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by Madeline Angela Meyer and Michael Alan Meyer, September 10, 2012

The primary objective of the CMS Innovations for the Accountable Care Organizations (ACO) envisions “Patient-centered, high quality care delivered efficiently” (CMS, 2012). So how does this objective affect US health services, preventive care and health outcomes?

Preventive Care Services

The CMS provides an annual “CMS Preventive Services Chart” and payment requirements for both providers and beneficiaries (CMS, 2012). There now is a second detailed listing of the mandated preventive services under the ACA at "Preventive Services” (Healthcare.gov, 2012).

The American Medical Association (AMA) has provided us with the CPT codes for the Medicare mandates in preventive care. These codes and their payment requirements are important for entry into your medical billing software systems to ensure compliance and accuracy in billing and in reimbursement. See: CPC Code Pocket Guides (AMA, 2012).

AMA's Medicare preventive services: A new benefit for patients and physicians CPT® Code Pocket Guide.AMA's ACA Preventive Services with Cost-sharing Waived CPT® Code Pocket Guide.

Health Outcome Measurements

Much like the Health Employment Data Information Set (HEDIS), the quality indicators used by payers to track provider performance, CMS has implemented its own set of health status indicators. The difference is that CMS ties its quality measures to financial incentives and/or penalties through multiple pay-for-performance (P4P) programs. It begins with Physician Quality Reporting System (PQRS), e-prescribing, electronic health records, and Hospital Quality Indicators (HQI). It is expanded to the Hospital Value-based Purchasing Program (HVPP) that begins in FY 2013 for payments of discharges occurring on or after October 1, 2012. Finally, there is the more complex ACO “Pay-for-Performance” (P4P). To explore the incentive programs and their status indicators, visit the links below (CMS, 2012)

Medicare Shared Savings Program (cms.gov) - For fee-for-service beneficiariesAdvance Payment Model - For certain eligible providers already in or interested in the Medicare Shared Savings ProgramPioneer ACO Model - Health care organizations and providers already experienced in coordinating care for patients across care settings

The bottom line is that CMS has tied preventive health services and its health outcomes, aka, quality measures to incentive based provider payments. The programs are complex. The provider pay or penalties change based on the implementation stage of the various programs, i.e., PQRS, HQI, eRx, and EHR incentive payments. See CMS report and chart for incentive based payments through 2021!

CMS (2012). Group Practice Reporting Option (GPRO); Requirements for Submission of 2012 Physician Quality Reporting System and Electronic (eRx) Incentive Program Data. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/downloads/2012_GPRO_Requirements_01032012.pdf CMS. (2012). Physician Quality Reporting System. [website]. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqrs
CMS. (2012). Quick Reference Information: Preventive Services. [.pdf]. Accessed September 7, 2012 from: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf
Healthcare.gov. (2012). Preventive Services Covered Under the Affordable Care Act [website]. http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforAdults

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