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Health Care Reform Law Highlights

Disease Prevention

Establishes a Prevention and Public Health Fund to provide for expanded investment in prevention and public health programs and a National Prevention, Health Promotion, and Public Health Council to develop a strategy for this within one year after the bill is enacted. Provides for a prevention and health promotion outreach and education campaign. Provides an annual comprehensive health risk assessment beginning in 2011 followed by a visit to a primary care provider for creation of a personalized prevention plan, including covered preventive services.

Beneficiaries have the option of choosing the Welcome to Medicare Physical Exam for this during the first 12 months after they become eligible for Part B services. The Health and Human Services (HHS) Secretary can modify coverage of existing preventive services if these are consistent with U.S. Preventive Services Task Force recommendations. Authorizes a Government Accountability Office study of the utilization of and payment for Medicare- covered preventive services and whether there are barriers to these services.      

Misvalued Codes

Directs the HHS Secretary to periodically identify physician services that are misvalued and make adjustments. The secretary will examine the following codes: fastest growing, experienced substantial changes in practice expense, been created for new technologies or services, multiple codes that are frequently billed in conjunction with a single service, billed multiple times for a single treatment and have not been reviewed since the implementation of RBRVS. Must be budget-neutral.

Physician Quality Reporting Initiative (PQRI)

Requires all eligible health professionals to participate by 2015, with a 1.5 percent penalty for those who fail to participate successfully. 2016 and beyond, the penalty would increase to 2 percent. Requires CMS to make PQRI payments available to eligible professionals who participate in a qualified Maintenance of Certification (MOC) or equivalent program and complete a qualified MOC practice assessment. Improves the physician feedback program, establishes an Interagency Working Group on Health Care Quality, a National Strategy to Improve Health Care Quality and an informal appeals process. Public reporting data will be aggregated.

Payment for Imaging Services

For 2010-2012, increases the utilization rate for calculating the payment for advanced imaging services from 50 to 65 percent, increases it to 70 percent in 2013 and to 75 percent in 2014. Ultrasound is excluded from this adjustment.

Waiver of Cost Sharing for Preventive Services 

Eliminates Medicare beneficiary co-pays for all preventive services.

Comparative Clinical Effectiveness Research

Establishes a private, non-profit Patient Centered Outcomes Research Institute to create comparative effectiveness priorities and a research project agenda and can appoint expert advisory panels. Establishes a 15-member Methodology Committee. Establishes a process for peer review of primary research and a Patient Centered Outcomes Research Trust Fund for funding.

Accountable Care Organizations

Allows high quality providers that coordinate Medicare fee for service care across a range of health care settings to share in savings they achieve in the Medicare program starting in 2012.

Incentives for Primary Care and General Surgery

Beginning in 2011, provides a 10 percent bonus on E & M codes for five years; this also pertains to general surgeons in rural and underserved areas. In addition, unused GME slots are redistributed to primary care and general surgery.

Medical Malpractice

The HHS Secretary has the authority to award a total of $50 million for demonstration grants to states for development, implementation and evaluation of alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers or organizations. MedPAC will conduct an independent review of the alternatives to determine the impact.   

Independent Payment Advisory Board (IPAB)

Creates an independent board in 2014 of 15 members appointed by the President for the purpose of reducing the per capita rate of growth in Medicare spending and extending Medicare solvency. MedPAC would continue to exist. In any year that the Board is not required to submit a proposal to Congress (beginning in 2014), it will submit an advisory report on the Medicare program. The Board will also produce a public report beginning in 2014. 

CMS Innovation Center

Establishes this center at CMS to research, develop, test and expand innovative payment and service delivery models to foster patient-centered care, improve quality, and slow the rate of Medicare cost growth.

Pilot Program on Payment Bundling

Establishes a voluntary program to achieve savings for the Medicare program through coordination of patient care in acute care inpatient and outpatient hospital services, physician services, and post-acute care settings starting in 2013 for five years.

National Health Care Workforce Committee

Creates a committee to develop and present a national workforce strategy to the HHS Secretary and Congress that will set the nation on a path toward recruiting, training and retaining a health care workforce that meets the nation’s current and future health care needs. Provides State Health Care Workforce Development Grants.


Extends the gainsharing demonstration until September 30, 2011, with the final report due on September 30, 2012. Appropriates an additional $1.6 million for this demonstration.

Value Based Payment Modifier Under the Physician Fee Schedule

Directs the HHS Secretary to develop and implement a budget-neutral payment system that will adjust Medicare physician payments based on the quality and cost of the care they deliver.  Quality and cost will be risk-adjusted and geographically standardized and this will be phased in over a two year period beginning in 2015.

Physician Payment Sunshine Act

Requires annual transparency reports from manufacturers of covered drugs, devices, biological or medical supplies under Medicare, Medicaid, and SCHIP. Reports must include payments to physicians for consulting fees, compensation for services other than consulting, honoraria, gifts, entertainment, food, travel, education, research, charitable contribution, royalty or license, current or prospective ownership or investment interest, compensation for serving as faculty or a speaker for a continuing medical education (CME) program or grant. This does not include associations representing physicians or CME organizations.     


Creates a personal responsibility requirement for health care coverage and requires insurance companies to issue coverage to all individuals regardless of health status. Establishes Health Insurance Exchanges that would standardize health plan premiums and coverage information, with one plan that offers abortion coverage and another that does not. Creates four benefit categories for the reformed health insurance market. Plans would not be allowed to set lifetime limits on coverage or annual limits on any benefits. Consumers could also choose to participate in non-profit Consumer Operated and Oriented Plans.