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: People with Medicare can use the Medicare Plan Finder online tool available at to search for plans available in their area and compare plan quality, costs, and coverage.


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

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

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

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

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

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

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

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

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

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


Remarks by Andy Slavitt: Talking with the industry about the future of health care in America

Talking with the industry about the future of health care in America

Below are the remarks as delivered by CMS Acting Administrator Andy Slavitt on October 5, 2016 at the forum on Marketplace Year 3: Issuer Insights and Innovations at the HHS Humphrey Building in Washington, D.C.


Thanks a lot Kevin and I really want to thank you all for being here today and for those of you watching on live stream. And as you return from lunch, I’m sure you’re ready for a good speech about SEPs and DMIs and other acronyms and other changes we are embarking on to keep improving the risk pools. Or the very exciting young adulting campaign.

But instead I’m going to talk about my commute to work.

When I fly into D.C. every Monday morning, there used to be long lines of us waiting for yellow cabs. More recently now, what I often see long lines of yellow cabs waiting as people walk, heads in their phones, across the street and directly into Ubers. In a short time, my experience was improved and a whole industry has radically changed. I saw something parallel happen in the early 2000s with online banking and brokerage. You used to need a broker to buy a stock, so only people who were really well-off really did it. As soon as E-Trade started offering trades for $8, it changed for better some might say for the worse– because everyone can buy stock now.

What’s been interesting is not just to see the innovation, but to see how incumbent players who have spent decades as undisputed leaders in their industries, make up their minds to adapt.  Big companies like Fidelity followed the online companies and brought their own unique scale and services into the mix. The biggest taxi company in Minnesota where I live that I used to use to get to the airport just put together an app called iHail so now I have two better choices.

For a lot of us, service has rapidly improved in our day to day lives and affordability has increased as industries have been disrupted by events– events like the digital and cloud based-economies—has seen new competition and new innovation.

It’s not just digital. There’s been regulatory disruption as well, which is a little closer to what we are talking about here. In 2003, when the FCC mandated mobile phone companies allow for phone number portability, this was considered a really big deal at the time, one industry executive predicted it would doom the industry as customers would become fickle and change mobile phone carriers every month for even slight decreases in price.

But you know that didn’t happen, the rampant churn and race to the bottom that many predicted ended up not happening as one carrier after another built loyalty programs– buying iPhones and Android upgrades for their long-term customers and integrating new “stickier” services and entertainment packages.

Another example, as emission standards moved up on American auto makers, the very demise of the auto industry was predicted. There was even a New York Times article written in 2009 entitled “Does the U.S. Need an Auto Industry?” There were similar headlines in other places.

Yet, just two years later came the story “How Ford went from losing $30 billion to posting big profits.”

Fast forward to today. If you look at the most recent auto sales from 2015 in the area where U.S. manufacturers have been historically least competitive– high end luxury sales– here’s what you’d find. Overall, industry sales were about flat, but it wasn’t a good year for a lot of companies.

Audi, down 8%
BMW, down 5%
Jaguar, down 16%
Lexus, down 16%
Mercedes, down 13%
Porsche, down 13%

So if sales were flat, where did those car buyers go?

The luxury brand that grew in 2015 was actually an American company– Tesla, which grew by more than 50 percent, and moved to #1 in market share. How? They brought a new vision of environmental consciousness to the luxury market. In fact, for those who thought the auto industry was doomed, we have seen that companies have come along and reinvented it, 2015 was U.S. manufacturers’ best year of sales ever, with a Chevy winning car of the year and with another all-electric Chevy one of the most anticipated new cars for 2017.

So, the answer to all the newspaper headlines is indeed, yes. American companies can transform and lead.

Over the past four decades, we’ve seen over and over again how new regulatory systems, new technologies, and new approaches change industries in America. And dating back to when the airlines were deregulated and the baby bells were broken up to the examples I just talked about, virtually every industry has under gone this type of a transformation– lowering costs in the end, expanding markets in the process, and delivering better services to people — now often out of necessity, but eventually leading to real success.

Now going through the process wasn’t necessarily easy and there was turmoil, but as any of the headlines that have alternatively doomed the auto industry, the financial services industry, Internet companies, and many others have proclaimed. But the thing we know is when the rules of the game change, winners emerge. It’s not just the “disrupters”– the Southwest’s airlines, the Tesla’s, the E-Trade’s of the world that have been successful.

The incumbent companies who saw that what was coming or adjusted to the new environment by bringing their own strengths turned out to be big winners. There are plenty of examples we know of that history can point us to that are fairly well known. Fidelity opened retail outlets and used its asset base to take on e-trade; H&R Block went on line and used its bricks and mortar to take on TurboTax. Wal-Mart used its buying power to adjust to Amazon and online retail.

Ok, why am I giving one of my last speeches of this term about industries in transformation instead of the more topical topics like the risk pool, Special Enrollment Periods or Open Enrollment? It’s really just to ask the question . . . Has health care’s turn to transform finally come?

Let’s start with what is the major disruption to American health care. Major disruption is this, for the first time in our country, we are promising our fellow citizens that even if they get sick or even if they have ever been sick, even if they lose their job, even if they have a lower income, we will insure them against their future care needs. And, by the way unlike in the auto industry, where we had dramatically shrinking markets and under-capitalized companies, what we see here is the opening up of a new $40 billion and growing market with lots of capital. So we are taking better care of people, we got the wherewithal to do it.  As disruptions go, this is a pretty great one.

We’ve chosen to address the need to transform in most traditional American way possible– through the private sector. Which means we’re relying on innovation and competition to serve consumers best. And as a country, we will all have to figure out what that looks like–what needs to change and what needs to stay the same. If critics want to pretend it happens automatically, just looking at other industries tells you that it doesn’t. If critics think we should abandon consumers and go back to the old way because it’s not all figured out just yet– the same way some that many predicted the demise of the auto industry– that misses the fundamental premise of: 1) how progress is actually made in our country; and, 2) your ability to innovate.

What are the biggest sources of current angst in the media? Rates are increasing. Many plans in many markets were underpriced over the first several years of the exchange. Why? What can we learn from this? I think it’s pretty simple. Nobody knew what it would cost to cover sick people. We’re still learning that.

Intellectual honesty requires us to say that rates are right now about 18 percent below what was originally projected. Would we all have preferred to be 10 percent higher say from the start with more gradual increases? Of course. You bet we would. But rates will adjust, and as they do the ACA will protect consumers with tax credits and with rebates if rates go up too much.

It’s also important to know that new disruptions require us to learn and adjust. If anyone’s premise was that by passing one law, we would fix the affordability of health care all at once, that’s just not how it works. We’re here because the law sets a path in motion.

Can things be improved with the law? Can we and the Administration and Congress continue to make the Marketplace better? Without question. But while some will want to spend their time hoping to roll back the rules or go back to the old way, leaders– many in this room, many who we have visited with– are looking at this time as an opportunity of competitive advantage; they are spending this period scrupulously experimenting– and profiting.

So forgive me if I’m not persuaded by the headlines or the Wall Street analysts predicting doom and gloom for the health care Marketplace.

I’ve had conversations with senior leaders at some of the companies I have talked about at Fidelity Investments, Delta Airlines, Intuit and others about that time in their lives in their industries when things were changing rapidly. And as you would expect, these were uncertain times with pressures from boards and Wall Street; a lot of uncertainty, the only certainty came from the doom and gloom they read about in the media.

Now the Secretary, Kevin Counihan, Mandy Cohen and I have also made it a point to personally talk to many of the CEOs and management teams about your experiences– what’s working, what’s not– and what both the data and your  own leadership instincts are telling you. Through this, we’ve compiled a list of five questions that I would suggest every organization might want to ask to be successful in this space.

First, what’s your vision and cultural reference point for serving this population?

It may seem like a strange question to start with, but in almost every conversation with the highest performers in the Marketplace, they start the conversation with an explicit reference to how this business relates to their mission and to what their employees believe. The missions aren’t always the same– some describe a focus explicitly on meeting the retail needs of consumers some see this as a transitional moment ahead moving from a business-to-business world to business-to-consumer world, some are focusing on providing care to under-served populations, others have a data-oriented culture, some deep community relationships that they know how to work through and some pride themselves on having nimble culture. The cultural focus in all those cases allows them to not only perform well, it’s actually helped them to galvanize their employees from across their organizations to meet the new opportunities of the Marketplace far more easily.

Second, how well do you know your customer?

Universally, we hear more than ever before, that you have to microscopically understand how consumers choose to buy, pay, seek care, and decide to persist. We all tend to think we know our customers’ needs, but do you know their health needs the same way Google knows your search needs? Do you know who’s most likely to misuse the ER because they have never had primary care relationships? Do you know what millennials want in a health care relationship? Do you know which diabetics are compliant and do you know which ones are most likely to respond to interventions.

An emerging best practice in the Marketplace from a number of you is to conduct health risk assessments at the time ID cards are activated to begin the relationship and the segmentation and stratification process that is so crucial to answering these questions. Now I would remind you, these skills that require you to do this exist everywhere in our economy they are the same consumer skills that have made each and every one of the industries I have talked about successful.

Third, can you build a relationship with consumers around things they need and value?

Particularly if you see churn in your book– as people move in and out of jobs and struggle with affordability, how do you build loyalty? Are you building on-boarding processes, monthly touch points, and other initiatives that create “stickiness.” Remember, consumers don’t like churning any more than you do. They are asking for reasons to stay in everything they do consumer have demonstrated they want to build relationships. We have to give them a reason.

Progressive Auto Insurance famously measures how safely people drive and allows them to earn points for safe driving which lowers costs and creates loyalty. I think there’s a misconception that you can’t have loyalty programs in the exchange. Not true. There are a number of successful ones. Using best practices is also delivering real bottom line results. Let me give you some rough numbers here, for most companies, something on the order of 25-30 percent of consumers don’t make timely binder payments.[1]

But for the top five companies in this category that number looks more like 10-15 percent.[2] What do they do differently? Well starting with they ask people why they weren’t paying. In many cases, a concern with credit held them back. One company began offering a program call Cashtie so payments could be made at local drug stores; one added a MoneyGram option; one added a smartphone app. And when one customer showed up at a company’s corporate headquarters with a check in hand, they started taking checks.

Fourth, have you created a product that meets the needs of your customers both for service and affordability– not a commercial product, not a Medicaid product– but a Marketplace product?

That’s not just a question of a tiered network and formulary or the question of broad or narrow network. It’s also how that network is engaged. Southwest Airlines had far fewer destinations than other airlines, but they turned that into a distinct advantage, turning “narrow” into “focused” as they targeted specific customers for the unique experience.

One area I have heard about from a number of plans is that some newly insured members continue to use the ER four or five times a year for services that they should get elsewhere. So here is an example, do you have your first tier hospitals contracted to manage aggressive ER utilization so people can get care in the right setting? Have you set up telemedicine, nurse lines, and other convenient forms of both coaching and steerage? Is there free primary care and other incentives to detect health concerns early? How financially engaged can you make your physician network to manage and reduce bed days? The broader point her is that if we think people many of whom have gone without insurance for years and years and years to automatically know how to use the system or behave like any of your other members, we are learning that is just not true.

Fifth, and finally, when you find what works how do you replicate it into a growth strategy?

A number of companies have told us they went too headstrong into too many markets and grew too fast before they had the opportunity to see how things were really working. Before they landed on consumer targeting, network and product strategies. Before they had models to replicate. Almost everyone, including those who are contracting this year, have told us they want to find a way to grow into this market and are still committing significant capital to getting their models right. One commercial plan is using Medicare Advantage physician collaborative to grow. Another, their Medicaid contracts. A third told me that step by step they see this as a chance to become a more national plan.

Mission, understanding the new customer, building relationships, designing the right products and turning that all into a growth strategy. These are some commonalities that we are hearing emerge in this Marketplace. But there is something else that I’ve observed the great companies in this room do well—and that is really simple.  It’s appreciate the joy and the meaning of delivering health and security to people. They tend not to describe people as “populations” or “pools” or “diabetics”; they understand that in the new world, the job is taking on sicker people and doing it better. They are not only committed to making people healthier every year, but they actually see greater financial opportunity in reducing acute episodes, in getting individuals to the right clinic, in making sure babies are born healthy, in bringing peace of mind to families, and in helping people get health issues  diagnosed early. They are actually winning because, in the new world, they see how to replace underwriting with care management.

No, none of this is not to take away from challenges that remain, as the President has said, in the “growing pains” of this new enterprise. The President specifically pointed to the “real problems” that remain to be addressed in making the ACA work better. Now it’s not because he’s pessimistic, but because he’s optimistic that the “growing pains” would actually be the time when we Americans make great progress. We at CMS and in the Administration are committed to taking these problems head on with you in what I see very much in the context of the classic American story of innovation and renewal.

Thank you all for your leadership. I look forward to an exciting open enrollment season.

[1] 2016 CCIIO Effectuation Rates
[2] 2016 CCIIO Effectuation Rates

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