After the Senate passed their version of the health care bill, many organizations have come out with key comparisons showing the differences between the House and Senate version.
The past few weeks the house and senate democrat staffers have been meeting to help come up with solutions to settle the differences between the bills that will ultimately be acceptable to both houses.
Representing the house is Speaker Nancy Pelosi (D-Calif.), Majority Leader Steny Hoyer (D-Md.), Energy and Commerce Committee Chairman Henry Waxman (D-Calif.), Ways and Means Committee Chairman Charles Rangel (D-N.Y.) and Education and Labor Committee Chairman George Miller (D-Calif.)
Representing the Senate is not finalized but it currently stands as: Majority Leader Harry Reid (D-Nev.) Finance Committee Chairman Max Baucus (D-Mont.) and Banking Committee Chairman Chris Dodd (D-Conn.).
According to Roll Call the House and Senate are facing huge divisions, normally the house would cave in (Senate needing 60 votes), but several factions are digging in their heels. “We’ve got a problem on both sides of the Capitol. A serious problem,” Ways and Means Chairman Charlie Rangel (D-N.Y.) said Tuesday evening. This may move the time line for passage of a bill into late February or March.
So what are some of the major differences? Below is a brief summary describing some of the larger differences between the house and senate bills.
Income-related premiums
The House version does not change the Part B premium policy, and there is no income-related Part D premium. The Senate version suspends indexing of threshold for income-related part B premium ($25 billion savings/premium revenue –increases premiums for beneficiaries). The Senate bill also institutes income-related part D premium and suspends indexing of the threshold ($11 billion savings/premium revenue – increases premiums for beneficiaries).
340B Drug Pricing Program
The House version expands entities eligible for section 340B discounts; no expansion to inpatient drugs; and no exceptions to group purchasing exclusion. The Senate version expands entities eligible for 340B; expands to inpatient drugs; and new exceptions to group purchasing exclusion.
Medicare Hospital Readmissions
The House version holds hospital and post-acute providers accountable for preventable hospital readmissions; applies to all hospitals, including critical access hospitals (CAH), beginning in 2012. The Senate version holds only selected hospitals accountable for preventable hospital readmissions, and allows exceptions for certain rural hospitals, including Critical Access Hospitals.
Medicare GME Policy
The House version Redistributes 90% of unused residency slots for primary care training in urban and rural areas, while the Senate bill redistributes 65% of unused residency slots, with virtually all of the redistributed slots going to rural hospitals. The Senate bill also exempts most rural teaching hospitals from having unused residency slots redistributed.
Donut Hole/Rebates
The House bill Phases-out the donut hole by 2019, financed with reinstated duals rebates and PhRMA discount. The Senate bill adopts PhRMA discount, and implements a one-time, one-year $500 reduction in donut hole in 2010 only.
Medicare Advantage
The House Bill eliminates MA overpayments by phasing down payments over three years to ultimately achieve parity with traditional Medicare payment levels in the community. ($154 billion savings). The House version also makes a coding adjustment that results in $15.5 billion in savings, for a total MA savings of $170 billion. There is also a bonus program established with strong standards for quality performance and low cost areas.
The Senate bill does not eliminate overpayments but, instead establishes new competitive bidding approach under which private MA plans will continue to be paid more than Medicare levels in some communities, less than Medicare in others, which results in $118 billion in savings. The Senate version also has coding adjustments that save an additional $1.9 billion for a total MA savings of $120 billion. Standards for bonus allocation spread money widely among most plans.
Medicare Commission
The House does not have a provision, but the Senate creates a New Independent Payment Advisory Board (IPAB) with fast track authority to implement Medicare payment changes with limited options for Congressional intervention or amendments. ($28 billion in savings due to savings target/trigger). The Board also has authority to make recommendations related to total system costs, but no fast track authority to make changes beyond Medicare.
Medicare Physician Payments
The Senate bill has no language but the House version establishes a companion bill to the health reform bill, which creates a permanent fix in sustainable growth rate (SGR) formula for physicians. The bill, HR 3961, will cost $209 billion.
Primary Care Payments
The Senate bill has no language but the House version phases Medicaid primary care payments up to Medicare levels to improve and protect access, which will cost approximately $57 billion cost.
Employer Contribution and Benefit Standards
The House bill requires employers provide a financial contribution level of 72.5% of premium for individuals and 65% for families, benefit standards, and consumer protection standards. Contributions can be made on a pro rata basis for employees who work less than full-time.
The Senate bill has no affirmative requirement, but employers pay a penalty if employer contributions don’t make the insurance affordable to full-time employees and employees then seek exchange coverage, and if they don’t meet some benefit standards. In addition, employees with an employer offer that is deemed “unaffordable,” i.e. their share of premiums fall between 8 percent and 9.8 percent of their income, can convert their employer contribution into a “free choice voucher,” which can be used to shop in the Insurance Exchange.
Employer Financial Requirements
The House bill states that employers that do not offer qualified coverage pay an 8% payroll tax on wages for all employees (including full-time, part-time and temporary). The total employer payment in lieu of providing coverage: $135 billion.
The Senate bill states that employers that do not offer any coverage pay $750 per employee if even one employee receives a tax credit in the Exchange. (This flat dollar amount equals about 1.5% of payroll for a firm with an average payroll of $50,000.) The requirement applies only to full-time workers (30 hours or more a week).
Employers that do offer some coverage pay a penalty for employees who go to Exchange and get tax credits where the employee share of the employer premium is more than 9.8% of income and/or the employer does not offer minimal coverage. The penalty is $3,000 per employee going into Exchange and getting a credit, but with a maximum penalty of $750 times the number of full-time employees in workforce. Employers also pay a penalty if they have a waiting period for coverage. Total employer payment in lieu of providing coverage: $28 billion
Physician Payment Sunshine Provisions
There are many differences between the two versions of payment disclosure the senate requires reporting of payments to physicians and hospitals, the house version includes all types of organizations. Reporting is retroactive in the House version (2010), the senate version starts in 2012 with reporting in 2013.
For a complete list of differences in the house and senate versions of the Sunshine Provisions