Improving the Marketplace through Innovation

By: Kevin Counihan, CEO of the Health Insurance Marketplace

The Health Insurance Marketplace has become a reliable source of health insurance coverage for millions of Americans, many of whom used to be locked out of coverage because it was either unaffordable or because of a preexisting condition. Thanks to the combination of the Health Insurance Marketplace, expanded Medicaid, and other provisions of the Affordable Care Act, the share of Americans without health insurance has fallen to the lowest it’s ever been.

The Marketplace continues to deliver on its promise to offer consumers a place to find affordable coverage that meets their needs. Now in its third year of operation, the Health Insurance Marketplace is a dynamic platform that allows consumers to compare plans not only on premium price, but also on other plan features like the size of the deductible and whether a consumer’s doctors, hospitals, and prescription medications are covered.

However, the Marketplace is still very young. Just four years ago, the individual market still relied on a business model of denying coverage to those most likely to need it, imposing limits and carve-outs on covered services, and capping insurance coverage well short of what a serious illness can cost. Thanks to the market reforms and financial assistance in the Affordable Care Act, the individual market now looks very different. Today, any consumer can buy any plan, and insurers compete based on the quality and cost-effectiveness of their products, instead of on how well they select their customers.

Everyone expected that it would take time for companies to adjust their pricing and practices to what is effectively a new market. And it’s also no surprise that the pace of adaptation has varied across issuers. Some companies have struggled so far in this new market, while others are already succeeding in providing affordable care through a sustainable business model.

The success stories come from all across the country and from diverse types of insurers and markets. But one theme that’s consistent is that success in the Marketplace requires a different approach to providing care than was required for success in the old individual market.

We are inviting health plans and issuers that have found particular success in serving the new population to present their insights and innovations at a forum on June 9th. At the forum, presenters will describe strategies around consumer engagement, provider contracting, and care coordination models tailored by population data. And everyone (including issuers Aetna, BCBS of Florida, BCBS of Massachusetts, CareSource, Horizon BCBS, SelectHealth, UPMC, and the Society of Actuaries) will have the opportunity to discuss novel techniques that may help companies offer better health care coverage at lower cost.

We’re excited to bring together national leaders within the Marketplace to discuss innovative strategies for providing private health insurance coverage. The issuers who will join our conference have diverse characteristics. They are each successful in the Marketplace, but represent plans that are big and small, are commercial and non-profit, and hail from around the country.

This discussion will also help us work together towards a vibrant Marketplace that drives high-value, high-quality health care. Whether you are a patient, a provider, a business, a health plan, or a taxpayer, the long-term stability of the Marketplace is in everyone’s interest – both families who need access to quality, affordable coverage they can count on, and companies that have a chance to expand into a new market with millions of consumers.

I look forward to our conversations about how to continue to support a competitive Marketplace that rewards better, smarter care. If you’d like to join our conversation on June 9, please watch a live stream at .

Acting Administrator Slavitt Speech at the American Hospital Association’s Annual Membership Meeting

Acting Administrator Slavitt Speech at the American Hospital Association’s Annual Membership Meeting

Below are the prepared remarks of CMS Acting Administrator Andy Slavitt before the American Hospital Association’s annual membership meeting on May 3, 2016, @aslavitt.

Good morning. I want to thank you for having me here on what looks to be great agenda. I want to publicly acknowledge Rich for the many years of service, straight talk and advocacy. And I want to personally thank Rick for you leadership and partnership as we both began these jobs around the same time. We’re both taken this on at an interesting time.

There is so much going on in health care. Change of every type – new consumers entering the system, changing payment models, advancing technology, issues of real challenge to rural hospitals, consolidation of all types – that it’s hard to keep track of it all. Even our roles are changing – as hospitals and physicians take risk for populations and the relationship with the patient changes and extends beyond traditional boundaries.

You’re right in the center of it. So we need to communicate about our progress and yours, our goals and yours and I’ll pick out some of the salient issues this morning so you know where CMS is heading and you can be better informed about what we need to hear from you.

I hope you take away three things-

First, as I’m sure you probably heard from Denis already this morning, I want to express our gratitude for the partnership we have built as we work together to serve the American public.

Second, I hope you hear and see increased clarity and transparency on our part. You shouldn’t have to guess where we’re headed or what’s important to us. We want to create as much consistency and predictability as possible.

And third, that you view our role not simply as a policy maker, a regulator or a payer, but as an ally in helping you thrive through all this change – thrive at delivering quality care, thrive in adapting your hospitals to the emerging needs, and thrive in meeting a collective set of challenges that are endemic to our health care system and that we all need to meet head on.

We’ve made significant progress as a nation since the passage of the ACA. Six years ago, prior to the ACA, we should all remember, our health care system was stuck in a repetitive loop. 16% uninsured rate, quality not improving, costs skyrocketing. Every year. Every year we would all go to conferences to discuss and bemoan this. We’d attend the same conferences the following year. Same issues, same result. The ACA laid the groundwork for us to make gains in access to care, quality and affordability.

First, 20 million Americans have gained coverage since the start of the ACA. The uninsured rate is now below 10%. And if states that haven’t done so, expanding Medicaid will allow millions more to have the security of coverage. 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 conditions. And there of course have been the economic effects – like reducing uncompensated care and hospital bad debt to the tune of billions of dollars.

Second, at the same time, the quality and safety of care has improved more significantly than ever before. Since the ACA has allowed us to begin rewarding for higher quality outcomes, 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.

Third, medical cost trends are rising at their lowest level in 50 years, closely paralleling broader inflation measures, and running about half the level prior to the ACA. Affordability is paramount as we seek to cover people with pre-existing conditions, people with hourly and seasonal jobs, and new immigrant communities.

I’m not suggesting that the law, or any law, is a silver bullet. Rather, that if we implement and execute skillfully, with changes we know are good for patients, we make real progress. I know how challenging it is on a day-to-day basis – evolving our business models, changing how we collaborate and coordinate care in a community, reducing unnecessary costs and waste. But because of all your effort, we have made considerable progress over the last six years.

All of this is a good start. We have more to do to sustain and advance the progress to the point where people feel the system work better for them. Community by community, patient by patient, we need to address challenges not just to bend a curve, but frankly to break the mold of our silos, of waste we can see but is challenging to reduce, and of making sure that every American can afford to access to their medications, to the part of the system that keeps them healthy, and to the critical care that we will all inevitably need someday. Americans say health care costs are their number one financial concern so I will start there.

The Consumer

If you want to understand what defines and drives CMS, it’s as simple as this – the care and well-being of 140 million Americans in the Medicare, Medicaid, Children’s Health Insurance and Marketplace programs and the millions more who will need these programs someday. Defining how we make progress together begins with a better understanding of this consumer, most on fixed or modest incomes, who are more diverse, more mobile, more demanding and much more sensitive to the cost of care than ever before.

  • They are Medicare patients leaving the hospital with five prescriptions to fill but unsure how to pay for them. We know keeping them at home will depend on the quality of the transition they make to their own doctor and with their medication;
  • 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 budgets will keep their parents healthy and independent for as long as possible;
  • They are parents with children with disabilities that require 24 hour care, who spend their lives watching every dollar and interviewing every home care worker; and,
  • They are marketplace customers who have coverage for the first time and are finally able to address symptoms they have long ignored.

These customers are our weathervane for costs as they feel – in the monthly premiums they pay each month – everything in the system that unnecessarily increases the cost to care.

There are, of course, millions of us in a wide diversity of health circumstances, but each of us are actually looking for a common set of things from the health care system: to intersect with a care system that understands us and provides reliable, quality care; to understand what comes next in the care process so we can get home and have as productive and as healthy life as possible; and increasingly, we worry about having have access to care we can afford.

So what becomes clear from understanding consumers better is that for the millions of us who work in health care, affordable care is now part of everyone’s job. While this question of affordability isn’t new, we are seeing it in a new way – through the eyes of the consumer.

We’ve talked for years about what health care would be like if consumers had a real voice in the health care system – if health care were retail like other industries. The health insurance exchanges have offered us the best insight into how consumer needs are reshaping health care. We’ve learned three things:

First, consumers are very active shoppers when they make their own decisions and unaffordable care is a deal breaker. Seventy percent of consumers changed plans during open enrollment and, those who switched, saved more than $500 a year. Where are they going? The winners are hospitals and plans that have partnered at lower overall costs.

Second, consumers prefer to shop for their health care, not their health coverage. Millions of times over, consumers on the exchange no longer shop by looking for a health plan; instead they select a hospital or physician or prescription they want, and then they see which health plan offers them.

And third, exchange customers are valuable relationships for care providers – most are previously uninsured patients who now have full benefits with no lifetime limits and often higher needs for care that span the spectrum of health care services. And many are looking to build new, solid health care relationships for their families.

With exchanges, we are moving to a world driven by highly engaged, relationship-oriented and valuable retail consumers. This means we all need to be a part of delivering access to care and reducing costs and premiums– governments with subsidies, health plans with MLR limits, and hospitals by reducing costs and passing it on to consumers. Ultimately, consumers will reward those who want their business and have an affordable strategy to get it.

Supporting Value

Access to care is one thing, but of course we want access to a system that delivers and re-enforces quality care. Our new alternative payment models are intended to recognize this and pay more for high quality care, smarter spending and care that results in healthier people.

We announced earlier this year that more than 30% of Medicare FFS payments are now linked to quality and cost outcomes. This means that more than 10 million Medicare patients are getting improved quality of care by having more time with their doctors and better coordinated care. And we are on track for alternative payment models to become the predominant payment system by 2018.

Patrick Conway will be here this afternoon to review the incredible progress over the last few years in the adoption of bundled payments, ACOs, and Medical Home models. He will also talk about the details of our newly released regulations coming out of the bi-partisan MACRA legislation. I will just touch at a high level on how we approached this critical implementation and what we hope to accomplish.


The implementation of MACRA allows us to take the next transformative step in the Medicare program, by introducing the Quality Payment Program to pay physicians and other clinicians for quality, with a more flexible approach, common-sense approach. Over the last several months, we have made an unprecedented commitment to listening to and learning from physicians and patients. We have spoken with more than 6,000 stakeholders across the country, physicians, patients, and other clinicians in a variety of local communities in order to design a proposal that is targeted to meet the needs of care delivery on the front lines.

First, the program is designed to be patient-centric by focusing on quality of care, the total care experience, and care coordination. We have reduced the number of measurements and built a lot of flexibility into the program so that the care measures selected can match the patient need as much as possible.

Next, we structured the program to be practice-driven by allowing physicians to choose their own metrics and the programs – whether the MIPS program introduced by Congress or the Advanced Alternative Payment Models that many clinicians are beginning to have experience with. MIPS is designed to be an attractive option while physicians consider ramping up over time into a variety of more advanced Alternative Payment Models. We also allow physicians who have experience with any ACOs to benefit from their experience.

Third, we have focused on simplicity wherever possible and taken what over time has become a patchwork of quality and other reporting programs and streamlined them into a single framework to reduce the burden on physician offices. Our proposal to replace Meaningful Use in the physician’s office with a new program Advancing Care Information, is an example of where we have responded to considerable feedback to move the focus from “clicking” to care provision and collaboration.

Over the next 60 days, the proposal will be available for public comment. We need meaningful engagement on this proposal and the team and I will be conducting dozens of listening sessions and educational sessions to collect feedback.

I offer one editorial comment on new payment models. We should all take a step back and recognize that all of them are at early stages. I compare them to the first and second generation iPhones, still getting their first use and allowing us to see what works and what doesn’t. We should – however – expect these models to get better and better with every release.

Our new 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 and we published a proposed rule that reflected a lot of the input we received.  As they develop, it would be a mistake to view these models as fully calibrated incentives; rather they offer change management opportunities for the changes we all see ahead. Culture and leadership will always drive quality care; our job is to recognize it and reward it and enable investment in it.

Unfinished Business

For CMS to be successful, we must be committed 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 that must intersect with an already complex system with many demands. 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 people seek care.

This translates into an aggressive agenda for CMS along several fronts which I want to be sure you’re aware of– simplification, rural health and interoperability.

Simplification. 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 two-midnight policy and the RAC program reflects the result of paying attention to 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. And we are in conversations now about finding opportunities to find ways to extend the simplifications of Advancing Care Information, the successor to Meaningful Use, into the hospital setting.

Rural health is another priority area for us. I recently announced a Rural Health Task Force to focus on short- and long-term steps to address the economics of health care in rural America, to look at access to care issues, and to make sure innovation gets driven evenly into rural America. That task force has hit the ground running and we have dedicated payment models, technical assistance funds, and provisions set up to specifically assist rural hospitals and other care providers.

We have worked with many of you and the vendors in the area of interoperability. Business models and practices that limit the flow of data and that don’t put the patient at the center must become a thing of the past. I encourage all of you to become part of our effort by using established standards and adopting contracts with vendors which doesn’t permit charges and other pernicious practices that prevent data from safely moving to where the care of the patient warrants. Together, we have made significant investments in new technology, but they will only be fully realized if Health IT becomes a connected platform for collaboration and innovation. Interoperability is a priority at the very highest levels of government.


I want to thank all of you for the work you do with Medicare and Medicaid beneficiaries every day.

I want to close by repeating the theme I hope you’ve heard from me as I laid out a very candid look at our agenda and the challenges we must all address. Success for us is helping build a better health care system for all Americans, with smarter spending, and that results in healthier people. 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 and reduce the distractions from patient care.

As leaders we have the opportunity to build on the record progress of the last several years and seize the mantle of delivering affordable care in this country. We look forward to doing everything we can as we work alongside in this in the months and years ahead.

CMS Finalizes its Quality Measure Development Plan

By: Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS

On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals and 150 organizations.

Thank you for your comments, which we carefully reviewed and considered as we revised and finalized the plan. I am happy to announce that we posted the final Quality Measure Development Plan on the CMS website today (

CMS aims to drive improvement in our national health care system through the use of quality measures and periodic assessment of the impact of such measurement. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established payment incentives for physicians and other clinicians based on quality, rather than quantity, of care. We recently released the proposed regulation to implement these payment incentives, and more information is available here: The Quality Measure Development Plan is an essential aspect of this transition, which will provide the foundation for building and implementing a measure portfolio to support the quality payment programs under MACRA.

Highlights from the comments we received on the draft plan include:

  • Many commenters expressed support for the strategic approach of the Quality Measure Development Plan.
  • Responses favored CMS’ intent to engage clinicians, medical societies, and other stakeholders more broadly in measure identification, selection, and development processes for MIPS and APMs.
  • Professional associations representing diverse clinical practice areas identified current measurement gaps and proposed priorities for measure development that are directly applicable to their specialties.
  • Consumer advocates urged CMS to partner with patients, families, and caregivers and recommended a model for engaging them in measure development.
  • Many commenters approved of the approach envisioned by the National Testing Collaborative and the National Quality Forum (NQF) Incubator to promote early engagement of stakeholders in measure development and testing.
  • Both organizations and individuals contributed insights into the integral roles of their clinical professions or practices in the U.S. health care delivery system.

Taking these comments and suggestions into consideration, CMS finalized the Quality Measure Development Plan to include:

  • Identification of known measurement and performance gaps and prioritization of approaches to close those gaps by developing, adopting, and refining quality measures, including measures in each of the six quality domains:
    • Clinical care
    • Safety
    • Care coordination
    • Patient and caregiver experience
    • Population health and prevention
    • Affordable care
  • CMS actions to promote and improve alignment of measures, including the Core Quality Measures Collaborative, a work group convened by America’s Health Insurance Plans (AHIP). On February 16, 2016, CMS and the Collaborative announced the selection of seven core measure sets that will support multi-payer and cross-setting quality improvement and reporting across our nation’s health care systems.
  • Partnering with frontline clinicians and professional societies as a key consideration to reduce the administrative burden of quality measurement and ensure its relevance to clinical practices.
  • Partnering with patients and caregivers as a key consideration for having the voice of the patient, family, and/or caregiver incorporated throughout measure development.
  • Increased focus and coordination with federal agencies and other stakeholders to lessen duplication of effort and promote person-centered health care.

The MACRA law provides the opportunity to further progress the Medicare program and our national health care system toward paying for value rather than volume.  However, the successful implementation of the Quality Payment Program established by MACRA requires a partnership with patients, their families, frontline clinicians, and professional organizations to develop measures that are meaningful, applicable, and useful across payers and health care settings. We thank all who contributed comments and dialogue to the draft CMS Quality Measure Development Plan, and we look forward to partnering with you on these exciting efforts related to our quality payment programs.


Simplifying Choices in the Marketplace-Simple Choice Plans and Quality Star Ratings

By Kevin Counihan, CEO of & Dr. Patrick Conway, Principal Deputy Administrator of CMS

It’s hard to believe the fourth year of Open Enrollment for the Health Insurance Marketplaces is just six months away. We’re continuing to learn how to make the consumer experience even better, and have been working hard to make improvements for this year. We’ve learned about what information consumers need to make decisions and how to improve the help and support we provide throughout the enrollment process. Because shopping is so important to make sure consumers have the plan that is right for them, we are making sure consumers have clear, easy-to-understand information. We’re excited to announce some new ways we’re doing that. We want to layout two new innovations we plan to pilot with in the next year.

Simple Choice Plans

This year for the first time, consumers will have the option to select “Simple Choice plans”. These are plans that have a uniform set of features – enabling consumers to compare plans on fewer important plan factors like monthly premiums and providers in the plan’s network with the confidence of knowing that the benefits won’t vary from plan to plan.

We expect these plans will be a core part of the shopping experience on this year. To improve decision making, Simple Choice plans will display prominently in Plan Compare, with clear visual cues that show consumers the plans that are easy to compare vs. the ones that should be researched for differences.  Consumers also will be able to choose to only see these types of plans, if they want to quickly compare them.

We will make sure that consumers understand that these plans have a fixed deductible and out-of-pocket limits, and standard copayments within a metal tier (bronze, silver, gold, and platinum). And, for certain services, for instance a primary care appointment, a consumer would pay the same amount in any Simple Choice plan, regardless of the metal tier. These plans emphasize coverage of core services before the consumer has reached their deductible.

We are testing with consumers display options and descriptions for these plans, so that consumers can best understand what they offer, a clear, easy-to-understand choice. Importantly, our approach does not stifle innovation so health plans can continue to offer all kinds of benefit options that will also be easy for consumers to find.

Many of our other consumer tools, such as the physician and prescription drug lookup, as well as the quality ratings discussed below will work together with these plans to help consumers make the most informed decisions they can. Simple Choice plans will help consumers make apples-to-apples cost-sharing comparisons as they shop, enabling them to choose plans with features they find valuable, such as particular providers or a plan’s experience managing chronic conditions.

Quality Ratings

In 2014, we began development of the Quality Rating System (QRS) to provide comparable and useful information to consumers about health plans offered through the Marketplace. The information provided through the rating system can inform consumers about the quality of health care services and enrollee experience, as well as assess the overall patient and consumer experience, for health plans offered on the Marketplaces.

We designed the star rating system with input from health care quality experts and other interested parties to inform the consumer-decision making process. Star ratings provide health plan quality information on important topics, such as how well physicians coordinate with enrollees and other physicians to provide the best care, whether the plan’s network providers give members health care that achieves the best results, and how other enrollees rate their doctors and the care they receive.

In the 2017 Open Enrollment period, CMS will pilot the display of star ratings using a 5-star rating scale. The pilot will be in several selected states that use the platform. During this period, we’ll continue testing consumer use and experience and improve the display of quality rating information. We also have provided the opportunity for state-based Marketplaces to choose to display quality rating information on their websites in the 2017 Open Enrollment period.

The pilot will include plans in Michigan, Ohio, Pennsylvania, Virginia, and Wisconsin — states that CMS selected because they have a large number of health plans participating. As with all quality ratings, they simplify a lot of information and in some cases, consumers would be wise to go beyond what they see here. Piloting the display of QRS star ratings will provide CMS with key feedback to inform the best way to provide quality rating information to consumers nationwide.

The introduction of Simple Choice plans and quality star ratings are just a few new features that will give consumers the information they may need to find a plan that is right for them and their families. We will continue to listen and learn as we get nearer to the next Open Enrollment period.


Moving toward improved care through information

By: Andy Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services
Dr. Karen DeSalvo, National Coordinator, Office of the National Coordinator for Health IT

Seven years ago, Congress passed a law to spur the country to digitize the health care experience for Americans and connect doctors’ practices and hospitals, thereby modernizing patient care through the Electronic Health Records (EHRs) Incentive Programs, also known as “Meaningful Use.” Before this shift began, many providers did not have the capital to invest in health information technology and patient information was siloed in paper records. Since then, we have made incredible progress, with nearly all hospitals and three-quarters of doctors using EHRs. Through the use of health information technology, we are seeing some of the benefits from early applications like safe and accurate prescriptions sent electronically to pharmacies and lab results available from home. But, as many doctors and patients will tell you (and have told us), we remain a long way from fully realizing the potential of these important tools to improve care and health.

That is why, as we mentioned earlier this year, we have conducted a review of the Meaningful Use Program for Medicare physicians as part of our implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), with the aim of reconsidering the program so we could move closer to achieving the full potential health IT offers.

Over the last several months, we have made an unprecedented commitment to listening to and learning from physicians and patients about their experience with health information technology – both the positive and negative. We spoke with over 6,000 stakeholders across the country, including clinicians and patients, in a variety of local communities. Today, based on that feedback, we are proposing to incorporate the program in to the Merit-based Payment System (MIPS) in a way that makes it more patient-centricpractice-driven and focused on connectivity. This new program within MIPS is named Advancing Care Information.

What We’ve Learned

In our extensive sessions and workshops with stakeholders, a near-universal vision of health information technology surfaced: Physicians, patients, and other clinicians collaborating on patient care by sharing and building on relevant information.

Three central priorities to address moving forward:

  1. Improved interoperability and the ability of physicians and patients to easily move and receive information from other physician’s systems;
  2. Increased flexibility in the Meaningful Use program; and
  3. User-friendly technology designed around how a physician works and interacts with patients.

This feedback created a blueprint for how we go forward to replace the Meaningful Use program for Medicare physicians with a more flexible, outcome-oriented and less burdensome proposal.

How We’re Moving Forward

Our goal with Advancing Care Information is to support the vision of a simpler, more connected, less burdensome technology. Compared to the existing Medicare Meaningful Use program for physicians, the new approach increases flexibility, reduces burden, and improves patient outcomes because it would:

  • Allow physicians and other clinicians to choose to select the measures that reflect how technology best suits their day-to-day practice
  • Simplify the process for achievement and provide multiple paths for success
  • Align with the Office of the National Coordinator for Health Information Technology’s 2015 Edition Health IT Certification Criteria
  • Emphasize interoperability, information exchange, and security measures and require patients to access to their health information through of APIs
  • Simplify reporting by no longer requiring all-or-nothing EHR measurement or quality reporting
  • Reduce the number of measures to an all-time low of 11 measures, down from 18 measures, and no longer require reporting on the Clinical Decision Support and the Computerized Provider Order Entry measures
  • Exempt certain physicians from reporting when EHR technology is less applicable to their practice and allow physicians to report as a group

A full list of the operational differences included in this new proposal is available here, along with more details on how it would work.

These improvements should increase providers’ ability to use technology in ways that are more relevant to their needs and the needs of their patients. Previously established requirements for APIs in the newly certified technology will open up the physician desktop to allow apps, analytic tools, and medical devices to plug and play. Through this new direction, we look forward to developers and entrepreneurs taking the opportunity to design around the everyday needs of users, rather than designing a one-size-fits-all approach. Already, developers that provide over 90 percent of electronic health records used by U.S. hospitals have made public commitments to make it easier for individuals to access their own data; not block information; and speak the same language. CMS and ONC will continue to use our authorities to eliminate barriers to interoperability.

Under the new law, Advancing Care Information would affect only Medicare payments to physician offices, not Medicare hospitals or Medicaid programs. We are already meeting with hospitals to discuss potential opportunities to align the programs to best serve clinicians and patients, and will be engaging with Medicaid stakeholders as well.

This proposal, if finalized, would replace the current Meaningful Use program and reporting would begin January 1, 2017, along with the other components of the Quality Payment Program. Over the next 60 days, the proposal will be available for public comment. It is summarized here and the full text is available here . We will continually revise and improve the program as we gather feedback from patients and physicians providing and receiving care under the Advancing Care Information category – and the Quality Payment Program as a whole. We look forward to hearing from you and working together to continue making progress in the coming months and years.

Medicaid Moving Forward

By Andy Slavitt, CMS Acting Administrator and Vikki Wachino, CMS Deputy Administrator and Director for the Center for Medicaid and CHIP Services

If you haven’t been paying close attention over the last several years, you may have missed some of the major changes that have taken place in the Medicaid program.

You may know that some 72 million Americans rely on Medicaid as their source of health insurance coverage this year – 14 million more than in October 2013 thanks largely to the Affordable Care Act’s coverage expansion. For millions of children who need checkups or follow up care, pregnant women who want their babies to get a healthy start in life, adults who need health coverage when they unexpectedly lose a job, or people with disabilities who want to live independently in their communities, Medicaid has been there over the last 50 years to provide comprehensive health coverage to millions low-income American families.

But a lot has happened to health insurance coverage through Medicaid over the past several years as millions more people have gained coverage because of the Affordable Care Act: The federal government and the states have sought to strengthen the program’s focus on the consumer, the delivery of high quality care, and providing greater access points, and on developing a modern set of rules.

Today, we’re taking a next step in that work today by finalizing a long-anticipated rule that updates how Medicaid works for the nearly two-thirds of beneficiaries who get coverage through private managed care plans. These improvements modernize the way these managed care health plans operate so that Medicaid and CHIP continue to provide cost-effective, high quality care to consumers. The rule strengthens states’ efforts to support delivery system reform and authorizes the first-ever Medicaid and CHIP quality rating system so that states can publicly report plan quality information, and people can use that information to select plans. It also deploys 21st century tools to improve beneficiary communications, like electronic notices to beneficiaries and creating online provider directories. It better aligns key rules and practices with those of Marketplace and Medicare Advantage, including the addition of reporting medical loss ratio to Medicaid to ensure managed care plans focus on delivering care, not profits. And the rule also helps strengthen and improve the delivery of health care to low-income children served by the Children’s Health Insurance Program (CHIP).

But before you look at a summary of these rules, it’s worth catching you up on other major developments in Medicaid that affect every aspect of the consumer’s experience–from enrolling, to accessing high quality care, to the availability of home and community-based services.

  1. A modern enrollment experience. Applying and enrolling in Medicaid coverage is now easier than it once was and similar to the processes for applying for other health insurance programs. Enrolling into Medicaid was once very complicated, involving lots of paperwork, long waits and in-person interviews. Now, most people apply on line, by phone, or at a location convenient for them. More convenient, one-stop enrollment is possible in part thanks to sophisticated technology pursuant to the Affordable Care Act that allows enrollee information to be verified electronically – and without paper documentation. In some states, as many as 50 percent of individuals now enroll through these automated processes.
  2. Access to high quality physicians and other care providers. Access to quality health servicesis always a central focus of CMS, which was strengthened through new policies recently that seek to ensure access to care. Today’s rules take additional steps that will more tightly align payment with better, more cost-effective care. And new rules create real accountability to ensure access to care is sufficient in key specialties. Thanks in part to the work that CMS and states have done to make sure people have access to health services, adults with Medicaid coverage are just as likely to obtain primary care services as  those with private insurance, while experiencing less difficulty paying their medical bills than others. And, people with Medicaid coverage report very high satisfaction, even higher than those who get health insurance through their place of employment.
  3. Quality care to strengthen health outcomes. Medicaid is also transforming the delivery of care. States are making gains in using population based payments, episodes of care, and quality-based payments. In addition, states operate 30 health home programs that focus on coordinating care for people with chronic conditions like obesity, diabetes and mental health conditions. Over the last several years, sates have undertaken significant efforts through State Innovation Models, integrated care models, and delivery system reform incentive programs to create alignment with physicians and hospitals to provide the highest quality of care. And we have proven that when we and states dedicate ourselves to changing the delivery of care, we get results. Consider the role Medicaid has played in supporting seniors and people with disabilities to receive care in their communities. Twenty years ago, more than 80 percent of Medicaid spending on long-term services was on institutional care. Now, thanks to CMS’ and states’ work to make more options available, community-based care has significantly increased. Medicaid has also partnered with several national organizations at the provider, consumer and state levels to help us think through ways to improve both the delivery and quality of care Medicaid and CHIP provides, such as the March of Dimes, the Medicaid State Dental Association and seven academic Centers of Excellence.
  4. A platform for innovation. Medicaid innovates more quickly when states have the tools to respond to the needs of their residents. To help support these delivery system reforms through improvements to the coordination of patient care, states, with the support of CMS, are working to update legacy IT systems to ones that leverage proven IT methods. This is key in helping to deploy tools, such as electronic health records, that improve the coordination of patient care, further supporting innovative efforts that lead to smarter spending and healthier people.

Most importantly, Medicaid is there when you need it, for working class families, working Americans, people falling on temporary hard times, or living with a disability. Take Todd, a full time student with two part time jobs in Utah who was recently profiled by the Kaiser Family Foundation. He and his wife, Erin, were uninsured but had a new baby. They learned that Erin and their baby Jane were eligible for Medicaid. “When we found out that my wife and Jane would be covered, it definitely felt like a burden lifted a weight off our shoulders,” Todd said. “We don’t make enough to really take care of ourselves the way we would like to.”

It’s because of people like Todd and Erin and people like you that we have invested so heavily and thoughtfully in Medicaid and put forward the rules we have today, which will also support physicians and hospitals and states in improving service, quality and health for millions of Americans.


Pursuing Health Equity for the Nation

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

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

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

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

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

Seeking New Approaches

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

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

Delivering Health Information and Services via Telecommunications

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

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

Reducing Disparities in Chronic Disease Treatment and Outcomes

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

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

Accelerating Health Equity

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


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