Potentially avoidable hospital readmissions

CMS Blog
http://blog.cms.gov/2016/09/13/new-data-49-states-plus-dc-reduce-avoidable-hospital-readmissions

 

September 7, 2016

By Patrick Conway, M.D., principal deputy administrator and chief medical officer, CMS; and Tim Gronniger, deputy chief of staff, CMS

The unfortunate experience of having to return to the hospital after recently being treated—or watching the same thing happen to a friend or family member—is all too common. Potentially avoidable hospital readmissions that occur within 30 days of a patient’s initial discharge are estimated to account for more than $17 billion in Medicare expenditures annually.[1]  Not only are readmissions costly, but they are often a sign of poor quality care. Many readmissions can be avoided through improvements in care, such as making sure that patients leave the hospital with appropriate medications, instructions for follow-up care, and follow-up appointments scheduled to make sure their recovery stays on track.

 

To address the problem of avoidable readmissions, the Affordable Care Act created the Hospital Readmissions Reduction Program, which adjusts payments for hospitals with higher than expected 30-day readmission rates for targeted clinical conditions such as heart attacks, heart failure, and pneumonia. The Centers for Medicare & Medicaid Services has also undertaken other major quality improvement initiatives, such as the Partnership for Patients, which aim to make hospital care safer and improve the quality of care for individuals as they move from one health care setting to another.

 

The data show that these efforts are working. As described below, between 2010 and 2015, readmission rates fell by 8 percent nationally. Today, CMS is releasing new data showing how these improvements are helping Medicare patients across all 50 states and the District of Columbia. The data show that since 2010: 

·         All states but one have seen Medicare 30-day readmission rates fall.[2]

·         In 43 states, readmission rates fell by more than 5 percent.

·         In 11 states, readmission rates fell by more than 10 percent.

 

 

 

Across states, Medicare beneficiaries avoided almost 104,000 readmissions in 2015 alone, compared to if readmission rates had stayed constant at 2010 levels. That means Medicare beneficiaries collectively avoided 104,000 unnecessary return trips to the hospital. Cumulatively since 2010, the HHS Assistant Secretary for Planning and Evaluation estimates that Medicare beneficiaries have avoided 565,000 readmissions.

 

The Hospital Readmissions Reduction Program is just one part of the Administration’s broader strategy to reform 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. Other initiatives include Accountable Care Organizations, as well as efforts by Quality Improvement Organizations and Hospital Engagement Networks, which fund quality improvement expert consultants to work with provider and hospital communities to improve care. The goal of all of these efforts is to spend our health care dollars more wisely to promote better care for Medicare beneficiaries and other Americans across the country.

State	2010		2015		% Change in Readmission Rates	Reduction in readmissions in 2015 compared to 2010
	Hospital Admissions	Readmission Rate	Hospital Admissions	Readmission Rate
AK	9,809	14.50%	9,954	13.70%	-5.50%	-78
AL	154,856	17.20%	143,210	16.20%	-5.80%	-1,503
AR	103,056	17.70%	92,562	16.60%	-6.20%	-993
AZ	135,293	16.60%	128,061	14.80%	-10.80%	-2,270
CA	574,176	17.60%	547,558	16.60%	-5.70%	-5,580
CO	83,346	14.20%	81,822	12.90%	-9.20%	-1,099
CT	109,888	18.10%	96,492	16.70%	-7.70%	-1,306
DC	23,907	20.00%	23,194	18.50%	-7.50%	-346
DE	29,827	17.40%	32,257	15.60%	-10.30%	-575
FL	619,368	18.20%	588,187	17.70%	-2.70%	-3,161
GA	209,500	17.50%	191,485	16.20%	-7.40%	-2,453
HI	16,824	14.90%	15,799	12.90%	-13.40%	-315
IA	100,490	15.50%	91,256	14.50%	-6.50%	-910
ID	25,432	12.50%	28,139	12.20%	-2.40%	-78
IL	421,395	19.80%	335,610	17.40%	-12.10%	-8,108
IN	210,919	17.40%	186,241	16.10%	-7.50%	-2,474
KS	90,545	16.30%	87,224	14.70%	-9.80%	-1,361
KY	162,249	19.70%	132,511	17.90%	-9.10%	-2,384
LA	129,123	18.70%	112,328	16.90%	-9.60%	-2,013
MA	208,356	19.00%	197,649	17.90%	-5.80%	-2,213
MD	189,323	21.10%	170,510	18.90%	-10.40%	-3,789
ME	43,450	16.10%	38,571	15.50%	-3.70%	-232
MI	343,346	18.60%	280,152	18.00%	-3.20%	-1,767
MN	129,642	15.70%	130,725	14.60%	-7.00%	-1,435
MO	203,685	18.20%	174,677	16.90%	-7.10%	-2,311
MS	106,281	19.10%	96,252	17.60%	-7.90%	-1,469
MT	27,962	13.90%	27,518	13.10%	-5.80%	-231
NC	269,108	17.00%	235,283	15.90%	-6.50%	-2,472
ND	26,562	15.40%	26,650	14.40%	-6.50%	-267
NE	60,007	15.70%	56,791	14.40%	-8.30%	-735
NH	36,189	15.70%	39,871	15.30%	-2.50%	-152
NJ	281,282	20.30%	250,924	17.60%	-13.30%	-6,774
NM	36,209	15.20%	33,016	14.80%	-2.60%	-118
NV	51,787	18.00%	52,308	17.00%	-5.60%	-529
NY	491,897	19.90%	402,439	17.80%	-10.60%	-8,407
OH	325,091	18.80%	267,743	16.80%	-10.60%	-5,405
OK	119,346	17.40%	106,073	15.60%	-10.30%	-1,878
OR	58,182	14.30%	61,393	14.20%	-0.70%	-75
PA	369,418	18.10%	324,166	16.60%	-8.30%	-4,995
RI	24,142	19.00%	24,705	17.00%	-10.50%	-487
SC	130,950	16.50%	125,993	15.50%	-6.10%	-1,237
SD	31,269	14.90%	30,806	13.20%	-11.40%	-515
TN	207,875	18.40%	180,666	16.80%	-8.70%	-2,905
TX	571,147	17.10%	509,738	16.10%	-5.80%	-4,960
UT	33,534	12.20%	38,142	11.50%	-5.70%	-261
VA	207,241	17.50%	211,674	16.40%	-6.30%	-2,302
VT	15,439	15.30%	16,332	15.40%	0.70%	21
WA	130,798	15.30%	131,817	14.20%	-7.20%	-1,388
WI	137,336	15.60%	124,274	14.50%	-7.10%	-1,373
WV	70,144	19.90%	60,630	18.60%	-6.50%	-777
WY	13,277	15.10%	12,838	14.20%	-6.00%	-110

 

 

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[1] Jencks, S. F., Williams, M. V. and Coleman, E. A. (2009). 'Rehospitalizations among patients in the Medicare fee-for-service program'. New England Journal of Medicine, 360 (14), 1418-1428.

[2] The readmission rate in Vermont was virtually unchanged, increasing slightly from 15.3% in 2010 to 15.4% in 2015. This change correlates to 21 additional readmissions compared to if the state’s rate had remained constant.

CMS BLOG
http://blog.cms.gov/2016/09/08/QualityPaymentProgram-PickYourPace

September 8, 2016
By Andy Slavitt, Acting Administrator of CMS

“Plans for the Quality Payment Program in 2017: Pick Your Pace"

As the baby boom generation ages, 10,000 people enter the Medicare program each day. Facing that demand, it is essential that Medicare continues to support physicians in delivering high-quality patient care. This includes increasing its focus on patient outcomes and reducing the obstacles that make it harder for physicians to practice good care.

The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) offers the opportunity to advance these goals and put Medicare on surer footing. Among other policies, it repeals the Sustainable Growth Rate formula and its annual payment cliffs, streamlines the existing patchwork of Medicare reporting programs, and provides opportunities for physicians and other clinicians to earn more by focusing on quality patient care. We are referring to these provisions of MACRA collectively as the Quality Payment Program.

We received feedback on our April proposal for implementing the Quality Payment Program, both in writing and as we talked to thousands of physicians and other clinicians across the country. Universally, the clinician community wants a system that begins and ends with what's right for the patient. We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians. We will address these areas and the many other comments we received when we release the final rule by November 1, 2016.

But, with the Quality Payment Program set to begin on January 1, 2017, we wanted to share our plans for the timing of reporting for the first year of the program. In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017. During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019. These options and other supporting details will be described fully in the final rule.

First Option: Test the Quality Payment Program.

With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar year.

You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.

Third Option: Participate for the full calendar year.

For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, 2017. For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We've seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.

Fourth Option: Participate in an Advanced Alternative Payment Model in 2017.

Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

However, you choose to participate in 2017, we will have resources available to assist you and walk you through what needs to be done. And however you choose to participate, your feedback will be invaluable to building this program for the long term to achieve outcomes that matter to your patients.

We appreciate the sincere and constructive participation in the feedback process to date and look forward to advancing step-by-step in that same spirit. We look forward to releasing the final details about the program this fall. Most importantly, we look forward to further engagement with physicians and other clinicians toward our shared goal of the highest quality of care and best outcomes for patients.

Competitive bidding program continues to maintain access and quality while helping to save Medicare millions

CMS News

FOR IMMEDIATE RELEASE
September 8, 2016

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 

Competitive bidding program continues to maintain access and quality while helping to save Medicare millions

Overview

The Centers for Medicare & Medicaid Services (CMS) today announced the new single payment amounts and began sending contract offers to successful bidders for Medicare’s Round 1 2017  Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. These new payment amounts and contracts go into effect on January 1, 2017. This program has been an essential tool to help Medicare set appropriate payment rates for DMEPOS items and save money for beneficiaries and taxpayers while ensuring access to quality items.

Prior to the DMEPOS Competitive Bidding Program, Medicare paid for these DMEPOS items using a fee schedule that is generally based on historic supplier charges from the 1980s. Numerous studies from the Department of Health and Human Services Office of Inspector General and the Government Accountability Office have shown these fee schedule prices to be excessive, and taxpayers and Medicare beneficiaries bear the burden of these excessive payments.   

Under the Competitive Bidding Program, DMEPOS suppliers compete to become Medicare contract suppliers by submitting bids to furnish certain items in competitive bidding areas. Since implementation of the DMEPOS Competitive Bidding Program on January 1, 2011, CMS has saved approximately $220 million per year in the nine Round 1 metropolitan statistical areas (MSAs) due to competitive bidding and other CMS fraud, waste, and abuse initiatives. Health monitoring data indicate that the program implementation is going smoothly with few inquiries or complaints and no negative beneficiary health outcomes.   

The Round 1 Recompete contract period expires on December 31, 2016. Round 1 2017 contracts will become effective on January 1, 2017 through December 31, 2018.

Background

The Medicare DMEPOS Competitive Bidding Program was established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (“Medicare Modernization Act” or “MMA”) after the conclusion of successful demonstration projects. Under the MMA, the DMEPOS Competitive Bidding Program was to be phased in so that competition under the program would first occur in 10 MSAs in 2007. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) temporarily delayed the program in 2008 and made certain limited changes. In accordance with MIPPA, CMS successfully conducted the supplier competition again in nine areas in 2009, referring to it as the Round 1 Rebid.

MIPPA also delayed the competition for Round 2 from 2009 to 2011 and authorized national mail-order competitions after 2010.  The Affordable Care Act of 2010 (ACA) expanded the number of Round 2 MSAs from 70 to 91 and specified that all areas of the country be subject to either DMEPOS competitive bidding or payment rate adjustments using competitively bid rates by January 1, 2016.

Competitive bidding contracts and pricing have been in place in Round 1 areas since January 1, 2011, and since July 1, 2013, in Round 2 areas. The national mail-order program for diabetes testing supplies was first implemented on July 1, 2013, with recompeted contracts and pricing being in place since July 1, 2016. Like Round 1 2017, Round 2 Recompete and the national mail-order recompete contracts will expire on December 31, 2018, at which point CMS will be implementing a consolidated round of competition to include all Round 1, Round 2, and national mail order competitive bidding areas.

Contract Award Process

The DMEPOS Competitive Bidding Program’s bid evaluation process ensures that there will be a sufficient number of suppliers to meet the needs of the beneficiaries living in a competitive bidding area. The new single payment amounts resulting from the competition replace the previous single payment amounts for the bid items in these areas. Small suppliers, those with gross revenues of $3.5 million or less, make up about 46 percent of the suppliers that will be offered contracts for Round 1 2017. All suppliers that are offered contracts went through a thorough vetting process and are accredited and meet financial and applicable licensing standards. 

CMS will now begin offering contracts to winning bidders. 1,523 contract offers will be made to 198 Round 1 2017 bidders. Of these offers, 97 percent are to bidders who currently furnish items in the awarded area or within the product category. The winning suppliers have 603 locations to serve Medicare beneficiaries in the competitive bidding areas. CMS expects to complete the contracting process in time to announce the contract suppliers in the fall of 2016. Bidders that are not offered contracts will be notified of the reasons why they did not qualify for the program when the contracting process is complete. Suppliers that are not contract suppliers for this round of the DMEPOS Competitive Bidding Program may bid in future rounds, unless they are precluded from participation in the program.

Additional information on the distribution of contract offers is available at the following Web site: www.dmecompetitivebid.com.

REAL-TIME MONITORING

Importantly, the program has maintained beneficiary access to quality products from accredited suppliers in all competitive bidding areas. Extensive real-time monitoring data have shown successful implementation with very few beneficiary complaints and no negative impact on beneficiary health status based on measures such as hospitalizations, length of hospital stay, and number of emergency room visits compared to non-competitive bidding areas. In addition to our real-time claims monitoring, CMS also requested feedback from beneficiaries through consumer satisfaction surveys conducted before and after the rollout of the program. CMS provides local, on-the-ground presence in each competitive bidding area through the CMS regional offices, local liaisons, and a Competitive Acquisition Ombudsman who closely monitors and responds to inquiries and complaints about the application of the program from beneficiaries who use items of DMEPOS under the program, contract suppliers who provide these items, and other stakeholders. There is also a formal complaint process for beneficiaries, caregivers, providers and suppliers to use for reporting concerns about contract suppliers or other competitive bidding implementation issues. In addition, contract suppliers are responsible for submitting reports identifying the brands of products they furnish, which is used to inform beneficiaries, caregivers, and referral agents. CMS will continue to employ the same aggressive program monitoring for future rounds.

ROUND 1 2017 PRODUCT CATEGORIES AND AREAS

The Round 1 2017 product categories are:

• Enteral Nutrients, Equipment, and  Supplies
• General Home Equipment and Related Supplies and Accessories
   o includes hospital beds and related accessories, group 1 and 2 support            surfaces, commode chairs, patient lifts, and seat lifts
• Nebulizers and Related Supplies
• Negative Pressure Wound Therapy (NPWT) Pumps and Related Supplies and Accessories
• Respiratory Equipment and Related Supplies and Accessories
  o includes oxygen, oxygen equipment, and supplies; continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies and accessories
• Standard Mobility Equipment and Related Accessories
  o includes walkers, standard power and manual wheelchairs, scooters, and related accessories
• Transcutaneous Electrical Nerve Stimulation (TENS) Devices and Supplies

For a list of the specific items in each product category, or for a list of the areas included in Round 1 2017, visit the Competitive Bidding Implementation Contractor website at www.dmecompetitivebid.com.

Round 1 2017 Timeline of Events

September 8, 2016     CMS announces new payment rates for Round 1 2017 and begins contracting process with winning suppliers

Fall 2016                     CMS announces the Medicare contract suppliers for Round 1 2017; intensifies supplier, referral agent, and beneficiary education program

January 1, 2017         Implementation of Medicare DMEPOS Competitive Bidding Program Round 1 2017 contracts and prices

ADDITIONAL INFORMATION

For additional information about the Medicare DMEPOS Competitive Bidding Program, please visit: http://www.cms.hhs.gov/DMEPOSCompetitiveBid/.

CMS finalizes rule to bolster emergency preparedness of certain facilities participating in Medicare and Medicaid

CMS News

FOR IMMEDIATE RELEASE
September 8, 2016

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 

CMS finalizes rule to bolster emergency preparedness of certain facilities participating in Medicare and Medicaid 

Today, the Centers for Medicare & Medicaid Services (CMS) finalized a rule to establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and man-made disasters.

Over the past several years, and most recently in Louisiana, a number of natural and man-made disasters have put the health and safety of Medicare and Medicaid beneficiaries – and the public at large – at risk. These new requirements will require certain participating providers and suppliers to plan for disasters and coordinate with federal, state tribal, regional, and local emergency preparedness systems to ensure that facilities are adequately prepared to meet the needs of their patients during disasters and emergency situations.  

“Situations like the recent flooding in Baton Rouge, Louisiana, remind us that in the event of an emergency, the first priority of health care providers and suppliers is to protect the health and safety of their patients,” said CMS Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., MSc. “Preparation, planning, and one comprehensive approach for emergency preparedness is key. One life lost is one too many.”

“As people with medical needs are cared for in increasingly diverse settings, disaster preparedness is not only a responsibility of hospitals, but of many other providers and suppliers of healthcare services. Whether it’s trauma care or long-term nursing care or a home health service, patients’ needs for health care don’t stop when disasters strike; in fact their needs often increase  in the immediate aftermath of a disaster,” said Dr. Nicole Lurie, HHS assistant secretary for preparedness and response. “All parts of the healthcare system must be able to keep providing care through a disaster, both to save lives and to ensure that people can continue to function in their usual setting. Disasters tend to stress the entire health care system, and that’s not good for anyone.”

After reviewing the current Medicare emergency preparedness regulations for both providers and suppliers, CMS found that regulatory requirements were not comprehensive enough to address the complexities of emergency preparedness. For example, the requirements did not address the need for: (1) communication to coordinate with other systems of care within cities or states; (2) contingency planning; and (3) training of personnel. CMS proposed policies to address these gaps in the proposed rule, which was open to stakeholder comments.

After careful consideration of stakeholder comments on the proposed rule, this final rule requires Medicare and Medicaid participating providers and suppliers to meet the following four common and well known industry best practice standards.

1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.

2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.

3. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems.

4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

These standards are adjusted to reflect the characteristics of each type of provider and supplier. For example:

• Outpatient providers and suppliers such as Ambulatory Surgical Centers and End-Stage Renal Disease Facilities will not be required to have policies and procedures for provision of subsistence needs.
• Hospitals, Critical Access Hospitals, and Long Term Care facilities will be required to install and maintain emergency and standby power systems based on their emergency plan.

In response to comments, CMS made changes in several areas of the final rule, including removing the requirement for additional hours of generator testing, flexibility to choose the type of exercise a facility conducts for its second annual testing requirement, and allowing a separately certified facility within a healthcare system to take part in the system’s unified emergency preparedness program.

The final rule also includes a number of local and national resources related to emergency preparedness, including helpful reports, toolkits, and samples. Additionally, health care providers and suppliers can choose to participate in their local healthcare coalitions, which provide an opportunity to share resources and expertise in developing an emergency plan and also can provide support during an emergency.

These regulations are effective 60 days after publication in the Federal Register. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date.

For more information please see a blog by Dr. Lurie, HHS assistant secretary for preparedness and response, and the CMS Survey & Certification – Emergency Preparedness webpage.

CMS BLOG
http://blog.cms.gov/2016/09/08/accountable-health-communities-track-1-funding-opportunity 

September 8, 2016
By Patrick Conway, M.D., principal deputy administrator and chief medical officer, CMS

Accountable Health Communities Track 1 Funding Opportunity 

In January 2016, the Centers for Medicare & Medicaid Services (CMS) released a new Funding Opportunity Announcement (FOA) for a model called the Accountable Health Communities (AHC) Model. This is the first Center for Medicare & Medicaid Innovation model to focus on the health-related social needs of Medicare and Medicaid beneficiaries. Many of these social issues, such as housing instability, hunger, and interpersonal violence, affect individuals’ health, yet they are rarely, if ever, detected or addressed during typical health care-related visits. The AHC Model is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.

The original Funding Opportunity Announcement requested applications for three different scalable tracks featuring interventions of varying intensity that would address health-related social needs for beneficiaries. After receiving significant interest, inquiries and stakeholder feedback, CMS has decided to make modifications to the Track 1 application requirements and is releasing a new FOA specific to Track 1 of the AHC Model. CMS believes two key modifications to Track 1 will make the model more accessible to a broader set of applicants

1.Reducing the annual number of beneficiaries applicants are required to screen from 75,000 to 53,000; and

2.Increasing the maximum funding amount per award recipient from $1 million to $1.17 million over 5 years.

Track 1 will support bridge organizations that are working to increase a patient’s awareness of available community services through screening, information dissemination, and referral. The Track 1 approach seeks to address the decreased capacity of clinical delivery sites to respond to beneficiaries’ health-related social needs because (1) health-related social needs remain undetected due to the lack of universal screening and (2) clinical delivery sites and patients may lack awareness about existing community service providers that could address those needs.  Track 1 award recipients will partner with the state Medicaid agency, community service providers and clinical delivery sites to implement the Model.

The AHC Model complements CMS’ growing focus on population health by providing the necessary tools and support for a successful transition to a holistic health system. The AHC Model will also enhance CMS’ understanding of the impact of interventions to address social needs on health care costs.

We look forward to the applications to this FOA. Please contact us at the email address below for further information.

Application Information:

Under this announcement, CMS is accepting applications from community-based organizations, health care practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and non-for- profit local and national entities with the capacity to develop and maintain relationships with clinical delivery sites and community service providers.  Applicants from all 50 states, U.S. Territories, or the District of Columbia (D.C.) may apply. All applicants, including those who applied to Tracks 1, 2 or 3 in the previous FOA, are eligible to apply to this FOA. Applicants that previously applied to Track 1 of the AHC Model under the original FOA (# CMS-1P1-17-001) must re-apply using this FOA (# CMS-1P1-17-002) to be considered for the Model.

The AHC Model is accepting applications for Track 1 at www.grants.gov through November 3, 2016.

Have a Question?

Questions about the AHC Model can be sent to AccountableHealthCommunities@cms.hhs.gov.

Additional Information:

For more information about the AHC Model, please visit our website at https://innovation.cms.gov/initiatives/ahcm. Follow us on Twitter at @CMSinnovates

For more information regarding the release, please see the CMS fact sheet here: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-09-08.html

Medicare Advantage Value-Based Insurance Design Model

CMS News

FOR IMMEDIATE RELEASE
August 10, 2016

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 

Medicare Advantage Value-Based Insurance Design Model

The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation is announcing refinements to the design of the second year of the Medicare Advantage Value-Based Insurance Design (MA-VBID) model.  The MA-VBID model is an opportunity for Medicare Advantage plans (MA plans), including Medicare Advantage plans offering Part D benefits (MA-PD plans), to offer clinically nuanced benefit packages aimed at improving quality of care while also reducing costs.

In the second year of the model, beginning January 1, 2018, CMS will: open the model test to new applicants; conduct the model test in three new states - Alabama, Michigan, and Texas; add rheumatoid arthritis and dementia to the clinical categories for which participants may offer benefits; make adjustments to existing clinical categories; and change the minimum enrollment size for some MA and MA-PD plan participants. 

Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure enrollee cost sharing and other health plan design elements to encourage enrollees to use high-value clinical services – those that have the greatest potential to positively impact enrollee health.  VBID approaches are increasingly used in the commercial market, and evidence suggests that the inclusion of clinically-nuanced VBID elements in health insurance benefit design may be an effective tool to improve the quality of care while reducing its cost for Medicare Advantage enrollees with chronic diseases.  As part of the “better care, smarter spending, healthier people” approach to improving health care delivery, CMS will test VBID in Medicare Advantage and measure whether structuring patient cost sharing and other health plan design elements encourages enrollees to use health care services in a way that improved their health and reduces costs.

The first year of the MA-VBID model will begin January 1, 2017 and run for five years.  CMS will announce the MA plans participating in the test’s first year in September 2016.  CMS expects to release a Request for Applications for the second year of the model test in the fall of 2016, and will accept proposals from MA and MA-PD plans to offer VBID benefits in 2018.

In its first year, CMS will test the model in seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee.  Beginning January 1, 2018, CMS will also test the model in Alabama, Michigan, and Texas.  These states have been selected in order to be generally representative of the national Medicare Advantage market, including urban and rural areas, areas with both high and low average Medicare expenditures, areas with high and low prevalence of Low-Income Subsidies, and areas with varying levels of penetration of and competition within Medicare Advantage.  Test states have also been selected based on the availability of appropriate paired comparison areas for the purposes of evaluation.  Eligible MA plans in these states, upon CMS approval, may offer varied plan benefit designs for enrollees who fall into certain clinical categories identified and defined by CMS.  Benefit design changes made through this model may reduce cost sharing and/or offer additional services to targeted enrollees; however, targeted enrollees can never receive fewer benefits or be charged higher cost sharing than other MA enrollees in their plan as a result of the model.

Background

The existing Medicare Advantage “uniformity” requirement generally requires that an MA plan’s benefits and cost sharing be the same for all plan enrollees.  Because of this, clinically-nuanced VBID approaches have generally not been incorporated into MA or MA-PD plans.

The model will test the hypothesis that giving MA plans flexibility to offer supplemental benefits or reduced cost sharing to targeted groups of enrollees with CMS-specified chronic conditions in order to encourage the use of services that are of highest value to them, will lead to higher-quality and more cost-efficient care.  The increase in high-quality, cost-efficient care is expected to improve beneficiary health, reduce utilization of avoidable high-cost care, and reduce costs for plans, beneficiaries, and the Medicare program.  The model is also intended to improve outcomes and reduce costs by encouraging targeted enrollees to obtain care from high-value providers and by providing new supplemental benefits specifically tailored to targeted enrollees’ clinical needs.

The MA-VBID model is authorized under Section 1115A of the Social Security Act (added by section 3021 of the Affordable Care Act) (42 U.S.C. § 1315a), which authorizes the Center for Medicare and Medicaid Innovation to test innovative health care payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while preserving or enhancing the quality of beneficiaries’ care.  CMS will test this model in the Medicare program through a limited waiver of the Medicare Advantage and Part D uniformity requirements. 

Description

The MA-VBID model supports improved health outcomes and health care cost savings or cost neutrality through the use of structured patient cost sharing and other health plan design elements that encourage enrollees to use high-value clinical services.  The MA-VBID model will provide flexibility for MA and MA-PD plans accepted into the model to develop clinically-nuanced benefit designs for enrollee populations that fall within certain clinical categories.

The conditions are:

• Diabetes
• Chronic Obstructive Pulmonary Disease (COPD)                                                
• Congestive Heart Failure (CHF)
• Patient with Past Stroke                                    
• Hypertension
• Coronary Artery Disease                                   
• Mood disorders
• Rheumatoid Arthritis (starting in 2018)
• Dementia (starting in 2018)                                                                  

In addition to developing interventions targeted at all enrollees in one or more of the above categories, participating MA plans will have the flexibility to identify specific combinations of the listed chronic conditions for one or more “multiple co-morbidities” groups and establish tailored VBID interventions for each group.  Participating MA plans are required to provide VBID benefits to all VBID-eligible enrollees in the selected group.  Participating MA plans selecting the Mood Disorders group will also have additional flexibility to focus on specific conditions within that group. 

For each of the selected enrollee groups, participating plans may select one or more plan design modifications from a menu of four general approaches.  Within each approach, plans have flexibility on how (and to what extent) to implement that approach.  Plans may vary their proposed interventions from one target population to another, and from one participating plan to another.  CMS will also consider proposals for related variants of these interventions offered to targeted groups of enrollees, such as supplemental benefits conditional on participation in a disease management program.

The four approaches are:

1. Reduced Cost Sharing for High-Value Services

Plans can choose to reduce or eliminate cost sharing for items or services, including covered Part D drugs, that they have identified as high-value for a given target population.  Participating plans have flexibility to choose which items or services are eligible for cost-sharing reductions; however, these services must be clearly identified and defined in advance, and cost-sharing reductions must be available to all enrollees within the target population.

Examples of interventions within this category include eliminating co-pays for eye exams for diabetics and eliminating co-pays for angiotensin converting enzymeinhibitors for enrollees who have previously experienced an acute myocardial infarction.

      2. Reduced Cost Sharing for High-Value Providers

Plans can choose to reduce or eliminate cost sharing when providers that the plan has identified as high-value treat targeted enrollees.  Plans may identify high-value providers based on their quality and  not solely based on cost, across all Medicare provider types, including physicians/practices, hospitals, skilled-nursing facilities, home health agencies, ambulatory surgical centers, etc.

Examples of interventions within this category include reducing cost sharing for diabetics who see a physician who has historically achieved strong results in controlling patients’ HbA1c levels and eliminating cost sharing for heart disease patients who elect to receive non-emergency surgeries at high-performing cardiac centers.

      3. Reduced Cost Sharing for Enrollees Participating in Disease Management or Related Programs

Participating plans can reduce cost sharing for an item or service, including covered Part D drugs, for enrollees who choose to participate in a plan-sponsored disease management or similar program.  This could include an enhanced disease management program, offered by the plan as a supplemental benefit, or it could refer to specific activities that are offered or recommended as part of a plan’s basic care coordination activities.  Plans using this approach can condition enrollee eligibility for cost-sharing reductions on meeting certain participation milestones.  For instance, a plan may require that enrollees meet with a case manager at regular intervals in order to qualify.  However, plans cannot make cost-sharing reductions conditional on achieving any specific clinical goals (e.g., a plan cannot condition cost-sharing reductions on enrollees achieving certain thresholds in HbA1c levels or body-mass index).

Examples of interventions within this category include elimination of primary care co-pays for diabetes patients who meet regularly with a case manager and reduction of drug co-pays for patients with heart disease who regularly monitor and report their blood pressure.

     4. Coverage of Additional Supplemental Benefits

Under this approach, participating plans can make coverage for supplemental benefits available only to targeted populations.  Such benefits may include any service currently permitted under existing Medicare Advantage rules for supplemental benefits.

Examples of interventions within this category include physician consultations via real-time interactive audio and video technologies for diabetics, or supplemental tobacco cessation assistance for enrollees with COPD.

Eligible Applicants

The MA-VBID model test is open to all qualifying MA and MA-PD plans in the test states that submit acceptable programmatic proposals to CMS.  Only certain MA and MA-PD plan types are eligible and certain restrictions apply to multi-state plans. 

CMS will generally restrict the model test to plans with a minimum enrollment in the test states of 2,000 enrollees. However, beginning in 2018, a MA organization participating in the model test with at least one plan with enrollment over 2,000 enrollees may have additional Plan Benefit Packages (PBPs) participate with a minimum enrollee requirement of 500 enrollees; an additional plan benefit package using this lower enrollment requirement may be from that MA organization or other organizations with the same parent organization.  CMS may also grant an exception upon request. 

Additionally, Plans must meet minimum quality thresholds, including: being rated by CMS at three stars or higher, not consistently low-performing, not an outlier in the CMS past performance analysis, not under sanction, and able to pass a program integrity screening.

The plan must have been offered in at least three annual coordinated election (open enrollment) periods prior to the open enrollment period for the year for which the plan is applying to participate. There is no cap on the total number of participating plans.

More information and Application Process

More information about the MA-VBID model test can be found in the model’s announcements and other documents, available at http://innovation.cms.gov/initiatives/VBID. The announcement includes instructions for providing CMS with feedback on this model test’s design.  Please also save the date for a webinar on the MA-VBID model test, to be held on August 25, 2016. Registration information is available on the same site.

CMS will accept applications for the second year of the MA-VBID model via a Request for Applications (RFA), to be released shortly.  Once released, application materials will be available at: http://innovation.cms.gov/initiatives/VBID.

For more information on the Center for Medicare and Medicaid Innovation’s division of Health Plan Innovation, please visit: http://innovation.cms.gov/initatives/HPI.

CMS BLOG
http://blog.cms.gov/2016/08/11/delivering-on-the-promise-of-better-care-for-older-adults 

August 11, 2016
By Andy Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services (CMS)

Delivering on the Promise of Better Care for Older Adults

Since becoming acting administrator, I have spoken frequently about to the importance of moving to the next chapter in implementing the Affordable Care Act. This new chapter goes beyond providing people with quality, affordable coverage – but making sure that we are delivering patient-centered care to all consumers at critical stages of their lives. 

What does that look like? It looks like more individualized care – care that allows people to heal, recover, and age in their homes and communities; care that is coordinated so we avoid people falling through the cracks; and care that includes family members and the realities of all the things that impact our health like culture, nutrition, and other social factors. For the growing number of aging and frail Americans, many living with Alzheimer's, it looks like PACE. 

The Programs of All-inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community in which they live instead of a nursing home or other care facility. The focus is on the participant. A team of health care professionals works to make sure that care is coordinated in the home, the community, and at a PACE center. 

Today, CMS proposed the first major update to the PACE program in a decade. This proposal will help the program reflect the latest advances in caring for frail elders and changes in the use of technology. The goal of this proposal is to strengthen beneficiary protections and provide PACE organizations with more administrative and operational flexibilities so they can do what they do best – caring for our nation’s most vulnerable individuals. While PACE serves a relatively small number of people today, our proposal is intended to encourage states to further expand these programs.

Our proposals aim to offer the kind of common sense supports to allow older adults to get the best care possible. For example, individual care team members would be able to serve more than one role in addressing the wide spectrum of a participant's needs, rather than just the one role they are permitted to occupy today. This would help better coordinate services, while providing important flexibility to care providers.  

We also propose more modern and simplified administrative and operational rules to enhance PACE organizations’ ability to do a number of things more easily, including a more automated application process to speed up and customize services to participants. 

Over the last six years, since the onset of the Affordable Care Act, we have been taking significant steps to care for more people, care for them better, and make health care more affordable. But for us to be successful, we need to work hand-in-hand with patients and their families, physicians and clinicians, and other actors to support new approaches to care. Team-based models that put the individual in the center, like PACE, will be a vital part of the fabric of our system.

We must work hard to support these approaches so our country can continue to provide our people with the care they need in the years ahead. 

Learn more about the proposed rule to update and modernize PACE at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-08-11.html.