CMS Doubling Down on Health IT; Patients

By Seema Verma, Administrator, Centers for Medicare & Medicaid Services

Americans enjoy the benefits of the best healthcare providers and innovators in the world. Yet while the volume of care consumed by American patients has not increased dramatically comparative to similar economies, the cost of care in the United States has accelerated at an alarming pace. Healthcare costs continue to grow faster than the U.S. GDP, making it more difficult with each passing year for CMS to ensure healthcare to not only its beneficiaries of today, but generations of beneficiaries in the future.

We believe at CMS that a major cause for the cost inefficiency of healthcare is attributable to a failure in the past to make the system about the patient and for the patient. It is the system that has become the centerpiece of policy debates, and it is the system that has become more about sustaining itself than serving patients. If the patient truly is what our healthcare system seeks to serve, then the patient must be the focal point of all policies and private industry decision-making.

CMS is committed to leveraging innovation to truly empower patients with their own data, decisions, and care. Evidence of this commitment can be found in a government-wide initiative launched by CMS and the White House Office of Innovation in March called MyHealthEData— designed to achieve true patient control and interoperability of their health records, and to enable patients to share their data with technology innovators and researchers to accelerate public health. See our new video for a simple explanation of MyHealthEData.

At CMS we are putting patients first, and we are moving to break down silos of patient information that is being captured by the system, and depriving the patient the access to the best quality, and most affordable care. Sustaining our exceptional healthcare depends now more than ever on driving down costs, and a major part of the CMS strategy to drive down costs depends on smart and innovative use of information technology (IT).

Through MyHealthEData, CMS envisions a future in which all patients have access to their own health data and use it to make the right decisions for themselves and to get the best value. We see health IT systems that work seamlessly with each other, and a government that supports secure data sharing and emerging technologies so that healthcare in America is better and less expensive.

To achieve these goals, CMS fully acknowledges that we cannot operate in a “way-we-have-always-done-it” manner and hope for different results. That is why CMS created the new role of CMS Chief Health Informatics Officer (CHIO) and has begun the process of filling this new role with a leading healthcare IT talent. The CHIO will drive health IT and data sharing to enhance healthcare delivery, improve health outcomes, drive down costs, and empower patients. Through this new function, CMS will effectively engage stakeholders from all parts of the healthcare market, including our Federal partners and industry leaders.

As CMS Administrator, I am deeply committed to programs, policies, and systems that put patients first. It’s 2018—most doctors are using electronic health records (EHRs) and most patients have access to the Internet and a smartphone, providing many ways to view healthcare data securely. Patients should expect health IT that enhances their care coordination instead of disrupting it. Their information should automatically follow them to all of their healthcare providers, so that everyone stays informed and can provide the best treatment. Patients also should know how much a health service costs so they can decide whether they want it, and “shop around” for where to get it.

Another reason behind our decision to create a CHIO role is that today at CMS, we are focused on data, not only to inform our strategy, but also to promote patient choice and drive down cost. We are evaluating the data we have and how best to apply it to our mission. We also are thinking about an Application Programming Interface (API) strategy across the entire agency that will allow us to securely provide data so that software developers, researchers, and others can design useful products (such as apps) powered by it, just as so many companies do to enhance their customer experience.

If we can solve these health IT challenges, not only will patients benefit, but so too will providers and payers. We are closer than ever to realizing these goals, but we are not there yet.

The truth is, as the largest healthcare payer in the country, CMS should have had a CHIO function long ago. Despite today’s amazing technology and decades of promises, we are not where we should be. The CHIO role will enhance my leadership team, working across CMS, with federal partners including the U.S. Digital Service, and alongside private industry and researchers to lead innovation and help inform CMS’s health IT strategy. The challenge is great, but so is the reward—building the next generation of interoperable health systems for millions of Americans and affecting national and global health IT for good.

We now have the momentum and focus to make this happen.

Although we will refine specific responsibilities, we anticipate the CHIO role will help drive forward the many health IT initiatives we have begun this year, including the Medicare Blue Button 2.0 program—a universal digital format for personal health information—and our overhaul of the CMS EHR Incentive Programs to focus on interoperability.

I look forward to meeting qualified CHIO candidates who wish to step up to this challenge and join the team that will lead CMS health IT over the “finish line” so that we can drive down costs and save lives. The time is now to realize the true potential of health IT for America’s patients.

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A New Era of Accountability and Transparency in Medicaid

By: Administrator, Seema Verma, Centers for Medicare & Medicaid Services

In his first 500 days in office, President Donald J. Trump has achieved results both at home and abroad for the American people, working to ensure government is more accountable to the American people. One of the many promises the Trump Administration has made and kept is improving accountability and transparency in Medicaid.

Medicaid provides healthcare for more than 75 million Americans, including many of our most vulnerable citizens, at an annual cost of over $558 billion. It has grown significantly over the years, consuming an every greater share of our public resources – from 10 percent of state budgets in 1985 to nearly 30 percent in 2016. Medicaid should improve the lives of those it serves by delivering high quality health care and services to eligible individuals at a maximum value to American taxpayers. As the administrators of the program, states, along with their local healthcare professionals who care for their neighbors, know best the unique healthcare needs of their community. Our success on delivering on Medicaid’s promise hinges on the critical role they play in managing the precious state and federal resources with which we are entrusted.

That’s why we have committed to resetting the state-federal partnership by ushering in a new era of state flexibility. We’ve approved groundbreaking Medicaid demonstration projections, including reforms to test how Medicaid can be designed to improve health outcomes and lift individuals from poverty by connecting coverage to community engagement. We are streamlining our internal processes and breaking down regulatory barriers that force states to commit too much of their time and resources to administrative tasks rather than focusing on delivering better care.

But with that commitment to flexibility must come an equal pledge to improve transparency and accountability. Too often we have struggled to articulate our collective performance in executing on our immense responsibility. This is best reflected in the fact that Medicaid is responsible for approximately half of the nation’s births, yet no one will argue that we are achieving the birth outcomes our future generations deserve. As we return power to states, we must shift our oversight role at CMS to one that focuses less on process and more on holding us all collectively accountable for achieving positive outcomes.

That is precisely why, last November, I announced that we would create the first ever CMS Medicaid and CHIP Scorecard to increase public transparency about the programs’ administration and outcomes. The data offered within the Scorecard begins to offer taxpayers insights into how their dollars are being spent and the impact those dollars have on health outcomes.  The Scorecard includes measures voluntarily reported by states, as well as federally reported measures in three areas: state health system performance; state administrative accountability; and federal administrative accountability. As states continue to seek greater flexibility from CMS, the Scorecard will serve as an important tool in ensuring that CMS is able to report on critical outcome metrics.

The first version of the Scorecard is foundational to CMS’s ongoing efforts to enhance Medicaid and CHIP transparency and accountability. We’ve begun this initiative by publishing selected health and program indicators that include measures from the CMS Medicaid and CHIP Child and Adult Core Sets along with federal and state accountability measures. For the first time, we are publicly publishing measures that show how we are doing in the business of running these immense programs, including things like how quickly we review state managed care rate submissions or approve state section 1115 Medicaid demonstration projects. Our stakeholders, including beneficiaries, providers, and advocates, deserve to have this information available to them.

And we’re just getting started. Public reporting of meaningful quality and performance metrics is an important and ongoing responsibility of states and the federal government given Medicaid’s vital role in covering nation’s children and as the single greatest payer for long-term care services for the elderly and people with disabilities.

That’s why, in future years, the Scorecard will be updated annually with new functionality and new metrics as data availability improves, including measures that focus on program integrity as well as opioid and home and community-based services quality metrics. Over time, we plan to add the ability for users of the Scorecard to generate year-to-year comparisons on key metrics, as well as to compare states on measures of cost and program integrity. While some variation may be inherent based on geographic, population, reporting or programmatic differences, the public should have access to information that allows them to understand how and why costs and outcomes can vary from state to state for the same populations. Then we can begin to ask important questions about what may really be driving differences in quality and efficiency.

CMS recognizes that continued insight from our state partners is a critical component in the maintenance of the Scorecard. I want to thank all the states for their assistance in the creation of this first iteration, particularly the 14 states that served on the National Association of Medicaid Director’s workgroup over the last six months. Many of the measures are only possible because of the commitment from states to collect and report on these important metrics.  Through this partnership with states, CMS will continue to advance policies and projects that increase flexibility, improve accountability and enhance program integrity and are designed to fulfill Medicaid’s promise to help Americans lead healthier, more fulfilling lives.

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program

CMS Blog

http://blog.cms.gov/2018/03/02/medicare-access-and-chip-reauthorization-act-of-2015-macra-funding-opportunity

March 2, 2018
By Kate Goodrich, MD
Director, CMS Center for Clinical Standards and Quality & CMS Chief Medical Officer

 

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity:Measure Development for the Quality Payment Program

CMS is pleased to announce a new funding opportunity for the development, improvement, updating, and expansion of quality measures for use in the Quality Payment Program. CMS will be partnering directly with clinicians, patients, and other stakeholders to provide up to $30 million of funding and technical assistance in development of quality measures over three years.

Cooperative agreements provide a unique opportunity for CMS to partner with external entities, such as clinical specialty societies, clinical professional organizations, patient advocacy organizations, educational institutions, independent research organizations, and health systems, in developing, improving, updating, and expanding quality measures for the Quality Payment Program. By giving external entities needed resources to help guide their measure-development efforts though this funding opportunity, CMS can leverage the unique perspectives and expertise of these external entities, such as clinician and patient perspectives, to advance the Quality Payment Program measure portfolio. The cooperative agreements will allow CMS to collaborate with stakeholders to address essential topics such as: clinician engagement, burden minimization, consumer-informed decisions, critical measure gaps, quality measure alignment, consumer-informed decisions, clinician engagement, and efficient data collection that minimizes health care provider burden.

The priority measures developed, improved, updated or expanded under the cooperative agreements will be aligned with the CMS Quality Measure Development Plan. The CMS Quality Measure Development Plan provides a strategy for filling clinician and specialty area measure gaps and for recommendations to close these gaps in order to support the Quality Payment Program, and identifies the following initial priority areas for measure development: Clinical Care, Safety, Care Coordination, Patient and Caregiver Experience, Population Health and Prevention, and Affordable Care. The gap areas include, but not limited to: Orthopedic Surgery, Pathology, Radiology, Mental Health and substance use conditions, Oncology, Palliative Care, and Emergency Medicine.

More broadly than the CMS Quality Measure Development Plan, which is specific for the Quality Payment Program, CMS measures work is guided by the Meaningful Measurement framework which identifies the highest priorities for quality measurement and improvement. The Meaningful Measure Areas serve as the connectors between CMS goals under development and individual measures/initiatives that demonstrate how high quality outcomes for our Medicare, Medicaid, and CHIP beneficiaries are being achieved. They are concrete quality topics which reflect core issues that are most vital to high quality care and better patient outcomes.

Through these cooperative agreements, CMS aims to provide the necessary support to help external entities expand the Quality Payment Program quality measure portfolio with a focus on clinical and patient perspectives and minimizing burden for clinicians. Focusing on patient perspectives will ensure measures focus on what is important to patients and drive the improvement of patient outcomes. To accomplish this, the cooperative agreements prioritize the development of: outcome measures, including patient reported outcome and functional status measures; patient experience measures; care coordination measures; and measures of appropriate use of services, including measures of overuse.

For more information, search for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program on Grants.gov or visit our website, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html.

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CMS’s 2017 Medicare Fee-For-Service improper payment rate is below 10 percent for the first time since 2013

 CMS Blog
http://blog.cms.gov/2017/11/15/cmss-2017-medicare-fee-for-service-improper-payment-rate-is-below-10-percent

November 15, 2017
By Kimberly Brandt, Principal Deputy Administrator for Operations (@cms.hhs.gov)

The Centers for Medicare & Medicaid Services (CMS) is committed to reducing improper payments in all of its programs, as evidenced by improper payment reduction efforts contained in the Fiscal Year 2018 President’s Budget. CMS’s new leadership is re-examining existing corrective actions and exploring new and innovative approaches to reducing improper payments, while minimizing burden for its partners. Due to the successes of actions we’ve put into place to reduce improper payments, the Medicare Fee-For-Service (FFS) improper payment rate decreased from 11.0 percent in 2016 to 9.5 percent in 2017, representing a $4.9 billion decrease in estimated improper payments. The 2017 Medicare FFS estimated improper payment rate represents claims incorrectly paid between July 1, 2015 and June 30, 2016. This is the first time since 2013 that the Medicare FFS improper payment rate is below the 10 percent threshold for compliance established in the Improper Payments Elimination and Recovery Act of 2010.

Improper payments are not always indicative of fraud, nor do they necessarily represent expenses that should not have occurred.  For example, instances where there is insufficient or no documentation to support the payment as proper are cited as improper payments under current Office of Management and Budget guidance.  The majority of Medicare FFS improper payments are due to documentation errors where CMS could not determine whether the billed items or services were actually provided, were billed at the appropriate level, and/or were medically necessary. A smaller proportion of Medicare FFS improper payments are payments for claims CMS determined should not have been made or should have been made in a different amount, representing a known monetary loss to the program.

Figure 1 provides information on Medicare FFS improper payments that are a known “monetary loss” to the program (i.e. medical necessity, incorrect coding, and other errors). The estimated known “monetary loss” improper payment rate is 3.0 percent, representing an estimated known monetary loss of $11.3 billion out of the total estimated improper payments of $36.2 billion.  In the figure, “unknown” represents payments where there was no or insufficient documentation to support the payment as proper or a known monetary loss. In other words, when payments lack the appropriate supporting documentation, their validity cannot be determined.  These are payments where more documentation is needed to determine if the claims were payable or if they should be considered monetary losses to the program.

Figure 1: FY 2017 Medicare FFS Improper Payments (in Millions) and Percentage of Improper Payments by Monetary Loss and Type of Error

 

CMS continues to implement tools and work with law enforcement partners and other key stakeholders to help focus on prevention, early detection, and data sharing to prevent and reduce improper payments in Medicare FFS.  Although documentation errors are the largest cause of improper payments, CMS employs multi-layered efforts to target all root causes of improper payments, with an emphasis on prevention-oriented activities.

CMS is pleased to have achieved this reduction in the improper payment rate, but we still have work to do.  We remain committed to collaborating across CMS and with stakeholders to address potential vulnerabilities and continuing to strengthen our program integrity efforts, while minimizing burden for our partners.

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Thank You For Your Service

CMS BLOG
http://blog.cms.gov/2017/11/11/thank-you-for-your-service

November 9, 2017
By:  Seema Verma, CMS Administrator

Thank You for Your Service

We’ve all heard the stories of bravery and sacrifice, or have personally experienced the inspiring dedication to service of our US Military veterans, but for me their heroism was made real on a visit to Normandy.

Early in the morning on D-Day, June 6, 1944, Army Rangers climbed the cliffs of Point-du-Hoc to the west of Omaha Beach to destroy a battery of 155mm German cannons on top of the cliff. As I stood there, viewing these cliffs as a tourist, I couldn’t help but imagine the fear that must’ve been going through their minds as they scaled those massive, rocky cliffs under heavy German fire, only to reach the top and face even heavier opposition. How, in the face of what they must have considered certain death, they pressed on knowing the importance of their mission, and that their actions would save countless American and foreign lives.

I then went to see the cemetery where those lost on D-Day, including the Army Rangers who died while taking that hill, were buried. While looking at that field of graves, I found myself emotionally overwhelmed thinking about how these men died for the freedom and safety of people they didn’t know and would never meet.

As a public servant, on this day and every day, I think about the sacrifices of America’s Veterans, both dead and living, that inspire me to also make sacrifices so that others can live better lives. When I think about the work we do at CMS, I think about those Rangers, I think about the price they paid for our freedoms, and I think about the fact that their sacrifice should be honored by making sure that we serve our country in a manner worthy of their heroism.

America’s veterans are heroes. CMS currently employs 591 veterans, comprising 10% of our workforce. Last year we hired 38 veterans, and will continue to recruit and retain veterans within our ranks because they not only bring a wealth of knowledge and skill, but a profound sense of honor and dedication to public service that is an important quality in all CMS employees.

To America’s veterans, thank you for your service, and your devotion to our country. We at CMS will never take for granted what you have done for us and for this country. On behalf of myself, my family, and CMS employees currently serving all across our country, I hope you have a great Veterans Day, you’ve earned it.

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Las Nuevas Tarjetas de Medicare Ya Llegarán Pronto

Por: Seema Verma, Administradora de los CMS

Como podría haber escuchado ya, o quizás ya vio un comercial de televisión, los Centros de Servicios de Medicare y Medicaid pronto emitirán a cada beneficiario de Medicare una nueva Tarjeta de Medicare, sin números de Seguro Social, para prevenir el fraude, mantener seguros los fondos de los contribuyentes, y para asegurar que siempre ponemos las necesidades de los pacientes primero.

Desafortunadamente los criminales están cada vez más interesados en las personas de 65 años o más para el robo de identidad médica, incluso cuando alguien usa ilegalmente el número de Medicare de otra persona. Un ladrón de identidad puede facturarle a Medicare por servicios costosos que nunca fueron proporcionados o cobrar más por los servicios proporcionados. Esto puede resultar en ambigüedades en los registros médicos, lo que puede significar el retraso en la atención o servicios negados para los pacientes y también impacta los fondos de los contribuyentes.

Para ayudar a combatir esto, les enviaremos a todos los beneficiarios de Medicare una nueva tarjeta con un número único asignado al azar. Cuenta con once caracteres, una combinación de números y letras mayúsculas.

Debido a que el número se genera al azar, no hay conexión a otra información de identificación personal. Este nuevo número reemplazará al número actual basado en el Seguro Social, y está diseñado para proteger la información personal de los beneficiarios de Medicare.

Comenzaremos a enviar por correo las recién diseñadas tarjetas de Medicare en abril de 2018, y reemplazaremos todas las tarjetas antes de abril de 2019. Si usted es beneficiario de Medicare o pronto lo será, no tendrá que hacer nada y podrá comenzar a usar su nueva tarjeta tan pronto como la reciba.

Cuando reciba su nueva tarjeta, le pediremos que destruya su tarjeta de Medicare de una manera segura. Asegúrese de traer la nueva tarjeta a las citas de sus médicos, y mantenga siempre confidencial su nuevo número. Esto ayudará a proteger su identidad personal y prevenir el fraude de identidad médica porque los ladrones de identidad no pueden facturar a Medicare sin un número de Medicare válido. Además, usted y sus proveedores de atención médica podrán utilizar herramientas seguras en línea que estamos desarrollando y que brindarán acceso rápido a su número de Medicare cuando sea necesario.

Usted va a escuchar mucho más acerca de esta iniciativa en las próximas semanas y meses, y también estamos ayudando a los médicos y otros proveedores de atención médica a prepararse para el cambio. Queremos hacer este proceso tan fácil como sea posible para todos los involucrados. Sobre todo, queremos que las personas con Medicare y los proveedores de atención médica sepan estos cambios con anticipación y tengan la información necesaria para asegurar una transición fácil a la nueva tarjeta.

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New Medicare Cards are Coming Soon

By:  Seema Verma, CMS Administrator

As you may have heard, or perhaps you’ve seen a recent TV commercial, the Centers for Medicare & Medicaid Services will soon be issuing every Medicare beneficiary a new Medicare Card, without Social Security Numbers, to prevent fraud, fight identity theft, and keep taxpayer dollars safe, and to help ensure that we always put the needs of patients first.

It’s unfortunate that criminals are increasingly targeting people age 65 or older for medical identity theft, including when someone illegally uses another person’s Medicare number. An identity thief may bill Medicare for expensive services that were never provided or overbill for provided services. This can lead to inaccuracies in medical records, which can mean delayed care or denied services for patients and impacts taxpayer funding.

To help combat this, we’ll be sending all Medicare beneficiaries a new card with a unique, randomly-assigned Medicare number.  It will consist of eleven characters, a combination of numbers and uppercase letters.

Because it is randomly generated, there is no connection to any other personal identifying information. This new number will replace the Social Security-based number currently used on all Medicare cards, and it’s designed to protect the personal information of Medicare beneficiaries.

We’ll begin mailing the newly designed Medicare cards in April 2018, and we’ll replace all cards by April 2019. If you’re a Medicare beneficiary, or soon will be, you don’t need to do anything, and you can start using your new card as soon as you get it.

When you get your new card, we’ll ask you to safely and securely destroy your current Medicare card.  Make sure you bring the new card to your doctors’ appointments, and always keep your new number confidential.  This will help protect your personal identity and prevent medical identity fraud because identity thieves can’t bill Medicare without a valid Medicare number. Additionally, you and your health care providers will be able to use secure online tools that we’re developing that will support quick access to your Medicare number when needed.

You’ll be hearing a lot more about this initiative in the coming weeks and months, and we’re also helping doctors and other healthcare providers get ready for the change.  We want to make this process as easy as possible for everyone involved. Above all, we want to ensure that people with Medicare and healthcare providers know about these changes well in advance and have the information needed to ensure an easy transition to the new card.

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The true strength of our healthcare system is its people

By Seema Verma, Administrator for the Centers for Medicare & Medicaid Services

As a wife and mother, my family’s health is always foremost on my mind. That is why a recent personal experience will forever shape the impact I want to have while serving as Administrator of the Centers for Medicare and Medicaid Services.

Earlier this month, while at an airport with our two children, my husband collapsed and went into cardiac arrest. He’s home now and his prognosis is excellent. However, if it weren’t for the courageous bystanders who administered CPR and the dedicated medical professionals at the Hospital of the University of Pennsylvania where he was admitted, he wouldn’t be with us today.

I wasn’t at the airport when my husband collapsed. I arrived at the hospital as soon as I could, and as I met the team of professionals who were caring for him, I was amazed by their skill and compassion. From the hospital administrators to the physicians, nurses, and many others who took charge of his care, I witnessed the true greatness of our healthcare system: the remarkable people who serve within it.

My life would be very different if it weren’t for the diligence and expertise of the first responders at the airport and the healthcare professionals at the hospital. Even in our age of advanced technology, procedures, and therapies, it’s the people that make our healthcare system one that we feel we can entrust with the care of our loved ones.

My husband is a physician, and I have many relatives and close friends who are healthcare professionals as well.  To a person these caregivers are some of the smartest and most selfless people I know. They have put in long hours and made many sacrifices along the path of medical education and training. What motivates them isn’t a promise of high salaries, or a quest for esteem, but a genuine drive to help patients and their families when they are most vulnerable.

Our healthcare system is made up of a community of professionals who want to do good.  As a wife and a mother I am so grateful for this, because these professionals saved my husband and my children’s father. As the Administrator of CMS, I am inspired by this and feel compelled to do everything I can to support these caregivers. Our agency must make it easier for them to focus on doing the work that patients and families need them to do without causing them to be subject to excessive regulatory and administrative burden.

That’s why in all of our recent proposed rules, CMS has asked healthcare providers for their thoughts on how to simplify our regulations. And over the next few months we will be announcing additional initiatives to ease the burden our government places on healthcare providers. We will continue to engage with our providers on their concerns.

Some regulations are necessary in order to ensure patient safety and well-being, and to protect the integrity of federal health care programs.  However, over the past few years, regulations have tilted more towards creating burdens than towards serving as a safeguard for the programs.  This shift is now having a negative impact on patient care, hindering innovation, and increasing healthcare costs.

To make sure we are addressing the actual pain points that doctors feel, we are visiting them where they work, listening to their stories about the challenges they face, and bringing those lessons back to CMS. We have heard time and again that documentation for payment and for quality reporting is unnecessarily time-consuming and keeps clinicians working late into the night just to keep up on paperwork. Electronic health records that were supposed to make providers’ lives easier by freeing up more time to spend on patient care have distanced them from their patients. New payment structures that were meant to increase coordination have added yet another layer of rules and requirements.

No one went into medicine to become a paperwork expert. We are listening, integrating the feedback we hear into our work at CMS, and making changes that will make it easier for doctors, nurses, and other clinicians to do what they entered medicine to do: take care of those in need.

It can be easy to forget how important our healthcare system is, to forget that every day, men and women are hard at work treating, comforting, and healing. For those of us whose families have received lifesaving care, we are forever grateful. The entire CMS team and I are committed to doing our part to make sure that these caring professionals can do their job without the burden of unnecessary regulation.

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/