CMS Strong Start for Mothers and Newborns Strategy II Initiative Second Annual Evaluation Report

By Patrick Conway, M.D., CMS Principal Deputy Administrator and Chief Medical Officer

Today, we at the Centers for Medicare & Medicaid Services (CMS) are pleased to announce findings from the second annual evaluation report for the Strong Start for Mothers and Newborns Strategy II Initiative. As noted with the release of our first annual report, Strong Start Strategy II seeks to build on work conducted by the Partnership for Patients and Strong Start Strategy I to improve newborn health through a reduction in early elective deliveries. Babies are generally healthier and have better long-range outcomes when they are born full-term.  Strategy I contributed to a 64.5% nationwide drop in early elective deliveries from 2010 to 2013.

The Strong Start II (hereafter referred to as Strong Start) builds on this success through prenatal care enhancements addressing the psychosocial needs of pregnant women eligible for Medicaid and CHIP.  Strong Start is an important federal initiative geared toward testing innovative approaches to improve maternal and infant health outcomes in low-income families.

Research consistently shows that infants born preterm (before 37 completed weeks of gestation) have higher mortality risks and may endure a lifetime of developmental and health problems when compared to their counterparts born after 37 weeks’ gestation.

Prenatal care enhancements provided through Strong Start are designed to promote overall maternal and infant health and particularly to reduce incidence of preterm birth and low birth weight.  The second annual report presents the progress Strategy II has made since its inception.

Strong Start has continued its partnership with 27 organizations representing nearly 200 provider sites in 32 states, Washington, D.C., and Puerto Rico.  The program continues to provide enhanced services through three approaches:

  • Group Care – Group prenatal care that incorporates peer-to-peer support in a facilitated setting for three components: health assessment, education, and support.
  • Birth Centers – Comprehensive prenatal care facilitated by midwives and teams of health professionals, including peer counselors and doulas.
  • Maternity Care Homes – Enhanced prenatal care at traditional prenatal sites with enhanced continuity of care and expanded access to care coordination, education, and other services.

Enrollment increased dramatically in the second year of program operations, with a total of 23,000 women enrolled from March 2013 to the end of the first calendar quarter of 2015. Enrollment is expected to continue to grow to more than 40,000 participants by the program’s end in February 2017.  Additionally, participants continue to express overwhelming satisfaction, with 90% stating that they were either very satisfied or extremely satisfied with their prenatal care.

In addition to their standard schedule of prenatal care visits, Strong Start participants receive enhanced care visits in accordance with their psychosocial needs.  Enhanced visits provide services such as care coordination, referrals to local resources, prenatal health education, and peer support.

Upon enrollment, Strong Start participants have several risk factors, including many pertaining to psychosocial needs:

  • Depression upon enrollment (nearly a quarter of participants report being depressed at intake)
  • Unstable housing
  • Unemployment
  • Unmet mental health and dental needs
  • Food insecurity
  • Unmarried or unpartnered status

Results from the second year evaluation indicate that, as was found in the first year, Strong Start participants have:

  • Lower rates of cesarean section than national averages, though there is wide variation among and within models
  • Higher rates of breastfeeding than national averages among similar populations

In addition, the new report finds that Strong Start participants have:

  • Overall preterm birth rates similar to national averages despite the high-risk population served
  • Lower preterm birth rates than national averages within racial-ethnic groups (Black , White, Hispanic)
  • Vaginal birth after cesarean rates that are nearly twice the national average

Although findings must be interpreted with caution because they are descriptive, we are pleased with what we have found thus far. Substantial progress was made during the second evaluation year in developing resources, particularly obtaining state Medicaid claims linked to vital records, which will enable development of a control group and an analysis of costs.  The third annual report is anticipated to contain analysis of further participant-level data, case studies based on site visits, and an initial analysis of linked data from states.

Much work remains to be done to reduce significant risks and complications for pregnant women and infants, but these early results from the Strong Start evaluation show promise for improving pregnancy outcomes.  We remain committed to working together to deliver higher quality care, smarter spending, and better health outcomes for low-income pregnant women and their newborns.

Keeping Consumers Covered

By Health Insurance Marketplace CEO Kevin Counihan

The latest open enrollment period exceeded our expectations, with more than 12.7 million people signing up for coverage or automatically renewing their plans for 2016. To me, this success is confirmation that the Health Insurance Marketplace is providing a needed service to connect people to quality, affordable health care coverage. This year’s progress is also confirmation of the hard work that went into improving the consumer experience on to help people shop for the coverage that is right for them and their families.

Consumers are more engaged, savvier and better informed. New customers came in earlier, allowing them to have a full year of coverage, and 70 percent of returning customers actively selected a plan. And because of operational improvements, we have more precise enrollment data, so the 12.7 million already takes into account a larger share of cancellations that took place during Open Enrollment.

These are all good signs for consumers retaining coverage for the year to come. And now that Open Enrollment is over, we are focusing even more of our energy on helping consumers stay covered.

There are many reasons consumers choose to leave the Marketplace – perhaps the most common is that the consumer finds a new source of coverage outside of the Marketplace, including getting a job with employer coverage or becoming eligible for programs like Medicare and Medicaid. What we don’t want is for eligible consumers to lose their coverage because they have trouble navigating our processes. Below are some of the things we’re doing to make sure that consumers who are eligible for and need coverage throughout the year are able to stay covered.

Consumer Payment Experience

Some consumers who are just entering the Marketplace don’t pay their first bill. In some cases, a consumer changes their mind or has had a life change and no longer needs Marketplace coverage. But in others, it’s because they have trouble navigating the payment process, aren’t clear on when their payment is due, or simply forget to pay before it’s too late. If a consumer doesn’t pay their first bill, or what’s called their binder payment, their coverage is terminated by their insurance company.

We’re working to improve the consumer payment experience this year in a couple of different ways:

  • We’ve made improvements to our Marketplace outreach, reminding consumers to make their first payment. We’re sending consumers additional reminders, sending them earlier in the process and providing clearer guidance on when their payment is due.
  • We’re also working closely with insurance companies to reinstate consumers who had trouble during the payment process.

Data Matching

Another reason consumers may lose their coverage is if we don’t receive the information we need to confirm their eligibility. The law specifies that when we can’t verify key information like a Social Security number or income immediately through automatic checks against other Federal data, consumers can enroll in coverage for 90 or 95 days while we work with them to verify their eligibility. But after that, their coverage is cancelled or their financial assistance is adjusted or ended.

The fact that we cannot immediately confirm eligibility does not mean an individual is ineligible for coverage or financial help. It just means that the information a consumer provided can’t be instantly validated by our data sources. Reasons this occurs can be as simple as a Social Security number typo or a government database that has first and last names switched. For many consumers, the issue is a change in employment or wages since they filed their last tax return. That’s why the law gives consumers time to provide more information, and that’s why the majority of “data-matching” issues are resolved because consumers successfully submitted documentation that substantiates what they told us on the application. Nonetheless, in 2015, coverage was terminated or APTCs were adjusted due to data matching issues for about 1.7 million consumers.

As with other Marketplace rules, CMS is committed to both making sure the process works better and limiting access to coverage and financial assistance to those individuals who are indeed eligible. We’ve already made significant improvements that we believe will help to reduce the share of consumers who lose coverage or financial assistance due to data matching issues this year.

To help consumers avoid data matching issues during the enrollment process:

  • We’ve made improvements to the online application that makes it clearer when a data matching issue is created and we encourage people to provide key information if they failed to do so initially, such as providing a Social Security number or an immigration document number to resolve the issue in real time.
  • We added functionality that helps make sure consumers do not generate a new data matching issue if they have previously resolved that issue with the Marketplace. This keeps consumers from having to summit the same documentation year after year.
  • Going forward, the 2017 payment notice allows CMS to establish more appropriate income verification thresholds next year for consumers.

And, to help consumers resolve data matching issues once they’ve been generated:

  • As a result of working with advocates and assisters, we have made improvements to our notice language to more clearly explain what documents a consumer should submit to resolve data matching issues. And we are developing a new resource guide designed to both prevent income data matching issues and improve resolution of generated income data matching issues.
  • Going forward, the FY 2017 budget proposes funding that would give CMS the ability to improve our outreach, including to consumers with data matching issues. The CMS team reaches out to consumers as many as 14 times to make sure consumers know what information they need to provide.

Because of these improvements, we’re starting to see promising signs, including a noticeable reduction in the rate of data matching issues, and consumers responding to our outreach efforts earlier and in larger numbers. While we won’t have final numbers for a couple of months, we are strongly encouraged by the progress we have made and hopeful that our progress will help consumers who need and are eligible for coverage stay covered all year.

Bridging the Healthcare Digital Divide: Improving Connectivity Among Medicaid Providers

Andy Slavitt, Centers for Medicare & Medicaid Services (CMS) Acting Administrator,

Karen DeSalvo, National Coordinator for Health Information Technology (ONC) and Acting Assistant Secretary for Health

The great promise of technology is to bring information to our fingertips, connect us to one another, improve our productivity, and create a platform for the next generation of innovations.. Technology, when widely distributed and available, enables providers to improve patient care by distributing information and best practices and leading to better experiences of care for individuals in the health care system. And technology can make a significant difference in the rapidly modernizing Medicaid program.

Connecting All Parts of the Health System

That’s why today, we are announcing an initiative to bring interoperable technology to a broader universe of health care providers, including long-term care, behavioral health providers, substance abuse treatment centers, and other providers that have been slower to adopt technology. This announcement will help to bridge an information sharing gap in Medicaid by permitting states to request the 90 percent enhanced matching funds from CMS to connect a broader variety of Medicaid providers to a health information exchange than those providers who are eligible for such connections today. This additional funding will enhance the sustainability of health information exchanges and lead to increased connectivity among Medicaid providers.

Doctors and other clinicians need access to the right information at the right time in a manner they can use to make decisions that impact their patient’s health. The free flow of information is hampered when not all doctors, facilities or other practice areas are able to make a complete circuit. Adding long-term care providers, behavioral health providers, and substance abuse treatment providers, for example, to statewide health information exchange systems will enable seamless sharing of a patients’ health information between doctors or other clinicians when it’s needed. This sharing helps create a more complete care team to collaborate on the best treatment plans and goals for Medicaid patients.

Modernizing Medicaid

Today’s announcement is another example of how Medicaid is leading change for its beneficiaries and throughout the health care system. But this is more than a technology initiative. It is part of a comprehensive effort to make sure that the 72 million adults, children, seniors and people with disabilities served by the Medicaid program have access to high quality, coordinated care. Improving population health and addressing the needs of complex populations requires strong health information technology tools.

The benefits are tangible – from care coordination to medication reconciliation to public health reporting. Exchanging care information can support patients with multiple chronic conditions as they navigate specialists, hospitals, primary care, home health care, and pharmacies. Medication reconciliation for children in the foster care system avoids duplicative or missed treatments. And, public health reporting sounds the warning bell on potential public health disasters and improves the use of preventive measures, such as immunizations. This investment should also speed the adoption of alternative payment models that focus on the quality rather than the quantity of care provided. As the Medicaid program moves towards paying for quality, technology infrastructure and information exchange is needed for better care coordination.

CMS and ONC look forward to partnering with and supporting states in these and other critical efforts to modernize and connect the Medicaid program for the millions of beneficiaries they serve.


CMS Acting Administrator Andy Slavitt’s Comments at Healthcare Information and Management Systems Society (HIMSS) During Panel Discussion with Karen DeSalvo, MD, Acting Assistant Secretary for Health

I love working with Karen De Salvo. She can talk in half sentences and I can finish them. We’ve naturally been working together for months on some of the initiatives we’re talking about here, and always check in to compare facts, see if we’re seeing the same thing. We went into these speeches in perfect harmony on what needs to be done.

True story. We exchange drafts and she sends me a note “Andy, I think your speech comes across as very negative. Why don’t you reread with that lens?” I erased the email I’d been writing to her– she’s always too positive for me anyway – and I think I sent her an emoticon of a happy face instead. Now one interpretation is she works with the technology community who by all accounts and from looking around the floor are generally happy. I hear more from docs trying to use technology and that may affect my moods a little bit.

We are now seven years in to the concerted launch of a truly national health information technology platform. Always a good time to see how it’s going.  I’ve been to HIMSS with a few different hats on and have been talking fairly publicly about Meaningful Use and about moving technology to a place where it becomes a more flexible tool to support physicians so they can improve patient care.  I’m certainly not bashful about what we need to do better and I’m not going to be bashful, even in the face of some very good reasons for optimism, to point to where we all need to take our game up.

We’ve all made a great start but we’re still at a stage where technology often hurts, instead of helping, physicians provide better patient care. And we are committed to taking a page out of consumer technology playbook and taking a user-centered approach to designing policy.  I’m asking you to redouble your efforts to do the same.

The Consumer

Understanding what we want from technology means first understanding how we provide and receive care today in America where the consumer is more diverse, more mobile and more demanding than ever before.  The consumers CMS serves are a good representation of all of our care needs– 140 million Americans– most on fixed or low incomes– in every type of care situation–

  • The Medicare patient leaving the hospital with five prescriptions to fill and 2 appointments to book;
  • The marketplace customer who will have coverage for the first time and finally be able to have his wife’s chronic fatigue looked at;
  • The daughter who has made the difficult decision to move her father in a nursing home and wants to know staffing ratios and quality ratings;
  • The family with a child with disabilities on Medicaid that requires 24 hour care and is watching every dollar and interviewing every home care worker.

Because of the way people get care today– on the go, on their own terms, often not anchored in the system – their information needs are ever more vital and yet so basic. Am I recognized when I show up? Are my needs, preferences, and history available?

And today’s technology at its best is ideally suited to meet these needs – the cloud, social media, one-click purchases, information at our fingertips, everything wired, convenient devices, expert systems, intelligent agents. We know what we need to do and the technology is available.


Let me talk about the user-centered policy design approaches we’ve been using to implement the new bipartisan MACRA legislation – legislation intended to bring value-based care to the everyday physician practice. We have created a new playbook at CMS by making our most concerted effort ever at listening to front-line physician and patient input upfront.

After first collecting feedback from across the health care sector, we launched our work with a four day session with physicians and technology companies and sought more comment through a public Request for Information (RFI). But the bulk of our work has been directly with front line physicians. We have completed 8 focus groups with front line physicians in 4 separate markets and have many more coming. And I’ve been on the road meeting with a number of physicians in their offices to see how they interact with technology directly. Our questions have been simple? What needs to work better with so the technology in your office can support you in delivering better patient care?

Let me show you a few of the more representative things we are hearing.

“It does put too much of a burden on us and it does take away our time from caring for patients.  It seems like most of what I’m doing during the daytime is entering data into the electronic record.” (Primary Care Provider, Atlanta)

 “…nobody’s EMR talks to someone else’s EMR.  And that’s the big mess that people put out there.  Like if you’re going to find out someone’s information, it’s going to be snail mail or somebody’s going to fax it or you have to walk over and get it.” (Primary Care Provider, Atlanta)

 “I think that the one thing that this really could’ve added to patient care is the one thing that hasn’t happened, and that’s the systems don’t talk to each other.  It’s actually the opposite.  If one of the EMRs I used, I can’t even access it at the hospital because of the firewall.  I can’t even get into the EMR at the hospital to look at patient records.” (Health Care Specialist, Chicago)

 “To order aspirin takes eight clicks on the computer.  To order full-strength aspirin, 16. . .That’s not patient care.  It’s clicks.” (Primary Care Provider, Atlanta)

 “The problem I have is I can see less patients in a day based on all of the stuff I have to do with a computer and that’s really killing me.  ” (Primary Care Provider, Los Angeles)

“There’s too much information, finding information in an EMR is difficult.  …  It’s just too much.  A certain level is good, but they’re going beyond that.  These aren’t the greatest on things all that, we just click and click and click.  It’s very hard to, it’s a very busy screen on the EMR now.  There’s a lot of other information that you don’t need now, you just have to click, click, click, and it’s too much.” (Primary Care Provider, Atlanta)

I have hundreds of these if you’re interested.

Three themes have emerged that have shaped the agenda you are hearing from Secretary Burwell, Karen and me.

  1. First is that physicians are hampered and frustrated by the lack of interoperability. It’s more practical than that. I don’t think anybody but us policy people actually use the word interoperability– it’s usually– I can’t track my patient’s referral, I don’t know what happens when they’re in the hospital.
  2. Second, regulations in their current form slow them down, create documentation burden and often distract them from patient care.
  3. And third, they find their EHR technology hard to use and cumbersome. It slows them down, doesn’t speed their path to answers.

So, let me summarize our agenda within these three themes before Karen and I take some questions.

The first area we are addressing is the documentation overhead associated with the Meaningful Use program. Since we are a few months away from having details available with the proposed MACRA rule that we will be open for public comment, let me share our approach.

Job One has been to try to close the gulf between our public policy work and what’s happening in the reality of patient care.

Second, what we are we hearing from all of our sessions with physicians? Stop measuring clicks, focus instead on allowing technology to become a tool and focus on the results technology can create. Give us more flexibility to suit our practice needs and ultimately more control.

Third, where possible, we favor “pull” vs. “push” incentives. What I mean by this is to let outcomes rather than activities drive the agenda. We can take advantage of how the landscape has changed over the last five years with the proliferation of programs that depend on care coordination and population health.

Roughly 25 million Medicare patients are now in Medicare Advantage or an ACO; April 1st, close to half of the hip and knee replacements in the country will come together in an impatient-outpatient full bundle. Medicare, Medicaid and commercial health plans are fast approaching a tipping point when more than half of all payments will be tied to improved care and cost outcomes.

Interoperability is the second area. It is an essential ingredient not only for better patient care, but as the President said last week, to the precision medicine that will unlock an entirely new future of better health.

As you know, yesterday Secretary Burwell announced that companies representing 90 percent of EHRs are committing to three vital steps to real interoperability that Karen just talked about. I thank the many who have made this commitment. It has the potential to set us on a new course, but we all need to be more committed than ever to making sure that the substance of this pledge translates to reality.

Why is a pledge important? There has to be a private sector commitment to the greater good. Regulations, like those requiring open APIs can help, but frankly there are just too many ways to step in the way of true interoperability that no regulation can anticipate – legal clauses, commercial impediments, documentation access, IP, “security” concerns, hidden documentation. The companies who live up to their commitments will be recognized. And I strongly encourage you to recognize those that don’t.

I’m also excited that on the interoperability front, today we are announcing funding to connect many of the remaining parts of the system that are not part of the EHR incentive program but serve our neediest Medicaid patients every day – long-term care, behavioral health and substance abuse providers.

But we can’t forget that interoperability is a means to an end. Ultimately it needs to open up a path to give physicians and patients what they want from their technology, so called bottom-up interoperability. We need to focus on the use cases that matter and have agreed that we will help facilitate building around two that have physicians have identified: closing the referral loop and patient engagement.

That leads directly to the third component to getting out of the EHR doldrums – to give the physician better tools that help them with patient care. It’s not only Meaningful Use that concerns physicians, they want better technology. With interoperability and open APIs, it’s time to finally create the improved workflows and the apps that physicians are looking for.

Shifting from MU-oriented design to developing certified technology that is user-centered is a big and necessary opportunity. Flexible EHR incentives should give tech companies new products to develop.

The open APIs requirements in the ONC CERT rule will allow new innovators, in addition to traditional EHR vendors, to break the current desktop lock that early EHR decisions created and create analytic applications, plug-ins, and other tools by securely moving data in and out of the EHR. Competition and innovation are a missing ingredient. So what am I most excited about? As Karen mentioned, ONC is launching an App Discovery Site, or what I call the FHIR Cloud, as an EHR-neutral place for new apps that can securely move data in and out of an EHR. We now have an opportunity to make it tangible.

What comes next for us? If all do our work right– and it will take all of us, physicians will at some point be talking about patient support tools, not EHRs or Meaningful Use. I don’t have illusions that anyone is ever going to enjoy being measured and evaluated– those systems are always imperfect, human biology too heterogeneous, government too far away from the judgments needed inpatient care. And frankly I never have and hope never to meet a physician that cares more about an incentive payment than doing what they think is right for their patient. So our policies need to communicate what’s important– improved patient care, better spending, and healthier people– without invading the space of how to get there. A challenging goal, but one made easier by talking about it publicly and listening to input.

It takes all of us to turn this around. We will do our part and for us, it is not a one-time fix or a single regulation that will change things – it is an ongoing process and commitment to closing the gap between on the ground care delivery and policies that promote the tools for better care. Most important for us is to commit to change how we work to listen and improve. Connecting to what happens in daily patient care is vital to our policy-making as we seek a better, smarter healthier system and a better patient outcome.

 We are committed to making real progress that makes a real difference. So let’s get to work.

CMS Acting Administrator Andy Slavitt’s Comments before the Federation of American Hospitals

Welcome to Washington! I could tell you stories… Not long ago I was where you were– in the private sector attending conferences. Now, after a lot of years in health care, I ended up here where I find myself focused on the role CMS can play to be a productive and simplifying force at a time when all of us in health care are going through substantial and dramatic changes. Newly eligible consumers … different payment models … technology advances … more care integration … new requirements. Even change we welcome represents new challenges and the sheer volume of change has driven us all into implementation mode. From the not-so-distant past, I remember how CMS often felt opaque to me and I probably said more than once how helpful it would be to know CMS’s agenda rather than divining them by poring through an often intricate set of regulations so my commitment to you is to talk straight and engage in real dialogue. In my time left at CMS, likely under a year, I’d like to focus our culture on closing the gulf between the transformative policy agenda that happens here and the realities of care delivery in the real world. We can do that only by listening and continually improving what we do. And in the midst of this, I see it as a great time for hospitals to not only advocate for what you want, but strategically plan for the changes we see ahead.

So today, I’ll lay out our 2016 agenda specifically as it relates to our work with the hospital community in three parts.

  • first is how hospitals can participate with us in what I will call the “retailization” of health care;
  • second is how we can advance our care delivery payment initiatives in ways that really advance the ball on care;
  • and third, and perhaps as important as anything, is how CMS can be a better, more responsive partner to you by listening and simplifying.

The agenda starts with our shared priority: understanding how we receive care today in America where the consumer is more diverse, more mobile and more demanding than ever before. The consumers CMS serves represent our country’s needs as a whole– 140 million Americans– most on fixed or low incomes in every type of care situation–

–the Medicare patient leaving the hospital with five prescriptions to fill and 2 appointments to book,

–the marketplace customer who will have coverage for the first time and finally be able to have his wife’s chronic fatigue looked at,

–the daughter who has made the difficult decision to move her mother in a nursing home,

–the Medicaid patient waiting for her kidney transplant and managing to make it to dialysis for most appointments,

–the cancer patient who has decided he wants to be treated at home in more comfort.

–the family with a child with disabilities on Medicaid that requires 24 hour care and is watching every dollar and interviewing every home care worker.

These are the people we serve every day and these are the people I wake up every day thinking about. Since my email address is available to the public, I’ve now learned that many of them wake up every day thinking about me too.

As I read the many emails beneficiaries send me, I see that even in a wide diversity of circumstances, everyone is hoping for the same basic things from the health care system: to get care they can afford, to keep their family well taken care of, to have some understanding of what comes next, and when they’re sick, they want nothing more than to get them home and return them to as productive and healthy life as possible.


Many hospitals have led the tremendous, nationwide effort to enroll people in new Marketplace or Medicaid coverage. And I thank you and congratulate you. Covering over 17 million newly insured Americans over the last few years is as profound a change as most of us have seen in our careers. Health care coverage says a lot about who we are as a country and is not only a more financially sensible way to get people care, but I know I speak for many that it provides a more moral and humane underpinning to how we feel about our industry.

New coverage must only be the start of things. We have the opportunity to change health in America like we did 50 years ago at the dawn of Medicare and Medicaid, back when 1/3 of seniors lived in poverty to a time, now, when less than 10 percebt of seniors live in poverty. When people have insurance, their lives change in profound ways– from being able to access preventive care to being able to afford the prescription drugs for their chronic condition, or no longer worrying about the financial threat that would accompany a cancer diagnosis. And there are of course the economic effects – like reducing uncompensated care and hospital bad debt – which I will come back to in a moment.

But as I thank you, I want to openly discuss the next opportunities in a retail world. We are all used to living in a wholesale world where employers and health plans sit on the other side of the table from you to negotiate for better prices and new types of contracts. But what if we were all of the sudden living in a world where millions and millions of consumers carried that clout as their own agents and could ask for the things that were right for them and their families? In other words, are you ready to respond to a fully retail world?

Do you see this shift? Well, it’s already happening. Consumers on the exchange are every day allowing you to see the most valuable commodity of all– the voice of your customer. Here’s what I mean. Consumers are already now selecting their plans not by looking at the plan first– but first selecting a hospital or physician or prescription they want . . . then looking at which health plan offers them. 3.6 million times this happened in the last 3 months in just the 38 Federal marketplace states. They are shopping for their health care, not their health coverage.  And it’s only a matter of time before the price of the hospital service and the quality score is known to them when making this decision. And even more compelling, 70 percent of renewing consumers on the Federal exchange– seven-zero— came back to the exchange to actually choose a plan at renewal instead of accepting automatic enrollment. These are millions of opportunities for consumers to find you every open enrollment.

What do they want? Consumers are screaming that affordability matters more to them than it does to employers when they act as their agents. 90 percent of people have selected bronze or silver plans. This compares with fifteen percent as the highest anyone has seen in traditional employer markets. And consumers typically want affordability– those who switched plans saved over $500/month. So if consumers want savings, what do they appear to be willing to compromise on? According to a Kaiser Family Foundation report last May, consumers would much prefer a narrower network to a higher deductible or higher premium. This means we all need to be a part of reducing premiums– governments with subsidies, health plans with MLR limits, and you as you respond to their direct feedback.

So one important decision for many hospitals is how to participate and what is the right pricing strategy. One approach is a “just say no” approach and treat exchange consumers like any other managed care negotiation. The other approach is to create a more aggressive “retail strategy.” Part of a retail strategy begins with acknowledging that unlike what most of us assumed– the exchange market developed alongside of, not in place of, the employer market. Many hospitals set their rates as if the Marketplace would be replacement business, not an additional market. Revisiting that assumption I believe gets you to a more marginal pricing approach for Marketplace business befitting the lower-income individuals who are 80 percent plus of the exchange population.

A retail strategy calls on you to imagine you are negotiating directly with a cash paying consumer who used to be a source of bad debt– except one who now has the wherewithal to pay for services and wants to build a relationship where they can also find elective, outpatient and wellness services. A retail strategy offers you the opportunity for innovation to meet the customer need. It may mean taking less and seeing more patients in response to their affordability preferences. It may mean partnering with smaller plans or offering your own exchange plans or other strategies you think of to build your retail business. Ultimately, consumers will reward providers who want their business and have a strategy to get it. Sounds like how retail markets work.

But retail won’t stop there. Consumers will want better service and fairer service, and will likely be less tolerant of things that don’t work well for them. When the auto mechanic tells you that your $3000 estimate turned out to be $10,000, you probably won’t go back. Hidden charges, for things that happen in the ER or when the anesthesiologist is out of network and has separate charges, won’t be tolerated. The promising news is that leaders always emerge– and I am beginning to have conversations with hospitals and physicians who want to lead the charge so there are no more consumer surprises in their hospitals. Those that make that promise can expect to be rewarded by consumers. The retail world is emerging and with it, there is new opportunity.

2. Delivery system reform

Access is one thing, but unless that access is to a better quality health care system, we are not going to succeed. So let me talk about our agenda for advancing new payment models that reward for quality and value. A year ago, we committed that by 2018 we will reach a point where over 50 percent of Medicare FFS payments will be in new models like ACO. Many CEOs and CFOs tell me that the “tipping point signal” is helpful. Living in a fee-for-service world today while preparing for a payment system that rewards more coordinated, more value-oriented care that is emerging is challenging. This commitment from us should help galvanize your organizations in the right direction. Change often boils down to practical decisions on where to invest and we aim to make the case that the investments you are making in a quality programs and population health will carry a greater return than another expensive MRI machine or a new wing in the hospital.

We see payment models not as an end, but rather as a tool to help you increase communication, coordination and improve patient care. On April 1, we are launching a large scale pilot to connect and coordinate care for patients having joint replacement surgery. We are excited about how many hospitals are redesigning care and focusing on whole patient episodes of care. Already hospitals and surgeons are telling us of new communication and data sharing relationships with post-acute facilities. This speaks not only to better care but also retail health care centered on the patient. We also just announced both the expansion and advancement of new ACO models. There are now over 475 total ACOs with 30,000 participating physicians and 8.9 million beneficiaries around the country. And, 64 representing 1.6 million people, are in 2-sided or full risk models, up from 19 just last year and zero before the Affordable Care Act.

Where do we go from here? We have been bringing a focus on outcomes to every area where a consumer or beneficiary of CMS seeks care– from the physician’s office to the hospital to home health. In 2016, the implementation of the bi-partisan MACRA legislation will touch more and more specialties and create more incentives for to join alternative payment models. One area still largely untouched is pharmaceuticals. How we bring this same thinking on value into the development and prescribing of medications is on the agenda in 2016. We have received a lot of input as we have laid out the need as a country to be able to drive innovation and new cures but also promote access to medication for all patients who need them.

3. Listen to what’s happening on the ground 

The third part of our agenda is about our commitment to improving the lines of communication that allow us to close the gap between policy making and the realities of frontline care delivery.

CMS has significant responsibility for implementing new laws which must intersect with an already complex system with many demands. And so good policy must be ultimately informed by the impact it has at the kitchen table of the American family and in the clinic or office where they seek care.

We have several important initiatives:

–We will focus specifically on policies that impact rural health and have established the Rural Health Council which will have three areas of focus in policy coordination and strategy: access to care issues, the economics of rural health care, and promoting innovation across rural America. The council will host a Rural Health Open Door forum call every six weeks to update you on new CMS policy and initiatives, and at one of our upcoming sessions, the Council will seek input into our very important 2016 agenda.

–We will continue our commitment to iteratively improving the new care delivery models we release. Our newly launched Next Generation ACO model is a good example. It contains the features you have told us would best enable you to coordinate care, including innovative options like telemedicine, home visits, and direct patient incentive and engagement options. We also clearly heard that hospitals want us to fundamentally re-think the benchmarking and rebasing methodologies in our Shared Savings ACO models. We published a proposed rule that reflected a lot of the input we received, and we are now receiving comments.  While these models will never perfectly represent the best way to capture the quality and cost performance of a hospital, they should be the early generation tools that can act as the change management opportunities to move towards more coordinated care in your community.

–To be truly responsive, we must lead a simplification kick to reduce burden and give physicians back more time to spend with patients. Several years ago, we launched an initiative that is reducing regulatory burden and saving hospitals $3.2 billion over five years on burden and regulatory reduction. But we are barely scratching the surface. The work we’ve done recently over the 2 Midnight policy reflects the result of receiving significant feedback and is intended to create more discretion for care providers and move the RAC program from a “gotcha” feeling to a more educational and partner-oriented approach using QIOs. We will watch the results from these changes closely in hopes that we can demonstrate that collaboration will lead to better results without driving up inappropriate costs.

–On the technology front, tonight Secretary Burwell will be speaking at HIMSS about the role of technology in improving care delivery and tomorrow night, I will be joined by Karen Desalvo, of ONC, to talk about how we are working together to push initiatives to promote interoperability, simplify requirements, and usher in a new wave of technology improvements. The implementation of the bi-partisan MACRA regulations in the next several months gives us the first opportunity to focus on the physician office incentives and we will look for opportunities to address these critical areas in the hospital setting as well. We want to move back to a world where doctors can focus on patient outcomes and technology is a helpful tool, not a hindrance. And it will take all of us– government, care providers, and innovators– to get there. Over the next day, we will talk about our approach and principles as we approach the MACRA regulations.


Before I close, I want to thank those of you that are demonstrating your commitment to health equity, especially by treating Medicaid patients and the dually eligible. I recognize the challenge this can add to your system and I want you to know that we have released several proposals both in Medicare and Medicaid intended to focus on improving reimbursement levels for lower socioeconomic status and higher need populations. And we are committed to looking at what more there is we can do. But I know that no matter what we do, that our lowest income and hardest to treat citizens won’t get the same high quality of care that others do without your commitment as part of your role in the medical community to provide high quality care for all patients. I thank you for it and I ask that you know our commitment to health equity will not waver.

I want to close by repeating the theme I hope you’ve heard from me today as I laid out a very candid look at our agenda. Success for us is helping build a better health care system for all Americans, with smarter spending, and resulting in healthier people. We are at early stages of a system where we cover more people and also change how we integrate and work together to provide for a more value-based system. I know this transformation creates challenges as it plays out every day– all progress does. As we move forward, we need to listen and stay close to the realities on the ground and work together with you to create new generations of solutions that work better and are simpler. We thank you for all the constructive engagement and look forward to working with you in the coming months and years.

The New Special Enrollment Confirmation Process

Kevin Counihan, Health Insurance Marketplace CEO and Shantanu Agrawal, M.D., CMS Deputy Administrator and Director, Center for Program Integrity

As the Marketplace continues to grow and mature, we continue to monitor the health of the Marketplace and are looking for ways to make improvements – whether that’s creating new decision support tools to help consumers choose the right plan, strengthening risk adjustment, or clarifying the rules of the road for special enrollment periods, as we did several weeks ago.

Today, we are announcing another step that will enhance program integrity and contribute to a stable rate environment and affordability for consumers: a new Special Enrollment Confirmation Process in the 38 states using the platform. Under the new process, all consumers applying through the most common special enrollment periods will need to submit documentation to verify their eligibly to use an SEP. This represents a major overhaul of the SEP process. You can read more about the Special Enrollment Confirmation Process here:

Special enrollment periods are an important way to make sure that people who lose health insurance during the year or who experience qualifying life changes have the opportunity to enroll in coverage. We are committed to making sure that special enrollment periods are available to those who are eligible for them. But it’s equally important to avoid misuse or abuse of special enrollment periods.

This change in’s special enrollment period process does not restrict anyone’s access to a special enrollment period who is rightfully able to enroll in coverage. But consumers will need to be sure to provide sufficient documentation to establish their eligibility. If an individual doesn’t respond to our notices, they could be found ineligible to enroll in Marketplace coverage and could lose their insurance.

As we begin work to implement the new process, CMS will solicit feedback from consumer advocates, insurers and other stakeholders over the next few weeks on verification requirements, processes and acceptable documentation. We welcome feedback and suggestions, which can be sent to

As we head into the third year of Marketplace coverage, we are pleased with the results of Open Enrollment and confident that the Marketplace will continue to thrive for years ahead. Making sure that the rules around special enrollment periods are clear and enforced is just one step we are taking to help make sure that consumers and insurers will continue to benefit from an attractive, competitive and growing Marketplace.

Lessons Learned: Reflections on CMS and the Successful Implementation of ICD-10

by Acting Administrator Andy Slavitt

It was early 2015 and we had just gotten through a second successful season with, the turnaround that originally brought me into government, when the articles and letters started flying on our next big implementation – one that would affect nearly every physician and hospital in the country. And, anxiety levels were high.

On October 1, 2015, the U.S. health care system transitioned the way patient visits are coded from ICD-9 to the next version ICD-10, a system which sets the stage for meaningful improvements in public health. If people know about ICD-10 at all – and chances are they don’t – it’s probably from press reports about the more colorful diagnostic codes like “other contact with shark” or “burn due to water-skis on fire, subsequent encounter.” More seriously, for people in the health care industry, it was being compared to Y2K, a transition with the potential to create chaos in the health care system.

One representative from the physician community told me that he was concerned that half of physicians in the country wouldn’t be ready by the October 1 date. The thought of physicians in small, rural practices unable to run their practices had my complete attention. It also brought home that we are responsible for more and increasingly complex implementations – from to ICD-10 to new physician payment systems.

As I look to the future, great implementation is even more central to life at CMS.

In my time in D.C., I’ve come to see our role as implementing policies in a way that bring them to the kitchen table of the American family and to the clinics and facilities where they receive care. Implementation in this context is a vital responsibility. And there are millions of Americans that count on us to do it well: the senior filling his prescription; the trustee of the community hospital; the parents of a child with disabilities in need of home resources; the doctor who drives for miles to take care of her patients in several rural communities.

Implementation Success: 4 Lessons

It was clear that CMS had an enormous opportunity – after everything we learned from – to take the lead in smoothly implementing this new policy. The ICD-10 implementation had all the hallmarks of how CMS could drive a successful implementation and aim for excellence. The approach we took, which has become our doctrine for getting things done, had four major elements:

Lesson 1: Be Customer Focused

We believe we must always start from the perspective of the real-world needs of the people who live with the results of our implementation at the center of our work. And in the case of ICD-10, listening and learning about the issues small physician practices were facing helped us understand their resource and technical assistance needs, as well as their concerns over claims payment and cash flow.

In response, we launched “The Road to 10” aimed specifically at smaller physician practices with primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation. CMS also released provider training videos that offered helpful ICD-10 implementation tips and a wealth of other material on Finally, Medicare offered an unprecedented level of external testing with its three periods of voluntary end-to-end testing for physicians and other clinicians.

Lesson 2: Be Highly Collaborative

Because health care is still fragmented, CMS can’t work alone in implementing major changes. If it wasn’t for our close partnerships with the American Medical Association (AMA), the American Hospital Association, the American Health Information Management Association, state medical societies, physicians and other clinicians, billing agencies, equipment suppliers, and a variety of stakeholders, the ICD-10 implementation would not have gone as smoothly as it did. Because we listened to and collaborated with our partners, we were able to address concerns and multiply our ability to get resources to physicians. Several physician groups went from being very concerned about our approach to leading the charge on implementation. As AMA said, “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs.”

Lesson 3: Be Responsive and Accountable

At CMS, we recognize that challenges happen and our efforts must be to anticipate them, make them visible, and be accountable for solving them. In the case of ICD-10, the potential for challenges weren’t only in our own systems, but in the systems of any physician office, hospital, or state Medicaid plan. At the suggestion of physician groups, we named an ICD-10 Ombudsman. Just as importantly, we committed to a three-business-day turnaround for every question or concern that came in from a provider. In the first month of implementation, we received approximately 1,000 inquiries and responded to 100 percent of them within three business days. We will never achieve perfection, but we will be visible and hold ourselves accountable for solving problems.

Lesson 4: Be Driven by Metrics

It’s not glamorous, but daily spreadsheets and scorecards keep complex implementations on track. Once we hit October 1, there were critical metrics to track. If doctors were sending us fewer claims, more claims than usual were denied, or a particular state was having trouble processing Medicaid claims, we needed to know as soon as possible.

Rather than waiting for the phone to ring, the CMS team created a scorecard and heat map to locate and track issues as they occurred. We launched an ICD-10 Coordination Center to handle any issues as they arose. A few days after ICD-10 launched, I received a call from a large physician organization representative asking me how things were going. I pulled out a version of the table below and read him the data. “This really is a new CMS,” he told me.

Final 2015 ICD-10 Claims Dashboard Medicare Fee-for-Service Metrics

Metrics Historical Baseline Q4 CY 2015
Total Claims Submitted 4.6 Million per day 4.6 Million per day
Total Claims Rejected 2% of total claims submitted 1.9%
Total ICD-10 Claims Rejected 0.17% of total claims submitted 0.07%
Total ICD-9 Claims Rejected 0.17% of total claims submitted 0.07%
Total Claims Denied 10% of total claims processed 9.9%


*NOTE: Metrics for total ICD-9 and ICD-10 claims rejections were estimated based on end-to-end testing conducted in 2015 since CMS has not historically collected this data. Other metrics are based on historical claims submissions.

Moving Forward

For thousands of physicians and other clinicians around the country, the change to ICD-10 was a big undertaking, requiring time, planning, and a period of adjustment. But on October 1, proper execution and good implementation made all the difference. On the big day, the ICD-10 Coordination Center was packed, and the CMS teams and our partners were geared up and ready to make sure that any burden on physicians could be minimized and concerns quickly addressed.

The ICD-10 Coordination Center

blog ICD

With preparation, planning, a focus on the customer, collaboration, clear accountability, and metrics, the dire Y2K fears didn’t come to pass. Instead, ICD-10 became like what actually occurred on Y2K, an implementation and transition most people never heard about.

With good implementations, we never declare victory and are still at the ready to continually improve. For those who still need help, CMS continues to provide technical support and respond to inquiries. For more information, visit

The magnitude of CMS’s big, complex implementations have accelerated in recent years. And over the next several years, we will be a part of implementing big and important changes that spend our health care dollars more wisely and keep people healthier – from how we pay for care to collecting and publishing data on how care is paid for to building consumer websites evaluating nursing homes to protecting beneficiary privacy and security. Because these changes impact consumers and physicians and other clinicians’ daily lives, CMS is responsible to the American people to make health care work better for the consumer and better on the front lines of health care.


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