In The News

Medicaid expansion lowers Marketplace premiums by 7 percent

New analysis finds Medicaid expansion brings down Marketplace rates – another benefit on top of gains for low-income individuals and state economies

Today, the U.S. Department of Health and Human Services released a report showing that expanding Medicaid lowers Marketplace premiums by about 7 percent in those states.

“Today’s report identifies yet another group that would gain if all states chose to expand Medicaid: Marketplace consumers, who would see lower premiums,” said Secretary Sylvia M. Burwell. “These gains are on top of the direct benefits of expansion for millions of Americans who would gain coverage and on top of the economic benefits for states. The Administration remains committed to working with all states to expand coverage and improve the health and financial wellbeing of their citizens.”

Read more about today's announcement.

Physicians and health care providers continue to improve quality of care, lower costs

Affordable Care Act Accountable Care Organization initiatives put patients at the center of their care while generating more than $1.29 billion in total Medicare savings since 2012

The Centers for Medicare & Medicaid Services (CMS) today announced the 2015 performance year results for the Medicare Shared Savings Program and the Pioneer Accountable Care Organization Model that show physicians, hospitals, and health care providers participating in Accountable Care Organizations continue to make significant improvements in the quality of care for Medicare beneficiaries, while achieving cost savings. Collectively, Medicare Accountable Care Organizations have generated more than $1.29 billion in total Medicare savings since 2012.

“The coordinated, physician-led care provided by Accountable Care Organizations resulted in better care for over 7.7 million Medicare beneficiaries while also reducing costs,” said CMS Acting Administrator Andy Slavitt. “I congratulate these leaders and look forward to significant growth in the program in the coming year.”

In 2015, Medicare Accountable Care Organizations had combined total program savings of $466 million, which includes all Accountable Care Organizations’ experiences, for 392 Medicare Shared Savings Program participants and 12 Pioneer Accountable Care Organization Model participants. The results show that more Accountable Care Organizations shared savings in 2015 compared to 2014 and those with more experience tend to perform better over time. 

Today’s results from the Medicare Shared Savings Program and the Pioneer Accountable Care Organization Model show significant improvements in the quality of care providers are offering to an increasing number of Medicare beneficiaries. Accountable Care Organizations are judged on their performance, as well as their improvement, on an array of meaningful metrics that assess the care they deliver. Those metrics include how highly patients rated their doctor, how well clinicians communicated, whether patients are screened for high blood pressure, and their use of Electronic Health Records.

All 12 participants in the Pioneer Accountable Care Organization Model improved their quality scores from 2012 to 2015 by more than 21 percentage points. Overall quality scores for nine out of 12 Pioneer participants were more than 90 percent in 2015.

Accountable Care Organizations in the Medicare Shared Savings Program also continued to show improvement, with Accountable Care Organizations that reported in both 2014 and 2015 improving on 84 percent of the quality measures that were reported in both years. Additionally, comparing 2014 and 2015 results, average quality performance improved by more than 15 percent on key preventive care measures including screening for risk of future falls, depression screening and follow-up, blood pressure screening and follow-up, and providing pneumonia vaccinations.

By meeting quality performance standards and their savings threshold, 125 Accountable Care Organizations qualified for shared savings payments. Since the passage of the Affordable Care Act, more than 470 Medicare Accountable Care Organizations – serving nearly 8.9 million Medicare beneficiaries – have been established through the Medicare Shared Savings Program, the Pioneer Accountable Care Organization Model, the Next Generation Accountable Care Organization Model, and the Comprehensive End-Stage Renal Disease Care Model.

“Accountable Care Organization initiatives in Medicare continue to grow and achieve positive results in providing better care and health outcomes while spending taxpayer dollars more wisely,” said Dr. Patrick Conway, CMS Principal Deputy Administrator and Chief Medical Officer. “CMS continues to work and partner with providers across the country to improve the way health care is delivered in the United States.”

Accountable Care Organizations were created to change the incentives for how medical care is delivered and paid for in the United States, moving away from a system that rewards the quantity of services to one that rewards the quality of health outcomes. They are groups of doctors, hospitals, and other health care providers who voluntarily come together to develop and execute a plan for a patient’s care and share information, putting the patient at the center of the health care delivery system. In addition, under the proposed Quality Payment Program, health care providers that sufficiently participate in advanced tracks of Medicare Accountable Care Organizations may qualify for exemption from payment adjustments under the Merit-based Incentive Payment System, as well as the additional incentive payments available beginning in 2019 for participation in Advanced Alternative Payment Models.

The Affordable Care Act provides tools, such as Medicare Accountable Care Organizations, to move our health care system toward one  that provides patients with high-quality, cost-effective care. Today’s announcement 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. These efforts support the Administration’s goal to have 50 percent of traditional Medicare payments flowing through alternative payment models by 2018 (already, 30 percent of Medicare payments go through alternative models).

For more detailed information on the quality and financial results, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-08-25.html

For additional information on the Medicare Shared Savings Program, please visit: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html

For additional information on the Pioneer Accountable Care Organization Model, please visit: https://innovation.cms.gov/initiatives/Pioneer-ACO-Model/

NIH establishes new research program to address health disparities of chronic diseases

Two centers will focus on development of community-based interventions to combat chronic diseases.

Click here to read the full article.

New Care Coordination Survey from AHRQ

AHRQ has developed and pilot tested a new care coordination survey that is designed for use in research and evaluation in primary care settings. The Care Coordination Quality Measure for Primary Care (CCQM-PC) is a reliable and valid survey that builds on AHRQ’s previous work to define care coordination (Care Coordination Measures Atlas) and on new research. It addresses key care coordination activities, such as information sharing and creating and using care plans, from the patient perspective. The survey fills a critical measurement gap.

The CCQM-PC is intended for use in health services research and primary care improvement activities. It is not a CAHPS™ survey and is not designed to be used for reporting or accountability purposes.

The CCQM-PC is in the public domain. The full survey and guidance for its use in research are available here. AHRQ strongly encourages primary care researchers to use the CCQM-PC in studies of primary care transformation and would welcome additional research to further refine the survey for use in primary care quality improvement activities.

For more about AHRQ’s funding commitment to primary care research and to improving the patient care experience, including research on care coordination, see our Special Emphasis Notices on Innovative Research in Primary Care and Optimizing Care for People Living with Chronic Conditions.

Affordable Care Act payment model continues to improve care, lower costs

The Independence at Home Demonstration continues to provide high quality primary care services for chronically ill Medicare beneficiaries in the home setting while saving the Medicare program money, according to a new analysis released today by the Centers for Medicare & Medicaid Services (CMS).

“The Independence at Home Demonstration is a patient-centered model that supports providers in caring for chronically ill patients in their own homes,” said Dr. Patrick Conway, CMS acting deputy administrator and chief medical officer. “These results continue to support what most patients already want – the ability to have high quality care in the home setting”.

The CMS analysis found that, for the second performance year, Independence at Home participants saved Medicare more than $10 million – an average of $1,010 per beneficiary – while delivering higher quality patient care in the home. CMS will award incentive payments of $5.7 million to seven participating practices that succeeded in reducing spending while improving quality.

In the second performance year, 15 practices served more than 10,000 Medicare beneficiaries. According to the CMS analysis, all 15 practices improved quality from the first performance year in at least two of the six quality measures for the Demonstration. Four practices met the performance measures for all six quality measures.

These quality results mean improved care for Medicare beneficiaries who are participating in Independence at Home practices. On average, beneficiaries:

  • Have follow-up contact from their provider within 48 hours of a hospital admission, hospital discharge, or emergency room visit;
  • Have fewer hospital readmissions within 30 days;
  • Have their medication identified by their provider within 48 hours of discharge from the hospital;
  • Have their preferences documented by their provider;
  • Use inpatient hospital and emergency room services less for conditions such as diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.

The Independence at Home Demonstration is part of the Administration’s broader strategy to improve the health care system by paying practitioners for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality. In March 2016, the Administration announced it reached its goal, nearly one year ahead of schedule, of tying 30 percent of Medicare payments to alternative payment models that reward the quality of care over the quantity of services provided to beneficiaries.

For more information on the Independence at Home Demonstration performance year two results, including individual practice results, please visit:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-08-09.html.

To learn more about the Independence at Home Demonstration, please visit:https://innovation.cms.gov/initiatives/Independence-at-Home/.  

Health Care Became More Affordable from 2011 to Mid-2015

The cost of health care became more affordable from 2011 to the first half of 2015 as fewer people overall reported having trouble paying their medical bills, according to AHRQ's newly released Chartbook on Care Affordability.

The percentage of people who reported trouble paying their medical bills decreased from 21 percent to 17 percent. This applied to people under age 65 of all income levels and race/ethnicity. However, blacks and Hispanics were more likely to have problems paying medical bills in all years as compared with whites. Find more chartbook details here.

Access the National Quality Strategy "Priorities In Focus" brief that outlines current payment and delivery system reforms to make care more affordable.

Medicare announces participants in effort to improve access, quality of care in rural areas

Today, the Centers for Medicare & Medicaid Services (CMS) announced the participants in the Frontier Community Health Integration Project (FCHIP) Demonstration, an effort to increase access to care for Medicare beneficiaries in areas of the country where access to health services can be limited because of distance from providers. Ten critical access hospitals (CAHs) in Montana, Nevada, and North Dakota will participate in the Demonstration, which begins this August. The FCHIP Demonstration is another example of how the Administration is working to ensure that Americans receive better care, we spend our health care dollars more wisely, and we have healthier people.

The FCHIP Demonstration, a statutory mandate launched by the CMS Innovation Center in collaboration with the Federal Office of Rural Health Policy, located in the Health Resources and Services Administration, will test new models of integrated, coordinated health care in the most sparsely populated rural counties in the nation over three years. This demonstration program will encourage the ten CAHs to provide essential services that are often not financially viable in rural communities with the goals of improving quality of care, increasing patient satisfaction in rural communities, and spending health care dollars more wisely. The demonstration will provide financial incentives for care coordination activities for local CAHs to reduce unnecessary admissions and readmissions across their networks of care.

"Medicare beneficiaries who live in frontier areas of the country sometimes travel hundreds of miles to see a doctor. This increases the cost of care and can discourage beneficiaries from seeking treatment," said Patrick Conway, M.D., principal deputy administrator and chief medical officer at CMS. "The effort that is beginning today will look at ways to shrink the distance between the Medicare beneficiary and the care they need."

Applications were received from CAHs in Montana, Nevada, and North Dakota (although eligible, CAHs in Alaska or Wyoming did not apply).

Specifically, the demonstration aims to:

  • support the CAH and local delivery system in keeping patients within the community who might otherwise be transferred to distant providers;
  • test whether payments for certain services will enhance access to care for patients, increase the integration and coordination of care among providers, and reduce avoidable hospitalizations, admissions, and transfers; and
  • test new CAH activities in three service categories: skilled nursing care, telehealth, and ambulance services.

HRSA's Federal Office of Rural Health Policy will monitor the work of the technical assistance provider, Montana Health and Research Education Foundation, and collect information on key policy challenges facing frontier providers, while CMS will test alternative payment and administrative strategies.

For more information on the Frontier Community Health Integration Project Demonstration, please visit: https://innovation.cms.gov/initiatives/Frontier-Community-Health-Integration-Project-Demonstration/.

CMS announces next phase in largest-ever initiative to improve primary care in America

Today, the Centers for Medicare & Medicaid Services (CMS) opened the application period for practices to participate in the new nation-wide primary care model, Comprehensive Primary Care Plus (CPC+). CPC+ is a five-year primary care medical home model beginning January 2017 that will enable primary care practices to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care. CPC+ is an opportunity for practices of diverse sizes, structures, and ownership who are interested in qualifying for the incentive payment for Advanced Alternative Payment Models through the proposed Quality Payment Program. CMS estimates that up to 5,000 primary care practices serving an estimated 3.5 million beneficiaries could participate in the model.

CPC+ is a public-private partnership in 14 regions across the nation. CPC+ is a multi-payer model - Medicare, state Medicaid agencies, and private insurance companies partner together to support primary care practices - so CMS selected the regions based on payer interest and coverage. By aligning Medicare, Medicaid, and private insurance, CPC+ moves the health care system away from one-size-fits-all, fee-for-service to a model that supports clinicians delivering the care that best meets the needs of their patients and improves health outcomes.

The following regions were selected for CPC+. Eligible practices in these 14 regions may apply between August 1 and September 15, 2016 to participate in CPC+:

  1. Arkansas: Statewide
  2. Colorado: Statewide
  3. Hawaii: Statewide
  4. Kansas and Missouri: Greater Kansas City Region 
  5. Michigan: Statewide
  6. Montana: Statewide
  7. New Jersey: Statewide
  8. New York: North Hudson-Capital Region
  9. Ohio: Statewide and Northern Kentucky Region
  10. Oklahoma: Statewide
  11. Oregon: Statewide
  12. Pennsylvania: Greater Philadelphia Region 
  13. Rhode Island: Statewide
  14. Tennessee: Statewide

As a key part of CPC+, CMS and partner payers are committed to supporting primary care practices of all sizes, including small, independent, and rural practices, said Dr. Patrick Conway, CMS deputy administrator and chief medical officer. We see CPC+ as the future of primary care in the U.S. and are pleased to partner with payers across the country that are aligned in this mission to transform our health care system. This model allows primary care practices to focus on what they care about most – serving their patients’ needs when and how they choose.

Building on the Comprehensive Primary Care initiative that launched in late 2012, CPC+ will benefit patients by helping primary care practices:

  • Support patients with serious or chronic diseases achieve their health goals
  • Give patients 24-hour access to care and health information
  • Deliver preventive care
  • Engage patients and their families in their own care
  • Work together with hospitals and other clinicians, including specialists, to provide better-coordinated care

Practices may participate in one of two CPC+ tracks. In Track 1, CMS will pay practices a monthly fee in addition to regular Medicare fee-for-service payments. In Track 2, practices will receive the monthly fee, as well as a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments to allow greater flexibility in how practices deliver care. Practices in Track 2 will provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs. To promote high quality and high value care, practices in both tracks will also receive prospective performance-based incentive payments that they will either keep or have to pay back to CMS based on their performance on quality and utilization metrics. In addition, practices that participate in CPC+ may qualify for the additional incentive payments available for the Advanced Alternative Payment Models in the proposed Quality Payment Program beginning 2019.

The Affordable Care Act, through the creation of the Center for Medicare and Medicaid Innovation, allows for the testing of innovative payment and service delivery models, such as the CPC+ model, to move our health care system toward one that rewards clinicians based on the quality, not quantity of care they provide patients. Today’s announcement 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. This new model supports the Administration’s goal to have 50 percent of traditional Medicare payments flowing through alternative payment models by 2018 (already, 30 percent of Medicare payments go through alternative models).

For questions about the model or the application process, visit http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus or email CPCplus@cms.hhs.gov

Final Fiscal Year 2017 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities (CMS-1647-F)

On July 29, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule outlining fiscal year (FY) 2017 Medicare payment policies and rates for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) and the IRF Quality Reporting Program (IRF QRP). The FY 2017 final policies are summarized below.

Updates to IRF payment rates

Updates to the payment rates under the IRF PPS. CMS is updating the IRF PPS payments for FY 2017 to reflect an estimated 1.65 percent increase factor (reflecting an IRF-specific market basket estimate of 2.7 percent, reduced by a 0.3 percentage point multi-factor productivity adjustment and a 0.75 percentage point reduction required by law). An additional approximate 0.3 percent increase to aggregate payments due to updating the outlier threshold results in an overall estimated update of approximately 1.9 percent (or $145 million), relative to payments in FY 2016.

No changes to the facility-level adjustments. For FY 2017, CMS will continue to maintain the facility-level adjustment factors at current levels as we continue to monitor the most current IRF claims data available to assess the effects of the FY 2014 changes.

Rural Adjustment Transition. Continue year two of the phase-out of the 14.9 percent rural adjustment for IRF providers in areas that were designated as rural and changed to urban under the new Office of Management and Budget (OMB) delineations.  In accordance with the policy finalized in the FY 2016 IRF PPS final rule, these IRFs will receive one-third of the rural adjustment for FY 2017, and no rural adjustment for FY 2018 and subsequent years.

Changes to the IRF Quality Reporting Program (QRP)

The Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) added Section 1899B to the Social Security Act (the Act) to require that IRFs report data on measures that satisfy measure domains specified in the Act. Section 1899B also requires that these measures be aligned with measures implemented for Long-Term Care Hospitals (LTCHs), IRFs, Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs). This final rule adopts three measures to meet the resource use and other measure domains and one measure to satisfy the domain of medication reconciliation. IRFs that fail to submit the required quality data to CMS will be subject to a 2 percentage point reduction to their applicable FY annual increase factor.

Finalized Changes:

The quality measures finalized for the FY 2018 payment determination and subsequent years to meet the resource use and other measure domains are as follows: 

  • Medicare Spending Per Beneficiary - Post-Acute Care (PAC) IRF QRP
  • Discharge to Community – PAC IRF QRP
  • Potentially Preventable 30-Day Post-Discharge Readmission – IRF QRP.

The quality measure finalized for the FY 2020 payment determination and subsequent years to meet the medication reconciliation domain is:

  • Drug Regimen Review Conducted with Follow-Up for Identified Issues.

In addition to the measures listed above, we are adopting an additional measure “Potentially Preventable within Stay Readmission for IRFs” for FY 2018 payment determination and subsequent years.

Further, we will begin publically reporting IRF quality data in fall 2016. We finalized four measures for public display for calendar year 2017, pending final data analysis, and adopted procedures associated with public reporting, including the review and correction of data and provider confidential feedback reports.

Finally, we have adopted an extension of the time frame for submission of exception and extension requests for extraordinary circumstances from 30 days to 90 days from the date of the qualifying event.

For More Information

The final rule will be displayed on July 29, 2016, at the Federal Register’s Public Inspection Desk and will be available under “Special Filings,” at http://www.federalregister.gov/public-inspection.

It will publish in the August 5, 2016 Federal Register.

For further information, please see: