Working Together for Value

June 20, 2018 

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

Working Together for Value

Over the past year, the Centers for Medicare & Medicaid Services (CMS) has engaged with the provider community in a discussion about regulatory burden issues. This included publishing a Request for Information (RFI) soliciting comments about areas of high regulatory burden. One of the top areas of burden identified in the over 2,600 comments received was compliance with the physician self-referral law (often called the “Stark Law”) and its accompanying regulations.  In response to these concerns, CMS undertook a review of the existing regulations to determine where the agency could consider potential areas for burden reduction. In coordination with HHS Deputy Secretary Eric Hargan, CMS is now soliciting specific input on a range of issues identified with the Stark Law to help the agency better understand provider concerns and target its regulatory efforts to address those concerns.

The Stark Law was enacted in the 1980s to help protect Medicare and its beneficiaries from unnecessary costs and other harms that may occur when physicians benefit from referring patients to health care entities with which they have a financial relationship. The law prohibits a physician from making referrals for certain health care services to an entity with which he or she (or an immediate family member) has a financial relationship. There are statutory and regulatory exceptions, but in short, a physician cannot refer a patient to any service or provider in which they have a financial interest.

Stark also prohibits the entity from filing claims with Medicare for services resulting from a prohibited referral and Medicare cannot pay if the claims are submitted. In its current form, the physician self-referral law may prohibit some relationships that are designed to enhance care coordination, improve quality, and reduce waste.

To achieve a truly value-based, patient-centered health care system, doctors and other providers need to work together with patients. Many of the recent statutory and regulatory changes to payment models are intended to help incentivize value based care and drive the Medicare system to greater value and quality. This has been a priority of CMS and HHS and is reflected in many of our current ongoing initiatives. Medicare’s regulations must support this close collaboration. The Stark Law and regulations, in its current form, may hinder these types of arrangements. To help better understand the impediments to better coordinated care caused by existing regulatory efforts, this RFI seeks to obtain input about how to address those concerns.

We invite you to share your ideas and suggestions as we work together for coordinated care and a better health care system for all Americans. The RFI can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/.

Medicare Open Enrollment – New Features make Shopping for 2018 Coverage Easier!

By Seema Verma, Administrator, Centers for Medicare & Medicaid Services (CMS)

Each October, as the days grow shorter, time seems to speed up. Maybe it’s because we start planning for the looming holidays or begin bracing for the cold winter, but before we know it we’re saying goodbye to one year and ringing in a new one. That’s why it’s important to set aside some time between now and early December to think about your 2018 healthcare needs by shopping for high-quality Medicare health and drug plans during Open Enrollment.

Medicare Open Enrollment kicked off on October 15 and will run through December 7. I’m pleased to share that you will have better access to high-quality health coverage choices offering more options and lower premiums in 2018. This means you should be able to find plans that cost less but still give you quality care and better customer service. In fact, the number of Medicare Advantage plans available to individuals across the country is increasing from about 2,700 to more than 3,100 – and more than 85 percent of people with Medicare will have access to 10 or more Medicare Advantage plans. We are estimating that the average Medicare Advantage monthly premium will decrease by $1.91 in 2018, from an average of $31.91 in 2017 to $30. The Medicare prescription drug plan average basic premium is projected to decline for the first time since 2012 (a decrease of approximately $1.20 below the 2017 average basic premium of $34.70).

The choices available demonstrate the benefits of supply and demand market forces in a strong healthcare market. Consumers are demanding more from their insurance plans and in turn Medicare Advantage and Part D plans, like any business, are responding with better service at a lower cost leading to a truly patient-centered approach to healthcare.

Medicare is making some exciting changes of our own to make it easier for you to make an informed choice between Original Medicare and Medicare Advantage. You may have noticed a few of these changes in your Medicare & You handbook, but it doesn’t stop there. We’re improving our digital features on Medicare.gov, where you can sign-up to get timely notices about Open Enrollment and other important Medicare updates directly to your inbox. While on Medicare.gov be sure to check out the new help wizard that will point you to resources that will help you make informed healthcare decisions. These updates mirror the private sector and reflect a few ways we’re modernizing the customer service experience.

If you’ve been thinking about starting your new year with a Medicare Advantage or Prescription Drug Plan, or you’re interested in making some changes to your current plan, now is the time to shop for your coverage. Medicare health and drug plans change each year, and so can your health needs. That’s why it’s always a good idea to consider what needs you may have for 2018 and take a look at the available plans in your area.

Your coverage will begin on January 1, 2018. If you miss the deadline, you will likely have to wait a full year before you are able to make changes to your plan. During Open Enrollment, you can decide to stay in Original Medicare or join a Medicare Advantage Plan. If you find your current coverage still meets your healthcare needs, then you’re done.

Open Enrollment is also a good opportunity to make sure you’re doing everything you can to protect your identity and your health by guarding your Medicare card like you would a credit card. Identity theft resulting from stolen Medicare numbers is becoming more and more common. Medicare is here to help in the fight by removing Social Security Numbers from Medicare cards and replacing them with a new, unique number for each person with Medicare. Medicare will mail new Medicare cards with the new numbers between April 2018 and April 2019.

Don’t let the opportunity to have better quality healthcare at a lower price pass you by. Get a jump start on your new year’s health resolution today. You can visit Medicare.gov (http://www.medicare.gov), call 1-800-MEDICARE, or contact your State Health Insurance Assistance Program (SHIP) to learn more.

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.

Extending participation in the Bundled Payments for Care Improvement initiative

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

The Centers for Medicare & Medicaid Services is pleased to offer the awardees in the Bundled Payments for Care Improvement (BPCI) initiative the opportunity to extend their participation in Models 2, 3 and 4 through September 30, 2018.

The first cohort of awardees in Models 2, 3, and 4 that began in October 2013 were scheduled to end their participation on September 30, 2016. This extension means that they, along with other organizations that joined later in 2014, have the opportunity to continue their participation in the Bundled Payments for Care Improvement initiative up until September 30, 2018. In addition, by extending their participation, CMS will be able to provide a more robust and rigorous evaluation of the initiative and determine whether the efforts of bundling payments are successful in providing better care while spending health care dollars more wisely. This would build on the first year evaluation.

As of April 1, 2016, the Bundled Payments for Care Improvement initiative has 1,522 participants, comprised of 321 Awardees and 1,201 Episode Initiators. In Models 2, 3 and 4 there are 48 clinical episodes from which participants are able to choose when considering their opportunities for care redesign, improving quality, and achieving savings.

Bundling payment for services that patients receive across a single episode of care – such as a heart bypass surgery or a hip replacement – is one way to encourage doctors, hospitals and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. The initiative 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 care to improve quality and reduce costs.

We are excited to offer the opportunity for awardees in the Bundled Payments for Care Improvement initiative to continue their participation, and we look forward to further working with them in providing high quality, coordinated care to Medicare beneficiaries.

For more information about the Bundled Payments for Care Improvement initiative, please visit: http://innovation.cms.gov/initiatives/bundled-payments.