Medicare cataract surgery alternate payment demonstration to be implemented

Health Care Financing Review, Spring, 1993

During the spring of 1993, the Health Care Financing Administration (HCFA) implemented a demonstration designed to test a negotiated bundled payment option for all services routinely provided within an episode of outpatient cataract surgery. The project combines physician and facility fees, intraocular lens costs, and the costs of selected pre- and postoperative tests and visits into one comprehensive package; in doing so, it offers providers greater flexibility to efficiently coordinate service delivery while shifting the focus of accountability from fragmented regulatory controls over process and payment to more meaningful assessments of appropriateness and outcome. The 3-year pilot demonstration will be conducted to assess operational feasibility and to identify potential refinements to the design. Five selected provider organizations in Cleveland, Ohio; Dallas/Fort Worth, Texas; and Phoenix, Arizona will participate in the demonstration.

Providers were selected to participate in the demonstration based on their ability to offer appropriate, high-quality cataract surgery services to Medicare beneficiaries at a lower total cost to Medicare. Discounts under the demonstration range from approximately 5 to 20 percent. It is expected that over 12,000 surgeries will be performed as part of the project.

Providers not participating in the demonstration will continue to treat Medicare beneficiaries and receive payment under the regular Medicare program, and beneficiaries will remain free to select the provider of their choice for cataract surgery. The demonstration incorporates a variety of safeguards to assure appropriate, quality care, with demonstration providers being subject to more intensive oversight of appropriateness and quality of surgery than non-demonstration providers. In addition, HCFA must approve demonstration-related marketing activities prior to their use.

For more information, contact Anne Francoeur-Wilson of the Office of Research and Demonstrations at (410) 966-6682.

Medicaid Report to Outline Community-Based Care and Services

The Office of Coverage Policy, Medicaid Bureau, is in the process of developing a report on community-based care and services. The purpose of the report is to stimulate discussion on how States may use Medicaid to deliver long-term care type services to individuals in their community.

Under Medicaid, States have considerable flexibility to offer a wide array of community-based care and services. The report examines various medical services and indicates which Medicaid benefits may be used to furnish the services. The coverage information is summarized in a five-page matrix. On a Medicaid benefit-by-benefit basis, the report indicates the type of services that can be made available. The matrix also provides information on coverage restrictions that commonly apply to Medicaid services. In addition to the matrix, the report includes a definition and reference section that provides further clarification of the types of services that may be available under a Medicaid benefit category.

For more information, contact Rob Weaver of the Medicaid Bureau at (410) 966-0673.