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ACTonAlzheimer’sHealthCareLeadershipSummit
ANa%onalPerspec%veonHealthcareQuality
ShariLing,MDSeptember29,2016
Disclaimers&DisclosureThispresenta,onwaspreparedasatooltoassistprovidersandisnotintendedtograntrightsorimposeobliga,ons.Althougheveryreasonableefforthasbeenmadetoassuretheaccuracyoftheinforma,onwithinthesepages,theul,materesponsibilityforthecorrectsubmissionofclaimsandresponsetoanyremi=anceadvicelieswiththeproviderofservices.Thispresenta,onisageneralsummarythatexplainscertainaspectsoftheMedicareandMedicaidPrograms,butisnotalegaldocument.Theofficialprogramprovisionsarecontainedintherelevantlaws,regula,ons,andrulings.Policychangesfrequently,andlinkstothesourcedocumentshavebeenprovidedwithinthedocumentforyourreferenceTheCentersforMedicare&MedicaidServices(CMS)employees,agents,andstaffmakenorepresenta,on,warranty,orguaranteethatthiscompila,onofinforma,oniserror-freeandwillbearnoresponsibilityorliabilityfortheresultsorconsequencesoftheuseofthisguide.Nofinancialconflictstodisclose.
• CMSisthelargestpurchaserofhealthcareintheworld• Ourprogramscurrentlyprovidehealthcarecoveragetoroughly
125millionbeneficiariesinMedicare,Medicaid,andCHIP;about1inevery3Americans
• 20Millionaddi,onallivesarenowcoveredthroughtheHealthInsuranceMarketplace,authorizedthroughtheAffordableCareAct
• Throughvariouscontractors,CMSprocessesover1.2billionfee-for-serviceclaimsannually
• Combined,MedicareandMedicaidpayapproximatelyone-thirdofna,onalhealthexpenditures(approximately$816B),about23%oftheFederalbudget
• Implementthelaw
SizeandScopeofCMSResponsibili?es
DeliverySystemReformwillresultinbeCercare,smarterspending,andhealthierpeople
Keycharacteris?cs! Producer-centered! Incen,vesforvolume! Unsustainable! FragmentedCare
SystemsandPolicies! Fee-For-ServicePayment
Systems
Keycharacteris?cs! Person-centered! Incen,vesforoutcomes! Sustainable! Coordinatedcare
SystemsandPolicies! Value-basedpurchasing! AccountableCareOrganiza,ons! Episode-basedpayments! Medical/HealthHomes! Quality/costtransparency
PublicandPrivateSectors
EvolvingfuturestateHistoricalstate
! SMARTERSPENDING:Healthcarecostsconsumeasignificantpor,onofstate,federal,family,andbusinessbudgets,andwecanfindwaystospendthosedollarsmorewisely
! HEALTHIERPEOPLE:Givingproviderstheopportunitytofocusonperson-centeredcareandtobeaccountableforqualityandcostmeanskeepingpeoplehealthierlonger
! BETTERCARE:Wehaveanopportunitytorealigntheprac,ceofmedicinewiththeidealsoftheprofession—keepingthefocusonpa,enthealthandthebestcarepossible.
DeliverySystemReform
5
ThePersonIsCentraltotheProvisionofCareinEverySeOng
TheNa?onalAlzheimer’sProjectAct(NAPA)
• CreatesandmaintainsanintegratedNa,onalPlantoaddressAlzheimer'sdisease
• CoordinatesAlzheimer'sdiseaseresearchandservicesacrossFederalagencies
• Acceleratesthedevelopmentoftreatmentsthatwouldprevent,halt,orreversethecourseofAlzheimer'sdisease
• Improvesearlydiagnosisandcoordina,onofcareandtreatment
• Decreasesdispari,esinAlzheimer'sdiseaseforethnicandracialminoritypopula,onsathigherrisk
• Coordinateswithinterna,onalbodiestofightAlzheimer'sdiseaseglobally
• EstablishedanAdvisoryCouncilonAlzheimer'sResearch,Care,andServicesandrequirestheSecretaryoftheDepartmentofHealthandHumanServices,collabora,ngwiththeCouncil,tocreateandmaintainaNa,onalPlantoovercomeADRD
Informa,onat:h=ps://aspe.hhs.gov/na,onal-alzheimers-project-act
CMSAuthorizedPrograms&Ac,vi,es
CMS
ClinicalStandards
Survey&Cert.
Payment*
Value-basedPurchasing*
Quality&Public
Repor,ng*
QualityImprovement*
Coverage
CMMI
MedicaidPhysicianFeeScheduleTelehealthHospiceHospitalReadmissionsReduc?onProgramHealthCareAssociatedCondi?onsProgram
ESRDQIPHospitalVBPPhysicianvaluemodifierSkilledNursingFacili?esHomeHealthAgenciesQualityPaymentProgram
TransformingClinicalPrac?ceIni?a?ve(TCPI)QIOs,HENsESRDNetworksHealthcarePayment&LearningAc?onNetworks
HospitalInpa?entQualityHospitalOutpa?entIn-pa?entpsychiatrichospitalsCancerhospitalsPost-acutecare(HomeHealthAgencies,Hospices,Long-termCareAcuteHospitals,In-pa?entrehabilita?onfacili?es,SkilledNursingFacili?es)Nursinghomes
AccountableCareOrganiza?onsCaremodeldemonstra?ons&projectsValue-basedinsurancedesignAccountableHealthCommuni?es
Hospitals,HomeHealthAgencies,Hospices,ESRDfacili?es,LongtermCarefacili?es
Na?onal&LocaldecisionsMechanismstosupportinnova?on(CED,parallelreview,other)
TargetsurveysQualityAssurancePerformance
Improvement
StateInnova?onModelsInnova?onAcceleratorProgram1115Waivers
Dualeligibledemonstra?onprojects
QualityMeasurementandADRD
TheCMSQualityStrategy
NeurologyMeasures
• NQFhasendorsed15measures(sixofwhichareendorsedwithareservestatusdesigna,on)andapprovedonemeasurefortrialuserelatedtoneurologicalcondi,ons
• Twoaredemen,ameasures:#2111,An(psycho(cUseinPersonswithDemen(a,PharmacyQualityAlliance,Endorsed#2872,Demen(a-Cogni(veAssessment,PCPI,Endorsed
• NQFalsoreleasedaFinalReportonADRDin2014,“PrioritySemngforHealthcarePerformanceMeasurement:AddressingPerformanceMeasureGapsforDemen,a”:
h=p://www.qualityforum.org/priority_semng_for_healthcare_performance_measurement_alzheimers_disease.aspx
TheFutureofQualityMeasurement
• Qualitymeasuresarebroad-based,meaningful,andperson-centered
• Measureconceptsarepriori,zedbasedonpopula,on-wideeffects,andthereareendorsedmeasuresforcaredomainswheregapscurrentlyexist
• Measuresarealigned,person-centered,andspanacrossallsemngsofcare
• Qualityiscapturedatthreemainlevels:provider,group-facility/popula,on-community
• Thereisacommonmeasurementplapormforelectronichealthrecords,healthinforma,ontechnologyisinteroperable,andburdenisminimized
PatrickConway,FarzadMostashari,CarolynClancy,2013,“TheFutureofQualityMeasurementforImprovementandAccountability”
QualityMeasureDevelopmentatCMS
• CMS,ameasuredeveloper,regularlysolicitscommentonqualitymeasuresandmeasureconcepts
• TheAgencyrecentlysolicitedcommentformeasurementofcogni?vefunc?onandmentalstatus
• Thecommentperiodisnowclosed,butCMSwills,lltakecomments(althoughtheywillnotbepubliclylogged)
• Seearchivedmaterialsbetween8/18-9/142016:h=ps://www.cms.gov/Medicare/Quality-Ini,a,ves-Pa,ent-Assessment-Instruments/MMS/CallforPublicComment.html
QualityMeasurementDevelopment(con?nued)
• CMSistakingpubliccommentsonmeasurespecifica,onsandjus,fica,oninthefollowingareasun(lOctober7:
• MeasuresforbeneficiariesduallyeligibleforMedicareandMedicaidandMedicaidonly,includingthosereceivinglong-termservicesandsupportsthroughmanagedcareorganiza,onsorfee-forservicedeliverymodels;peoplewithcomplexneedsandhighcosts(e.g.demen,a);andbeneficiariesreceivinghomeandcommunity-basedservices
Informa,onat:h=ps://www.cms.gov/Medicare/Quality-Ini,a,ves-Pa,ent-Assessment-Instruments/MMS/CallforPublicComment.html
HomeandCommunity-BasedServicesQuality
• Mostpeoplewanttoremainathomeintheircommuni,esastheyageorbecomedisabled
• CMS’sMoneyFollowsthePersonDemonstra,onandtheIndependenceatHomeDemonstra,onhaveshowngainsinbeneficiarysa,sfac,on,quality,andcost,augmentedby30yearsofsuccessfulHCBSprogramsinMedicaid
• TwoyearsagoHHScontractedwiththeNa,onalQualityForum(NQF)todefineHCBS,examinequalitymeasurementinHCBS,andiden,fygapsinHCBSmeasurement
• MeasuringqualityinHCBSsemngs,wherefewendorsedmeasuresexist,hasbecomeincreasinglyimportantinthenewcross-semnghealthcareparadigm
• CMSrecentlyreceivedCAHPS®endorsementfortheHCBSExperienceofCareSurvey,andNQF’sPersonandFamilyCenteredCareCommi=eehasrecommendedthesurveymeasures(#2967)
• NQFissuedafinalreportyesterdayonHCBSQualitythatoutlinesmeasurementdomainsandwillguidefuturemeasuredevelopmentefforts
Informa,onat:h=p://www.qualityforum.org/Measuring_HCBS_Quality.aspx
Bi-par,sanbillintroducedinMarch,U.S.House&Senate;passedonSeptember18,2014andsignedintolawbyPresidentObamaOctober6,2014RequiresStandardizedPa?entAssessmentDatathatwillenable:
– AssessmentandQMuniformity– Qualitycareandimprovedoutcomes– ComparisonofqualityacrossPACsemngs– Improvedischargeplanning– Interoperability– Facilitatecarecoordina,on
RequiresassessmentdatatobestandardizedandinteroperableforexchangeamongPACprovidersandotherproviderstoallowaccesstolongitudinalinforma,ontofacilitatecoordinatedcareandimprovebeneficiarypa,entoutcomes,includingthedischargeplanningprocess.
ImprovingMedicarePost-AcuteCareTransforma?on(IMPACT)Actof2014
16
DataIsStandardized,CareisIndividualized
17
InformationFollowsthePerson
Long Term CareInstitutional and
Home and Community-Based Services (HCBS)
Person-centered care: Prevention, Mitigation, Risk Reduction, Continuity of Care & Care Coordination
Acute Care Post-Acute Care Home HealthPerson
PCP
EMR
EHR EHR EHR EHR
QualityImprovement
Na?onalPartnershiptoImproveDemen?aCareAn?psycho?cMedica?onUseTrendUpdate
• SincethestartoftheNa,onalPartnershiptoImproveDemen,aCarein2012,therehasbeena28.8%reduc,oninthena,onaluseofan,psycho,cmedica,onsamonglong-staynursinghomeresidents
• In201223.9%oflong-stayresidentswereonan,psycho,c
medica,ons.Bytheendof2015,thepercentagedroppedto17.0%
• SuccesshasvariedbystateandCMSregion,withsome
statesandregionsrecordinggreaterreduc,onsInforma,onat:h=ps://www.cms.gov/Medicare/Provider-Enrollment-and-Cer,fica,on/SurveyCer,fica,onGenInfo/Downloads/Survey-and-Cert-Le=er-16-28.pdf
“AddressingNeuropsychiatricSymptomsinPa?entswithDemen?a”
• InJuneCMSsponsoredaMedscapecon,nuingeduca,onopportunity• Theprogramprovidesasummaryoftreatmentgoalsforcomprehensive
demen,acare,addressesneuropsychiatricsymptommanagementincludingaDICE(describe,inves,gate,create,evaluate)approachtodifficultbehaviors,providesforacutehospitalmanagement,andlistsclinicalandadministra,veresources
• Thefocusisonimprovingandmaintainingqualityoflifeofpeoplewithdemen,a,includingsupportforfamiliesandcaregiversacrosssemngsofcare
• Con,nuingMedica,onEduca,onCreditisvalidthrough06/09/2017• CMSisexploringproducingotherlearningproductsondemen,a-related
topics
Overthepastthreemonthstheprogramhasbeenviewednearly9,000learners!!!!
h=p://www.medscape.org/viewar,cle/863605?src=acdmpart_hhs_863605
Payment
ProposedChangestothe2017MedicarePhysicianFeeSchedule
• APFSbillingcodesetthatmoreaccuratelyrecognizestheworkofprimarycareandothercogni,vespecial,estoaccommodatethechangingneedsofMedicarebeneficiaries
• Separatepaymentsforcertainexis,ngCurrentProceduralTerminology(CPT)codesdescribingnon-face-to-faceprolongedevalua,onandmanagementservices
• Re-evalua,onofexis,ngCPTcodesdescribingface-to-faceprolongedservices• Separatepaymentsusingnewcodestodescribethecomprehensiveassessmentandcare
planningforbeneficiarieswithcogni,veimpairment(e.g.,demen,a)• AdvanceCarePlanningdeliveredthroughtelehealth• Separatepaymentsusingnewcodestopayprimarycareprac,cesthatuseinter-professional
caremanagementresourcesforbeneficiarieswithbehavioralhealthcondi,ons• SeparatepaymentsforcodesdescribingChronicCareManagementforbeneficiarieswithgreater
complexity• Changestoreduceadministra,veburdenassociatedwithfurnishing/billingtheChronicCare
ManagementservicecodesPleaseseetheproposedregula?onfordetails(commentsarenowclosed):
h=ps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-
Federal-Regula,on-No,ces-Items/CMS-1654-P.html
CMSCodesforBeneficiaryManagement
Procedure CMSCodeAnnualwellnessvisit,firstvisitAnnualwellnessvisit,subsequentvisitaWelcometoMedicareexama
HCPCSG0438andG0439HCPCSG042
Chroniccaremanagementa
CPTcode99490–cannotbebilledduringsamemonthas:Transi,onalCareManagement–CPT99495and99496HomeHealthcareSupervision–HCPCSG0181HospiceCareSupervision–HCPCSG9182CertainESRDservices–CPT90951-90970
Caretransi,onsb
CPTCode99495–communica,onwiththepa,entorcaregiverwithintwobusinessdaysofdischarge.Thiscanbedonebyphone,e-mail,orinperson.Itinvolvesmedicaldecisionmakingofatleastmoderatecomplexityandaface-to-facevisitwithin14daysofdischargeCPTCode99496–communica,onwiththepa,entorcaregiverwithintwobusinessdaysofdischarge.Thiscanbedonebyphone,e-mail,orinperson.Itinvolvesmedicaldecisionmakingofhighcomplexityandaface-to-facevisitwithinsevendaysofdischarge
Advancedcareplanningc CPTcode99497tobebilledforthefirst30minutes,and99498foreachaddi,onal30minutes
a.AAPwebsite;b.HHS-CMSwebsite;c.HHS-CMSwebsite.
CMSDemonstra?onModelsandADRD
TheCMSInnova?onCenterwascreatedbytheAffordableCareActtodevelop,test,andimplementnewpaymentanddeliverymodels
“Thepurposeofthe[Center]istotestinnova,vepaymentandservicedeliverymodelstoreduceprogramexpenditures…whilepreservingorenhancingthequalityofcarefurnishedtoindividualsundersuch,tles”
Threescenariosforsuccess1. Qualityimproves;costneutral2. Qualityneutral;costreduced3. Qualityimproves;costreduced(bestcase)
Ifamodelmeetsoneofthesethreecriteriaandotherstatutoryprerequisites,thestatuteallowstheHHSSecretarytoexpandthedura?onandscopeofamodelthroughrulemaking
ComprehensivePrimaryCarePlus(CPC+)CMS’slargest-everini(a(vetotransformhowprimarycareisdeliveredandpaidforinAmerica
GOALS PARTICIPANTSANDPARTNERS
CARETRANSFORMATIONFUNCTIONS PAYMENTREDESIGNCOMPONENTS
1. Strengthenprimarycarethroughmul,-payerpaymentreformandcaredeliverytransforma,on.
2. Empowerprac,cestoprovidecomprehensivecarethatmeetstheneedsofallpa,ents.
3. Improvequalityofcare,improvebeneficiaries’health,andspendhealthcaredollarsmorewisely.
Accessandcon,nuity
Caremanagement
Comprehensivenessandcoordina,on
Personandcaregiverengagement
Plannedcareandpopula,onhealth
• 5yearmodel:2017-2021• Upto5,000prac,cesinupto20regions• Twotracksdependingonprac,cereadinessfortransforma,onandcommitmenttoadvancedcaredeliveryforpa,entswithcomplexneeds
• PublicandprivatepayersinCPC+regions• HITvendors(officialpartnersforTrack2only)
PBPMrisk-adjustedcaremanagementfees
Performance-basedincen,vepaymentsforquality,experience,andu,liza,onmeasuresthatdrivetotalcostofcare
ForTrack2,hybridofreducedfee-for-servicepaymentsandup-front“ComprehensivePrimaryCarePayment”toofferflexibilityindeliveringcareoutsidetradi,onalofficevisits
ComprehensivePrimaryCarePlus(con?nued)
• Enrolledbeneficiarieswithcomplexneeds(e.g.cogni,veimpairment,chroniccondi,ons,frailty)willbebe=erabletoachievetheirgoalsandbecomeengagedincare,have24houraccess,andreceivepreven,veservicesandcarecoordina,on
• Toensurebeneficiarieswithdemen,aareiden,fiedandflexiblycaremanaged,CPC+Track2prac,cesarepaid$100PB-PMforpa,entswithdemen,adiagnoses:h=ps://innova,on.cms.gov/Files/x/cpcplus-prac,ceslidepres.pdf
• CPC+CareDeliveryrequirements2.2and2.6areespeciallyrelevantforpeoplewithdemen,a:h=ps://innova,on.cms.gov/files/x/cpcplus-prac,cecaredlvreqs.pdf
Informa,onat:h=ps://innova,on.cms.gov/ini,a,ves/comprehensive-primary-care-plus
MedicareAdvantageValue-BasedInsuranceDesignModel(VBID)
• TheVBIDmodelwilltestthehypothesisthatgivingMAplansflexibilitytooffersupplementalbenefitsorreducedcostsharingtoenrolleeswithspecifiedchroniccondi,onsinordertoencouragetheuseofservicesthatareofhighestvaluetothemwillleadtohigher-qualityandmorecost-efficientcare
• Clinically-nuancedVBIDapproacheshavegenerallynotbeenincorporatedintotheplansun,lnow
• Inthesecondyearofthemodel,beginningJanuary1,2018,CMSwilladddemen,atotheclinicalcategoriesforwhichpar,cipantsmayofferbenefits
• Inaddi,ontodevelopinginterven,onstargetedatallenrolleesinoneormoreoftheabovecategories,par,cipa,ngMAplanswillhavetheflexibilitytoiden,fyspecificcombina,onsofthelistedchroniccondi,onsforoneormore“mul,pleco-morbidi,es”groupsandestablishtailoredVBIDinterven,onsforeachgroup.
Informa,onat:h=p://innova,on.cms.gov/ini,a,ves/VBID
HealthCareInnova?onAwards(HCIA)
• Goal – to identify and support a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs through improvement in communities across the nation
• RoundOneFundingPeriod:July2012–June2015
– 1stAnnualReportavailableat• h=p://innova,on.cms.gov/Files/reports/HCIA-DS-FirstEvalRpt.pdf
– TrusteesofIndianaUniversity– RegentsoftheUniversityofCalifornia,LosAngeles
• h=p://innova,on.cms.gov/Files/reports/HCIA-CHSPT-FirstEvalRpt.pdf– UniversityofArkansasforMedicalSciences,– UniversityofNorthTexasHealthScienceCenter– UniversityofRhodeIsland
– 2ndAnnualReport-released:h=ps://innova,on.cms.gov/ini,a,ves/Health-Care-Innova,on-Awards/
– 3rdAnnualReportan,cipatedrelease:Early2017
HCIA Round One Projects - People with Dementia Awardee Brief Description
Regents of the University of California, Los Angeles
Coordinated, comprehensive, patient and family-centered program. Five key components: (1) patient recruitment and a dementia registry; (2) structured needs assessments of patients and their caregivers; (3) creation and implementation of individualized dementia care plans; (4) monitoring and revising care plans as needed; and (5) providing access 24/7, 365 days a year for assistance and advice.
Trustees of Indiana University
The Aging Brain Care program incorporates the common features of several evidence-based collaborative care models into one program designed to deliver high quality, efficient medical care to older adults suffering from dementia and or depression.
University of Rhode Island
The Living Rite Innovations project is delivering holistic coordinated care through the project’s two Living Rite Centers. The Centers provide comprehensive chronic care management in order to coordinate services between multiple community providers, improve health and decrease unnecessary hospitalizations and ER visits.
University of Arkansas for Medical Sciences
Project is providing enhanced training of both family caregivers and the direct-care workforce in order to improve care for elderly patients requiring long-term care services, including Medicare beneficiaries qualifying for home healthcare services and Medicaid beneficiaries who receive homemaker and personal care assistant services.
University of North Texas Health Science Center
The awardee in partnership with Brookdale Senior Living (BSL), is developing and testing the Brookdale Senior Living Transitions of Care Program, which is based on an evidenced-based assessment tool called Interventions to Reduce Acute Care Transfers (INTERACT) for residents living in independent living, assisted living and skilled nursing facilities. The goal of the program is to prevent the progress of disease, thereby reducing complications, improving care, and reducing the rate of avoidable hospital admissions for older adults.
HCIA Round 2 Awardees Serving People with Dementia
Awardee Brief Description
The Regents of the University of California, San Francisco
This project will test a model to provide high quality dementia care. The model consists of four specific modules targeting caregivers, decision-making, medications, and functional monitoring.
Johns Hopkins University
This project will test a comprehensive care management program for patients with Alzheimer's disease/Dementia designed to help patients remain in their homes.
Forthe2ndroundofHCIA,proposalsweresolicitedin4specificcategoriesofcare,including“improvecareforpopula,onswithspecializedneeds,”whichdesignatedproposalsthattargetcareforpersonswithADasaprioritypopula,on
2awardsfundedaroundADRDFundingPeriod:Sept1,2014toAug31,2017.
WhereWeareHeading
HHSGoalsforValue-BasedPaymentsinMedicare
During2016,the30%goalwasachievedoneyearaheadofschedule!
" A better, smarter Medicare for healthier people " First step to a fresh start " We’re listening and help is available " Pay for what works to create a Medicare that is enduring " Health information needs to be open, flexible, and user-centric
Quality Payment Program as Proposed TheMedicareAccessandCHIPReauthoriza?onActof2015(MACRA)
The Merit-based Incentive
Payment System (MIPS)
Advanced Alternative
Payment Models (APMs)
or
" Repeals the Sustainable Growth Rate (SGR) Formula
" Streamlines multiple quality reporting programs into the new Merit-based Incentive Payment System (MIPS)
" Provides incentive payments for participation in Advanced Alternative Payment Models (APMs)
TransformingClinicalPrac?ceIni?a?ve(TCPI)
• TCPIisdesignedtosupportmorethan140,000clinicianprac,cesinsharing,adap,nganddevelopingcomprehensivequalityimprovementstrategiesthroughpayment/prac,cereform,carecoordina,on,community-basedhealthteamssuppor,ngchroniccaremanagement,andaprac,cetransforma,oncollabora,ve
• Ofnoteisthe“TCPIChangePackage,”acompila,onoftestedinterven,onsthatincludesimprovementtac,csbasedonthreepillars–personandfamily-centeredcare,datadrivequalityimprovement,andsustainablebusinessprac,ces:h=ps://www.acponline.org/prac,ce-resources/business-resources/payment/transforming-clinical-prac,ce-ini,a,ve
TheHealthcareCommuni?esTCPIPortal:www.healthcarecommuni?es.org
• MaincommunityforTCPIpar(cipants
andstakeholders• Sub-communi(esforeachPrac(ce
Transforma(onandSupportAlignmentNetwork
• Publicpagefornewsandresults• Announcements• EventCalendarwithregistra(onand
reminders• Shareresourcesandtools-advanced
searchfunc(on• Subscribetodocumentupdates• Hear/Viewothers’stories• Gethelp–SingleSolu(onsCenter
Connectwithotherslocallyandna(onallyandbytopic–Listservs,BlogsandForums
• Shareresultsandsuccess
36
Whatdata,research,evidenceisneededtogainmoreac,ononana,onallevel?Whatofthesewouldbemosthelpfultomovethedialforsystem/policychange?Ifstakeholdersweretoinvestlocaldollarstogeneratethisinforma,on-whatshouldwefocuson?Whatarethebiggestdata,evidence,researchgapsfromCMS’sperspec,ve?
TheCMSQualityStrategy
# Focusontheaimsofbe=ercare,smarterspending,andhealthierpeople
# Maximizethequalityofcareyoudeliver
# Learnaboutqualitymeasurement
# Investinneededinfrastructure
# Focusondatacollec,onandperformancetransparency
# HelpCMSdevelopnewpaymentandservicedeliverymodels
# Engageinalterna,vepaymentandintegratedcaremodels
# Testinnova,ons,scalesuccess,andshareyourresults
# Par?cipateinopportuni,esforpubliccomment
WhatCanYouDotoImproveCareQuality?
Makingcaresaferbyreducingharmcausedinthedeliveryofcare.
Source:PartnershipforPa(ents
PartnershipforPa?entsModelTestFocusedonTwoBreakthroughAims
“40/20by‘14”
Ensuringthateachpersonandfamilyareengagedaspartnersintheircare.
• HowcanwebesthelppeoplewithADRDandtheircaregiverspriortohavingtherightinfrastructureandcaremodelinplace?
• Itseemswhenpa,entsgettothenursinghomewithobviouscogni,veimpairment...whenwediscussdemen,a,itseemslikethefirst,methefamilyhasheardaboutit...itseemsprimarycareandhospitalprovidersarenottalkingabouttheelephantintheroom.Howcanweaddressthisissue?
Promo(ngeffec(vecommunica(onandcoordina(onofcare.
• Howdowecon,nuetoalignpolicy,programs,andpaymenttosupportdemen,acare?
• Whatwillittaketoinvolvelocalmedicalsystems?• Howcanwebesuretoalignallqualityandcasemanagementexpecta,onstoavoid
confusionandduplica,on?
• HowdoesCMSenvisionpayingforthewraparoundservicesrequiredtosupportdemen,apa,entsandtheircaregivers,outsideofthefeeforserviceworld?
• Isthereateambasedmodelforreimbursementofdemen,acareintheambulatorysemng?
• HowcanCMSu,lizetheInnova,onCenterand/orthedualsofficetointegratedemen,acareacrosssemngs(e.g.,includingclinic,behavioral,hospital,managedlong-termservicesandsupports,homehealth,homeandcommunity-basedservices,assistedliving),andacrossdisciplines?
• Howcanwepromotethevalueofcarecoordina,onwithpaymentmodelstosupport?
• Howdoyouseethefutureofreimbursementandapplica,onoftelehealthenhancingdemen,acare?
• ArethereanyplansforMedicaretoengageinacaregivertrainingpilot?
Promo(ngthemosteffec(vepreven(onandtreatmentprac(cesfortheleadingcausesofmortality,star(ngwithcardiovasculardisease.
• Howcanweimprovedetec,onofdemen,ainabusyprac,ceeffec,velyandefficiently?• HowcanCMSdrivedetec,on?• HowcanCMShelptopriori?zedetec?onandmanagementofdemen?ainprimarycare?• Alzheimer'sisacomplexdiseasetoassessanddiagnose,yettheassessmenttoolsarenotreimbursedforphysicians
whotake,metoimplementthem.Inordertoimproveoutcomes,weneedtoenablehealthcareprac,,onerstobereimbursedandmake,meforathoroughassessment.Howcanthisbeimplemented?
• Thehealthcaresystemcurrentlyrewardsprocedure-basedspecial,es,andtradi,onally,specialistsindemen,acareareviewedasaliabilityintermsofearningpoten,al.HowwillCMSincen,vizethecounselingworkthatisinvolvedindemen,acareandmanagementacrossprovidertypes?
• Howdoyousuggestweusealliedhealthproviderstobe=erimprovecaretopeoplewithdemen,a(pharmacists,OT,PT)?
• HowcanCMSuseitsdatatounderstanddispari,esindetec,on,diagnosisandmanagement?• Whatcanwedotoincreaseawarenessofthelinkbetweendemen?aandco-morbiddisorders?• Howcanweencouragepromotethereasonsforearlydetec,on,careplanning,andreferral?• Howdowemakedemen,acarepartofmedicalcare?Howdowemaketrea,ngbrainfailureliketrea,ngcancer,
heartfailure,kidneyfailure,etc.?• Therearecurrentlymul?pleproblemsassociatedwiththeprimarycarephysician’scurrentencounterswiththe
demen?apa?ent-thedura?onofvisits,financialincen?vesassociatedwithcare,anddelayeddiagnosisinthispa?entpopula?on.ArethereanyplansfromaCMSperspec?vetobeCersupportprimarycareprovidersinthemanagementofdemen?a?
• ForamyloidimagingtobereimbursedthroughMedicare,wouldbothprimaryendpoints(e.g.decisionmakingandreducedhealthcarecosts)needtobemetorwoulditbesufficienttomerelyshowanimpactonphysiciandecision-making?
• Whatwouldyouencourageasthefirststepforhealthplanstoconsiderwhendevelopingafocusondemen?a?
Workingwithcommuni(estopromotewideuseofbestprac(cestoenablehealthyliving.
• Howcanweencourageclinicianstobe=ercoordinatecarefortheirpa,ents,andu,lizethenewCMScarecoordina,onpaymentcodetobereimbursed?
• IfyoucouldchangeonethingatCMStoencourageearlydetec,onanddiagnosisofdemen,a,whatwouldthatbe?• ThecurrentMedicareWellnessExamdoesnotspecifythediagnos,ctoolstobeusedincogni,vescreening.Canwe
expectthemandateofevidencebaseddiagnos,ctools?• Onceabenefitisimplemented(e.g.AnnualWellnessVisit),underwhatcircumstancesmightitbediscon,nued?• HowdoesCMSuseclinicianinputindesigningnewbenefits?• Isitpossibletomakedemen,aaqualitycareindicatorforpa,ents>65yearsold?• WhatrolemightMedicarereviewersplayinhelpingimprovedetec,onanddiagnosis?• Howwouldyoudescribeidealdemen,acare,andwhatpolicychangeswouldneedtohappenforthistypeofcare
tobefinanciallysustained?• Howdoesdemen,arankonthena,onalprioritylist?ForCMS?
• WhatmechanismsdoesCMShavetoeducateprovidersandbeneficiariesaboutgoalsandimplementa,onofspecificbenefits?
• Whatadvicedoyouhaveinsuppor,ngsmallruralprac,cesinimprovingtheirdemen,adetec,on,diagnosis,treatment,andcare?
• CanwecreateCentersofExcellenceOlderAdultswithCMSfunds?• InAugust,SecretaryClintonannouncedaplantointegratementalandphysicalhealthcaresystems.Herplan
encompassestheintegra,onofmentalandphysicalhealthcaresystems,includinganexpansionofreimbursementstructuresinMedicareandMedicaid,taskingtheCMSInnova,onCentertocreateandimplementthenewpaymentmodels.HowdoyouseetheAlzheimer’sDiseasecommunityfimngintothisproposedagenda?
TelehealthHistory
• Medicarecoverageandpaymentforservicesdeliveredthroughtelecommunica,onssystemswasauthorizedbytheCongressnearly20yearsagowhenitadded‘MedicareReimbursementforTelehealthServices’totheSocialSecurityAct
• In2000statutoryrequirementsamendedtheActbyaddinganewsec,on,‘PaymentforTelehealthServices,’whichallowsMedicaretomakeapaymentforalimitednumberofPartBserviceswhenfurnishedbyaneligiblephysicianorprac,,onertoaneligibleMedicarebeneficiaryviaatelecommunica,onsystem
• TheActlimitsMedicare’spaymentauthoritytoonlythetypesoftelehealthservicesdefinedinthestatute
• Medicaredoesnotcurrentlyhavepaymentauthorityforservicesfurnishedviamobilehealth(mhealth)orelectronichealth(ehealth)methods,aswellaspaymentforothertechnologicalandwebbasedadvancementsincarethatwerenotcontemplatedinthestatutedecadesago
Telehealth(con?nued)• TheActdefinesMedicaretelehealthservicestoincludeconsulta,ons,officevisits,office
psychiatryservices,andanyaddi,onalservicespecifiedbytheHHSSecretary,whenfurnishedviaatelecommunica,onssystem
• CMSfinalizedaprocessthatprovidesthepublicwiththeopportunitytosubmitrequestsforconsidera,onofaddi,onaltelehealthservicesiftheservicefallsintooneoftwocategories:Category1:Servicesthataresimilartoprofessionalconsulta(onsandofficevisitsthatarecurrentlyincludedonthelistofeligibleMedicaretelehealthservicesandCategory2:ServicesthatarenotsimilartoservicescurrentlyonthelistofeligibleMedicaretelehealthservices,butwheretherequestincludesanassessmentoftheserviceanddocumentsthatwhentheserviceisfurnishedviatelehealthaclinicalbenefitforthepa(entisdemonstrated
• CMShasfurnishedguidanceonthetypesofbenefitsthatareacceptablewhenconsideringtheappropriatenessoffurnishingaprofessionalserviceviatelehealthincludingoninterven,onsincarethatreducenega,vehealthoutcomesandrestora,onandpromo,onofbeneficiarywell-being
Forinforma,ononsubmimngatelehealthservicerequesttoCMSforconsidera,onintheannualtelehealthupdateprocess:h=ps://www.cms.gov/Medicare/Medicare-General-Informa,on/Telehealth/Criteria.htmlFactSheeton2016Telehealthcoverage:h=ps://www.cms.gov/Outreach-and-Educa,on/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publica,ons-Items/CMS1243327.html
MedicaidTes?ngExperienceandFunc?onalToolsGrants
h=ps://www.medicaid.gov/medicaid-chip-program-informa,on/by-topics/delivery-systems/grant-programs/te�-program.html
