CMS Releases Latest Value-Based Purchasing Program Scorecard

By Dr. Patrick Conway, CMS Chief Medical Officer and Director of the Centers for Clinical Standards and Quality

On November 14, for the second year in a row, the Centers for Medicare & Medicaid Services (CMS) posted Hospital Value-Based Purchasing payment incentive adjustment factors for fiscal year 2014. We think this second anniversary deserves recognition—it’s a sign that value-based purchasing in Medicare is becoming routine.

The Affordable Care Act gave CMS many new tools to convert Medicare from a program that paid for decades on automatic pilot into one that deliberately pays to promote better health. Now, thanks to one of these tools, the Hospital Value-Based Purchasing program, Medicare is no longer a program that just pays the bills. Acute-care hospitals across the country not only are paid more for higher quality care, they also have skin in the game.

In FY 2014, 1.25 percent of a hospital’s Medicare base-operating DRG payments go into a value-based purchasing pool. Depending on how well hospitals measured up to their peers on important health-care quality indicators during a prior performance period, they will either break even, get a bonus, or—if their performance is lower than average—get back less than what they contributed to the FY 2014 pool.

FY 2014 payments began October 1. About half of the hospitals participating in the program —over 1300 hospitals—will essentially break even over the course of the year, that is, their payment change is between -0.2 percent and +0.2 percent. Across the country, 630 hospitals—just under a quarter—will receive a bonus, that is, an increase in Medicare payment above +0.2 percent. Just over a quarter of hospitals (778) will receive an overall decrease in Medicare payment, which means that it is less than -0.2 percent.

But even though we’d like to see every hospital across the country offer the highest quality care possible, we’re pleased with this round of results. Hospital Value-Based Purchasing provides a useful snapshot of how hospitals are performing on important indicators for patient safety, care, quality, and well-being. The Hospital Value-Based Purchasing program refines the measures it uses to evaluate performance annually.
In FY 2014, there were fewer higher performers—that is, their incentive payment is greater than the amount they contributed—than lower performers—their incentive payment is lower than the amount they contributed, that higher performers’ bonuses on average will be larger than the lower performers’ losses over the course of the year.

Finally, a little over two-thirds of the higher performers were higher performers last year, and about three-quarters of the lower performers also had an incentive adjustment factor of less than one in FY 2013. That’s good news too. The fact that not every higher performing hospital last year made the grade this year, and not every lower performing hospital last year will see payment decline this year,, means that hospitals are adjusting to the new world of value-based payment. It also may mean that the important addition of 30-day mortality measures for heart attack, heart failure and pneumonia had an impact on hospitals’ scores.

As the Hospital Value-Based Purchasing program continues to evolve with a richer set of measures including an efficiency measure in FY 2015, we may see the mix of value-based payment adjustment factors change again. Meanwhile, value-based purchasing in Medicare continues to move ahead, improving the way that health care is delivered to people with Medicare now and helping create a health care system that will ensure quality care for generations to come.

To see the November 14, 2013 value-based incentive payment adjustment factors, please go to: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/

Virtual Research Data Center Offers Secure Timely Access to Data at Lower Cost

By Niall Brennan, Acting Director, Offices of Enterprise Management

One of the Obama administration’s top priorities is to make healthcare affordable through better quality and more efficient delivery.  But a thoughtful approach to health system transformation requires the country’s best minds working on it, using the most comprehensive, up-to-date evidence available.

On November 12, the Obama administration took an important step forward on this path.  At the White House’s Data to Knowledge to Action event, Building New Partnerships, the Centers for Medicare & Medicaid Services (CMS) announced the new Virtual Research Data Center (VRDC), which can provide the nation’s researchers with access to the most comprehensive, up-to-date data sets available through CMS.

CMS covers 100 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program, and soon through the Health Insurance Marketplace. The Medicare program is the nation’s largest health insurer, handling more than 1 billion claims per year.  We have made our data sets available to researchers for many years.  Studies that help us better understand the healthcare ecosystem are published almost weekly in major medical journals based on CMS data.

Demand for CMS data has grown exponentially in recent years.  Historically, the scale of CMS data and a lack of technological alternatives meant most researchers were physically shipped data, with yearly updates as permitted. Medicare data for 2012 is only just now being physically shipped to researchers. Through the VRDC, we are changing that. The VRDC will help investigators access data in a much timelier manner and will provide them with a variety of tools to analyze the data.  It will also help approved researchers doing approved surveillance and other studies that require current data, which needs to be refreshed on a regular basis, something that has traditionally been unavailable.

We also want CMS data to be affordable, and the VRDC helps with this, too. The lowest price of a complete set of Medicare Parts A, B, and D data was more than $100,000 for a single year, and many researchers need multiple years of data.  Now, with the VRDC, a single researcher conducting one project over the course of the year can have access to as much data as his or her research requires for $40,000.  User fees reflect the cost of making the data available and are used to fund CMS data dissemination to researchers.  Additional users can be added to a project for $15,000. We believe this helps lower any price-based barriers to obtaining Medicare data.

Finally, the VRDC will make data sharing more secure.  In the VRDC, sensitive, individually-identifiable information about beneficiaries never leaves the CMS data environment.  This can help prevent breaches or unauthorized data use.  In addition, since researchers will be accessing CMS data through a secure virtual desktop, they no longer need to maintain expensive data infrastructures of their own or prove to CMS through data security assessments that their data infrastructure meets the security requirements in the CMS Data Use Agreement.   However, I also want to assure established CMS data users who have invested significant sums in an existing data storage infrastructure:  you can still get your data physically as you always have. CMS data has the potential to help create a more efficient, higher-quality healthcare system. Our goal is to break down barriers to information and encourage innovation in health care delivery.  Even under the old system, CMS data has provided the basis for breakthroughs in healthcare reform.  We look forward to using the VRDC to stimulate innovations that are equally groundbreaking in years to come.

For more information or to submit a VRDC research request, visit the ResDAC VRDC webpage: http://www.resdac.org/cms-data/request/cms-virtual-research-data-center.

Fighting Medicaid Fraud, Waste, and Abuse Through Education

By Ted Doolittle, CMS Deputy Director, Center for Program Integrity

The Centers for Medicare & Medicaid Services (CMS) wants everyone to join in the fight against fraud, waste, and abuse as part of our comprehensive strategy to protect federal health care programs and taxpayer dollars.  We are now making it easier than ever before for health care providers, managed care plans, and individuals and families with Medicaid benefits to use the education and training materials on the new Medicaid Program Integrity website.

Resources available on the website include videos, fact sheets, and checklists, made specifically for providers and beneficiaries.  These tools are national in scope, but some information can be personalized by your State of residence (or where you live) upon request.  One of the key resources is a brochure on how people with Medicaid can protect themselves and the Medicaid program from fraud. You can also email MedicaidProviderEducation@cms.hhs.gov for the state contact number for reporting fraud.

State program integrity professionals and counselors will also find valuable education and training materials on the site – all available at no cost.  We have developed toolkits to address hot issues and frequently asked questions about Medicaid program integrity, including beneficiary protections and compliance resources for dental professionals and managed care organizations.  Take a moment to learn more about the CMS Medicaid Program Integrity education and training materials available by clicking on this link, that will take you to the CMS.gov website.

Click here to join our listserv to receive timely notices of new material as it becomes available. Listserv members are also notified when new training, education, or speaking events are scheduled.

We value your feedback, recommendations, questions, and requests and encourage you to e-mail the Education Medicaid Integrity Contractor at medicaidprovidereducation@cms.hhs.gov for further information.

Thank you for being a partner in Medicaid program integrity!

And for more information on CMS’s efforts to protect consumers in the Health Insurance Marketplace, please visit: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-09-18.html

Premium and Prescription Savings are Good News for People with Medicare

By Jonathan Blum, CMS Principal Deputy Administrator

The Centers for Medicare & Medicaid Services (CMS) has announced the 2014 Part B premiums in original Medicare and most seniors and people with disabilities will not increase next year, staying at $104.90 a month for Part B premiums.

For the third year in a row Medicare premium costs are meeting or beating expectations.  Monthly Medicare premiums in 2013 are lower than the $109.10 they were projected to be.   The year before, premium costs came in six dollars lower than the experts predicted.  The last five years have been among the slowest periods of average Part B premium growth in the program’s history.

Lower original Medicare costs are just one of the positive changes we’ve seen in Medicare since the Affordable Care Act was signed into law.

Since 2010, more than 7.1 million seniors and people with disabilities who reached the donut hole have saved $8.3 billion on their prescription drugs, an average of $1,167 per person.     In 2014, people with Medicare who have entered the donut hole will receive discounts and coverage of about 53 percent on the cost of brand name drugs and 28 percent coverage for the cost of generic drugs. Prescription drug savings and Medicare coverage will gradually increase until 2020, when the donut hole will be closed.

Medicare Advantage plan benefits and prices continue to improve thanks to a new Affordable Care Act star-rating system that pays plans based on quality.  Since passage of the Affordable Care Act, average Medicare Advantage premiums are down by 9.8 percent.  More beneficiaries are able to access and choose high quality plans – more than half are in four or five-star plans for 2014, up from 37 percent this year.

Other Affordable Care Act changes that pay hospitals and doctors based on the quality of care they deliver for patients—like reducing hospital readmissions, which have started to drop after being stuck for the past five years—are beginning to have an effect.  Programs like Hospital Value-Based Purchasing and Accountable Care Organizations are making sure that improved quality of care for patients is at the center of efforts to reduce cost growth.  Over the last four years, the stronger anti-fraud measures instituted by the Affordable Care Act has enabled the Obama administration to recover over $14.9 billion for taxpayers.

And health care spending has grown more slowly in the past few years than it has since the 1960s.  We’re working hard to make sure these gains continue.  Meanwhile, lower costs and better care is great news for the Trust Funds, great news for taxpayers, and really great news for people with Medicare.

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Moving Forward on Arkansas’ Innovative Plan to Provide Health Coverage to 200,000 Arkansans

By Cindy Mann CMS Deputy Administrator and Director, Center for Medicaid and CHIP Services

Today, the Centers for Medicare & Medicaid Services announced the approval of the Arkansas Medicaid 1115 Demonstration to expand Medicaid coverage to over 200,000 people that do not have access to health coverage.  This demonstration is part of the state’s larger initiative to create affordable, quality coverage options for all its residents. This coverage is possible thanks to the Affordable Care Act.

Over the last few months, CMS has worked closely with Arkansas on the Arkansas Health Care Independence Program, or as they call it in Arkansas, the Private Option and has benefited from public comments from a diverse group of stakeholders. Under the Private Option demonstration, the state will use premium assistance to provide adults who make $15,280 or less with coverage provided by Qualified Health Plans operating in the Health Insurance Marketplace. As a result, most of the newly eligible adults in Medicaid will receive almost all of their Medicaid benefits and cost-sharing coverage through the same plans that are serving Arkansans who enroll through the federally facilitated Marketplace. Under this and all premium assistance approaches, individuals in the demonstration retain all the rights, responsibilities, and protections as other Medicaid beneficiaries, including cost-sharing protections.

Outreach, the application process, and plan choice will be the same regardless of whether an Arkansas resident is enrolled in Medicaid or has a premium tax credit through the Marketplace. Arkansas is leading the state’s outreach effort for the Marketplace.  It is training “Health Insurance Guides” to help individuals in all 75 counties understand their options.  It has been running advertising on 28 television stations, 24 regional radio stations, 118 community radio stations, and in 120 community newspapers.  In addition, ads have been placed on 227 billboards, 100 gas pumps, two Central Arkansas Transit buses, and direct mail will be sent to 254,000 households and 172,000 small businesses.  The marketing tag line of “Get In” has switched to “Get Informed” and will be shift to “Get Enrolled” beginning October 1, 2013. Open enrollment for the new Medicaid demonstration as well as the Marketplace will begin on October 1, 2013 with eligibility effective January 1, 2014.

The Administration remains committed to working with states on the flexibility and resources they need to build new systems for health coverage.  Premium assistance is one option, and we will continue to work with states on solutions that work best to meet shared goals.  We encourage states to come to us with their delivery system ideas, and look forward to continuing to work with states on these and other innovative approaches to provide affordable coverage to all Americans.

Encouraging news about enrollment in Medicaid and CHIP

By Cindy Mann, Deputy Administrator and Director, Center for Medicaid & CHIP Services, Center for Medicare & Medicaid Services (CMS)

When it comes to getting children the health coverage they need, our nation is moving in the right direction.  According to a new analysis by the Urban Institute, the participation rate in Medicaid and the Children’s Health Insurance Program (CHIP) has increased to 87.2 percent in 2011, up 5.5 percentage points from 81.7 percent in 2008. Over that same time period, the number of eligible uninsured children has declined from 4.9 million to 4.0 million.  At CMS, we are greatly encouraged by this progress, because we know a bump in participation means that more children are getting access to the comprehensive health benefits – including preventive services – that all children need.

In addition to the work states have done over the past decade or more to simplify and streamline enrollment procedures, outreach efforts that include providing application assistance directly to families have played a key role in improving enrollment.  Secretary of Health and Human Services, Kathleen Sebelius helped galvanize these efforts in 2010, when she launched the Connecting Kids to Coverage Challenge, calling upon leaders at all levels of government, community-based organizations, health centers, school districts, faith-based groups, Indian tribes and others to find and enroll all uninsured children eligible for Medicaid and CHIP eligible children.  We are proud that, working together, our national Connecting Kids to Coverage Campaign, our outreach and enrollment grantees and many other partners have helped to achieve the progress described in the Urban Institute report.

But, there is still more to be done.  Too many uninsured children who could be eligible for Medicaid and CHIP today remain uninsured.  As the Connecting Kids to Coverage Campaign continues to reach out to families across the country, we know that new opportunities to boost enrollment are just around the corner.  Beginning October 1, as a result of the Affordable Care Act, many more parents will be eligible for Medicaid or other coverage available through the Health Insurance Marketplace.  And we know that when eligible parents enroll, they are also likely to enroll their children and take advantage of the preventive services that help them stay healthy.

To find the children’s Medicaid/CHIP participation rate in your state check out this map: http://www.insurekidsnow.gov/professionals/reports/index.html

To find out about health insurance opportunities for the whole family:

https://www.healthcare.gov/

For recent children’s health coverage outreach materials and ideas for how best to use them:

http://www.insurekidsnow.gov/professionals/back_to_school.html

Watch the Insure Kids Now television public service announcement here: http://www.insurekidsnow.gov/professionals/outreach/strategies/tv_and_radio_psas.html

Find out more about the grants we’ve awarded to groups across the country: http://www.insurekidsnow.gov/professionals/index.html

 

A guide for new and first-time physicians participating in federal healthcare programs

By Shantanu Agrawal, MD

With a new class of medical residents beginning their training, and residents and Fellows graduating from their programs every July, it’s important that our critical partners in the delivery of healthcare have the tools they need to understand federal program requirements.  At the Centers for Medicare & Medicaid Services (CMS) we have a comprehensive strategy to reduce fraud, waste and abuse that is designed to target risk – that means as we make it harder for bad actors to enroll or bill in our systems, we are always evaluating how to make it easier for legitimate physicians and other providers to participate in Medicare and care for beneficiaries.

CMS demonstrates this commitment with several initiatives:

  • Providers enrolling in Medicare for the first time now have a much easier experience enrolling than in years past. Since 2012, paper is no longer required to complete an application.  Everything can be submitted online, using web-based “PECOS” (the Provider Enrollment, Chain and Ownership System – the official record of every provider in Medicare). That includes required signatures and attachments, such as medical licensure. If an application fee is required – typically owed by organizations – it can also be paid online. The conveniences of the web-based PECOS system allow for faster application processing times over paper-based applications.
  • We recently launched two free mobile applications for Apple iOS and Android devices to help various stakeholders comply with the new requirements of the Open Payments program (commonly known as the Physician Payments Sunshine Act). This program tracks financial relationships between covered physicians and the health care industry – such as pharmaceutical and medical device companies – and will make the data available to the public annually on a website currently being designed. Physicians are not required to report any data, but the mobile applications will help them to track financial relationships and assess reported data for accuracy.
  • CMS is also modernizing how we communicate with physicians. We are now using Facebook / Facebook4 and Twitter / Twitter10 to keep tech-savvy providers up-to-date on the latest CMS news and progress being made.  Use these resources to engage and share your comments on our program efforts via Email and Google.
  • At CMS we also know the risks and challenges that many new physicians face in today’s healthcare landscape. We are dedicated to helping new physicians stay on track with important updates in our Medicare and Medicaid operations. That’s why the Center for Program Integrity is making it easier for physicians to resolve issues of identity theft. We’re providing information on how to protect your medical identity, numerous educational toolkits and Continuing Medical Education (CME) on CMS program integrity activities.

New and practicing physicians should note that as CMS shifts its fraud-fighting strategy to become more proactive, people committing fraud are doing the same. In our long-running patient education programs, we have provided ways patients and their families can spot and prevent scams. And we are developing more fraud-focused materials for health care providers and suppliers.

New physicians are emerging as a new vulnerability because of their inexperience with federal programs, financial obligations resulting from medical school, and aggressive scammers skillfully crafting schemes that appear to be legitimate.

New doctors should be aware of job offers that appear “too good to be true.” As with any other professional offer received or found — in print, on the internet, or other reputable or often-used resources – please be wary of offers that pay large sums of money in exchange for reviewing medical records written by others. Most often these include night and weekend work offers for your professional services to assist home health and durable medical equipment operations, usually off-site.

For Medicare fraud scams, they will require that you enroll or be enrolled in Medicare or PECOS. Never accept money or gifts for work you did not perform. Scammers that are offering cash for your participation in fraud are quick to disappear and have no issue with leaving you out to dry. Convictions for certain health care fraud violations will result in exclusion from federal healthcare programs – and potentially preventing your participation in certain State Medicaid programs and private health plans. Remember, the penalties are much larger than any short-term benefit.

To help new physicians develop defenses against these scams, CMS urges you to:

And most importantly, all doctors and their patients should report fraud as soon as it is suspected to the HHS Office of Inspector General. Tips can be reported either online or by phone at 1-800-HHS-TIPS. It’s never too late to report information, and by doing so you will be joining the fight to protect federal healthcare programs for future generations.

Shantanu Agrawal, M.D., is the Medical Director for the Center for Program Integrity at the Centers for Medicare & Medicaid Services.

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