Mark Your Calendars: January 31st is quickly approaching

If you still need health coverage for 2017, you have until January 31^st to sign up for coverage through HealthCare.gov. Through the website you can review your choices and see if you qualify for financial help. Issuers have confirmed that consumers who select a plan and pay their first premium will have coverage for 2017. And, insurers have signed contracts to provide coverage through 2017.

Consumers who want coverage – whether you are new to the Health Insurance Marketplace or have previously enrolled in health coverage – can visit HealthCare.gov, update your information, or add it for the first time, and select a plan. You may also compare plans online or on your mobile device. You can review the core plan features like cost-sharing and provider networks.

When you log onto HealthCare.gov, you need three pieces of information – your zip code, family size, and household income – to see what plans are available to you and to get an estimate of how much the plans cost. If you had coverage through HealthCare.gov for 2016, you can come back to update your information and compare your options for 2017. If you have questions or want to talk through your options with a trained professional, enrollment specialists are available all day, every day, at 1-800-318-2596. Free, confidential, in-person assistance is also available at enrollment sites and events in your state. Visit localhelp.healthcare.gov to find assistance in your community.

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Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents

By Niall Brennan, Director of the CMS Office of Enterprise Data and Analytics, and CMS Chief Data Officer; and, Tim Engelhardt, Director of the Federal Coordinated Health Care Office at CMS

 

Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents

For long-term care facility residents, avoidable hospitalizations can be dangerous, disruptive, and disorienting. Keeping our most vulnerable citizens healthy when they are residents of long-term care facilities[1] and reducing potentially avoidable hospital stays has been a point of emphasis for the Centers for Medicare & Medicaid Services (CMS).

Over the last several years, with the help from the Affordable Care Act, Medicare and Medicaid have worked with other federal government agencies, states, patient organizations, and others to identify and prevent those health conditions that have caused long-term care residents to be unnecessarily hospitalized. Because of these efforts, we have seen a dramatic reduction in avoidable hospitalizations over the last several years, according to below analysis released by CMS today.

In 2001, the Agency for Healthcare Research and Quality (AHRQ) first identified a set of measures designed to identify hospitalizations that could potentially be avoided with appropriate outpatient care. They include hospital admissions for largely preventable or manageable conditions like bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, and chronic obstructive pulmonary disease. More recently, CMS’s own Office of Enterprise Data and Analytics found that instances of these potentially avoidable hospitalizations (PAH) were disproportionally high among some of our nation’s most vulnerable people, those dually eligible for Medicare and Medicaid living in long-term care facilities.

Treating conditions before hospitalization and preventing these conditions whenever possible would not only help long-term care facility residents stay healthy, but may also save Medicare and Medicaid money. After carefully examining this problem, CMS and others focused on reducing the instances of potentially avoidable hospitalizations from these facilities.

In 2015, Medicare fee-for-service (FFS) beneficiaries living in long-term care facilities had a total of 352,000 hospitalizations. Of this number, Medicare beneficiaries eligible for full Medicaid benefits living in long-term care facilities (LTC Duals) accounted for 270,000 hospitalizations. And, almost a third (approximately 80,000) of these hospitalizations were caused by six potentially avoidable conditions: bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, chronic obstructive pulmonary disease or asthma, and skin ulcers.

Through the concerted effort by CMS and many other to address these potentially avoidable conditions, real progress has been made to improve the health and wellbeing of some of our country’s most vulnerable citizens. In recent years, the overall rate of hospitalizations declined by 13 percent for dually eligible Medicare and Medicaid beneficiaries. But we have seen even larger decreases in hospitalization rates for potentially avoidable conditions among beneficiaries living in long-term care facilities.  Specifically, between 2010 and 2015, the hospitalization rate for the six potentially avoidable conditions listed above decreased by 31 percent for Medicare and Medicaid dually-eligible beneficiaries living in long-term care facilities.

In 2010, the rate of potentially avoidable hospitalizations for dually-eligible beneficiaries in long term care facilities was 227 per 1,000 beneficiaries; by 2015 the rate had decreased to 157 per 1,000.[2] This decrease in potentially avoidable hospitalizations happened nationwide, with improvement in all 50 states. The reduced rate of potentially avoidable hospitalizations means that dually-eligible long-term care facility residents avoided 133,000 hospitalizations over the past five years. 

Percent Change in Medicare Hospitalization Rates Since 2010

Note: FFS (fee-for-service), LTC (long-term care facility), PAH (potentially avoidable hospitalization)

Potentially Avoidable Hospitalization Rates for Dual-Eligible Beneficiaries Living in Long-Term Care Facilities, by State

Note: Labeled states contain facilities in the CMS “Initiative to reduce avoidable hospitalizations among long-term care facility residents”, discussed below.

This success would not be possible without the committed work by those who directly serve older adults and people with disabilities. We also should consider the range of other contributing factors, including:

• An initiative launched in 2011 by the Medicare-Medicaid Coordination Office, CMS Innovation Center, and other partners to reduce avoidable hospitalizations among nursing facility residents in seven sites across the country.[3] This initiative aimed at keeping dually-eligible long-term care residents healthy by focusing on preventable conditions that lead to hospitalizations.[4]
• The AHRQ Safety Program for Long-Term Care significantly reduced catheter-associated urinary tract infections in hundreds of participating long-term care facilities nationwide, which helped prevent a recognized cause of hospitalizations in residents of these facilities.
• This work is in addition to the many other efforts and initiatives, including the Hospital Readmission Reduction Program, and systemic efforts to reduce readmissions through the Partnership for Patients;
• The efforts to align care with quality through Accountable Care Organizations, the Bundled Payments for Care Improvement models, and other delivery system reforms;
• And, finally, the countless other industry-led initiatives focusing on quality improvement and specifically reducing hospitalization rates among long-term care facility residents.

This success shows that a sustained commitment to smarter spending across the entire health care system can yield dramatic results and improve the lives of vulnerable Americans. These results are also consistent with other ongoing collaborative efforts to improve the quality of care patients received through preventing hospital-acquired conditions where approximately 125,000 fewer patients died due to hospital-acquired conditions and more than $28 billion in health care costs were saved from 2010 through 2015.

Finding the best possible long-term care facility care for a loved one is one of the most difficult decisions family members can make. Family members want to be assured that their loved one will receive the highest quality of care in a healthy environment. And thanks to efforts across the health care industry, and with tools from the Affordable Care Act that allow CMS to improve quality and test innovative strategies, these residents are living in safer, healthier environments.

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[1] Analysis includes residents living in nursing homes or nursing facilities. It does not include residents receiving skilled nursing facility services paid through the Medicare program.

[2] The population of dual-eligible beneficiaries  living in long-term care facilities consists of Medicare FFS beneficiaries with full Medicaid benefits residing in  long-term care  facilities but not receiving skilled nursing facility services. The number of days that beneficiaries met this criteria was annualized so that 365 days was equivalent to one beneficiary. Hospitalizations of long-term care residents were counted as potentially avoidable if the primary diagnosis of the admission was bacterial pneumonia, urinary tract infections, congestive heart failure, dehydration, chronic obstructive pulmonary disease or asthma, or skin ulcers.

[3] The seven sites were: Nevada, Nebraska, Missouri, New York, Pennsylvania, Indiana, and Alabama. Note that six of these sites have continued into “Phase II” of the Initiative, which launched in October 2016.

[4] For more information, see the Initiative website at: https://innovation.cms.gov/initiatives/rahnfr/

CMS announces extension of 2016 reporting deadline and intends to modify 2017 requirements for reporting eCQM data under the Inpatient Quality Reporting and EHR Incentive Programs for Hospitals

By Kate Goodrich, MD
Director, CMS Center for Clinical Standards and Quality & CMS Chief Medical Officer

Today, I am pleased to announce that the Centers for Medicare & Medicaid Services (CMS) is notifying eligible hospitals and critical access hospitals participating in the Hospital Inpatient Quality Reporting (IQR) and/or the Medicare Electronic Health Record (EHR) Incentive Programs of a deadline extension.  The extension is for the submission of electronic Clinical Quality Measure (eCQM) data for the 2016 reporting period, pertaining to the fiscal year (FY) 2018 payment determination.  The deadline has been changed from Tuesday, February 28, 2017, to Monday, March 13, 2017, at 11:59 p.m. PT.  This extension is being granted to provide hospitals additional time to submit eCQM data.

CMS also intends to initiate the rulemaking process regarding modifications to the eCQM requirements established in the FY 2017 Inpatient Prospective Payment System (IPPS) final rule in response to concerns raised by stakeholders.  In order to help reduce reporting burdens while supporting the long term goals of these programs, we intend to include proposals regarding the 2017 eCQM reporting requirements for the Hospital IQR and EHR Incentive Programs for eligible hospitals and critical access hospitals in the FY 2018 IPPS proposed rule that we anticipate to be published in the late spring of 2017.

Specifically, in the FY 2018 IPPS proposed rule, CMS plans to address stakeholder concerns regarding challenges associated with hospitals transitioning to new EHR systems or products, upgrading to EHR technology certified to the 2015 Edition, modifying workflows, and addressing data element mapping, as well as the time allotted for hospitals to incorporate updates to eCQM specifications in 2017.  CMS is also considering to propose in future rulemaking to modify the number of eCQMs required to be reported for 2017 as well as to shorten the eCQM reporting period.

We believe that these efforts reflect the commitment of CMS to create a health information technology infrastructure that elevates patient-centered care, improves health outcomes, and supports the healthcare providers who care for patients.  We continuously strive to work in partnership with hospitals and the provider community to improve quality of care and health outcomes of patients, reduce cost, and increase access to care.

For more information about eCQM reporting for the Hospital IQR and EHR Incentive Programs, please visit the QualityNet.org and the CMS.gov websites.

CMS partners with commercial and state insurers to support primary care practices and reduce clinician burden

By    Dr. Patrick Conway, Acting Principal Deputy Administrator and Deputy Administrator          for Innovation & Quality and
Pauline Lapin, MHS, Director, Seamless Care Models Group, Center for Medicare &                  Medicaid Innovation

Over the past few years, the Centers for Medicare & Medicaid Services (CMS) has committed to supporting clinicians by providing them with actionable data. This is part of the Administration-wide initiative to unlock government data to promote innovation and best practices. Today, we are highlighting one way we have reached this goal and sharing how we plan to use the lessons we’ve learned in future efforts.

With the growing use of health information technology to support care delivery, using data to guide patient care has become increasingly important and common. Not surprisingly, data transparency has become a focus of primary care clinicians. In the past, practices were often left wondering what happened to patients outside of the four walls of their primary care offices. Even when practices do have access to data, clinicians often spend time sifting through multiple reports from different insurers, each with its own set of measures, and format, and much of the data is only applicable to a portion of the clinicians’ patients. Aggregated data allows clinicians to get an overall snapshot of their patient population to identify care gaps and target areas for population health improvement. It also reduces burden and saves staff time, which helps primary care clinicians focus on what they were trained to do: deliver high-quality patient care.

In the Comprehensive Primary Care initiative (CPC), a model from the CMS Innovation Center that ran from 2012 to 2016 and aimed to strengthen primary care, CMS convened payers in seven regions to test whether delivering comprehensive primary care at each CPC practice site — supported by multi-payer payment reform, the continuous use of data to guide improvement, and meaningful use of health information technology — could achieve better care, smarter spending, and healthier people. In three of these regions – Colorado, the greater Tulsa region of Oklahoma, and the Cincinnati-Dayton region of Ohio and Kentucky – CMS and payers collaborated to produce reports that combined privacy-protected patient-level health data from multiple payers into a single report given to participating primary care practices. Payers worked closely with participating CPC practices and CMS to define priorities, governance structures, and refine the format and content of the reports. In turn, data aggregation specialists collaborated with the payers in each region to combine and streamline delivery of that data, ensuring the highest level of security of the health information.

“This was a much anticipated solution to the complexities posed by not having access to consistent claims data, and a continuous desire to improve our approach to meeting CPC Milestones [program requirements],” said Dr. Austin Bailey, Medical Director of University of Colorado Health (UCHealth), which participated in CPC. By having all data in one place, UCHealth practices were able to quickly and easily identify gaps in patient care and see exactly what services their patients were receiving outside of their practices.

“Our practices will continue to leverage the use of aggregated claims data using Stratus [the tool for practices in Colorado] to identify the cost patterns of high risk patients — for example, among our patients with diabetes, is the greatest cost associated with specialists, emergency department utilization, or medications?  Having this information across multiple payers makes it more relevant and helps to build our confidence in selecting the appropriate interventions, identifying trends, and effectively assigning care management resources,” said Dr. Bailey.

Many CPC practices are taking the important skills and lessons they’ve learned into the newest CMS Innovation Center primary care model, Comprehensive Primary Care Plus (CPC+). Built on the foundation of CPC, CPC+ began this month on January 1, 2017, supporting primary care practices located in 14 regions across the country, with over 50 commercial payers and state Medicaid agencies partnering with CMS.

We expect that aggregated data reports will be a top priority for CPC+ practices and partner payers and we look forward to the opportunity to build on the tremendous success we’ve had with data aggregation in CPC. Public and private payers working in partnership with primary care clinicians, engaging patients, and delivering the right data and information is essential to improving our health system and the care delivered to patients.

Vendors and partner payers that participated in CPC data aggregation with CMS, by region:

Colorado
Vendor: Best Doctors, Inc.
Participating payers: Aetna, Anthem Blue Cross Blue Shield, Cigna, Colorado Choice Health Plans, Colorado Department of Health Care Policy and Financing (Medicaid), Medicare fee-for-service, Rocky Mountain Health Plans, UnitedHealthcare

Greater Tulsa region
Vendor: My Health Access Network, Inc.
Participating payers: Blue Cross Blue Shield of Oklahoma, CommunityCare, Medicare fee-for-service, Oklahoma Health Care Authority (Medicaid)

Cincinnati-Dayton region
Vendor: The Health Collaborative
Participating payers: Aetna, CareSource, Buckeye Health Plan, Anthem Blue Cross Blue Shield, Humana, Medical Mutual of Ohio, Medicare fee-for-service, Ohio Medicaid, UnitedHealthcare

Transforming Health Care Delivery through the CMS Innovation Center: Better Care, Healthier People, and Smarter Spending

 

By Dr. Patrick Conway, Acting Principal Deputy Administrator and Deputy Administrator for Innovation & Quality

Transforming Health Care Delivery through the CMS Innovation Center: Better Care, Healthier People, and Smarter Spending

We have made great progress in recent years on reforming our system into one that delivers better quality of care for patients and pays for care in a smarter way, including investing more in prevention and primary care.

Before 2010, there had been only modest efforts to improve care and reduce costs. Medicare – the country’s largest health care insurance program – was largely paying for health services based on volume – where providers were paid for every service they ordered or performed – which didn’t necessarily improve the health of beneficiaries or preserve the program for future generations. To improve our health care system, the largest payer of health care stepped up to partner with providers, doctors and other clinicians, states, private payers, consumers, and others to spur innovation. The market and people in communities across the nation have responded this initiative in extraordinary ways and delivered better care to patients.

This has been the mission of the Center for Medicare and Medicaid Innovation (CMS Innovation Center), to align incentives, partner with others to improve the health system, and implement best practices for coordinating patient care. Since opening its doors in late 2010, the CMS Innovation Center has worked tirelessly to enhance the quality of health care delivered while not increasing costs for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. The CMS Innovation Center takes locally-driven approaches – approaches from doctors and other health care partners providing care to patients every day – and gives them the platform to be tested through a collaborative process.

Today, based on the successful work of the CMS Innovation Center and countless public and private sector partners, we can now say that health care delivery system reform addressing both quality and cost has become part of the fabric of Medicare, Medicaid, and the health care sector nationwide. According to a new report to Congress prepared by the CMS Innovation Center:

• Over 30 new payment models have been launched over the past six years
• Investments in electronic medical records and a data and analytics infrastructure are sparking a new set of innovative companies.
• The CMS Innovation Center’s portfolio of models has attracted participation from a broad array of health care providers, states, payers, and other partners. An estimated 18 million individuals, including CMS beneficiaries and individuals with private insurance included in multi-payer models, have been impacted by, have received care, or will soon be receiving care furnished by more than 207,000 health care providers participating in CMS Innovation Center payment and service delivery models and initiatives. These models are delivering care to people in every state across the nation.
• Medicare exceeded – earlier than predicted – the goal to tie more than 30 percent of fee-for-service payments by the end of 2016 through alternative payment models to quality and cost metrics. Medicare is on pace to reach 50 percent by the end of 2018.

The Innovation Center has partnered with Medicare, Medicaid, and private health plans in the commercial market on new models of care and innovation. And, a number of exciting initiatives will be coming to more beneficiaries over the next few years:

• The Medicare Diabetes Prevention Program expanded model, set to begin in 2018, will pay for services to prevent the onset of diabetes to all eligible Medicare beneficiaries, improving their health and that of the Medicare program both now and in the future.This is important because we estimate that Medicare spent $42 billion in 2016 on fee-for-service, non-dual eligible, over age 65 beneficiaries with diabetes.
• Three new payment models—the Acute Myocardial Infarction Model, the Coronary Artery Bypass Graft Model, and the Cardiac Rehabilitation Incentive Payment Model—will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation.
• Through the Comprehensive Primary Care Plus Model, primary care doctors can care for their patients the way they think will deliver the best outcomes, and they’ll get paid for achieving results and improving care.
• One new payment model—the Surgical Hip and Femur Fracture Treatment Model—will support clinicians in providing care to patients who undergo surgery after a hip or femur fracture beyond hip replacement. In addition, we finalized updates to the Comprehensive Care for Joint Replacement Model, which began in April 2016.
• The Accountable Health Communities Model, beginning in 2017, will test whether increased awareness of and access to services addressing health-related social needs will impact total health care costs and improve health and quality of care for Medicare and Medicaid beneficiaries in selected communities. This model will address a critical gap between clinical care and community services in the current delivery system.
• Thirty-eight states and territories are engaged in the State Innovation Models initiative where they are testing their own best ideas to improve health, quality of care, and lower costs. Additionally, Vermont and Maryland have entered into global payment arrangements to improve care for the whole state’s population.
• And, already, investments in patient safety from the CMS Innovation Center, including through the Partnership for Patients, have contributed to an estimated 125,000 lives saved, over 3 million infections and adverse events avoided, and $28 billion in savings. We expect to see these numbers and savings continue to grow in the coming years.

These exciting approaches are the result of careful design, thorough and rigorous evaluation, and close collaboration with patients, doctors, and other stakeholders to achieve real, measurable, and significant results in improving health and lowering spending. CMS conducts an independent evaluation of every CMS Innovation Center model and releases those findings publicly. These reports provide stakeholders with information on the impact of the model as a whole on health care expenditures and utilization, beneficiary and health care provider experiences with care, and, where feasible, health outcomes. The reports also often provide site-specific results.

Using the CMS Innovation Center to advance better, smarter health care has become even more important over time. Since the passage of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the CMS Innovation Center has been instrumental to its implementation. The Quality Payment Program, which implements provisions of MACRA, includes a five percent incentive payment for physicians and other clinicians sufficiently participating in Advanced Alternative Payment Models. The CMS Innovation Center is the mechanism to create new Advanced Alternative Payment Models in the future. In fact, the CMS Innovation Center has recently announced more than five new or re-opened opportunities for clinicians to join Advanced Alternative Payment Models. CMS expects 125,000 to 250,000 clinicians to be participating in Advanced Alternative Payment Models by 2018. The CMS Innovation Center looks forward to partnering with doctors, clinicians, patients, and others on new models.

The CMS Innovation Center continues to work on behalf of current and future Medicare, Medicaid, and CHIP beneficiaries. After more than six years, the health care system is objectively safer while making Medicare more financially secure for future generations. Such significant progress is possible because we have worked with Congress and stakeholders to listen, adapt, and advance proven ideas. Our work in developing and expanding new payment models will continue to be guided by the following core principles:

• Supporting innovative payment and service delivery models with strong potential to improve health care quality and lower costs.
• Engaging with and listening to consumers, providers, and other stakeholders allowing for open and transparent dialogue, including through the appropriate use of notice-and-comment rulemaking and ombudsmen.
• Evaluating results based on appropriately scoped and sized demonstrations and advancing best practices based on their impact on quality and cost.

Together we can continue to strive to achieve better care, healthier people, and smarter spending.

To read more detail of the accomplishments of the CMS Innovation Center, read the most recent biennial report to Congress on the Innovation Center website: https://innovation.cms.gov/Files/reports/rtc-2016.pdf

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