Supporting Comprehensive and Innovative Care for Children: Request for Information on a Potential Pediatric Alternative Payment Model

February 27, 2017

By Patrick Conway, M.D., M.Sc., Acting Administrator, Centers for Medicare & Medicaid Services; Deidre Gifford, M.D., M.P.H., Deputy Director, Center for Medicaid and CHIP Services; Ellen-Marie Whelan, N.P., Ph.D., Chief Population Health Officer, Center for Medicaid and CHIP Services; and Alex Billioux, M.D., D.Phil., Director, Division of Population Health Incentives and Infrastructure, Center for Medicare & Medicaid Innovation

In partnership with states and providers, the Centers for Medicare & Medicaid Services (CMS) plays a leading role in safeguarding the health of America’s future by providing coverage for more than one in three American children[1]. Through Medicaid and the Children’s Health Insurance Program’s (CHIP) mandatory and optional benefits, children receive access to a spectrum of comprehensive and preventive health care services aimed at providing a sound start for lifelong health. As a result, children enrolled in Medicaid and CHIP lead the nation in participation in preventive care and access to needed care[2].

CMS and states have also demonstrated consistent commitment to improving the health of children through care redesign and innovation in programs such as Medicaid Health Homes, the Medicaid Innovation Accelerator Program, and models tested under the Center for Medicare and Medicaid Innovation (Innovation Center), including the State Innovation Models Initiative and Strong Start for Mothers and Newborns Initiative. To build on those efforts, the Innovation Center, in partnership with the Center for Medicaid and Chip Services (CMCS), is releasing a Request for Information (RFI) today seeking input on the design of alternative payment models focused on improving the health of children and youth covered by Medicaid and CHIP. As the insurer of a third of the nation’s children and a leader in health care innovation, CMS is uniquely positioned to improve the health of America’s children.

We know there is more to health than health care alone, and for children, factors such as sound nutrition, safe living environments, responsive adult caregivers, and nurturing social relationships are especially critical for healthy growth and development. Inadequate or inconsistent access to these factors can have physical and behavioral impacts that reverberate throughout a child’s life course as he or she grows into adulthood. Some children and youth enrolled in Medicaid and CHIP, especially those that are high-need and high-risk, may experience barriers to accessing the optimal combination of child-focused programs and services that are available to address these critical factors. Through the RFI, we are seeking input on approaches to improve the quality and reduce the cost of care for children and youth enrolled in Medicaid and CHIP. In particular, we are exploring concepts that encourage pediatric providers to collaborate with health-related social service providers (e.g., early childhood development programs, child welfare services, and home and community based service providers) at the state and local levels and share accountability for health outcomes for children and youth enrolled in Medicaid and CHIP.

CMS seeks input through the RFI from the broad community of child and youth-focused stakeholders on concepts critical to addressing the comprehensive health needs of children and youth, such as:

  • Opportunities and impediments to extending and enhancing integrated service model concepts like accountable care organizations (ACOs) to the pediatric population;
  • Flexibilities and supports states and providers may need in order to offer such models of care to a state’s pediatric population; and
  • Approaches for states and providers to coordinate Medicaid and CHIP benefits and waivers with other health-related social services for children and youth.

Investing in child health can provide lifelong benefits and improve the nation’s health. We look forward to front-end comments from our state partners and other stakeholders who share our dedication to improving the health of our nation’s children.

For more information on the RFI, please visit: https://innovation.cms.gov/initiatives/pediatric-apm. To be assured consideration, RFI comments must be received by April 7, 2017.

[1] Department of Health and Human Services. 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP. February, 2016. https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-sec-rept.pdf

[2] See CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Final Findings, available at

http://www.mathematica-mpr.com/~/media/publications/pdfs/health/rpt_chipevaluation.pdf; Kreider AR, French B, Aysola J, Saloner B, Noonan KG, Rubin DM. Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families. JAMA Pediatr. 2016;170(1):43-51. doi:10.1001/jamapediatrics.2015.3028

 

CMS releases its Person and Family Engagement Strategy

By: Kate Goodrich, MD MHS, Director, Center for Clinical Standards and Quality, CMS

At the Centers for Medicare & Medicaid Services (CMS), we are working with numerous partners to transform our health care delivery system to one that delivers better health outcomes while spending dollars more wisely. In November of 2015, we updated the CMS Quality Strategy, incorporating the ongoing work to shift Medicare from paying for the number of services provided to paying for better outcomes for patients. We know that a key strategy to achieving better outcomes is to meaningfully engage patients as partners in decisions about their health care. Therefore, one of the six goals outlined in this strategy is: Strengthen person and family engagement as partners in care. Today, we are excited to announce the release of the CMS Person and Family Engagement Strategy, which we believe can lead to significant progress toward this important goal.

What does person and family engagement mean? We view this as patients and families being part of the health care team by working collaboratively with their doctor or other health care professional to be active partners when making decisions about their health.

Why is this important? Because consideration of the health, values, and goals of the individual in consultation with the entire health care team leads to an improved experience and better care. When people feel responsible for their own health and are partners with their providers in goal-setting and decision-making, they are much more likely to achieve their health care goals.

  • If individuals feel their beliefs, desires, and culture are considered in their care, they are more likely to follow their care plan.
  • If individuals are able to communicate effectively with their providers and have a prominent role in making health care decisions, they will receive better care, can more effectively manage their health, and may receive appropriate preventive care while relying less on emergency or urgent care[1].

The CMS Person and Family Engagement Strategy will serve as a guide for the implementation of person and family engagement principles and strategies throughout CMS programs. This strategy will expand the awareness and practice of person and family engagement by providing the following goals and objectives:

  • Goal 1: Actively encourage person and family engagement along the continuum of care within the broader context of health and well-being in the communities in which people live.
  • Goal 2: Promote tools and strategies that reflect person and/or family values and preferences and enable them to actively engage in directing and self-managing their care.
  • Goal 3: Create an environment where persons and their families work in partnership with their health care providers to develop their health and wellness goals informed by sound evidence and aligned with their values and preferences.
  • Goal 4: Develop meaningful measures and tools aimed at improving the experience and outcomes of care for persons, caregivers, and families. Also, identify person and family engagement best practices and techniques in the field that are ready for widespread scaling and national integration.

This Strategy emphasizes that person and family engagement goes beyond informed consent. It is about including the patients voice in policy and program planning. It is about proactive, effective communication and partnered decision-making with patients, families, and caregivers. It is about building a care relationship based on trust and inclusion of patients’ beliefs, values, preferences, and culture which can even lead to a reduction in health care disparities. Health care decision-making should not always be limited to the patient and provider. It is essential to include family members, care-givers, and close friends in the conversation about health when the patient desires inclusion of others. As delivery system reform efforts move the nation to focus on the quality of care and not the quantity of care received, person and family engagement is an essential part of a health care system that delivers high quality care, spends dollars more wisely, and improves the health of people in their communities.

[1] Epstein RM, Street RL, Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.

Tackling Tough Issues Together: The CMS Rural Health Council Solution Summit

By Cara James, Director of CMS Office of Minority Health and John Hammarlund, Regional Administrator 

In 1909, President Theodore Roosevelt’s Country Life Commission issued a report finding that in rural populations, “the physicians are further apart and are called in later in cases of sickness, and in some districts, medical attendance is relatively more expensive.” We have made progress in closing some of the access gap in recent years. Since the Affordable Care Act was signed into law by President Obama in 2010, uninsured rates in rural America have dropped by nearly 40 percent with corresponding improvements in access to care. Nevertheless, rural Americans are more likely to live in states that have not expanded Medicaid, more likely to live in areas with fewer physicians per capita, and more likely to have difficulty accessing timely emergency care.

To address these issues, earlier this year CMS established the CMS Rural Health Council. Made up of experts from across the agency, the Rural Health Council has been thinking about three strategic areas – first, ways to improve access to care for all Americans in rural settings; second, ways to support the unique economics of providing health care in rural America; and third, making sure the health care innovation agenda appropriately fits rural health care markets.

Supported by the Council, CMS has undertaken a number of efforts to reach out to stakeholders to hear about ways to improve access to services for rural Americans. CMS has rural health coordinators at each of our Regional Offices, who meet monthly with the Health Resources and Services Administration (HRSA) to discuss emerging issues. During the Rural Health Open Door Forums, CMS engages with stakeholders to provide current information on CMS programs, answer questions, and learn about emerging rural health issues.

Through our rural health coordinators and the Rural Health Council, CMS has conducted nearly two dozen listening engagements nationwide on key rural health issues, such as telemedicine, hospice, and hospital support. We’ve heard directly from physicians and hospitals who are treating their patients while juggling the unique challenges of rural health care.

In recent years, CMS reformed Medicare regulations that were identified as obsolete or excessively burdensome on hospitals and rural health care providers, which will save providers nearly $660 million annually and $3.2 billion over five years.

Going forward, we’re continuing to embed a rural focus into new programs. For example, with the proposed new Quality Payment Program, we’re making a special effort to reach clinicians in rural areas. Through technical assistance and other activities, we’ll help them transition to the proposed Quality Payment Program’s new approach for paying clinicians for the value and quality of care they provide.

We hope that all of our ongoing efforts, including the work of the CMS Rural Health Council, will give us a better understanding of how our policies and programs affect rural communities.

But we can’t address the challenges of rural communities alone. That’s why we recently announced we will be conducting the CMS Rural Health Solutions Summit on October 19, 2016, at CMS headquarters in Baltimore, Maryland. The CMS Rural Health Council will be bringing in stakeholders from all sectors of the health care industry as we engage in in-depth discussions about ways to improve access to care in rural America and support local innovation in care delivery. We’re excited to bring together national, state, and local leaders to discuss innovative strategies for improving rural care, access, and cost. This discussion will help us work together towards rural health policy and implementation that drives high-value, high-quality health care. If you’d like to join our conversation on October 19, please register at https://register.mitre.org/CMS_Rural_Health_Solutions_Summit/index.html

 

Advancing Health Equity for Sexual and Gender Minorities

By: Cara V. James, Ph.D., Director of the Office of Minority Health at the Centers for Medicare & Medicaid Services

Each June we celebrate National Lesbian, Gay, Bisexual, and Transgender (LGBT) Pride Month by increasing awareness of sexual and gender minority populations’ health disparities and advances in promoting health equity for all.

However, despite making progress on a state and national level with inclusive policies, this June we have been reminded that there are still many challenges to overcome. In many places young people are still distanced from their families because of their sexual orientation and gender identity. For many sexual and gender minorities in the U.S. it is still difficult to be out to family, friends, and co-workers. A survey of U.S. adults found that more than 75% of lesbian, gay, or bisexual respondents reported experiencing discrimination in their lifetime. Experiences of discrimination and unfair treatment have been linked to poor health outcomes among older adults who identify as lesbian, gay, bisexual, and transgender (LGBT). These stressors and impacts are amplified when individuals identify with multiple marginalized groups (e.g., sexual, gender, and/or racial minority). That said, studies have shown that LGBT individuals who have good social support have higher self-esteem, a more positive group identity, and more positive mental health.

Although we commonly speak about the LGBT community as a single population it is important to remember that it is actually made up of many diverse individuals from many unique backgrounds and just about as many different ways of identifying themselves. At CMS it is especially important to remember that racial and ethnic minorities, people with disabilities, and older adults may also be sexual and gender minorities.

The CMS Office of Minority Health strives to increase understanding and awareness of disparities, create and share solutions to address those disparities, and implement effective actions to achieve health equity. To that end, we are developing a web-based training to aid providers in the collection of sexual orientation and gender identity (SOGI) data. We are working on a new best practices tool box for providing culturally and linguistically appropriate services (CLAS) with an emphasis on sexual and gender minorities and people with disabilities.

What can you do? Get informed. Learn more about health disparities for sexual minorities age 65 and older in CMS’ June data brief. Find out about the Office for Civil Rights’ rule highlighting your right to be free from discrimination in health careimplementing regulations under on the basis of sex, including sex stereotyping and gender identity. You can also learn more about LGBT health and well-being by looking at the work of our sister agencies within HHS. Think about how you can contribute to bringing health equity to your work. We encourage you to join us on the path to health equity by using the resources discussed in this blog, bookmarking the CMS OMH website, joining our listserv, and of course building on your own health equity activities!

Pursuing Health Equity for the Nation

By: Cara V. James, Ph.D., Director of the Office of Minority Health at the Centers for Medicare & Medicaid Services
Romana Hasnain-Wynia, M.S., Ph.D., Program Director for Addressing Disparities at the Patient-Centered Outcomes Research Institute (PCORI)  

‘Accelerating Health Equity for the Nation’ is this year’s theme for National Minority Health Month, which we mark every April as a time to focus on efforts to help all Americans achieve the highest level of health they can. Health equity is a challenging goal given how many factors contribute to optimal health, but it is a goal we can never stop striving to attain. There are numerous barriers minorities and other underserved populations face in accessing the health care and those barriers often lead to disparities in health and healthcare outcomes. The Centers for Medicare & Medicaid Services Office of Minority Health and the Patient-Centered Outcomes Research Institute (PCORI) are two of the organizations established by the ACA working to address these barriers and accelerate progress toward health equity.

The CMS Office of Minority Health is dedicated to increasing understanding and awareness of health disparities among CMS beneficiaries and ensuring that the voices and needs of minority and underserved populations are included in developing, implementing, and evaluating CMS programs and policies. It does this through its “USA” framework, which has three interconnected elements that together will help lead to health equity —increasing Understanding and awareness of disparities among its beneficiaries; creating and sharing Solutions; and accelerating the implementation of effective Actions. Key activities include strengthening CMS data and using it to create initiatives that organizations can use to reduce disparities, through such specific efforts as the CMS Equity Plan to Improve Quality in Medicare, the Mapping Medicare Disparities Tool, and From Coverage to Care.

PCORI’s mandate is to improve the quality and relevance of evidence available to help a range of healthcare stakeholders—including patients, caregivers, clinicians, employers, insurers, and policy makers—make better-informed health decisions. It does this by funding research that compares two or more approaches to care to determine what works best, for whom, under which circumstances, based on the outcomes most important to patients.

PCORI’s authorizing legislation directs it to pay particular attention to health disparities and to include members of minority groups in research whenever possible. That’s one reason why Addressing Disparities is one of PCORI’s five National Priorities for Research, which govern how PCORI awards its research dollars. The Addressing Disparities program now includes a substantial portfolio of studies designed to determine how to reduce barriers to effective preventive, diagnostic, or therapeutic care, taking into account individual and group preferences, to achieve the best outcomes in each population.

Seeking New Approaches

Both the CMS Office of Minority Health and PCORI also are concerned with strengthening the healthcare workforce to better serve vulnerable and underserved patient populations. This includes initiatives focusing on how to better make use of lay members of healthcare teams—who are known, for example, as community health workers, patient navigators, and promotores de salud—as links between patients, communities, and the healthcare system.

CMS Office of Minority Health is working on how to support, engage, and empower these professionals, while PCORI has funded more than 50 projects that are comparing health outcomes and other aspects of programs that do and don’t include lay members of healthcare teams. One large study involving 30 primary care clinics and almost 1,900 patients compares the effectiveness of a clinic-based standard of care to a collaborative approach that includes community health workers. It asks whether the collaborative approach improves hypertension control for racial and ethnic minorities and other groups that experience disparities in this condition. 

Delivering Health Information and Services via Telecommunications

Telehealth is another area that both CMS and PCORI are exploring as a means to reduce disparities.

PCORI is currently funding 26 projects on telehealth, many of which focus on underserved populations. One of these studies compares the effectiveness of a telehealth self-management approach versus traditional in-person care for African-American and Hispanic/Latino patients with chronic heart failure. In the telehealth intervention, a care provider contacts the patient weekly via a video call. The study will measure emergency room use, quality of life, and other outcomes. Another CMS initiative is looking for ways to expand the use of telehealth in rural areas, where health care tends to be less available than elsewhere.

Reducing Disparities in Chronic Disease Treatment and Outcomes

Both the CMS Office of Minority Health and PCORI have a commitment to reducing disparities in the treatment of a range of illnesses. Among these is asthma, which is more prevalent and severe among African Americans and Hispanics/Latinos than among whites, as are a range of disparities in health outcomes.

At PCORI, there are more than a dozen projects addressing racial and ethnic disparities in asthma treatment outcomes. These include eight studies that compare ways to increase patient and clinician adherence to the National Asthma Education and Prevention Program guidelines. Project teams include patients, clinicians, insurers, health systems, community clinics and practices, public health departments, and patient and caregiver advocacy organizations.

Accelerating Health Equity

The CMS Office of Minority Health and PCORI are just two of many organizations working to move our nation further along the path to health equity.  However, to achieve that goal, we need more individuals, organizations, and communities to join the effort. We look forward to working with you to make health equity a reality.

The Next Step – Making the Most of Your Coverage

By: Cara V. James, Ph.D., Director of the Office of Minority Health at the Centers for Medicare and Medicaid Services

Millions of Americans are gaining health coverage every year. Between 2013 and 2014, African Americans and Latinos saw the largest declines in uninsured rates[1]. During the 2016 open enrollment period, over 2.2 million individuals of color selected plans through the Marketplace[2]. Getting coverage is a big accomplishment, but it is just the first step. Regardless of your race or ethnicity, taking advantage of your coverage so you and your family stay healthy is an equally important step.

You may be getting coverage for the first time, or you may have coverage but do not use it very often. Regardless of how long you have had health coverage or where your coverage comes from (e.g., your employer, the Marketplace, or other sources of coverage), you may have a lot of questions on how you and your family can best use it to get the care you need. In 2014, the Centers for Medicare & Medicaid Services (CMS) launched, From Coverage to Care (C2C) to help individuals do just that – move from getting coverage to receiving the care they need. C2C is an ongoing initiative designed to help individuals achieve better health and navigate their way through the health care system.

C2C includes a number of resources such as the Roadmap to Better Care and a Healthier You and the newly released 5 Ways to Make the Most of Your Health Coverage, is designed to help you figure out what you can do to put your health first for a long and healthy life. One of the first ways is to confirm your coverage. Make sure your enrollment is complete and that you have paid your premium if you have one. This way you can use your health coverage when you need it.

The next step is to know is where to go for answers if you have questions about your enrollment and coverage. If you have questions about your enrollment status or premium, contact your health plan. Your health plan will also be able to tell you what services are covered and what your costs are likely to be. The Roadmap can help explain key health insurance terms, like “coinsurance”,” and “deductible”. The Roadmap also provides information on establishing and maintaining a healthy lifestyle, finding a provider, and helping patients engage in their health care. The Roadmap is available for download in eight languages, a tribal version, and in video format on the C2C website.

It’s important to remember that health insurance isn’t just for when you are sick. You can use your coverage to get recommended health screenings and preventive services which can help you stay healthy. You can find out which screenings may be right for you by visiting, MyHealthfinder.gov. Seeing your healthcare provider also provides an opportunity to ask questions about what you can do to stay healthy. When choosing a provider and making an appointment, it is important to pick someone who is in your network, if your plan has one. If the provider you select is out-of-network, the visit may end up costing more. If illness does take you to the doctor’s office, be sure to fill any prescriptions that the doctor may prescribe. Some drugs cost more than others, so if you are concerned about potential costs, ask in advance how much the prescription is and if there are more affordable options.

Insurance can be confusing, but there is help. Check out all of the From Coverage to Care resources and find out what you need to do to make the most of your coverage so you can live a long and healthy life.

 

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[1] Office of the Assistant Secretary for Planning and Evaluation (2015). ASPE Data Point: Health Insurance Coverage and the Affordable Care Act. Retrieved from: https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-september-2015

[2] Office of the Assistant Secretary for Planning and Evaluation (2016). ASPE Issue Brief: Health Insurance Marketplaces 2016 Open Enrollment Period: Final Enrollment Report. Retrieved from:

https://aspe.hhs.gov/sites/default/files/pdf/187866/Finalenrollment2016.pdf

Mapping Medicare Disparities

By: Cara V. James, Ph.D., Director of the Office of Minority Health at the Centers for Medicare and Medicaid Services

In 2014, two-thirds of Medicare beneficiaries had multiple chronic conditions and accounted for 94 percent of Medicare spending.1 Racial and ethnic minorities experience disproportionately higher rates of disease, inferior quality of care, and reduced access to care as compared to their white counterparts.2 Understanding disparities and their geographic variations is important to inform policy decisions and to identify populations and localities to target for interventions.

As health care delivery system reform continues, the Centers for Medicare and Medicaid Services (CMS) has an important opportunity and a critical role to play in promoting health equity.  In September 2015, the CMS Office of Minority Health (OMH) released the first CMS Equity Plan for Improving Quality in Medicare. In March 2016, CMS OMH launched a newly developed interactive tool to increase understanding of geographic disparities in chronic disease among Medicare beneficiaries.  The Mapping Medicare Disparities (MMD) Tool presents health-related measures from Medicare claims by sex, age, dual eligibility for Medicare and Medicaid, race and ethnicity, and state and county. It provides users with a quick and easy way to identify areas with large numbers of vulnerable populations to target interventions that address racial and ethnic disparities. The MMD Tool is expected to help government agencies, policymakers, researchers, community-based organizations, health providers, quality improvement organizations, and the general public analyze chronic disease disparities, identifying how a region or population may differ from the state or national average.

Mapping Tool Map

Please, take a moment to explore the MMD Tool.  Investigate what health care disparities look like in your county or state, then pick a priority and develop a plan that could be used to help provide better care for every individual in the United States.

  1. Centers for Medicare & Medicaid Services (CMS). Chronic Conditions among Medicare Beneficiaries, Chartbook, 2014 edition. Baltimore, MD: CMS, 2014.
  2. Agency for Healthcare Research and Quality (AHRQ), 2014 National Healthcare Quality and Disparities Report, Publication No. 15-0007. Rockville, MD: AHRQ, May 2015.

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