The Medicare Current Beneficiary Survey: Celebrating Our 25th Anniversary and a Bright Future Ahead

By Niall Brennan, Chief Data Officer, CMS

This year marks the 25^th anniversary and the one millionth beneficiary interview for the Medicare Current Beneficiary Survey (MCBS), a survey that the Centers for Medicare & Medicaid Services (CMS) first fielded in 1991. This in-person survey of 15,000 Medicare beneficiaries collects valuable information about aspects of the Medicare program that cannot be analyzed based on CMS administrative data alone.  In particular, the MCBS gathers information on self-reported health status, satisfaction with care, and functional limitations.  The MCBS also collects information on beneficiaries that is key to understanding patient-centered care.   Beneficiary’s out-of-pocket spending and source of payment for medical services received outside the Medicare program provides a window into the “invisible” and missed costs of health care. One unique aspect of the MCBS is that it includes beneficiaries who reside in institutional settings, such as a nursing home, as well as those in the community.

The MCBS is used across CMS to provide important insights that support internal program analyses.  For example, over the past several years, the MCBS has become a key resource for evaluating the impact of CMS Innovation Center demonstration models as well as for approving Medicare Advantage and Prescription Drug Plan benefits.

The MCBS also serves as the foundation for thousands of health policy analyses across a diverse external user community.  To date, we know of more than 1,000 peer-reviewed papers based on MCBS data in leading publications such as the New England Journal of Medicine, the Journal of the American Medical Association, Journal of Health Economics, and the Journal of the American Geriatrics Society.

Today, I want to acknowledge a number of important efforts CMS has undertaken to ensure the MCBS remains a valuable resource for the agency and external stakeholders.  We have made the data more accessible, releasing the first ever MCBS public use file in May of this year.  While MCBS data files have always been available for a relatively nominal fee, we heard that this fee was a barrier to entry for certain users such as students.  We believe that increased access through this freely available public resource will expand the MCBS user community, and thus help cement its importance as a critical tool in the evaluation of systemic changes in the US health care delivery system.

We are also implementing changes to the MCBS questionnaire and survey design.  Revising and improving the survey questions is underway.  We have added new relevant content including an updated dental utilization module, a module on care coordination, and new questions on food security.   Enhancing the sampling methodology to include newly enrolled beneficiaries in the first year of their Medicare enrollment, conducting an oversample of Hispanic beneficiaries, and, beginning in 2017, conducting an oversample of low-income beneficiaries increase our ability to conduct disparities research and improve our survey estimates.

We are also committed to a more rapid data release schedule, with improved user documentation and file structure.  The 2015 MCBS files will be the first to have many of the improvements discussed above. We anticipate releasing the 2015 data file in the 2^nd quarter of 2017, more than one year earlier than the previous file release schedule.   The release of the 2015 data will also include improved chart books to accompany data releases and more intuitive naming conventions and file layouts with modern file formats for SAS, Stata, and R use.  However, to accommodate these long overdue innovations, we had to make the difficult decision not to release 2014 data files.

As we celebrate our 25^th anniversary of the MCBS, we are renewing our commitment to providing the most useful and relevant information about the Medicare program and, more importantly, the health and satisfaction of its beneficiaries.

We hope that you’ll visit us on our MCBS webpage at https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index.html where you can also subscribe for important updates and announcements.

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Delivering coordinated, high quality care for patients

By Dr. Patrick Conway, Acting Principal Deputy Administrator and Chief Medical Officer

In July 2016, CMS proposed new bundled payment models that continue the Administration’s progress to shift Medicare payments from rewarding quantity to rewarding quality by creating strong incentives for hospitals and clinicians to deliver better care to patients at a lower cost. These proposed new bundled payment models focus on heart attacks, heart bypass surgery, and hip fracture surgery. They would reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery. This proposal follows the implementation of the Comprehensive Care for Joint Replacement Model that begin earlier this year, which introduced bundled payments for certain hip and knee replacements.

Patients want the peace of mind that comes with knowing they will receive high quality, coordinated care from the minute they are admitted to the hospital through their recovery. Bundling payments for services that patients receive across a single episode of care – such as a heart bypass surgery or hip replacement – encourages better care coordination among hospitals, doctors, and other health care providers. Providers participating in bundled payments must work together when patients are in the hospital as well as after they are discharged, which should improve their recovery and avoid preventable complications and costs by keeping people healthy and at home.

Doctors, patient advocates, and health care experts across the country support these models because they have seen firsthand their potential for delivering better quality and more cost-effective care. Public and private-sector bundled payment models have already shown promise in improving patient outcomes while lowering costs, including for cardiac and orthopedic care. In Medicare, more than 1,400 providers are currently participating in bundles through the Bundled Payments for Care Improvement initiative. Early results are encouraging: orthopedic surgery bundles, in particular, have shown promising results on cost and quality in the first two years of the initiative. These models keep the patient at the center of care delivery and focus on well-coordinated, high quality care.

Today, CMS is releasing the second annual evaluation report for Models 2-4 of the Bundled Payments for Care Improvement initiative, which include both retrospective and prospective bundled payments that may or may not include the acute inpatient hospital stay for a given episode of care. This report describes the characteristics of the participants and includes quantitative results from the first year of the initiative. Future evaluation reports will have greater ability to detect changes in payment and quality due to larger sample sizes and the recent growth in participation of the initiative, which generally is not reflected in this report. Key highlights include:

• 11 out of the 15 clinical episode groups analyzed showed potential savings to Medicare. Future evaluation reports will have more data to analyze individual clinical episodes within these and additional groups;
• Orthopedic surgery under Model 2 hospitals showed statistically significant savings of $864 per episode while showing improved quality as indicated by beneficiary surveys. Beneficiaries who received their care at participating hospitals indicated that they had greater improvement after 90 days post-discharge in two mobility measures than beneficiaries treated at comparison hospitals; and
• Cardiovascular surgery episodes under Model 2 hospitals did not show any savings yet but quality of care was preserved. Over the next year, we will have significantly more data available, enabling us to better estimate effects on costs and quality.

While there is more work to be done, CMS continues to move forward to achieving the Administration’s goal to have 50 percent of traditional Medicare payments tied to alternative payment models by 2018. The 2016 goal of tying 30 percent of Medicare payments to alternative payment models was met eleven months ahead of schedule, and we are committed to keeping that momentum. Bundled payments – including the ongoing Comprehensive Care for Joint Replacement Model – continue to be an integral part of transforming our health care system by creating innovative care delivery models that support hospitals, doctors, and other providers in their efforts to deliver better care for patients while spending taxpayer dollars more wisely.

To view the evaluation report, please visit the CMS Innovation Center website at: https://innovation.cms.gov/Data-and-Reports/index.html.

Accountable Health Communities Track 1 Funding Opportunity

By Patrick Conway, M.D., principal deputy administrator and chief medical officer, CMS

In January 2016, the Centers for Medicare & Medicaid Services (CMS) released a new Funding Opportunity Announcement (FOA) for a model called the Accountable Health Communities (AHC) Model. This is the first Center for Medicare & Medicaid Innovation model to focus on the health-related social needs of Medicare and Medicaid beneficiaries. Many of these social issues, such as housing instability, hunger, and interpersonal violence, affect individuals’ health, yet they are rarely, if ever, detected or addressed during typical health care-related visits. The AHC Model is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.

The original Funding Opportunity Announcement requested applications for three different scalable tracks featuring interventions of varying intensity that would address health-related social needs for beneficiaries. After receiving significant interest, inquiries and stakeholder feedback, CMS has decided to make modifications to the Track 1 application requirements and is releasing a new FOA specific to Track 1 of the AHC Model. CMS believes two key modifications to Track 1 will make the model more accessible to a broader set of applicants

1. Reducing the annual number of beneficiaries applicants are required to screen from 75,000 to 53,000; and

2. Increasing the maximum funding amount per award recipient from $1 million to $1.17 million over 5 years.

Track 1 will support bridge organizations that are working to increase a patient’s awareness of available community services through screening, information dissemination, and referral. The Track 1 approach seeks to address the decreased capacity of clinical delivery sites to respond to beneficiaries’ health-related social needs because (1) health-related social needs remain undetected due to the lack of universal screening and (2) clinical delivery sites and patients may lack awareness about existing community service providers that could address those needs.  Track 1 award recipients will partner with the state Medicaid agency, community service providers and clinical delivery sites to implement the Model.

The AHC Model complements CMS’ growing focus on population health by providing the necessary tools and support for a successful transition to a holistic health system. The AHC Model will also enhance CMS’ understanding of the impact of interventions to address social needs on health care costs.

We look forward to the applications to this FOA. Please contact us at the email address below for further information.

Application Information:

Under this announcement, CMS is accepting applications from community-based organizations, health care practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and non-for- profit local and national entities with the capacity to develop and maintain relationships with clinical delivery sites and community service providers.  Applicants from all 50 states, U.S. Territories, or the District of Columbia (D.C.) may apply. All applicants, including those who applied to Tracks 1, 2 or 3 in the previous FOA, are eligible to apply to this FOA. Applicants that previously applied to Track 1 of the AHC Model under the original FOA (# CMS-1P1-17-001) must re-apply using this FOA (# CMS-1P1-17-002) to be considered for the Model.

The AHC Model is accepting applications for Track 1 at www.grants.gov through November 3, 2016.

Have a Question?

Questions about the AHC Model can be sent to AccountableHealthCommunities@cms.hhs.gov.

Additional Information:

For more information about the AHC Model, please visit our website at https://innovation.cms.gov/initiatives/ahcm. Follow us on Twitter at @CMSinnovates

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Looking Back on Promising Progress in Round One State Innovation Model, Looking Forward to the Future of State Based Innovation

by Patrick Conway, M.D., CMS Principal Deputy Administrator and Chief Medical Officer
The State Innovation Models (SIM) Initiative began in April 2013, and has supported over 38 states, territories and the District of Columbia in two rounds of awards.  Yesterday, we released the second annual independent evaluation report for the Round 1 State Innovation Model Test Awards, including the first findings available for SIM after the baseline data summary.  This report shows both progress in states being catalysts for health care transformation and the value of CMS’ collaboration with states. Today, we are releasing a Request for Information (RFI) to obtain input on the design and future direction of the SIM Initiative.

Overview of SIM

SIM states are testing strategies to transform health-care across their entire state, specifically to have a preponderance of payments to providers from all payers in the state be in value-based purchasing and/or alternative payment models.

In the SIM Initiative, CMS is testing models for how state governments can use their policy and regulatory levers to accelerate statewide health care system transformation from encounter-based service delivery to care coordination, and from volume-based to value-based payment.  Round 1 states are implementing statewide health care innovation plans that support health care transformation through a variety of methods, including:

• primary care practice transformation through patient-centered, coordinated care;
• integration of primary care with other health and social services, including behavioral health services and long-term services and supports;
• payment reforms that promote delivery system transformation and a variety of enabling strategies to facilitate and sustain an improved health system that puts the patient at the center of care delivery; and
• community-based population health and prevention.

Central to enhanced care coordination, population health, behavioral and physical health integration, and alternative payment models is the use of health information technology (IT) and a robust data infrastructure.  The Round 1 Test states are strengthening these capacities through:

• engaging and supporting providers that have not typically been connected to health IT;
• requiring participating providers to report on data and/or implement health IT;
• making available patient-level health information to providers and systems to improve care coordination; and
• improving data analytics to support quality improvement and payment reform, and aligning metrics and data infrastructure across payers and initiatives.

Evaluation findings from Year 2 of SIM Round 1

In SIM Round 1, Model Test awards were made to six states: Arkansas, Massachusetts, Maine, Minnesota, Oregon, and Vermont. The SIM Initiative has made notable progress in accelerating health care transformation among the Round 1 Test states. Over time, many states have been able to increase the populations served by their SIM-supported models.

• Over 70% of eligible Medicaid primary care providers participate in Arkansas’ patient-centered medical home, which serves about 80% of their eligible Medicaid population.
• Alternative payment models supported by SIM funds in Minnesota and Vermont are reaching about 50% of each state’s total population, with Oregon and Vermont also reaching over 80% of their total Medicaid population.

The evaluation found that states have been successful in engaging a wide swath of the payer, provider, purchaser, and patient communities and building stakeholder consensus by balancing standardization and flexibility when expanding payment reforms statewide. States have leveraged multi-payer efforts to implement payment and delivery system reforms, engaged the provider community in SIM-related activities, and used a range of policy levers to effect change. Some of the most substantial changes to delivery systems and payment methods are in areas where public and private payers are working together to accelerate transformation. For example:

• In Arkansas, Arkansas Blue Cross Blue Shield, QualChoice and some large self-insured employer groups, including Walmart, participate in the SIM-supported patient-centered medical home and episode of care models.
• Vermont’s SIM Initiative focuses on supporting Accountable Care Organizations. Providers participating in both Medicaid and commercial ACOs now represent a significant majority of the state’s available primary care providers. ACOs offer services to nearly all residents statewide, and about half of eligible beneficiaries were participating as of late 2014.
• In Oregon, participation in the Coordinated Care Model under the SIM Initiative currently includes commercial insurance carriers contracting with the state to cover state employees and Medicaid beneficiaries.

It remains too early to attribute specific quantitative results directly to the SIM Initiative. However, analyses based on Medicare and commercial populations show that states were making progress on health outcomes, such as declines in emergency room visits and inpatient readmissions through models pre-dating SIM and models upon which SIM efforts are expanding. Future evaluation reports will provide more detail on quantitative results and whether and how the SIM Initiative is affecting and accelerating trends in health outcomes and spending.

SIM Supports Health Care Transformation

The Affordable Care Act provides tools through the CMS Innovation Center, like the SIM Initiative, to move our health care system toward one that provides better care to patients, spends dollars more wisely, and results in healthier communities. Today’s announcement is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate patient care to improve quality.

In 2015, the Administration announced goals for Medicare to tie payment to quality or value. These goals are for 30 percent of Medicare fee-for-service payments to be made through alternative payment models by the end of 2016 (and 50 percent by 2018), and tying 85 percent of payments to quality or value by 2016 (90 percent by 2018). In early 2016, the Secretary announced that HHS had reached its goal of 30 percent of Medicare payments made through alternative payment models ahead of schedule. HHS is also working with private payers, employers, consumers, providers, states and state Medicaid programs, and other partners to expand alternative payment models. Initiatives like SIM are an important part of states’ role in health care transformation and tying payments to quality or value.

Looking to the future, we are also seeking input through an RFI on the following concepts related to the evolution of the SIM Initiative:

• Partnering with states to implement delivery and payment models across multiple payers in a state that could qualify as Advanced Alternative Payment Models (APMs) or Advanced Other Payer APMs under the proposed Quality Payment Program, making it easier for eligible clinicians in a state to become qualifying APM participants and earn the APM incentive;
• Implementing financial accountability for health outcomes for an entire state’s population;
• Assessing the impact of specific care interventions across multiple states, and;
• Facilitating alignment of state and federal payment and service delivery reform efforts, and streamline interaction between the Federal government and states.

For more information on the RFI, please visit: https://innovation.cms.gov/Files/x/sim-rfi.pdf.  To be assured consideration, RFI comments must be received by October 28, 2016.  Comments should be submitted electronically to: SIM.RFI@cms.hhs.gov with “RFI” in the subject line.

CMS supports states through SIM and other innovation efforts to move towards this vision of multi-payer delivery system reform across an entire state.  Health system transformation and improvement happens at the state and local level and CMS will continue to support states in their transformation journey to improve care for people across the nation.