Round One Health Care Innovation Awards Show Some Promising Results

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

The Health Care Innovation Awards is a Centers for Medicare & Medicaid Services (CMS) Innovation Center initiative that tests new payment and service delivery models and aims to find better ways to deliver care and bring down costs for Medicare, Medicaid, and/or Children’s Health Insurance Program (CHIP) enrollees. Today we are sharing the second annual independent evaluation reports of round one of the Health Care Innovation Awards. Overall, these evaluation reports show a wide range of experiences that have resulted in tangible benefits for patients and helped inform CMS in the development of new payment and service delivery models.

Where data are available, these reports describe preliminary impact estimates on key outcome measures such as hospitalizations and readmissions. A number of awardees showed favorable results on one or more measures of cost, hospitalizations, readmissions, and emergency room visits. Here are some early highlights of a few of the awards:

  • Innovative Oncology Business Solutions, Inc. – through its Community Oncology Medical Home – reached more than 2,100 cancer patients through seven community oncology practices across the United States. Through comprehensive and coordinated oncology care, the model established pathways that:
    • allowed providers to identify and manage symptoms in real time;
    • improved patient access to providers through same-day appointments and extended night and weekend office hours; and
    • provided disease management guidance for providers to improve treatment decision-making, symptom recognition, and assistance with patients’ self care, pain management, and caregiver support.

The evaluation report shows that this award demonstrated a significant reduction in hospital readmissions and emergency room visits. In addition, qualitative findings suggest that staff highly value the triage pathways for making their workflow more efficient, and patients greatly appreciate weekend hours and increased capacity for urgent care visits during the day. Elements of this model were incorporated into the design of the Oncology Care Model.

  • The High-Risk Children’s Clinic at the University of Texas Health Science Center at Houston’s (HRCC) offered dedicated outpatient services (primary, specialty, post-acute, chronic disease management) and around-the-clock phone access for extremely fragile and complex chronically ill children enrolled in Medicaid. Every family in the HRCC has an assigned clinician who involves the parent in all health assessments, empowering parents as experts in their child’s health condition and educating families on exacerbating symptoms. The evaluation found that the program significantly reduced emergency department visits and hospital admissions, which drove savings in medical and hospital cost of care for participating children. In addition, the report finds that the patient and family centered approach appears to have resulted in improved patient and family caregiver experience.
  • Welvie is a program that offers education, health information, and decision-making resources regarding preference-sensitive surgeries to Medicare beneficiaries. Welvie conducts regularly scheduled, population-based outreach well before treatment decisions need to be made. Program administrators also review regional health care utilization patterns and mail outreach materials to arrive before periods of increased surgery utilization so that beneficiaries can recall and access the resources when needed. The program has enrolled over 181,000 beneficiaries in Ohio and almost 54,000 beneficiaries in Texas. Enrollees in Ohio had a statistically significant decrease in mortality as well as indications of a reduction in hospital readmissions following surgery-related hospital admissions for the Medicare FFS beneficiaries. The program was also associated with reductions in various surgery-related categories of expenditures among Medicare Advantage beneficiaries.

Diabetes Prevention Program

We recently announced that a round one Health Care Innovation Awards project — the Diabetes Prevention Program – is eligible for expansion under Medicare. The National Council of Young Men’s Christian Associations of the United States of America (Y-USA) enrolled eligible Medicare beneficiaries at high risk for diabetes in a program that could decrease their risk for developing serious diabetes-related illnesses. Beneficiaries in the program attended weekly meetings with a lifestyle coach who trained participants in strategies for long-term dietary change, increased physical activity, and behavior changes to control their weight and decrease their risk of type 2 diabetes. After the initial weekly training sessions, participants could attend monthly follow-up meetings to help maintain healthy behaviors. The main goal of the program was to improve participants’ health through improved nutrition and physical activity, targeting at least a five percent weight loss for each individual.

The independent CMS Office of the Actuary certified that expansion of the Diabetes Prevention Program would reduce net Medicare spending. The expansion was also determined to improve the quality of patient care without limiting coverage or benefits. This is the first time that a preventive service model from the CMS Innovation Center has become eligible for expansion into the Medicare program.

Health Care Innovation Awards Background

In July 2012, the CMS Innovation Center awarded 107 cooperative agreements through round one of the Health Care Innovation Awards to implement the most compelling ideas that aimed to deliver better care while spending health care dollars more wisely. Up to $1 billion were awarded to organizations that tested projects across the country that worked to achieve better quality of care and save money for people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program. The evaluation reports are divided into large topical areas:

  • Behavioral health and substance abuse;
  • Complex and high risk patient targeting;
  • Community resource planning and prevention;
  • Disease specific;
  • Hospital interventions;
  • Primary care redesign; and
  • Shared decision making/medication management

The first annual evaluation reports were released in April 2015 and provided qualitative findings largely focusing on the implementation experience covering the period from the award date through summer 2014. The reports released today synthesize findings from additional rounds of interviews and site visits conducted from the award date through summer 2015, preliminary estimates of impacts on four core measures (cost, hospitalizations, readmissions, emergency room visits) depending on the intervention and data availability, and results from select surveys of providers focusing on workforce and primary care.

While the results of the awards are wide-ranging, the evaluation of round one of the Health Care Innovation Awards is still ongoing and future reports will add to the current results. There is still much to learn, and we hope that other public and private entities will continue to invest in initiatives and efforts that improve the health care system in this country.

For more information on round one of the Health Care Innovation Awards and to view the second annual evaluation reports, please visit: https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/

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 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf).

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: https://federalregister.gov/a/2016-10032. 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.

 

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.

The Next Step – Making the Most of Your Coverage

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

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

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

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

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

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

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

 

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

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

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

Extending participation in the Bundled Payments for Care Improvement initiative

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

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

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

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

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

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

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

Mapping Medicare Disparities

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

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

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

Mapping Tool Map

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

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

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Reflecting on Our Journey towards Health Equity

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

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

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

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

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

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

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