Healthcare Challenges -Current CMS Initiatives
Steve McAdooDeputy Regional Administrator, DallasCenters for Medicare & Medicaid [email protected]
CMS Initiatives
Preventive Services Covered by Medicare Medicare Part D – The Drug Benefit Medicare Advantage (MA) The Value Driven Healthcare Initiative
(VDHC) The Physician Quality Reporting Initiative
(PQRI)
Services to Help You Stay Healthy
“Welcome to Medicare”physical exam
Bone mass measurement
Cardiovascular screening
Colorectal cancer screening
Diabetes screening, services, and supplies
Glaucoma screening Pap test and pelvic exam
with clinical breast exam Prostate cancer screening Screening mammogram Smoking cessation
counseling Influenza, Pneumococcal
and Hepatitis B immunization
“Welcome to Medicare” Physical ExamMMA Section 611
Initial preventive physical exam Height, weight, blood pressure, and EKG Education, counseling, and referral for other
preventive services Within first 6 months of Part B coverage 20% copayment after Part B deductible in Original
Medicare Plan When provider accepts assignment
Preventive Services – The Problem
Pneumococcal covered since 1981 – only 69% report getting it.
Flu vaccine – Only about 65% got the flu shot last year.
Mammogram – Less than half of eligible women get the test.
Similar utilization rates with most preventive services.
www.MyMedicare.gov
You may use MyMedicare.gov to: View claim status (excluding Part D claims), Order a duplicate Medicare Summary Notice (MSN) or
replacement Medicare card, View eligibility, entitlement and preventive services
information, View enrollment information including prescription drug
plans, View or modify your drug list and pharmacy information, View address of record with Medicare and Part B
deductible status, and Access online forms, publications and messages sent to
you by CMS.
Part D – A Status Report Competition & choice resulted in an average monthly
premium of $24 for 2007, the same as 2006. 83% of beneficiaries in PDPs have access to plans
that cost less than their previous coverage. Average number of drugs included on formularies
increased 13%. More plans with coverage for preferred brands and/or
generics in the coverage gap (at least one in each state).
Beneficiaries are saving an average of $1,200 annually on their drug costs.
Five separate opinion surveys show beneficiaries are overwhelmingly satisfied with their plan.
Part D Enrollment RatesSelected West Texas Counties
State County
Total Medicare Beneficiaries
Total Enrolled in any Drug Plan Percentage
Texas Andrews 1,885 1403 74.43%
Texas El Paso 88,299 61932 70.14%
Texas Hansford 840 600 71.43%
Texas Lubbock 33,086 23182 70.07%
Texas Taylor 19,373 12657 65.33%
Texas Tom Green 16,852 11206 66.50%
Texas Val Verde 6,416 4268 66.52%
The Drug Benefit in Rural America
Help with Costs Leads to Better Health and Lower Risk of Complications
Geography and Access to Pharmacies CMS efforts to continue to enroll eligible
Medicare beneficiaries who have never enrolled, will focus on rural areas this fall.
Special focus on beneficiaries entitled to extra help.
Low Income Subsidy PenetrationSelect West Texas Counties
State County
Total Medicare Beneficiaries
Estimate of Benes Entitled to LIS who have not applied
Percentage
Texas Andrews 1,885 82 4.350%
Texas El Paso 88,299 4,321 4.894%
Texas Hansford 840 36 4.286%
Texas Lubbock 33,086 1,246 3.766%
Texas Taylor 19,373 914 4.718%
Texas Tom Green 16,852 936 5.554%
Texas Val Verde 6,416 403 6.281%
CMS LIS Toolkit: http://www.cms.hhs.gov/Partnerships/Toolkits/Social Security Administration: 1-800- 772-1213
Growth in Managed Care Enrollment Rural
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
2005
350,000
2006
520,000
2007
780,000
Medicare Advantage
The Medicare Modernization Act (MMA) vastly expanded the options for managed care in Medicare.
Medicare Advantage – HMOs & PPOs Special Needs Plans Private Fee For Service Plans
MA Expansion Impact on Rural Areas
Expanding insurance to rural areas and areas previously underserved by plans
Significant legislation: Risk Corridors Stabilization Fund Essential Hospital Payments
Growth in enrollment in PFFS plans PFFS are available in 96% of rural counties 59% of all rural beneficiaries in MA are in PFFS
plans
MA Enrollment RatesSelected West Texas Counties
State County
Total Medicare Beneficiaries
Total Enrolled in Medicare Advantage Percentage
Texas Andrews 1885 92 4.88%
Texas El Paso 88299 19424 22.00%
Texas Hansford 840 18 2.14%
Texas Lubbock 33086 1984 6.00%
Texas Taylor 19373 1211 6.25%
Texas Tom Green 16852 679 4.03%
Texas Val Verde 6416 532 8.29%
Value-Driven Health Care System
The goal of VDHC is to provide public information about the quality and cost of services delivered by health care providers.
Consumers cannot adequately compare on the basis of quality and cost.
Practitioners cannot compare performance to standards of practice.
Public reporting is the surest way to achieve better health care at lower cost.
Value Driven Healthcare Initiative (VDHC)I. Health Information TechnologyII. Reporting on QualityIII. Reporting on PricesIV. Incentives for Quality and Value
Community Leaders Value Exchanges
Physician Quality Reporting Initiative (PQRI) Voluntary quality reporting program Doctors and other medical professionals may
participate. Participants may receive a 1.5% bonus on
allowed charges. On selected procedures participants report
procedure codes, plus a quality code.
PQRI and Rural Practitioners
Historical impact of Medicare reimbursement methodologies. Reasonable charge reimbursement Physician fee schedule Pay for performance
Initial emphasis is on reporting of quality factors and bonus payments are based on reporting alone.
All feedback to participants will be confidential.
TrailBlazer Health Chosen as Medicare Administrative Contractor
• Award for Jurisdiction 4 made on August 2, 2007
• One of 15 new MAC jurisdictions to be awarded by 2009
•Recompeted every 5 years.
•Full transition to be implemented no later than Spring 2008
•The transition will affect approximately 3,855,000 beneficiaries, being served by 831 hospitals and 106,000 physicians and other health professionals.
•The jurisdiction accounts for approximately 9.4% of the national Medicare claims workload.