In The News

Learn more about the new Medicare Quality Payment Program - Upcoming Webinars

The Centers for Medicare & Medicaid Services (CMS) invites you to join webinars on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) final rule with comment period. The webinars will provide an overview of the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) incentive payment provisions under MACRA, collectively referred to as the Quality Payment Program.

Webinar Details

Thursday, October 27, 2016 | 2:00 – 3:00 p.m. EDT

APMs in The Quality Payment Program for SSP Participants

This session is targeted to SSP participants but all are welcome to join to learn more.

Registration is now open.

 

Tuesday, November 01, 2016 | 2:00 – 3:00 p.m. EDT

Medicaid in The Quality Payment Program

This session is targeted to state model participants but all are welcome to join to learn more.

Registration is now open.

 

Wednesday, November 02, 2016 | 3:00 – 4:00 p.m. EDT

Advanced APMs in The Quality Payment Program

This session is targeted to Advanced APMs participants but all are welcome to join to learn more.

Registration is now open.

 

Tuesday, November 08, 2016 | 3:00 – 4:00 p.m. EST

APMs in The Quality Payment Program

This session is targeted to all model participants. All are welcome to join to learn more.

Registration is now open.

 

During these calls, participants will learn about the provisions in the recently released final rule; participants should review the rule prior to the call. A question and answer session will follow the presentation.

Space for these webinars is limited. Register now to secure your spot. After you register, you will receive an email message with a dial-in number and webinar link. Please note, you will not be able to share your participant information because it will be unique to you.

For More Information

To learn more about the final rule and the Quality Payment Program, view the following resources:

Structure of primary cannabinoid receptor is revealed

October 20, 2016

Findings give insight into designing safe and effective cannabinoid medications.

New research is providing a more detailed view into the structure of the human cannabinoid (CB1) receptor. These findings provide key insights into how natural and synthetic cannabinoids including tetrahydrocannabinol (THC)—a primary chemical in marijuana—bind at the CB1 receptor to produce their effects. The research was funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health.

There is considerable interest in the possible therapeutic uses of marijuana and its constituent cannabinoid compounds. Molecules that target CB1 receptors may have promise in treating a variety of conditions such as pain, inflammation, obesity, nerve cell diseases, and substance use disorders. However, some synthetic cannabinoids such as K2 or Spice can produce severe and even deadly reactions, whereas other cannabinoids produce less serious side effects.

"Cannabinoids can produce very different outcomes, depending on how they bind to the CB1 receptor," said NIDA Director Nora D. Volkow, M.D. "Understanding how these chemicals bind to the CB1 receptor will help guide the design of new medications and provide insight into the therapeutic promise of the body's cannabinoid system."

Researchers used a specific chemical, AM6538, to inactivate and crystallize the CB1 receptor. They then computed the three-dimensional structure of the CB1-AM6538 complex through crystallography, which determines molecular shape by measuring the angles and intensities of x-rays that are bounced off a crystal structure. Based upon prior evidence showing how specific cannabinoids attach to different chemical configurations, researchers were able to predict how these cannabinoids would fit into the three-dimensional CB1 model. The model was also used to calculate how long each cannabinoid bound to the CB1 receptor, thereby providing clues into mechanisms whereby some chemicals produce longer-lasting effects.

"We found that the CB1 receptor consists of multiple sub-pockets and channels," said Alexandros Makriyannis, Ph.D., director of the Center for Drug Discovery, Northeastern University in Boston, and a co-author on the paper. "This complex structure will allow chemists to design diverse compounds that specifically target portions of the receptor to produce desired effects."

The paper by Hua, et al., can be found at http://www.cell.com/cell/abstract/S0092-8674(16)31385-X

To learn more about NIH-supported research on marijuana and cannabinoids, go to: www.drugabuse.gov/drugs-abuse/marijuana/nih-research-marijuana-cannabinoids.

This study was funded in part by NIDA under grants DA009158 and DA023142.

About the National Institute on Drug Abuse (NIDA): The National Institute on Drug Abuse (NIDA) is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world's research on the health aspects of drug use and addiction. The Institute carries out a large variety of programs to inform policy, improve practice, and advance addiction science. Fact sheets on the health effects of drugs and information on NIDA research and other activities can be found at www.drugabuse.gov, which is now compatible with your smartphone, iPad or tablet. To order publications in English or Spanish, call NIDA's DrugPubs research dissemination center at 1-877-NIDA-NIH or 240-6450228 (TDD) or email requests to drugpubs@nida.nih.gov. Online ordering is available at drugpubs.drugabuse.gov. NIDA's media guide can be found at www.drugabuse.gov/publications/media-guide/dear-journalist, and its easy-to-read website can be found at www.easyread.drugabuse.gov. You can follow NIDA on Twitter and Facebook.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

CMS BLOG: Medicare’s investment in primary care shows progress

October 17, 2016
By Dr. Patrick Conway, CMS Principal Deputy Administrator and Chief Medical Officer

Medicare’s investment in primary care shows progress

Today, the Centers for Medicare & Medicaid Services (CMS) announced the Comprehensive Primary Care (CPC) initiative’s second round of shared savings results, with nearly all practices (95 percent) meeting quality of care requirements and four out of seven regions sharing in savings with CMS. These results reflect the work of 481 practices that served over 376,000 Medicare beneficiaries and more than 2.7 million patients overall in 2015.

As the largest test of advanced primary care in U.S. history, CPC demonstrates the potential of primary care clinicians redesigning their practices to deliver better care to their patients, and provides clinicians support to innovate and deliver care in ways that better meet their patients’ needs and preferences.

During 2015, its second shared savings performance year, CPC generated a total of $57.7 million gross savings in Part A and Part B expenditures. These savings are essentially equivalent to the $58 million paid in care management fees to the practices. Four of the seven regions participating in CPC – the states of Arkansas, Colorado, and Oregon, and the Greater Tulsa region in Oklahoma – realized net savings (after accounting for the care management fees paid) and will share in those savings with CMS. Although three of the CPC regions had net losses, the savings generated in the other four regions covered those losses, such that care management fees across CPC were offset by reduced spending on Medicare Part A and Part B services. Further, more than half of participating CPC practices will receive a share of over $13 million in earned shared savings.

In addition to the gross Medicare savings, CPC practices showed positive quality, with lower than expected hospital admission and readmission rates, and favorable performance on patient experience measures. CPC practices’ performance on electronic Clinical Quality Measures (eCQMs) also exceeded national benchmarks, particularly on preventive health measures.

This is the first year CMS has included eCQM performance in Medicare shared savings determinations for CPC. eCQM reporting covering the entire practice population at the practice site level is critical to using health information technology as a tool to support care delivery transformation. eCQM data are recorded in the electronic health record in the routine course of clinical care, allowing practices to engage in real time quality improvement efforts that drive population health. As we move to a health care system that rewards value over volume, CPC practices are at the forefront of using eCQMs for quality improvement, measurement, and reporting.

Quality highlights from the 2015 shared savings performance year include:

  • 97 percent of CPC practices successfully reported 9 eCQMs. For ten out of the eleven eCQMs in the CPC measure set, the majority of CPC practices who reported surpassed the median national performance.
  • Nearly all (99 percent) practices reported higher levels of colorectal cancer screening and influenza immunization compared to national benchmarks. Additionally, 100 percent of practices who reported on screening for clinical depression surpassed national benchmarks.
  • Compared to 2014, most regions maintained or improved their scores on hospital readmissions and admissions for chronic obstructive pulmonary disorder and congestive heart failure.
  • Patients rated the care they receive from their CPC practitioners highly, particularly on how well practitioners supported them in taking care of their own health and the attention they paid to care from other providers.

The positive performance is a testament to the efforts CPC practices have made to provide truly “comprehensive primary care.”

CPC is a multi-payer partnership launched by the Center for Medicare and Medicaid Innovation (Innovation Center) in October 2012 to advance primary care by paying clinicians to deliver accessible, comprehensive, and coordinated care in seven regions across the country. CPC supports advanced primary care as the foundation of our health system. In addition to attending to patients’ acute, chronic, and preventive health care needs, primary care practices act as the quarterback of each patient’s health care team. CPC practices help patients navigate their care, communicate with specialists and hospitals, and ensure that patients with complex social and medical needs do not “fall through the cracks” of the health care system.

These results build on the first shared savings performance year in 2014. Gross savings nearly doubled from the first performance year to the second and practices in four regions were eligible to receive shared savings, compared to one region in 2014. Primary care transformation takes time, and it is especially encouraging that CPC practices maintained such positive quality of care results while also seeing gross Medicare savings in the 2015 performance year.

The experience in CPC has contributed to our continued efforts to support primary care going forward in the Innovation Center’s Comprehensive Primary Care Plus (CPC+), which will begin on January 1, 2017 and for which we recently announced the 14 selected regions and are currently reviewing practice applications. CMS anticipates that CPC+ could meet the criteria to qualify as an Advanced Alternative Payment Model (Advanced APM) under the recently finalized Quality Payment Program rule, which implements the Medicare Access and CHIP Reauthorization Act of 2015. A robust primary care system is essential to achieve better care, smarter spending, and healthier people. For this reason, CMS is committed to supporting primary care clinicians to deliver the best, most comprehensive primary care possible for their patients.

HHS finalizes streamlined Medicare payment system that rewards clinicians for quality patient care

MACRA rule will accelerate health care system’s shift toward value

Today, the Department of Health & Human Services (HHS) finalized a landmark new payment system for Medicare clinicians that will continue the Administration’s progress in reforming how the health care system pays for care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program, which replaces the flawed Sustainable Growth Rate (SGR), will equip clinicians with the tools and flexibility to provide high-quality, patient-centered care. With clinicians as partners, the Administration is building a system that delivers better care, one in which clinicians work together and have a full understanding of patients’ needs, Medicare pays for what works and spends taxpayer money more wisely, and patients are in the center of their care, resulting in a healthier country.

Click here to read the full article

CMS NEWS: MACRA Quality Payment Program Final Rule (CMS-5517-F)

HHS finalizes streamlined Medicare payment system that rewards clinicians for quality patient care
MACRA rule will accelerate health care system’s shift toward value

Today, the Department of Health & Human Services (HHS) finalized a landmark new payment system for Medicare clinicians that will continue the Administration’s progress in reforming how the health care system pays for care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program, which replaces the flawed Sustainable Growth Rate (SGR), will equip clinicians with the tools and flexibility to provide high-quality, patient-centered care. With clinicians as partners, the Administration is building a system that delivers better care, one in which clinicians work together and have a full understanding of patients’ needs, Medicare pays for what works and spends taxpayer money more wisely, and patients are in the center of their care, resulting in a healthier country.

“Today, we’re proud to put into action Congress’s bipartisan vision of a Medicare program that rewards clinicians for delivering quality care to their patients,” said HHS Secretary Sylvia M. Burwell. “Designed with input from thousands of clinicians and patients across the country, the new Quality Payment Program will strengthen our health care system for patients, clinicians and the American taxpayer.”

With the Affordable Care Act, America has made important strides in helping more Americans than ever afford quality health insurance and access patient-centered care. The Affordable Care Act created important tools to put individuals at the center of their own care and unlock access to health care data for patients and their clinicians. Today’s announcement builds on this progress and make our health care system work better for everyone. With MACRA, Congress gave HHS the tools to keep improving how we pay for care, so clinicians can focus on the quality of care they give, not the quantity of services they provide; and to keep improving the way care is delivered, by encouraging better coordination and prioritizing wellness and prevention.

“It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care. To be successful, we must put patients and clinicians at the center of the Quality Payment Program,” said Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS). “A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as the program matures.”

Today’s rule is informed by a months-long listening tour with nearly 100,000 attendees and nearly 4,000 public comments. A common theme in the input HHS received was the need for flexibility, simplicity, and support for small practices. And that’s what this final policy aims to provide. First, the new payment system creates two pathways. These paths let clinicians pick the right pace for them to participate in the transition from a fee-for-service health care system to one that uses alternative payment models that reward quality of care over quantity of services. Clinicians will choose between two options:

  • The first path gives clinicians the opportunity to be paid more for better care and investments that support patients. It reduces existing requirements, while still emphasizing and rewarding quality care. In the first year, it also provides a flexible performance period, so that those who are ready can dive in immediately, but those who need more time can prepare for participation later in the year.
  • The second path helps clinicians go further by participating in organizations that get paid primarily for keeping people healthy. For example, they could be part of an Accountable Care Organization where clinicians come together to coordinate high-quality care for the patients they serve. When they get better health results and reduce costs for the care of their patients, the clinicians receive a portion of the savings.

Evolving along with payment reform

CMS is building the Quality Payment Program to evolve along with the health care system. That’s why it facilitates participation in new payment models. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (Innovation Center) to implement and scale the best ideas from the medical community to improve the quality of care for Medicare beneficiaries while lowering costs. Thanks to the Innovation Center’s work so far, Medicare has a plan for eligible beneficiaries to receive free diabetes prevention services, the quality of hip and knee replacements are being improved while lowering costs, and primary care clinicians are using flexibility to deliver the best outcomes with a payment system that rewards results. CMS intends to broaden opportunities for clinicians, including small practices and specialties, to participate in these kinds of initiatives. For example, a major opportunity being considered for 2018 will be the new Accountable Care Organization Track 1+ model that provides more flexibility for clinicians. CMS is also reviewing reopening some existing Advanced Alternative Payment Models for application to allow more clinicians to join these types of initiatives. In 2018, CMS expects about 25 percent of eligible clinicians will be a part of the second path of Advanced Alternative Payment Models.

Providing comprehensive support to clinicians

To further support small practices, MACRA provides $20 million each year for five years to train and educate Medicare clinicians in small practices of 15 clinicians or fewer and those working in underserved areasBeginning December 2016, local, experienced organizations will offer free, on-the-ground, specialized help to small practices using this funding. In addition, Jean Moody-Williams, Registered Nurse and Deputy Director of the CMS Center for Clinical Standards and Quality (CCSQ), is leading an outreach effort to individual clinicians nationwide to help them prepare for the Quality Payment Program. In addition, CMS has launched a long-term initiative, led by Dr. Shantanu Agarwal, to improve the clinician experience with Medicare.

Today, we’re also launching a new Quality Payment Program website, which will explain the new program and help clinicians easily identify the measures most meaningful to their practice or specialty. There will also be a service center available by email and phone that will answer questions about the Quality Payment Program.

Continuing to listen

Today’s rule incorporates input received to date, but it is only the next step in an iterative process for implementing the new law. We are launching a new interactive website to help clinicians understand the program and successfully participate. We will continue to host listening and learning sessions throughout the country, and welcome additional feedback from patients, caregivers, clinicians, health care professionals, Congress and others on how to better achieve these goals. HHS looks forward to feedback on the final rule with comment period and will accept comments until 60 days after the final rule’s release date.

For more information about today’s rule, including a fact sheet, please visit: https://qualitypaymentprogram.cms.gov/education

Comments may be submitted electronically through our e-Regulation website at http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking

CMS News: CMS announces new initiative to increase clinician engagement

First step of the initiative is to reduce medical review for certain Advanced Alternative Payment Models.

Today, the Centers for Medicare & Medicaid Services (CMS) announced a new initiative to improve the clinician experience with the Medicare program. As we implement delivery system reforms from the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), this new long-term effort aims to reshape the physician experience by reviewing regulations and policies to minimize administrative tasks and seek other input to improve clinician satisfaction. The initiative will be led by senior physicians within CMS who will report to the Office of the Administrator.

“Physicians and their care teams are the most vital resource a patient has. As we implement the Quality Payment Program under MACRA, we cannot do it without making a sustained, long-term commitment to take a holistic view on the demands on the physician and clinician workforce,” said Andy Slavitt, CMS Acting Administrator. “The new initiative will launch a nationwide effort to work with the clinician community to improve Medicare regulations, policies, and interaction points to address issues and to help get physicians back to the most important thing they do – taking care of patients.”

Acting Administrator Andy Slavitt is appointing Dr. Shantanu Agrawal to lead the development of this function and implementation, which will cover documentation requirements and existing physician interactions with CMS, among other aspects of provider experiences. To ensure CMS is hearing from physicians on the ground, each of the ten CMS regional offices will oversee local meetings to take input from physician practices within the next six months and regular meetings thereafter. These local meetings will result in a report with targeted recommendations to the CMS Administrator in 2017. Three of CMS’s regional Chief Medical Officers – Dr. Barbara Connors in Philadelphia, Dr. Ashby Wolfe in San Francisco, and Dr. Richard Wild in Atlanta – have agreed to serve as regional champions of this initiative.

“CMS is turning a new page in assessing not only how to reward for quality, but also to reduce administrative hurdles,” said Dr. Agrawal. “I look forward to hearing about what steps we can take to make the practice of medicine in Medicare more efficient and rewarding.”

Launch of First Initiative: Medical Review Reduction

The first action is the launch of an 18-month pilot program to reduce medical review for certain physicians while continuing to protect program integrity. Under the program, providers practicing within specified Advanced Alternative Payment Models (APMs) will be relieved of some scrutiny under certain medical review programs. Advanced APMs were identified as a potential opportunity for this pilot because participating clinicians share financial risk with the Medicare program. Two-sided risk models provide powerful motivation to deliver care in the most efficient manner possible, greatly reducing the risk of improper billing of services. After the results of the pilot are analyzed, CMS will consider expansion along various dimensions including additional Advanced APMs, specialties, and provider types.

“Like all successful changes, we will begin with the basic steps and build over time,” said Dr. Ashby Wolfe, Region IX Chief Medical Officer. “Most importantly, we are excited to build on the listening and engagement process we began this year by creating more opportunities for physicians to interact with CMS, especially through our regional offices.”

The dedicated team of clinicians participating in Medicare serve over 55 million of the country’s seniors and individuals with disabilities. Through this new initiative, CMS is focused on supporting and empowering those clinicians through a flexible, modern Medicare program informed by clinician expertise and experience.

For more information, please visit:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-13.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Overview.html

NIH funds additional medical centers to expand national precision medicine research program

NIH today announced awards to add four regional medical center groups to the national network of health care provider organizations that will implement the PMI Cohort Program.

Click here to read the full article

NIH task force formed to develop first nutrition strategic plan

Strategic plan will complement and enhance ongoing research efforts across NIH on diseases and conditions affected by nutrition.

Click here to read the full article

CMS NEWS: 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 MA-VBID model will begin January 1, 2017 and run for five years. 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 overall 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 enzyme inhibitors 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 specific 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.

Value-Based Insurance Design Participants for 2017

Medicare Advantage Organization

State

BCBS of Massachusetts

Massachusetts

Fallon Community Health Plan

Massachusetts

Tufts Associated Health Plan

Massachusetts

Geisinger Health Plan

Pennsylvania

Aetna

Pennsylvania

Independence Blue Cross

Pennsylvania

Highmark

Pennsylvania

UPMC Health Plan

Pennsylvania

Indiana University Health Plan

Indiana

Eligible Applicants and Application Process for 2018

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.

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.

More information

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.

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.

Government as a Platform for Progress: HHS’s Open Government Plan

By: Mary K. Wakefield, Ph.D., RN, HHS Acting Deputy Secretary

One of the first actions President Obama took after taking office was to direct federal agencies to find new ways to increase transparency, collaboration and public engagement. Since then, one of our top priorities at HHS has been to make our Department more open and accountable to the people we serve.

With the publication of our fourth HHS Open Government Plan, we’re building on our past performance in making government more transparent to the public and engaging in new ways of collaborating and partnering with our stakeholders. 

Read more: Government as a Platform for Progress: HHS’s Open Government Plan