans and providers.
A per c a p i t a levy on insurance premiums, w i t h t h e
amount established by the National Health Board,
funds t h e t e c h n i c a l assistance program.
Providers and health plans are not required t o use
t e c h n i c a l assistance resources as a c o n d i t i o n of
p a r t i c i p a t i o n i n t h e new h e a l t h care system,
although h e a l t h plans are accountable f o r improving
performance on n a t i o n a l q u a l i t y measures.
ROLE OF ALLIANCES
As p a r t o f t h e q u a l i t y management program, h e a l t h a l l i a n c e s :
Resolve consumer complaints,
leave a h e a l t h plan.
grievances and requests t o
Disseminate t o consumers information r e l a t e d t o q u a l i t y
and access t o a i d i n t h e i r s e l e c t i o n of plans.
Prepare comparative r e p o r t s on t h e q u a l i t y o f h e a l t h
plans, providers and p r a c t i t i o n e r s w i t h i n t h e a l l i a n c e .
Conduct education programs t o a s s i s t consumers i n using
q u a l i t y and other information i n choosing h e a l t h plans.
98
�WORKING GROUP DRAFT
PRIVILEGED AND CQMEIPENTIAL
ROLE OF HEALTH PLANS
-
As p a r t of t h e q u a l i t y management program, h e a l t h plans :
Measure and disclose performance on q u a l i t y measures.
Maintain and improve t h e q u a l i t y of care d e l i v e r e d by
providers and p r a c t i t i o n e r s .
Meet n a t i o n a l , uniform Conditions of P a r t i c i p a t i o n
established f o r h e a l t h plans the by the National Health
Board (See "Health Plans," Tab 9 ) .
DEVELOPING INFORMATION FOR QUALITY MANAGEMENT
An e l e c t r o n i c network containing uniform enrollment,
f i n a n c i a l and u t i l i z a t i o n data i s created, as o u t l i n e d i n t h e
section on Information Systems. As p a r t of the o v e r a l l
information systems framework, q u a l i t y management data i s reported
through the network and includes information r e l a t e d t o
enrollment, c l i n i c a l encounters, consumer s a t i s f a c t i o n , and
q u a l i t y measures. Regional centers are l i n k e d e l e c t r o n i c a l l y w i t h
s t a t e q u a l i t y programs, h e a l t h a l l i a n c e s and plans, p r o v i d i n g upto-date q u a l i t y and u t i l i z a t i o n information by plan and provider,
as w e l l as comparative information on other h e a l t h plans and
s t a t e s . Regional centers a u d i t samples of data provided by plans
and providers t o ensure i n t e g r i t y .
To supplement r o u t i n e l y c o l l e c t e d i n f o r m a t i o n , h e a l t h plans
gather c l i n i c a l data s p e c i f i e d by the n a t i o n a l q u a l i t y management
program from samples of medical records.
To assure coordination w i t h other data a c t i v i t i e s , the consumer
s a t i s f a c t i o n surveys are conducted as described i n the section on
Information Systems. Consumer surveys, i n combination w i t h other
data captured i n the information system, w i l l gauge access t o
care, use of h e a l t h services, outcomes and s a t i s f a c t i o n .
BOLSTERING THE KNOWLEDGE BASE FOR IMPROVING QUALITY OF CARE
To enhance the p r a c t i c e of medicine and promulgate
i n f o r m a t i o n about best p r a c t i c e s and e f f e c t i v e treatment
approaches, t h e National Q u a l i t y Management Program:
Develops p r a c t i c e guidelines t h a t a s s i s t providers i n
achieving q u a l i t y standards t h a t underpin n a t i o n a l
measures of q u a l i t y .
99
�WORKING GROUP DRAFT
PRIVILEGED AND CQMPIDENTIAL
Designs sample surveys t o include representation of
populations considered t o be a t r i s k f o r inadequate
h e a l t h care.
Develops methodology standards f o r p r a c t i c e g u i d e l i n e s ,
an evaluation and voluntary c e r t i f i c a t i o n process f o r
guidelines developed by the p r i v a t e sector.
Operates a clearinghouse and dissemination
practice guidelines.
program f o r
Disseminates information documenting c l i n i c a l l y
i n e f f e c t i v e procedures and treatments.
Establishes s c i e n t i f i c standards and procedures f o r
evaluating the c l i n i c a l appropriateness o f protocols
used t o manage h e a l t h service u t i l i z a t i o n .
Finances research on t o p i c s c e n t r a l t o q u a l i t y
management and improvement, i n c l u d i n g dissemination
methods, and ways of measuring q u a l i t y .
With the advice o f the n a t i o n a l q u a l i t y advisory
committee, and i n coordination w i t h t h e h e a l t h services
research community, establishes p r i o r i t i e s f o r h e a l t h
services research and evaluation r e l a t e d t o Q u a l i t y
Management. Such p r i o r i t i e s w i l l t a r g e t diagnoses w i t h
the highest l e v e l of u n c e r t a i n t y i n treatment decisions,
widest v a r i a t i o n i n p r a c t i c e p a t t e r n s , and/or
s i g n i f i c a n t costs and incidence.
STREAMLINING REGULATORY ACTIVITIES
Minimum Standards f o r Health Care I n s t i t u t i o n s . The n a t i o n a l
q u a l i t y management program develops uniform standards f o r
l i c e n s i n g o f h e a l t h care i n s t i t u t i o n s t h a t focus on e s s e n t i a l
performance requirements r e l a t e d t o p a t i e n t care. As they are
developed, those standards replace current r e g u l a t i o n s except i n
areas o f f i r e s a f e t y , s a n i t a t i o n and p a t i e n t r i g h t s .
Current standards are retained u n t i l new ones are t e s t e d ,
promulgated, evaluated and implemented. I n t h e i n t e r i m ,
government agencies responsible f o r l i c e n s i n g and c e r t i f y i n g
h e a l t h care i n s t i t u t i o n s are required t o coordinate inspections,
minimize paperwork and reduce the number o f inspections.
100
�WORKING GROUP DRAFT
PRIVILEGED AND GOHriDENTTAL
When the new standards are i n place, agencies charged w i t h
c e r t i f y i n g h e a l t h i n s t i t u t i o n s w i l l pay p a r t i c u l a r attention- t o
i n s t i t u t i o n s w i t h problematic records, i n response t o complaints
and randomly selected v a l i d a t i o n s i t e s .
By January 1, 1996, the n a t i o n a l q u a l i t y management program
completes demonstration p r o j e c t s f o r new performance standards and
r e v i s e standards according t o the f i n d i n g s .
Demonstration
p r o j e c t s must evaluate the impact o f these standards i n assuring
q u a l i t y o f care, reducing cost and burden on p r o v i d e r s .
Medicare Peer Review Organizations. The peer review o r g a n i z a t i o n
system under Medicare continues u n t i l the new q u a l i t y system i s
implemented and the Secretary of the Department of Health and
Human Services determines t h a t Medicare enrollees are protected
adequately through National Q u a l i t y Management Program. PROs w i l l
end a t t h a t time.
During the i n t e r i m , the PRO program i s streamlined.
Requirements f o r physician a t t e s t a t i o n of discharge diagnoses and
procedures i s streamlined and annual acknowledgement of p e n a l t i e s
f o r inaccurate r e p o r t s i s replaced w i t h s i n g l e acknowledgement
when granted h o s p i t a l p r i v i l e g e s . (See " A d m i n i s t r a t i v e
Simplification.")
The C l i n i c a l Laboratory Improvement Act. Regulation o f
c l i n i c a l l a b o r a t o r y t e s t i n g are re-focused t o emphasize q u a l i t y
p r o t e c t i o n w h i l e reducing a d m i n i s t r a t i v e burdens.
BUDGET
As p a r t o f the PHS i n f r a s t r u c t u r e budget, $300 m i l l i o n i n FY 1996
funds w i l l be used t o develop the a n a l y t i c and support f u n c t i o n s
necessary t o provide t e c h n i c a l assistance, analyze data and r e p o r t
on plan performance. Funds f o r the operating costs o f the
National Q u a l i t y Management Program w i l l be included i n the
operating costs of the h e a l t h care reform program.
101
�WORKING GROUP DRAFT
PRIVILEGED AND -COHriDENTIAL
INFORMATION SYSTEMS
Timely and r e l i a b l e information represents a c r i t i c a l
element i n e f f o r t s t o reform the h e a l t h care system and t o
p r o t e c t and improve t h e h e a l t h o f t h e Nation.
Health care reform establishes a new framework f o r h e a l t h
i n f o r m a t i o n . Using standard forms, uniform h e a l t h data
sets, e l e c t r o n i c networks, n a t i o n a l standards f o r e l e c t r o n i c
data transmission, consumer surveys and p u b l i c h e a l t h
s u r v e i l l a n c e , the information framework supports:
o
The development o f clear and u s e f u l information f o r
consumers.
o
Measurement of h e a l t h s t a t u s .
o
Monitoring and evaluation o f the h e a l t h care system.
o
Issuance o f Health Security Cards.
o
Development of l i n k s among health care records t o
improve p a t i e n t care.
o
Analysis of patterns of health care.
o
Streamlined and s i m p l i f i e d a d m i n i s t r a t i o n w i t h
associated cost savings; improved p o l i c y development
and budget management.
o
I d e n t i f i c a t i o n o f fraudulent a c t i v i t i e s .
The new information system features:
o
Strong privacy, c o n f i d e n t i a l i t y and s e c u r i t y
protections.
o
Strong p u b l i c / p r i v a t e partnerships and shared
responsibilities.
o
C l i n i c a l and a d m i n i s t r a t i v e data standards.
o
Appropriate l i n k s t o the National
I n f r a s t r u c t u r e programs.
o
E l e c t r o n i c networks t o insure t i m e l y a v a i l a b i l i t y o f
r e l i a b l e information.
Information
DETERMINED TO BEAN
ADMINISTRATIVE MARKING
INITIALS: J M L DATE J 2 / t e / p
�WORKING GROUP DRAFT
PRIVILEGED AND OONriDEMTIAL
DATA AND INFORMATION SYSTEM FRAMEWORK FOR HEALTH REFORM
Every American i s enrolled in the health care plan of choice
and receives a health security card to assure access to
needed health services throughout the United States.
Much l i k e ATM cards, the health security card f a c i l i t a t e s
access to information about health coverage through an
integrated national electronic data network. The card
i t s e l f contains a minimal amount of information.
The National Health Board [HHS position: HHS i s responsible
for t h i s ] , in consultation with State and private e n t i t i e s
and other relevant organizations, develops and implements
uniform national standards for administrative, c l i n i c a l ,
f i n a n c i a l and other health care related information.
Standards include:
o
Uniform minimum health data sets with standard data
items and definitions.
o
Electronic data interchange standards for transfer of
the information.
A comprehensive health care information privacy framework i s
established, including mechanisms for management and
oversight of privacy and security. Principles of the
framework include:
o
Uniform privacy and confidentiality rights with special
emphasis on protection of highly sensitive data.
o
Definitions of f a i r information practices.
o
Appropriate security measures and technology.
o
Enforcement mechanisms and penalties.
o
Coordination with the p o l i c i e s established under the
National Information Infrastructure programs.
The Board [HHS position: HHS i s responsible for t h i s ]
establishes unique i d e n t i f i e r numbers for plans, providers
and patients. To ensure that a l l views and concerns are
heard and addressed, the decision regarding the choice of
individual ideriti£ieat±aTr~numbers i s made through public^,
/hearjjTgs-^tma^af orma 1 notice and comment process. The Bq^rd
{'[HHsPposition:
HHS i s responsible for t h i s ] has authoj
\£o designate the Social Security Number as a unic
i t i f i e r for persons i f that option i s
�WORKING GROUP DRAFT
PRIVILEGED AND eONFIDENTIAL
INFORMATION SYSTEMS
Health plans maintain uniform documentation, i n e l e c t r o n i c
form, o f a l l c l i n i c a l encounters w i t h h e a l t h p r o v i d e r s .
o
Records may be based on insurance claims or c l i n i c a l
encounters (depending on t h e type o f h e a l t h d e l i v e r y
system).
o
The record system may be plan or community-based, or
shared among several plans.
o
Encounter records conform t o t h e uniform minimum
a d m i n i s t r a t i v e and c l i n i c a l data sets developed by t h e
Board [HHS p o s i t i o n : HHS i s responsible f o r t h i s ] , and
are t r a n s m i t t e d as appropriate t o t h e n a t i o n a l network
(see discussion below).
o
Emphasis i s placed on t h e goal o f e l e c t r o n i c records
and e l e c t r o n i c data interchange w i t h associated
economic e f f i c i e n c i e s . A phase-in p e r i o d , w i t h
i n c e n t i v e s , i s planned t o achieve t h i s goal. During
the phase-in p e r i o d , standard forms may be used.
o
Current i n f o r m a t i o n systems technology r e a d i l y supports
the capture, r e t e n t i o n and e l e c t r o n i c data interchange
of encounter records as a byproduct o f t h e p r o v i s i o n of
care and w i t h favorable b e n e f i t cost e f f i c i e n c i e s .
o
Development of r e g i o n a l encounter data systems i n t h i s
fashion w i l l also support a n a l y s i s o f u t i l i z a t i o n and
treatment p a t t e r n s , as w e l l as q u a l i t y and outcome
monitoring as a basis f o r improving h e a l t h care.
Analysis of treatment p a t t e r n s and c r e a t i o n of
normative data on t h e f u l l range of medical, personal
and p u b l i c h e a l t h v a r i a b l e s r e q u i r e s such l a r g e numbers
of encounters as t o preclude t r a d i t i o n a l sampling
approaches.
Within t h i s framework, plans are encouraged t o innovate t o
meet requirements.
o
I t i s not t h e i n t e n t of h e a l t h care reform t o mandate
e x p l i c i t approaches t o t h i s requirement. Rather,
f l e x i b l e , l o c a l s o l u t i o n s t o l o c a l needs and c o n d i t i o n s
w i l l be f o s t e r e d .
o
This requirement does not c a l l f o r implementation o f a
very c o s t l y , f u l l - s c a l e computerized p a t i e n t record.
I t c a l l s f o r using today's technology t o capture, use
and access information.
�WORKING GROUP DRAFT
PRIVILEGED AND OONFIPENTIAL
o
The framework promotes the formation of community based
h e a l t h information systems t h a t improve t h e q u a l i t y o f
care and reduce cost by minimizing d u p l i c a t e
procedures, t e s t s and adverse drug i n t e r a c t i o n s .
o
Plans, providers, states and h e a l t h a l l i a n c e s receive
f e d e r a l t e c h n i c a l assistance t o enable t i m e l y
conformance w i t h these requirements and t o s e l e c t cost
effective technical solutions.
o
Federal assistance i s compatible w i t h moving t h e h e a l t h
care system toward t h e p o i n t - o f - s e r v i c e information
system v i s i o n described below.
A POINT-OF-SERVICE INFORMATION SYSTEM
The long-term information strategy f o r h e a l t h reform
envisions the c r e a t i o n of a h e a l t h care "Point-of-Service"
i n f o r m a t i o n system t h a t brings value-based h e a l t h
i n f o r m a t i o n t o bear on decisions by consumers,
p r a c t i t i o n e r s , payers and p o l i c y makers. I n a p o i n t - o f service information system, c l i n i c a l , a d m i n i s t r a t i v e and
payment data are exchanged e l e c t r o n i c a l l y among employers,
h e a l t h plans, physicians o f f i c e , h o s p i t a l s , l a b o r a t o r i e s ,
pharmacies, and other providers. Like current c r e d i t card
and automatic t e l l e r machine systems, t h e system:
o
C o l l e c t s information as a by-product o f t h e d e l i v e r y of
care.
o
Protects the privacy, c o n f i d e n t i a l i t y and s e c u r i t y o f
the information.
o
Provides immediate access t o information f o r
appropriate uses.
The n a t i o n a l system w i l l evolve from today's plan, community
and r e g i o n a l h e a l t h information systems. Accelerating
development o f p o i n t - o f - s e r v i c e information systems requires
a d d i t i o n a l funding from the f e d e r a l government t o support
technology development and r e g i o n a l demonstration p r o j e c t s
i n plans, communities, a l l i a n c e s and f e d e r a l f a c i l i t i e s .
FEDERAL, ALLIANCE, PLAN AND STATE DATA NETWORK
An e l e c t r o n i c network o f r e g i o n a l centers containing
enrollment, f i n a n c i a l , and u t i l i z a t i o n data i s created. The
network receives standardized enrollment, encounter, and
r e l a t e d data from plans f o r aggregation, analysis and
feedback t o plans, a l l i a n c e s , states and t h e Federal
Government.
�WORKING GROUP DRAFT
PRIVILEGED AND CONFIDENTIAL
o
The network supports the various a n a l y t i c needs budget monitoring, measuring u t i l i z a t i o n , access, and
s t a t e a c c o u n t a b i l i t y , assessing q u a l i t y - o f States,
h e a l t h plans, h e a l t h a l l i a n c e s and the f e d e r a l
government.
o
Federal funds finance the network, which i s b u i l t on
c o l l a b o r a t i o n w i t h p r i v a t e sector, State and e x i s t i n g
f e d e r a l programs.
o
Required data i s entered once and i s a byproduct o f
r o u t i n e a d m i n i s t r a t i o n and p r o v i s i o n of care a t the
plan and a l l i a n c e l e v e l .
o
Health plans maintain uniform e l e c t r o n i c records o f a l l
encounters/claims.
o
Plans t r a n s m i t encounter data, i n the form of a uniform
minimum data set, t o the network on a regular basis.
Uniform encounter data set i s designed t o meet a
v a r i e t y of data needs.
o
A n a t i o n a l enrollment information system i s maintained.
Health a l l i a n c e s / p l a n s c o l l e c t and maintain d e t a i l e d
l o c a l enrollment f i l e s and submit a p o r t i o n of those
f i l e s t o the network on a regular basis.
Creation of the network does not i n h i b i t plans and h e a l t h
a l l i a n c e s from being innovative i n meeting the information
needs discussed above.
CONSUMER SURVEYS AND PUBLIC HEALTH SURVEILLANCE
Consumer surveys of s a t i s f a c t i o n , access t o care and r e l a t e d
measures are conducted on a plan-by-plan and State-by-State
basis.
o
HHS c a r r i e s out the consumer surveys i n accordance w i t h
the o v e r a l l q u a l i t y measures and standard survey
questionnaires developed by the Advisory Council t o the
National Q u a l i t y Management Program.
o
I n a d d i t i o n t o economic e f f i c i e n c i e s , c e n t r a l i z e d
a d m i n i s t r a t i o n of the consumer surveys assures the
u n i f o r m i t y and c o m p a r a b i l i t y of survey i n f o r m a t i o n and
provides the basis f o r o b j e c t i v e n a t i o n a l , State and
r e g i o n a l norms and comparisons.
�WORKING GROUP DRAFT
PRIVILEGED AND CONFIDENTIAL
National population based surveys are conducted by HHS t o
monitor t h e implementation o f h e a l t h care reform and assess
i t s impact on t h e general population, p o t e n t i a l l y vulnerable
populations, States and t h e h e a l t h care system.
Public h e a l t h s u r v e i l l a n c e and data systems w i l l continue t o
be needed monitor t h e h e a l t h status o f t h e population and t o
i d e n t i f y and address emerging t h r e a t s t o t h e p u b l i c h e a l t h .
Public h e a l t h data systems i n v o l v i n g t h e f e d e r a l government,
States, and l o c a l governments are strengthened and more
c l o s e l y i n t e g r a t e d w i t h i n t h e o v e r a l l information systems
framework.
GOVERNANCE
A National Health Data Advisory Council i s established. The
Council, r e p o r t s t o the Board [HHS p o s i t i o n : t h e Secretary
of HHS does t h i s ] and oversees t h e information and data
a c t i v i t i e s , i n c l u d i n g standard s e t t i n g and privacy
p r o t e c t i o n s , of t h e f e d e r a l government under h e a l t h care
reform. Membership includes consumers, users and providers
of data developed by plans, a l l i a n c e s , States and t h e
f e d e r a l government.
BUDGET
As p a r t of t h e PHS i n f r a s t r u c t u r e budget, $200 m i l l i o n w i l l
be necessary t o carry out t h e consumer survey program.
Funds t o e s t a b l i s h and operate t h e information system and
networks w i l l be included i n t h e operating costs o f t h e
h e a l t h care reform program.
�TABLE OF CONTENTS
T i t l e I , F i n d i n g s and Purposes
1. )
Findings
2. )
Purposes
Title I I ,
H e a l t h Care S e c u r i t y
3. ) Coverage
4. ) B e n e f i t s
5. ) S t a t e R e s p o n s i b i l i t i e s
6. ) A l l i a n c e s
7. ) H e a l t h Plans
8. ) F e d e r a l
Title I I I ,
Responsibilities
New B e n e f i t s
9. ) Medicare Drug B e n e f i t
10. ) Long-Term Care
T i t l e IV, P u b l i c Health
Initiatives
11. ) Workforce
12. ) Academic H e a l t h Centers
13. ) M e d i c a l Research
14. ) P u b l i c H e a l t h Programs
T i t l e V, Government
Programs
15. ) Medicaid
16. ) Medicare
17. ) A u t o m o b i l e Insurance
18. ) Workers' Compensation
19. ) I n d i a n H e a l t h S e r v i c e
�r
20. ) Department o f Defense
21. ) Veterans' A d m i n i s t r a t i o n
T i t l e V I , System Changes
22. ) R i g h t s and Remedies
23. ) A n t i t r u s t
24. ) M a l p r a c t i c e
25. ) Fraud and Abuse
Title VII,
Transition
26. ) T r a n s i t i o n
T i t l e V I I I , Budget and F i n a n c i n g
27. ) Budget
28. ) F i n a n c i n g
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Working Group Drafts [Folder 2] :[Health Initiatives and Benefits]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Simone Rueschemeyer
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 33
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092987" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092987-20060885F-Seg3-033-001-2015
12092987