The Next Step – Making the Most of Your Coverage

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

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

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

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

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

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

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

 

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

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

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

Extending participation in the Bundled Payments for Care Improvement initiative

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

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

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

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

Bundling payment for services that patients receive across a single episode of care – such as a heart bypass surgery or a hip replacement – is one way to encourage doctors, hospitals and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. The initiative is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality and reduce costs.

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

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

Check your 2015 Open Payments data

By Shantanu Agrawal, M.D, Deputy Administrator and Director of CMS’ Center for Program Integrity

The Centers for Medicare & Medicaid Services’ continues to publish data from applicable manufacturers and group purchasing organizations (GPOs) about payments they make to physicians and teaching hospitals on its website, https://openpaymentsdata.cms.gov/. We’re pleased that the public has searched Open Payments data more than 6.3 million times. Doctors, teaching hospitals and others receiving payments or other transfers of value that are sent to us from reporting entities, should take steps to ensure that this information about you, your related research, ownership, and other financial concerns are accurate.

Doctors and teaching hospitals have the chance to review and dispute the information shared about them before we post the new and updated Open Payments data on June 30, 2016. The data we post on June 30th is now available for review through May 15, 2016. Since April 1, this is the only chance for these health care providers to dispute inaccurate or incomplete data before we post it. After that they only have until the end of the year that this financial data is published to review and dispute any payment records and how it was attributed from GPOs, drug and device manufacturers.

Any doctor or teaching hospital that wants to look at the financial information reported on them by manufacturers and GPOs can register on the Open Payments website to create an account or log if they already have an account. Visit our website for instructions and quick tips.

Last June, we posted payments and ownership interests reported in 2014 about more than 607,000 physicians and 1,122 teaching hospitals, valued at $6.45 billion. Health care practitioners and teaching hospitals were paid for items like medical research, conference travel and lodging, gifts and consulting.

The Open Payments program is one way we can give patients, their families and caregivers transparency and information that helps them:

  • Become better informed health care consumers.
  • Talk to their doctors and other care professionals.

If you want to learn more about the program, visit the Open Payments program website or send questions to openpayments@cms.hhs.gov

Mapping Medicare Disparities

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

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

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

Mapping Tool Map

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

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

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CMS Acting Administrator Comments before the National PACE Association

Below are the comments as prepared for delivery of CMS Acting Administrator Andy Slavitt at the National PACE Association on April 5, 2016, @aslavitt

Good afternoon. I want to thank you for having me here and I hope you have had, and have, productive meetings here in Washington. I want to talk today about some of the essential changes for our health care system over the next number of years as we move to the next chapter of the implementation of the ACA and this is the perfect audience to do it. Six years ago, prior to the ACA, our health care system was not doing the job for the people who needed it the most.

Health care spending was growing well in excess of inflation virtually every year — and as costs continued to increase without limit, neither the quality we experienced as patients nor the quantity of people covered was getting better.

It’s not as if well-intended people weren’t working on solutions– to the contrary, in each and every quarter people were tackling part of the issue — the “quality” community; the “drug innovation sector”, the “tech” sector; health plans an array of other interventions; pilot programs and legislation here and there . . . But for all the work — the national results never improved because we couldn’t address issues or patients comprehensively as a Nation.

The passage of the ACA disrupted our trajectory as for the first time in many years there became no such things as business as usual. As a nation, we began to collectively move the health care system in a new direction. And over the last 6 years, we have begun a new chapter marked by significant gains.

  1. We started offering more people the opportunity for coverage, and the hunger was real. 20 million Americans have since gained coverage; the uninsured rate is now lower than 10% and if more states expand Medicaid, millions more would have the security of coverage.
  2. Quality outcomes have moved in larger increments than ever before. With the ACA, we used the tools to reward for higher quality outcomes, and since then, unnecessary hospital admissions are down, 95% of quality metrics have improved nationally and hospital safety has improved by 17%, saving 87,000 lives in the process. 
  3. And medical cost trends are rising at their lowest level in 50 years, at the level of broader inflation measures. The CBO estimates that the ACA is coming in 25% under budget and making an impact on both deficit reduction and on the life of the Medicare Trust Fund.

What is most striking about these national improvements in cost, quality, and access to care since the ACA is that none of these measures had improved in decades. So why have we made this progress and how will it continue? I think it has as much to do with how we react to and implement the law as the law itself; how we keep pressing forward for better and better results.

NEXT CHAPTER

While we have made tremendous progress, there is still much to be done. We know we need to make care sustainably affordable. Our commitment to quality must become imbedded and we must find ways to reach all the people that are still left behind and left out of the system. As I think about all the work left to be done… we are now trying to evolve the broader system closer toward the principles that have driven PACE for decades by treating people and their needs comprehensively, patient by patient, community by community.

That comprehensive view of care that is a hallmark of the PACE program is a strong example of what we need as a nation. As you know better than anyone, delivering care that accounts for the entire needs of the patient is not simply an operational change; it requires a different way of thinking and we need to get on that path across all sectors where a patient gets care.

So as we enter our next chapter of health care reform, there are three important ingredients that will be critical in shaping our success.

  1. First, when we say patient-centered or consumer-driven, it has to mean something that improves, empowers and engages the life of the consumer.
  2. Second, we need to support what we value. Being treated for all your symptoms is preferable to being treated one off. Your doctor’s office is preferable to an emergency room. Being treated in a comfortable setting — at home or in the community is often better than an institution. Managing a chronic conditions is preferable to neglecting it. High-priced technology or medication is no replacement for understanding and managing a patient’s needs. And prevention is best of all.
  3. And third, our moral commitment must be as strong as our financial one.

As I look at the PACE program and all that it represents, I believe you can show us the way.

The Consumer

In order to put meaning behind a truly consumer-oriented health care system, we first must have a renewed understanding for who we as a country are taking care of and what their needs are. The health care consumer is more diverse, more mobile and more demanding than ever before. CMS now serves — 140 million Americans– most on fixed or low incomes live in every type of care situation–

–they are Medicare patients leaving the hospital with five prescriptions to fill and not sure how to pay for them, but keeping them at home depends on the quality of the transition they make;

marketplace customers who have coverage for the first time and are finally be able to look after conditions they have long ignored. They will bear the cost of every inefficiency and everyone’s margins in their premiums and deductibles and will be a vital weathervane to affordability;

–they are daughters and sons who have to make the difficult decisions on how to care for their parents who are losing their independence and need more and more assistance. They want to understand their options for both home and institutional care and how quality, staffing, cultural commitment and their budgets will impact what is most personal to them;

–and they are parents of children with disabilities that require 24 hour care who spend their lives watching every dollar and interviewing every home care worker.

There are millions of us in a wide diversity of circumstances, but each of us are hoping for the same basic things from the health care system: to intersect with a care system that understands us and provides quality care; to make sure we have access to care we can afford, and when a loved one is sick, to understand what comes next and be able to get them home and productive and with as healthy a life as possible.

The great question, of course, is how we – as a country – are set up to meet those needs, particularly as our country ages, grows in diversity, and as our health needs become more complex.

On Lok

And this really hit me when I had the privilege to visit On Lok in San Francisco last year. What I saw was something familiar to you.

  • The typical person cared for is 83 and has 19 medical diagnosis
    • 59% have Alzheimer’s or dementia
  • The vast majority speaking a language other than English and
  • 90% of the patients are dually eligible.

What I saw at On Lok was a staff that was caring, a kitchen which prepared a diverse set of ethnic meals, vans that brought people in from all over the city to an array of activities, and an interaction with family caregivers in what appeared to be an extension of the family. And I thought to myself . . . wow. For our highest need patients, we can make it work. But to do so, the institutions that make up our health care system will need to compete on how best to solve real life problems for real life consumers and build real relationships. It’s a model the health plans, hospitals, clinics, and government institutions would be wise to pay attention to.

Supporting Value

It leads to my second ingredient of what’s essential in our next chapter of reform– how we support the delivery of the kind of care we want— high value and with a focus on smarter spending and keeping people healthier. To be crystal clear, it’s all of our jobs to allow us to afford all the high quality care we as Americans will need.

Nowhere is this more apparent than when I look at how we care for the elderly and how we afford the care our seniors will need.  According to the Medicare actuaries, we have extended the life of the trust fund since the ACA passed by 13 years—to 2030 by which time we will have twice the number of seniors as in 2000 and the number of Americans over 85 will double. Already people over 80 comprise a quarter of Medicare beneficiaries. And Medicare spending more than doubles between the ages of 70 and 96. Thought of another way, what a typical family may pay in taxes to support the Medicare and Medicaid programs every year may only cover half of the cost of caring for the oldest of the patients. 

How are we going to meet this national challenge? We need a new set of national solutions—not just more money.  It’s the perfect kind of challenge for our country in this next chapter. And this is where we need innovation to come in and where PACE has an opportunity to establish itself as a part of the national solution.

Our agenda is not to sit back and expect all this change to happen on its own, but to help people succeed. Secretary Burwell last year committed the federal government to change how we pay for care. We announced last month that after being entirely FFS through 2011, now over 30% of Medicare FFS payments are now linked to quality and cost outcomes on track for this to become the predominant payment system by 2018. Behind this commitment, are the actions that support the kind of care patients in this country want and deserve.

  • Investing in prevention as we now move to make community-based diabetes prevention more prevalent.
  • Linking the totality of care for a patient together for an entire episode, inpatient and out, for major treatments like joint replacements and cancer care
  • Improving reimbursements for those who demonstrate quality in everything from home health to patient care to surgical care to hospice
  • Paying physicians for something so antiquated, it’s now innovative– paying physicians to talk to patients, not just to prescribe to them, cut them or use expensive technology
  • Focusing on care coordination and population health. There are now over 475 total ACOs with 30,000 participating physicians serving 8.9 million beneficiaries, or better than one in five 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 ACA.
  • AND– Of course — supporting models that bring investment in care to the people who need it the most— home and community based services, dual eligible demos, and PACE.

And we have made investments to support this change – with hundreds of millions of dollars in technical support and a significant effort in simplifying and supporting integrated care delivery – we have major initiatives aligning quality measures, reducing burden, streamlining technology requests, and providing useful and near-real time data to patients and physicians.

Commitment

We see payment models not as an end, but rather as a change management tool to help physicians and other clinicians increase communication, coordination and improve patient care.   Incentives alone will never be enough to make the health care system work the way we want it to. Our health care needs are too complex and too interdependent and the interests and needs of patients and the care provider community too diverse and heterogeneous. If we appeal to everyone’s self interest better, we can make a certain amount of progress. But I believe we quickly get stuck. Our next chapter must be driven by leaders with a commitment to success beyond their own organizations.

There are three commitments we need to focus on:

-Last year we released our first-ever Health Equity Plan for Medicare. We are calling for the same level of quality care delivery that are targeted at the needs of populations and are culturally-competent for all races, ethnicities, geographies, and other ethnic, sexual or gender-based minorities. This must be measured and highly transparent and we are putting forward more and better data this month as part of National Minority Health Month. As I have seen when I visited On Lok, this is something you all know how to do if we commit to it.

-Second, affordability is all of our jobs and we need to increase the affordability of medicines and emergency room benefits and the premiums we pay. Leaders around the country must seize the mantle of change to reduce unnecessary costs and unnecessary admissions; reduce waste where they see it, redesign care processes and coordinate patient care to better manage chronic disease.

-Finally, to make progress, we must be committed to overcoming barriers as they arrive and work collaboratively. Models of care – whether PACE or ACO or Medical Home -may all be in iterations of what will ultimately become the most successful models. We are still at the stage where Marketplace plans are still experimenting with how to offer benefits and networks in ways that deliver affordability to consumers, and drug companies are seeking to define and deliver value in new models. If we either give up or retrench in these early innings, we risk seeing our progress slip or becoming outmoded as new solutions develop. Which brings me to PACE.

PACE

For the many reasons I described, a locally-based, patient-centered and comprehensive commitment to patients is vital to our future. I believe PACE is a model with great promise and I want to affirm my commitment to cultivating that promise. Over the last five years, we have seen demand grow and we at CMS are committed to providing support for further growth. We are committed to proposing a regulatory update which will assist the path to growing successful. For us, this is aimed at facilitating more interdisciplinary care, increasing operational flexibility, improving access to community-based providers, and improving our enforcement processes. We issued a report to Congress last year on the topic of opening the PACE program to for-profits and facilitating conversions as appropriate. And as you heard from Tim this morning, we are working through options on the PACE Innovation Act and look forward to new opportunities to test PACE-like models for new populations.

But PACE is still a secret and in the minds of the public. The challenge is not simply to grow the program, but to define the brand by educating the public and making PACE a clear part of the solution. We need to collect and report on quality metrics so that we can demonstrate a definite proposition that more comprehensive care will led to both better outcomes and lower overall spending. We will, in concert with the NQF, be pushing aggressively on the quality agenda. This is the key to growth. Second, we need the industry to set the standard in compliance. At this still early stage in the evolution of PACE, bad apples sometimes still define the overall brand, often unfairly. And third is to create the innovation that helps manage the population challenge that we as a country are facing. The cry for high-quality patient-focused services is growing more intense for our parents and ourselves. At full potential, PACE will not only be successful but become one aspect of the solution that solve bigger and bigger portions of our national challenge.

Conclusion

I want to close by saying thank you for all the care you and your organizations provide to our Medicare and Medicaid beneficiaries and their families. I get to wake up every day thinking about the 140 million Americans that today rely on CMS’s programs—Medicaid, Medicare, CHIP, the health insurance marketplace. And I have a public email address so I have learned that many of them wake up every day thinking about me too. As that helps me see, and as you can see, there is a great deal of work to do and it is exciting work because we can all play a role in defining the next chapter. Even as we focus on consumer needs today, as my visit to On Lok reminded me, we need to do the work now to think about the lives of our beneficiaries over the next 20 years, and of our future beneficiaries.

With your help, this next chapter will take what we’ve started and impact people more comprehensively, while building a smarter system that can ultimately sustain our needs as a country. We need your leadership to show us the way and we at CMS are committed to working with you to get there.

Reflecting on Our Journey towards Health Equity

By: Dr. Cara James, Director of the CMS Office of Minority Health

Each April, in recognition of National Minority Health Month, we commemorate past achievements, acknowledge current efforts, and outline our continued journey towards health equity and equality for all. Fifty years ago, our journey included stops in Independence, Missouri where Medicare and Medicaid became law; in Selma and Montgomery, Alabama; and in Washington, D.C. for the signing of the Voting Rights Act and Civil Rights Act.

Since then, there have been many more landmark achievements in health equity. Events such as the publication of the Secretary’s report on Black & Minority Health (the Heckler Report) and the creation of the HHS Office of Minority Health illustrate the increased national attention on the need to address health and health care disparities. The publication of the Agency for Healthcare Research and Quality’s annual National Healthcare Quality and Disparities Report illustrates our commitment to track our progress. The passage of the Affordable Care Act and the enrollment of millions of Americans, including many people of color in health plans, illustrate our continued advancement towards better care and healthier communities.

Five years ago, the Affordable Care Act established three additional offices of minority health within six HHS agencies. While several HHS agencies already had offices of minority health, the Office of Minority Health (OMH) at the Centers for Medicare & Medicaid Services (CMS) was an office newly established through the Affordable Care Act. The principal aim for CMS is better care, healthier people, and smarter spending. To help achieve this aim, the CMS Office of Minority Health ensures that the voices and needs of minority and underserved populations are present in the development, implementation, and evaluation of CMS programs and services. We are dedicated to working on behalf of all CMS beneficiaries, while strategically focusing on racial and ethnic minorities, individuals with disabilities, and Lesbian, Gay, Bi sexual and Transgender (LGBT) minorities. CMS OMH activities include: From Coverage to Care, the CMS Equity Plan for Improving Quality in Medicare, strengthening CMS data collection and analysis, and working across the agency to embed a focus on health equity into new and existing programs and policies.

From Coverage to Care is an ongoing initiative designed to help consumers understand their healthcare coverage and how to access the care they need. Additionally, the CMS Equity Plan for Improving Quality in Medicare is CMS’ first strategic equity plan. Launched in 2015, this equity plan identifies six priorities and provides an action-oriented, results-driven approach for advancing health equity by improving the quality of care provided to racial and ethnic minority and other underserved Medicare beneficiaries. Last month, CMS OMH launched an interactive web based tool for mapping Medicare disparities. The Mapping Medicare Disparities Tool contains health outcome measures for disease prevalence, costs, and hospitalization for 18 specific chronic conditions, emergency department utilization, readmissions rates, mortality and preventable hospitalizations.

We know we cannot achieve health equity on our own. It will take the support of partners from the federal to the community level.  We encourage you to join us on the path to health equity by using the resources discussed in this blog, bookmarking the CMS OMH website, joining our listserv, and of course building on your own health equity activities!

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Our Hopes for the Comprehensive Care for Joint Replacement Model

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

Today’s launch of the Comprehensive Care for Joint Replacement Model (CJR) is a major step toward transforming care delivery in Medicare. Why? Because this model looks to improve care and quality for the most common procedures that Medicare beneficiaries have, hip and knee replacements. In 2014, more than 400,000 Medicare beneficiaries received a hip or knee replacement, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers. For instance, the rate of complications, like infections or implant failures, after surgery can be more than three times higher for procedures performed at some hospitals than at others.

The model aligns with what matters to beneficiaries—better outcomes for a whole episode of care. The model includes patient-reported outcomes after surgery and incentivizes better care coordination. One beneficiary said it best when she described that what she cared about for her hip replacement was getting out of the hospital as quickly as possible without an infection or complication and then being able to go back to playing with her grandkids and gardening. The model incentivizes a system that aligns with her goals and the goals of so many beneficiaries.

We are excited about the CJR model’s potential to improve the quality and efficiency of care for Medicare beneficiaries, to contribute toward a health care system that delivers better care, spends our dollars more wisely, and leads to healthier Americans.

How will CJR work? About 800 hospitals located in 67 selected markets will be accountable for the costs and quality of related care from the time of the hip or knee replacement surgery through a post-hospitalization period. They will receive target prices for these joint replacement cases at the beginning of each year. The target price represents expected spending for lower joint replacement episodes, including the initial hospital stay for the procedure and 90 days after discharge from the hospital. If patients receive high quality care and spending is less than the target, a hospital may receive an additional payment from Medicare. If their spending is above the target, hospitals may be required to repay Medicare for a portion of the difference.

We expect this incentive to coordinate the services a patient receives before, during, and after surgery will encourage hospitals and clinicians to partner with nursing facilities, home health agencies and other providers of rehabilitation services to provide seamless, high quality care.

We want hospitals to be successful under this model because success means that Medicare’s beneficiaries will receive better quality care. In the run up to today’s launch, our staff individually contacted the program coordinators at all 800 hospitals to offer data and other resources to assist them on this multi-year journey. CMS will continue to collaborate with hospitals and their physicians and other clinicians to provide support and share best practices.

What will beneficiaries notice? First, beneficiaries will continue to choose their doctor, the hospital where they receive treatment, and the type and location of rehabilitation care they receive. If their hospital is a model participant, they will get a letter explaining the model. Patients whose chosen hospital participates in the model should experience improved care coordination. For instance, we expect that nursing facilities will understand a patient’s needs better before that patient is discharged from the hospital.

The CJR model offers a chance for hospitals, doctors, and other providers to partner with CMS in furthering our shared goal of improving the quality of care for beneficiaries undergoing the most common inpatient surgery, lower extremity joint replacements. The model is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality.

We are excited to begin this groundbreaking initiative and will work with hospitals, physicians, and other providers throughout the model to ensure they have the tools to succeed and improve upon what they do best: provide high quality, coordinated care to beneficiaries.

For more information about the CJR model, please visit: https://innovation.cms.gov/initiatives/cjr.

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