A Healthier Medicare: Focusing on Primary Care, Mental Health, and Diabetes Prevention

A Healthier Medicare: Focusing on Primary Care, Mental Health, and Diabetes Prevention

By Andy Slavitt, CMS Acting Administrator (@aslavitt) and
Patrick Conway, MD, MSc, CMS Acting Principal Deputy Administrator and Chief Medical Officer

We’ve discussed a number of times how our country’s health care system historically invested far more in treating sickness than maintaining health. This imbalance contributes to more spending on institutions, hospitals, and nursing homes, rather than keeping people healthy at home and in their communities.

By better valuing primary care, care coordination and prevention, we help people access the services they need to stay well. In addition to keeping people healthy, health care costs are often lower when people have a primary care provider and team of doctors and clinicians overseeing and coordinating their care. And efforts to reduce documentation burden in care management and coordination, tied in with our strategy of physician and clinician engagement, helps keep the focus on patient care that pays for what works and better supports and engages the medical community.

That’s why Medicare and Medicaid, with invaluable support from the CMS Innovation Center, have implemented policies to sharpen their focuses on individuals and their care. Continuing that work, today, Medicare is finalizing policies that improve how it pays for primary care, care coordination, and mental health care, and expanding an exciting CMS Innovation Center payment and service delivery model that aims to prevent diabetes.

Preventing Diabetes & Protecting the Medicare Trust Fund

About 26 percent of people 65 years or older, more than 11 million people, have diabetes. They face higher risks of debilitating complications like heart disease, kidney failure, limb amputations, and blindness. And the treatment of people with diabetes is expensive. It costs Medicare more to support care for those with diabetes than those without diabetes. In total, we estimate that Medicare will spend $42 billion more in the single year of 2016 on fee-for-service, non-dual eligible, over age 65 beneficiaries with diabetes than it would spend if those beneficiaries did not have diabetes — $20 billion more for Part A, $17 billion more for Part B, and $5 billion more for Part D.

On a per-beneficiary basis, this disparity is just as clear. In 2016 alone, Medicare will spend an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services, and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes. That’s approximately $7,300 or 86 percent more per beneficiary, per year for someone with diabetes. This increased spending reflects only Medicare’s share of costs; diabetic beneficiaries likely experience higher out-of-pocket spending as well. Taking care of people with diabetes is important, which is why Medicare provides quality services and support to those with diabetes.

This chart compares estimated 2016 Medicare spending per beneficiary between beneficiaries with diabetes and beneficiaries without diabetes. In 2016 alone, Medicare will spend an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services, and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes.

But what if we could slow – or even reduce – the number of people developing diabetes in the first place? What if by focusing on primary care and prevention, we could help people live healthier lives while reducing the costs to the health system and beneficiaries.

The Diabetes Prevention Program model test set out to test this idea. Participants at high risk for developing diabetes were provided strategies to increase their physical activity, control their weight, and decrease their risk of type 2 diabetes. This model led to approximately 5 percent reduction in weight and saved Medicare an estimated $2,650 for each person enrolled in the Diabetes Prevention Program model test over a 15-month period, more than enough to cover the cost of the program.

The Medicare Diabetes Prevention Program (MDPP) expanded model, set to begin in 2018, hopes to make these services available to all eligible Medicare beneficiaries, improving their health and that of the Medicare program both now and in the future. We know that fewer people with diabetes saves patients and Medicare money because they use fewer expensive prescription drugs and have fewer hospital visits. And most importantly, by preventing diabetes, patients and families across the country can avoid suffering from a debilitating disease. That’s why we are expanding the model to make MDPP services available to all eligible Medicare beneficiaries.

The Medicare Diabetes Prevention Program expanded model is the latest successful effort at the Innovation Center to inform the evolution of the Medicare program over time. Other Innovation Center models have tested new ways for doctors and hospitals to work together to support and coordinate care for their patients and better patient safety. Models are eligible for expansion under Section 1115A(c) of the Social Security Act if they meet the following criteria: First, the Secretary of the Department of Health and Human Services determines that such expansion is expected to improve quality of patient care without increasing spending or reduce spending without reducing quality of patient care. Second, the independent CMS Chief Actuary must certify that the expanded model would reduce or not result in any increase in net program spending. Third, the HHS Secretary determines that such expansion will not deny or limit the coverage or provision of benefits Medicare beneficiaries receive. The Medicare Diabetes Prevention Program expanded model meets these criteria.

Refocusing Medicare on Primary Care and Behavioral Health

Also, today, Medicare announced an important set of changes that would improve how Medicare pays for primary care, care coordination, and mental health care. These changes will result in an estimated $140 million in additional funding in 2017 to physicians and practitioners providing these services. Over time, if the clinicians qualified to provide these services were to fully provide these services to all eligible beneficiaries, the increase could be as much as $4 billion or more in additional support for care coordination and patient-centered care.

Clinicians will additionally be able to bill and be paid more appropriately when they spend more time with their patients, serving their patients’ needs outside of the office visit, and better coordinating care. These changes are designed to improve health outcomes. With today’s final primary care payment policies, Medicare continues to move toward a health care system that encourages teams of clinicians to work together and collaborate in order to provide more personalized care for their patients.

Geriatricians, internists, and family physicians provide core services for the Medicare program, including the kinds of care management and patient-centered care that are described by these new codes. Over time, we estimate that the payment increases attributable to these new codes could be as much as 30 and 37 percent respectively to these specialties.

We are also finalizing new coding and payment for care using the Psychiatric Collaborative Care Model that supports mental and behavioral health through a team-based, coordinated approach involving a psychiatric consultant, a behavioral health care manager, and the primary care clinician and which extends beyond the scope of an office visit. This care model has been shown to improve behavioral health outcomes for patients and save money.  Payment for care using this model will help address one of the health system’s major challenges — access for behavioral and mental health care.  For anyone who has struggled to gain access to behavioral health care for themselves or a loved one, the importance of these services cannot be overestimated.

Strengthening Primary Care beyond Medicare

As more people age into the Medicare program, we know that access to primary care is an essential tool for their health and wellbeing. We know that effective primary care, care coordination and planning, mental health care, substance use disorder treatment, and care for patients with cognitive and functional impairments can improve outcomes and result in smarter spending. Today’s changes are part of CMS’s broader goal to improve how we pay for care, including through our recently announced Quality Payment Program for Medicare physicians.

We expect to see the impact of these policies far beyond Medicare beneficiaries and hope that they will help strengthen the fabric of primary care throughout the country.

For more information, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-11-02.html and https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02.html.


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CMS Announces Updates to Dialysis Facility Compare: Patient Experience Ratings Now Available

By: Kate Goodrich, M.D., Director, Center for Clinical Standards and Quality

Today, the Centers for Medicare & Medicaid Services (CMS) announced changes to the Dialysis Facility Compare (DFC) website on Medicare.gov, which provides information about thousands of Medicare-certified dialysis facilities across the country, including how well those centers deliver care to patients.

These changes are in direct response to the important feedback CMS has received from dialysis patients and their caregivers about what is most important to them in selecting their dialysis facility. CMS remains committed to seeking and incorporating input from all stakeholders, but especially patients, on an ongoing basis so that we can continually improve our Compare sites and make health care quality information more transparent and understandable for patients and their caregivers.

Since the initial release of the Dialysis Facility Compare website, patients have emphasized in their feedback to CMS that understanding how others like them view a dialysis center— in particular the cleanliness of the facility and how well the staff cares for them— is valuable information when choosing a facility. As a result, visitors to the updated Dialysis Facility Compare website will now be able to see how patients rate their experiences with dialysis facilities.

CMS collects patient experience data though the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) Survey, which measures patients’ perspectives on the care they received at dialysis facilities. A total of six ratings on patients’ experiences with care will be reported, including three that cover specific aspects of patient experience and three overall patient ratings of the kidney doctors, the facility staff and the dialysis facilities. For each dialysis center on Dialysis Facility Compare, the site will include this patient experience information, the quality star rating, and detailed clinical quality information.

CMS is also adding two quality measures to Dialysis Facility Compare:

  • The standardized infection ratio (SIR) is a ratio of the number of bloodstream infections that are observed at a facility versus the number of bloodstream infections that are predicted for that facility, based on national baseline data.
  • The pediatric peritoneal dialysis Kt/V measure equals the percent of eligible pediatric peritoneal dialysis patients at the facility who had enough waste removed from their blood during dialysis.

Other major changes to the site include modifications to the methodology for calculating dialysis facility star ratings based on recommendations from a 2015 Technical Expert Panel. The updated methodology for calculating star ratings:

  • Establishes a baseline to show improvement by taking into account year-to-year changes in facility performance on the quality measures compared to performance standards set in a baseline year. Star ratings will reflect if a facility improves (or declines) in performance over time.
  • Limits the impact of a few very low scores by applying a statistical method called truncated z-scores to percentage measures. This ensures that star ratings are not determined by extreme outlier performance on a single measure.
  • Ensures accuracy of ratings by keeping the continuity of the measures.

A final change to the DFC website relates to ratio measures:

  • The Standardized Mortality Ratio, Standardized hospitalization Ratio, Standardized Transfusion Ratio, and Standardized Readmission Ratio will now be reflected as rates to display them more clearly.

These changes reflect CMS’ ongoing commitment to making sure that Dialysis Facility Compare meets the needs of individuals with kidney disease and their caregivers. This Compare website and today’s updates are part of the agency’s larger effort to make health care quality information more transparent and understandable for consumers.  As part of that effort, CMS also has other Compare websites to help in selecting providers across the continuum of care, including Home Health Compare, Hospital Compare, Nursing Home Compare, and Physician Compare.

For more information, see the fact sheet: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-28.html 


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CMS Awards Special Innovation Projects to Quality Innovation Network-Quality Improvement Organizations Aimed to Drive Better Care, Smarter Spending, and Healthier People

By: Patrick Conway, MD, MSc
Acting Principal Deputy Administrator
Deputy Administrator for Innovation and Quality
CMS Chief Medical Officer

Kate Goodrich, MD
Center for Clinical Standards and Quality

Dennis Wagner, MPA
Director, Quality Improvement and Innovation Group
Centers for Clinical Standards and Quality

The Centers for Medicare & Medicaid Services (CMS) has taken another step toward ensuring that beneficiaries receive better care, better value, and achieve better overall care, smarter spending, and healthier people by awarding 20, two-year Special Innovation Projects (SIPs) to 12 regional Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs). The SIPs offer QIN-QIOs and their partners, clinicians, schools of higher education, innovation labs, and Medicare beneficiaries and their families the opportunity to address critical health care issues important to their constituency in the areas of quality improvement that may be underutilized, but represent a significant opportunity if spread locally, regionally, or nationally. QIN-QIOs serve the Medicare population by working with Medicare beneficiaries, providers, and communities in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality.  QIN-QIOs were eligible to submit proposals for two types of SIPs in 2016:

  1. Projects addressing issues of quality occurring within the QIN-QIOs’ local service area: “Advance Local Efforts for Better Care at Lower Cost.”
  2. Projects focusing on expanding the scope and national impact of quality improvement interventions that have proven success in limited areas or scope: “Interventions that are Ready for Spread and Scalability.”

Projects that “Advance Local Efforts for Better Care at Lower Cost” include:

  • Great Plains QIN will work with 25 home health agencies in Kansas, Nebraska, North Dakota, and South Dakota to develop and test educational interventions to prevent and manage common infections observed in home health such as respiratory, urinary tract and wound infections.
  • Health Services Advisory Group will be building capacity for telepsychiatry services in the Virgin Islands of St. Croix, St. John, and St. Thomas to address the lack of psychiatric specialty services available.
  • TMF Quality Innovation Network will be working with 80 physician practices in Arkansas, Missouri, Oklahoma, and Texas to increase primary care physician knowledge of treatment for depression and alcohol use disorder through knowledge transfer from specialists to primary care physicians.

Topic areas for “Interventions that are Ready for Spread and Scalability” were identified through consultation with the Strategic Innovation Engine (SIE). The Strategic Innovation Engine (SIE) is a new endeavor that will advance CMS’ six quality goals by rapidly moving innovative, evidence-based quality practices from research to implementation throughout the QIN-QIO program and be made available to the greater health care community. The SIE will serve as an instrument in furthering the science of improvement to better inform quality improvement efforts in the future for QIOs and others that draws upon the literature, healthcare quality data, and experts and practitioners in the field to ensure safe, effective practices are available for use by providers seeking to improve quality and reduce costs.

These high leverage topic areas include streamlining patient flow in health care settings; working with health plans and care coordination providers on approaches to post-acute care that results in enhanced care management; increasing value, patient affordability, and appropriate use of specialty drugs by applying evidenced based criteria to prescribing practices; addressing acute pain management in sickle cell patients; and utilizing big data analytics to reduce preventable harm in health care. Examples of funded projects for “Interventions that are Ready for Spread and Scalability” include:

  • Alliant Quality, utilizing the breakthrough collaborative model, will work with 30 emergency departments in Georgia and North Carolina to improve the triage, treatment, and quality of care received by patients with sickle cell disease who present to the emergency room in vaso-occlusive crisis (VOC). It is expected that interventions will result in appropriate and timely pain management and improved patient experience.
  • Atlantic Quality Innovation Network, working in New York (Orange, Putnam, and Dutchess Counties) with physician offices, pharmacies, hospitals, nursing homes and county health departments, seeks to modify and standardize prescribing practices for managing anticoagulants during the periprocedural period to reduce anticoagulant adverse drug events in all patients, including Medicare Fee-for-Service beneficiaries. Interventions include the operationalization of a mobile/web-based application for clinical decision support in hospital/ambulatory surgery settings and optimization of patient education using health information technology.
  • Qualis Health, working in Washington and Idaho, seeks to improve the quality, safety, and reliability of the care transition process by focusing on a comprehensive assessment of the social determinants impacting beneficiaries’ transitions from the hospital to the home and creating robust linkages to community social service providers for high-risk beneficiaries to improve care coordination and reduce avoidable medical care utilization.

CMS sought proposals with scientific rigor, a strong analytic framework and a reasonable, proposed intervention based on the supporting evidence. CMS looked for evidence of QIN-QIO partnerships at the community, regional and national levels, and inclusion of patients and families in each project as well as direct links to the CMS Quality Strategy goals.

A complete list of 2016 SIP awardees is located on the QIO Program website.

We are committed to innovation and are excited to study the results produced by these SIPs and to identify ways in which to incorporate them throughout the QIO Program based upon their results. The SIPs create an exciting opportunity for providers, professional organizations, innovation labs, and others to innovate and impact health care quality in the Medicare program at local, regional and national levels through the QIO Program.

Remarks by Andy Slavitt: Meeting the health challenges of rural America

The following are the remarks delivered by CMS Acting Administrator Andy Slavitt at the CMS Rural Health Summit on October 19, 2016 in Woodlawn, MD.

Somewhere in the country right now, of the 140 million people covered by Medicare, Medicaid, CHIP or the Marketplace, someone is having a care need met. Someone is having a tumor diagnosed by an excellent technician; someone is getting affordable asthma medication for their daughter; someone is meeting with a caring nursing home staff for the first time after their father-in-law moved in. Some parent is sleeping well for the first time because they have coverage through expanded Medicaid or the Exchange.

If we could give every American the best of what the health care system has to offer, we would improve health outcomes, enhance Americans’ financial and health security, and spend our precious resources more wisely. And we would be able to keep people healthier and more comfortable as they age. And there is clear evidence that we are making progress. The uninsured rate is down to 8.3%, cut nearly in half, with 20 million newly insured Americans; medical cost trends remain at record lows; and 95 out of 100 quality measures improved nationally.

But the great black mark on our health care system are the vast disparities in the care people receive. Not everyone has access to that ideal care experience. Among other factors, where you live matters. And for the millions of Medicare Americans who live in some towns and rural counties, lifespans are shorter by two years. All of which means we need to get to work. And we have some challenges I’d like to start with, but also things to be hopeful about.


So let me start with what I’m worried about.

For us at CMS, I always like to start with an understanding of the people we are serving. Rural health care issues are not monolithic. People in the rural South the economic challenges and poverty are dominant issues and people don’t seem to get nearly as good hospice care as people who live in the north. In rural New England, the disparities aren’t as significant but the aging of the population intensifies the needs. In the upper Midwest and Great Plains – isolation, loneliness, depression and substance abusers are prevalent. In the Mountain states, there are geographic challenges to access, and in the West, language and cultural barriers are more significant, particularly in the rural Southwest. All of which is to say, there is no “one” rural America. There are diverse issues that need airing.

There are, of course, some issues that hit all rural areas disproportionately. So forgive me for generalizing. Lower volumes, aging and limited infrastructure are real concerns and chronic disease rates and those treatment needs are higher. One significant source of coverage, care and funding aimed at addressing many of these issues is Medicaid expansion. But in almost all the states that have chosen not to expand Medicaid, they are either entirely rural or almost entirely rural. The uninsured rate in rural America is 11%+ where Medicaid has been expanded, but 14.6% where it hasn’t. Unfortunately, the impact of not expanding doesn’t end there. Insurance rates than become 7% higher and that of course has made markets less competitive and more expensive.

Workforce issues are also of great concern when I talk to physicians and community hospital executives. Approximately 10% of physicians practice in rural America, although nearly 20% of our population lives there. 65% of our health professional shortage is in rural areas. Physician assistants and nurse practitioners carry the lion share of the primary care load. This isn’t necessarily a bad thing, but we should note that in urban settings, that’s more like 8%. Access to specialists is one of the biggest challenges, and that becomes more important as the health needs of the population become more complex.

This really begins to stand out when it comes to behavioral health. With prescription drug abuse, increasing suicide rates, and the opioid epidemic taking its toll, our shortages of psychiatrists and psychologists– a problem everywhere– are deeper in rural counties. One in 8 rural counties are now without any behavioral health specialist and those that have them have between 1/3 and 1/2 of the levels of more urban areas.

We worry too about the nature of hospital economics and the impact of hospital closures. 78 rural hospitals have closed since 2010 and the obvious impact on the community is profound. And we are in need of a sustainable solution. The more remote a hospital, on average, the lower the operating margins. Other things hit the economics– higher uncompensated care due to lack of Medicaid expansion, fewer higher paying commercial payers, and continued declining utilization as we learn to take care of people in lower cost settings.

While these are real challenges, in many cases, given demographics– this is a boat we are in with you. As in some communities, it is Medicare and Medicaid that are becoming the principal financial resources. Which is why this February, we announced the formation of the Rural Health Council– to start putting together long term solutions with you.

I wanted to start with my concerns because we believe it’s important for CMS, for Cara and John and all our leaders, that we show you we understand the challenges you face. And so if we are missing something or don’t have it right, we want you to tell us.

Despite the challenges, what I believe is our best minds, working together, taking the long view give us a lot to be excited about. Will we wind back the clock to a day before these challenges exist? No. Is the answer to try to recreate what health care in rural America looked like 30 years ago? No. But just as challenges in rural America are unique, so too are the assets: the long-term relationships with patients and doctors, a care system that’s easier to navigate, and tighter communities that know how to pull together to solve problems.

Our initial focus is on access to care, the economics of care and innovations that fit right with the opportunities and needs in rural America.

And there is reason for optimism. To start with there have been great strides in access across rural community since the ACA.  The percent of uninsured adults in non-metropolitan areas decreased by 39% from 2010 to 2015. In 2016, 1.7 million people in rural areas signed up for coverage in just the Federal Marketplace states, an 11% increase from 2015– actually higher than from urban areas. And as I’m ever the optimist, there are still 19 state governors, I would dare to say virtually all of whom see the benefits of Medicaid expansion. They may have their own approaches, many of which we have shown ourselves to be open to. And they all have state legislatures to deal with, but at some point, the budget benefit, the economic benefit, and of course the benefit to state residents will be too much to pass up.

I’m also optimistic about the steps we are taking to make it easier to operate and improve the economic conditions of operating in rural communities. Our rural council is instituting a focus on elevating an understanding of the rural impact of all of our work and steps we can take to reduce burden.

Last week we announced a new initiative targeted at engaging physicians by focusing directly on burden reduction. We’ve reduced some of the restrictions on critical access hospitals, around both patient care policies and physician supervision. We’re finding places to simplify things where we can– from Meaningful Use to hospital organization flexibility to paperwork reduction and revisions to our approach to the 2 Midnights policy and auditing.

Each is a small step but there’s an increasing consciousness to reduce the burden and the cost. I know big administrative and legislative priorities remain on your list and there is always more we can do. But in addressing economics, we must have a dialogue about the longer term economics and allocation of resources in rural communities.

Mostly, I’m excited about our ability to innovate together. Telemedicine has been introduced into many of the new models in the CMS Innovation Center and advancing behavioral health through telehealth has great promise. Our innovation center is expressly focused on developing opportunities for rural care providers to find the models that will define the future. That means measures, programs, and technical assistance that are specific to local needs.

The ACO Investment Model was designed to help rural communities move down a path receiving better payment for delivering better healthcare — undoubtedly the key to managing through our economic challenges. In this rural-oriented model, we prepay shared savings to ACOs in rural areas – an oxymoron, but a clear acknowledgement that you need to invest when that’s not always easy and a sign of our willingness to invest along with you.

And in a report we released this morning indicates, for those rural hospitals that participate in value based initiatives, the results reflect many of the strengths we know are in these communities– rural hospitals perform better than urban counterparts and better on a host of safety measures.

And the Innovation Center is the key to unlocking more flexibility and finding and testing new ways at approaching opportunities to innovate. We invite your ideas so we can test them, pay for them, and grow what works. It’s what allows us to be nimble and invest alongside you.

We understand that all Americans deserve the best of the American health care system and that means tailoring solutions to the needs we see together.


And we are excited. I can tell you that the Rural Council has brought out the passion that exists all across CMS and HHS – especially HRSA- for rural health care. The “rural road show” that John leads in the Northwest every year and the various other things that are regions do represent our desire first to listen and understand; second, to work together with you on policy responses. Our commitment is to listen and respond and make sure there is a visible, vocal forum for the issues that matter to you.

As I close I want to extend my deep appreciation for the leadership that Secretary Burwell and Acting Deputy Secretary Mary Wakefield provide. Both growing up in rural towns, in different parts of the country, they carry that responsibility in to every decision that is made across HHS.

And while she could not be here today, the Secretary did record this welcome video for us to watch right now.

Thank you. Enjoy the day. And I can’t wait to hear what comes out of today and the listening sessions to follow.


Medicare’s investment in primary care shows progress

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

Today, the Centers for Medicare & Medicaid Services (CMS) announced the Comprehensive Primary Care (CPC) initiative’s second round of shared savings results, with nearly all practices (95 percent) meeting quality of care requirements and four out of seven regions sharing in savings with CMS. These results reflect the work of 481 practices that served over 376,000 Medicare beneficiaries and more than 2.7 million patients overall in 2015.

As the largest test of advanced primary care in U.S. history, CPC demonstrates the potential of primary care clinicians redesigning their practices to deliver better care to their patients, and provides clinicians support to innovate and deliver care in ways that better meet their patients’ needs and preferences.

During 2015, its second shared savings performance year, CPC generated a total of $57.7 million gross savings in Part A and Part B expenditures. These savings are essentially equivalent to the $58 million paid in care management fees to the practices. Four of the seven regions participating in CPC – the states of Arkansas, Colorado, and Oregon, and the Greater Tulsa region in Oklahoma – realized net savings (after accounting for the care management fees paid) and will share in those savings with CMS. Although three of the CPC regions had net losses, the savings generated in the other four regions covered those losses, such that care management fees across CPC were offset by reduced spending on Medicare Part A and Part B services. Further, more than half of participating CPC practices will receive a share of over $13 million in earned shared savings.

In addition to the gross Medicare savings, CPC practices showed positive quality, with lower than expected hospital admission and readmission rates, and favorable performance on patient experience measures. CPC practices’ performance on electronic Clinical Quality Measures (eCQMs) also exceeded national benchmarks, particularly on preventive health measures.

This is the first year CMS has included eCQM performance in Medicare shared savings determinations for CPC. eCQM reporting covering the entire practice population at the practice site level is critical to using health information technology as a tool to support care delivery transformation. eCQM data are recorded in the electronic health record in the routine course of clinical care, allowing practices to engage in real time quality improvement efforts that drive population health. As we move to a health care system that rewards value over volume, CPC practices are at the forefront of using eCQMs for quality improvement, measurement, and reporting.

Quality highlights from the 2015 shared savings performance year include:

  • 97 percent of CPC practices successfully reported 9 eCQMs. For ten out of the eleven eCQMs in the CPC measure set, the majority of CPC practices who reported surpassed the median national performance.
  • Nearly all (99 percent) practices reported higher levels of colorectal cancer screening and influenza immunization compared to national benchmarks. Additionally, 100 percent of practices who reported on screening for clinical depression surpassed national benchmarks.
  • Compared to 2014, most regions maintained or improved their scores on hospital readmissions and admissions for chronic obstructive pulmonary disorder and congestive heart failure.
  • Patients rated the care they receive from their CPC practitioners highly, particularly on how well practitioners supported them in taking care of their own health and the attention they paid to care from other providers.

The positive performance is a testament to the efforts CPC practices have made to provide truly “comprehensive primary care.”

CPC is a multi-payer partnership launched by the Center for Medicare and Medicaid Innovation (Innovation Center) in October 2012 to advance primary care by paying clinicians to deliver accessible, comprehensive, and coordinated care in seven regions across the country. CPC supports advanced primary care as the foundation of our health system. In addition to attending to patients’ acute, chronic, and preventive health care needs, primary care practices act as the quarterback of each patient’s health care team. CPC practices help patients navigate their care, communicate with specialists and hospitals, and ensure that patients with complex social and medical needs do not “fall through the cracks” of the health care system.

These results build on the first shared savings performance year in 2014. Gross savings nearly doubled from the first performance year to the second and practices in four regions were eligible to receive shared savings, compared to one region in 2014. Primary care transformation takes time, and it is especially encouraging that CPC practices maintained such positive quality of care results while also seeing gross Medicare savings in the 2015 performance year.

The experience in CPC has contributed to our continued efforts to support primary care going forward in the Innovation Center’s Comprehensive Primary Care Plus (CPC+), which will begin on January 1, 2017 and for which we recently announced the 14 selected regions and are currently reviewing practice applications. CMS anticipates that CPC+ could meet the criteria to qualify as an Advanced Alternative Payment Model (Advanced APM) under the recently finalized Quality Payment Program rule, which implements the Medicare Access and CHIP Reauthorization Act of 2015. A robust primary care system is essential to achieve better care, smarter spending, and healthier people. For this reason, CMS is committed to supporting primary care clinicians to deliver the best, most comprehensive primary care possible for their patients.

A Letter from CMS to Medicare Clinicians in the Quality Payment Program: We Heard You and Will Continue Listening

By Andy Slavitt, Acting Administrator

Today, we are finalizing policies to implement the new Medicare Quality Payment Program. Part of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program aims to create a more modern, patient-centered Medicare program by promoting quality patient care while controlling escalating costs through the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs).

After issuing our proposal for how to implement the new program earlier this spring, we held a listening tour across the country to hear your thoughts and concerns first-hand about the Quality Payment Program. Whether you formally submitted one of the over 4,000 comments we received, or were one of the nearly 100,000 attendees at our outreach sessions, there have been record levels of clinician engagement. The interactions reflect the importance you place on serving the more than 55 million individuals that have Medicare coverage.

We found an eagerness to help the Medicare program improve and an interest in being engaged in how we address the challenges and opportunities ahead. We also heard concerns, which is not surprising, given the challenge of changing something as large and important as the Medicare program. But, we found that there is near-universal support for moving towards a future focused on patient care that pays for what works, reduces clinician burden, and better supports and engages the medical community.

The policy released today is the first step in a multi-year journey in which we are particularly focused on allowing clinicians to transition at their own pace, continuing to get feedback from the field, providing meaningful support, and improving the program over time. As we read your comments, engaged directly with many of you, sought guidance from Congress, and considered all the options, we identified these priorities for the design of the program.

Focus on the patient

Patients tell us they want and expect us to pay for what works and for higher-quality outcomes. Clinicians tell us that they want to focus on delivering the care that is best for their patients, not on reporting or paperwork. For example, one physician group in Texas urged us to concentrate on quality metrics “that are most meaningful to our practices and our patients.” For this reason, we have reduced the number of required measures and provided practices more flexibility to select the measures that they believe best represent their patients’ needs. And, to free up more time for clinicians to spend on patient care, we announced yesterday an initiative to reduce burden and improve physician engagement with CMS, including a regulatory review to begin reducing unnecessary documentation.

Start out gradually

Other than a 0.5 percent fee schedule update in 2017 and 2018, there are very few changes when the program first begins in 2017. If you already participate in an Advanced APM, your participation stays the same. If you aren’t in an Advanced APM, but are interested, more options are becoming available. If you participate in the standard Medicare quality reporting and Electronic Health Records (EHR) incentive programs, you will find MIPS simpler. And, if you see Medicare patients, but have never participated in a Medicare quality program, there are paths to choose from to get started. The first couple of years are aimed at getting physicians gradually more experienced with the program and vendors more capable of supporting physicians. We have finalized this policy with a comment period so that we can continue to improve the program based on your feedback.

More pathways to participate in Advanced Alternative Payment Models (APMs)

In listening to many of you and working with the Congress, we have heard strong interest in providing more opportunities for physicians to participate in Advanced APMs. Our goal over the next few years is to have more options that fit the diversity of practices and care across the nation, while maintaining robust models that actively encourage high-value care – the best care at the best price – for our Medicare beneficiaries.

In today’s rule, for both Medicare primary care clinicians and specialists, we are announcing our intent to explore testing a new Advanced APM in 2018 – ACO Track 1+ — which has lower levels of risk than other Accountable Care Organizations (ACO). Specifically for specialists, in addition to oncology and nephrology, we recently proposed allowing participants in new cardiac and orthopedic bundled payment models the possibility to qualify as Advanced APMs beginning in 2018. We are also reviewing the other models established through the CMS Innovation Center and are in the process of updating and possibly re-opening them to allow for more participation. And physicians can soon submit proposals for new models to the new Physician Focused Payment Model Technical Advisory Committee, which can now be designed with a lower level of risk than we had originally proposed, which may make more Advanced APMs available to small practices.

With these new Advanced APMs, we estimate that about 25 percent of eligible Medicare clinicians could be in an Advanced APM by the second year of the program.

Adapt for small and rural practices

We know that small practices deliver the same high-quality care as larger ones. Yet at every practice we visited or event we held, we heard from physicians in small and rural practices concerned about the impact of new requirements.

We heard these concerns and are taking additional steps to aid small practices, including: reducing the time and cost to participate, excluding more small practices (the new policy will exclude an estimated 380,000 clinicians), increasing the availability of Advanced APMs to small practices, allowing practices to begin participation at their own pace, changing one of the qualifications for participation in Advanced APMs to be practice-based as an alternative to total cost-based, and conducting significant technical support and outreach to small practices using $20 million a year over the next five years, as well as through the Transforming Clinical Practice Initiative. Due to these changes, we estimate that small physicians will have the same level of participation as that of other practice sizes.

Simplified reporting and scorekeeping in MIPS

Many of you asked us for simplified scoring, better feedback, and clear rules. The policies finalized today begin that alignment and simplification process, which we intend to continue as the program matures.

First, we are simplifying requirements for the two quality components of the program – the quality measures and practice-specific improvement activities. Second, we are moving to align the measurement of certified EHR technology with the improvement activities. This will begin 2017 with a portion of the Advancing Care Information measures; we intend to align more of these measures with quality in later years, to further ensure that certified EHRs are being used to support high-quality care. We also narrowed the focus to those measures that support hospitals and physicians safely and securely exchanging information, and we expect both registries and certified EHRs to move to make reporting more “push button,” making such reporting easier for clinicians. Finally, we are rolling out the new Quality Payment Program website, which will explain the new program and help clinicians easily identify the measures and activities most meaningful to their practice or specialty.

Overall, we are deeply appreciative to everyone, from the Congress to practicing physicians, patient advocates, people with Medicare and their families, and technology companies, who provided input into the launch of the program. We listened and made changes based on your input.

There are a number of ways to learn more about the details and how you can get help in the Quality Payment Program: here. We want everyone to participate over time and will provide intensive support to clinicians through our new Quality Payment Program website, as well as directly through in-person and virtual educational sessions and webinars.

Through this process and the input you have given us, CMS is becoming even more open, transparent, and responsive. We are committed to paying close attention to the impact of our policies on care delivery and adjusting along the way. By working together, we can all make real progress in improving the delivery of care in our country.

Improved quality of Medicare health and drug plans means great news for Medicare beneficiaries

by Sean Cavanaugh, Deputy Administrator and Director of the Center for Medicare

As we get further into the fall season, the Centers for Medicare & Medicaid Services (CMS) is preparing for the annual Medicare Open Enrollment, which begins on October 15 and ends on December 7. For the 2017 plan year, Medicare Advantage and the Medicare Prescription Drug Plans continue to provide high-quality options for people with Medicare.

Recently, I wrote about how the Affordable Care Act has strengthened Medicare health and drug plans. In 2017, enrollment in Medicare Advantage is expected to reach an all-time high of about 18.5 million, a 60 percent increase from 2010, the year the Affordable Care Act was passed. About one-third of all Medicare enrollees will be in a Medicare Advantage plan in 2017.

And enrollees in Medicare health and drug plans are receiving better care as a result of the Affordable Care Act, which provides bonuses to higher quality plans (i.e., those with four or five stars on a five-star scale).  In 2009, only about 17 percent of Medicare Advantage enrollees were in four and five star plans; for 2017, 68 percent of enrollees are in four and five star plans.

Medicare Prescription Drug Program enrollees are also benefiting from quality improvement among plans, with about 41 percent of prescription drug plan enrollees in plans with four or more stars for 2017, compared to 27 percent of enrollees in such plans in 2009.

For people with Medicare, this is good news. Plans that are rated higher deliver a higher level of care, such as improving the coordination of care, helping enrollees to manage diabetes or other chronic conditions more efficiently, screening for and preventing illnesses, or making sure people get much-needed prescription drugs. A high rating also means that these plans give better customer service, with fewer complaints or long waits for care.

CMS is continuing to strengthen Medicare Advantage and the Prescription Drug Programs so that they continue to provide high-quality affordable accessible care for current and future Medicare beneficiaries.

To learn more about the Star Ratings in Medicare Advantage and the Prescription Drug Program, please visit: http://go.cms.gov/partcanddstarratings. People with Medicare can use the Medicare Plan Finder online tool available at www.Medicare.gov to search for plans available in their area and compare plan quality, costs, and coverage.


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