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CMS Updates

The following posts are updates and press releases from Centers for Medicare & Medicaid Services.

2019 Medicare Physician Fee Schedule Final Rule

Posted December 17, 2018

Prepared by Barbara J. Connors, DO, MPH and Patrick M. Hamilton, MPA - Centers for Medicare & Medicaid Services

Click HERE to download the 2019 Medicare Physician Fee Schedule Final Rule

New Online Tool Displays Cost Differences for Certain Surgical Procedures

Posted November 28, 2018

CMS NEWS
FOR IMMEDIATE RELEASE
November 27, 2018
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 

New Online Tool Displays Cost Differences for Certain Surgical Procedures
Procedure Price Lookup will help patients with Medicare consider potential cost differences when choosing among safe and clinically appropriate settings


Today, the Centers for Medicare & Medicaid Services (CMS) launched a new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider.

“Price transparency in health care is a priority for the Trump Administration. Working with their clinicians, the Procedure Price Lookup will help patients with Medicare consider potential cost differences when choosing where to have a medical procedure that best meets their needs,” said CMS Administrator Seema Verma.

The Procedure Price Lookup tool is launching as required by Congress in the 21st Century Cures Act. Medicare’s statutes require that CMS maintain separate payment systems for different types of healthcare providers, meaning both CMS and patients may pay different amounts for the same service, depending on the site of care.

“The different payment rates are a prime example of Medicare’s misaligned financial incentives, under which providers can make more money if they see patients at one location as opposed to another,” Administrator Verma said.

Procedure Price Lookup, part of the agency’s eMedicare initiative, joins other patient-oriented transparency tools, including an overhauled version of the agency’s drug pricing and spending dashboards, which provide patients with Medicare and Medicaid spending information for thousands more drugs than ever before and, for the first time, list the prescription drug manufacturers that were responsible for price increases.

CMS recently launched the eMedicare initiative to empower beneficiaries with cost and quality information. This announcement included the launch of an enhanced interactive online decision support feature to help people better understand and evaluate their Medicare coverage options. eMedicare also offers a mobile-optimized out-of-pocket cost calculator to provide beneficiaries with information on overall plan costs and prescription drug costs.

For a blog post on the Procedure Price Lookup took by Administrator Verma, please visit: https://www.cms.gov/blog/you-have-right-know-price.

The Procedure Price Lookup tool is available at: https://www.medicare.gov/procedure-price-lookup/.

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Updated: QPP Participation Status Tool Now Includes Second Snapshot of 2018 Qualifying APM Participant and MIPS APMs Data

Posted November 9, 2018

QPP Participation Status Tool Now Includes Second Snapshot of 2018 Qualifying APM Participant and MIPS APMs Data

The Centers for Medicare & Medicaid Services (CMS) updated its Quality Payment Program Participation Status Tool based on calculations from the second snapshot of Medicare Part B claims data to calculate the Alternative Payment Model (APM) entities threshold scores. The second snapshot are for dates of participation between January 1 and June 30, 2018. As a reminder, the tool includes 2018 Qualifying APM Participant (QP) and MIPS APM status.

By the end of this year, CMS will release the third QP and MIPS APM status data based on snapshots of claims between January 1, 2018 and August 31, 2018. To learn more about how CMS determines QP and MIPS APM status for each snapshot, please view the QP Methodology Fact Sheet.

What Does QP Status Mean?
If you qualify as a QP, this means you are:

  • Eligible for the 5% APM incentive bonus, and
  • Exempt from participating in MIPS.

What Does MIPS APM Participation Mean?

If you are in participating in a MIPS APM you receive the benefit of being scored under the APM Scoring Standard. As a MIPS APM participant we recommend you check the QPP Participation Status Tool to see if you’re eligible for MIPS in 2018.

How Do I Check My QP or MIPS APM Status?


To view your QP or MIPS APM status as an individual:

To check your group’s 2018 eligibility at the APM entity level:

  • Log into the CMS Quality Payment Program website with your EIDM credentials
  • Browse to the Taxpayer Identification Number affiliated with your group
  • Access the details screen to view the eligibility status of every clinician based on their NPI

What APMs are Included in the QPP Participation Status Tool?

The updated Quality Payment Program Participation Status Tool includes the following 2018 Advanced APMs and MIPS APMs:

  • Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)
  • Comprehensive ESRD Care (CEC) Model (LDO arrangement)
  • Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement)
  • Comprehensive ESRD Care (CEC) Model (non-LDO one-sided risk arrangement)
  • Comprehensive Primary Care Plus (CPC+) Model
  • Medicare Accountable Care Organization (ACO) Track 1+ Model
  • Medicare Shared Savings Program Accountable Care Organizations – Track 1, 2, 3
  • Next Generation ACO Model
  • Oncology Care Model (OCM) (one-sided Risk Arrangement)
  • Oncology Care Model (OCM) (two-sided Risk Arrangement)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

For a comprehensive list of APMs, visit the QPP Resource Library.

Reducing Clinician Burden

Posted November 9, 2018

Special Edition – Thursday, November 8, 2018

Today CMS released a letter to clinicians outlining how the agency is reducing burden through reform of documentation and coding requirements. We encourage you to read and share with your stakeholders.  

Access to Quality and Resource Use Reports and PQRS Feedback Reports Available Until December 31, 2018

Posted November 9, 2018


Access to Quality and Resource Use Reports and PQRS Feedback Reports Available Until December 31, 2018

The final performance period for the Value Modifier and Physician Quality Reporting System (PQRS) programs was 2016 and the final payment adjustment year is 2018. Therefore, the Quality and Resource Use Reports (QRURs) and PQRS Feedback Reports will no longer be available after the end of 2018. All QRURs and PQRS Feedback Reports provided under these programs will remain available for download until December 31, 2018. Authorized representatives of groups and solo practitioners can access their QRURs and PQRS Feedback Reports at https://portal.cms.gov using an Enterprise Identity Management (EIDM) system account with the correct role. The QRURs can be downloaded as PDF or Excel files, and the PQRS Feedback Reports can be downloaded as Excel files. For instructions on signing up for an EIDM account and accessing the QRURs and PQRS Feedback Reports, please visit the How to Obtain a QRUR webpage.

For access to PQRS Taxpayer Identification Number (TIN) or National Provider Identifier (NPI) reports from program year 2013 or earlier, please contact the QualityNet Help Desk, Monday - Friday; 7:00 a.m. - 7:00 p.m. Central Time (CT) as they are no longer available from the “Communication Support Page” section of the QualityNet Secure Portal.

The Merit-based Incentive Payment System (MIPS) under the new Quality Payment Program replaced the Value Modifier and PQRS programs. We encourage everyone to learn more about the Quality Payment Program by visiting qpp.cms.gov. Please note that the QRURs and PQRS Feedback Reports are not the same as the MIPS Performance Feedback that is available under the Quality Payment Program.

Questions:

  • For information on your PQRS Feedback Report, visit the Analysis and Payment webpage.
  • For information on your QRUR, visit the Value Modifier webpage.
  • For assistance with Enterprise Identity Management or PQRS Feedback Reports, contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715- 6222) or qnetsupport@hcqis.org.
  • For assistance with the QRURs or Value Modifier, contact the Physician Value Help Desk at pvhelpdesk@cms.hhs.gov or 888-734-6433 (select option 4).
  • Both help desks are available from 7:00 a.m. to 7:00 p.m. CT, Monday through Friday.

Now Available: Accredited Online Course; Help CMS Improve the Quality Payment Program!

Posted November 9, 2018


Now Available: Accredited Online Course - Quality Payment Program in 2018: Advanced APMs Web-Based Training Course — Revised

With Continuing Education Credit

A revised
Quality Payment Program in 2018: Advanced APMs Web-Based Training Course is available through the MLN LMS.
Learn about:

  • Advanced Alternative Payment Models (APMs), including how to identify an Advanced APM and a CMS Advanced APM
  • How to participate in QPP via an Advanced APM

Participants will gain knowledge and insight on the program all while earning valuable continuing education credit. Keep checking back with us for updates on new courses. First time participants will need to register for the MLN Learning Management System. Once registered, you will be able to access additional courses without having to register.  For information on how to login or find training, please visit our MLN Learning Management System FAQ sheet.

The Centers for Medicare & Medicaid Services designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Credit for this course expires October 23, 2021. AMA PRA Category 1 Credit TM is a trademark of the American Medical Association.

Accreditation Statements

Please click here for accreditation statements


Help CMS Improve the Quality Payment Program!

Interested in providing feedback on the Quality Payment Program website to CMS as we continue to improve the Quality Payment Program experience? Email CMSQPPFeedback@Ketchum.com to participate in our feedback sessions.


PA Health Care Cost Containment Council Special Data Requests Update

Posted November 9, 2018

Data User Series

Impact of Type 2 Diabetes on Healthcare Utilization in Rural and Urban Pennsylvania
Dr. Trina Thompson, Director, and Konstantinos Panitsas, Research Project Manager, of the 1889 Jefferson Center for Population Health used hospital data from the Pennsylvania Health Care Cost Containment Council (PHC4) to study diabetes in rural Pennsylvania. Results of the study showed that, independent of stratification by age, gender, type of insurance and race, patients with a secondary diagnosis of diabetes had, on average, higher total expenditures when compared to patients without diabetes or to patients hospitalized specifically for diabetes–a finding consistent at the state and county level. More Details.

PHC4 Research Briefs 

Cost of Care for Pennsylvania’s Heart Failure Patients
This research brief examines adult Pennsylvania residents, insured by Medicare fee-for-service, who were hospitalized for heart failure and the medical services they subsequently received for up to one-year. It includes payment amounts by type of service, and it includes county-level population-based rates. More Details

Breast Cancer Surgery in Pennsylvania
This research brief examines breast cancer surgeries performed in Pennsylvania hospitals and ambulatory surgery centers during 2017.  It includes county-level population-based rates. More Details

Hospitalizations for Opioid Overdose 

Population Differences
As part of a series that examines opioid-related hospitalizations, PHC4 released a research brief focusing on demographic differences among Pennsylvania residents hospitalized for opioid overdose, including those with the highest rates and those with the highest rate increases. More Details

Opioid Overdose & Opioid Use Disorder
This brief, also part of the series on opioid-related hospitalizations, extends previous analysis on opioid overdose to include hospitalizations related to opioid use disorder. More Details

PHC4 Reports


Financial Analysis 2017 Volume 2 – Ambulatory Surgery Centers

A report with statewide and facility-specific information on the financial health of Pennsylvania’s ambulatory surgery centers. The report covers fiscal year 2017. More Details

The Quality Payment Program Resource Library is Back on QPP.CMS.GOV

Posted October 31, 2018


The Quality Payment Program Resource Library is Back on QPP.CMS.GOV


Visit the Quality Payment Program Website to Find Available Resources


The Centers for Medicare & Medicaid Services (CMS) has moved Quality Payment Program (QPP) resources from CMS.gov to the newly redesigned Quality Payment Program Resource Library on qpp.cms.gov. Following feedback from clinicians and others in the health care community, we wanted to make Quality Payment Program information and resources available in one place. We’ve also made it easier for you to find the resources you’re looking for by including a search function that allows you to search for resources by year, reporting track, performance category, and by document type (e.g., fact sheet, user guide, measure specifications).

Additional resources including materials from educational webinars will be added to the new Quality Payment Program Resource Library soon. Stay tuned for more information!

For More Information

Questions?
Contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222)

Register for Medicare Diabetes Prevention Program (MDPP) Office Hours: Crosswalk Guidance

Posted October 25, 2018

Register Today!

Medicare Diabetes Prevention Program (MDPP)
Crosswalk Guidance Webinar
October 31, 2018
11am ET


MDPP suppliers are required to maintain a crosswalk file that lists beneficiary identifiers used for the Centers for Disease Control and Prevention (CDC) performance data submissions and the corresponding Medicare identifiers for each beneficiary who receives MDPP services. This requirement will facilitate the evaluation of the MDPP expanded model.

During this webinar, we will walk through the recently released MDPP Crosswalk Guidance, which outlines the form and manner in which all MDPP suppliers must maintain the crosswalk file. Register here.

CMS model addresses opioid misuse among expectant and new mothers

Posted October 24, 2018

CMS NEWS

FOR IMMEDIATE RELEASE
October 23, 2018
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 

CMS model addresses opioid misuse among expectant and new mothers
Goals are to improve quality of care, increase access to treatment based on state-specific needs, and reduce expenditures

Today the Centers for Medicare & Medicaid Services (CMS) announced the Maternal Opioid Misuse (MOM) model, an important step in advancing the agency’s multi-pronged strategy to combat the nation’s opioid crisis. The model addresses the need to better align and coordinate care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD) through state-driven transformation of the delivery system surrounding this vulnerable population. By supporting the coordination of clinical care and the integration of other services critical for health, wellbeing, and recovery, the MOM model has the potential to improve quality of care and reduce expenditures for mothers and infants.

“Too many barriers impede the delivery of well-coordinated, high-quality care to pregnant and postpartum women struggling with opioid misuse, including lack of access to treatment and a shortage of providers in rural areas, where the opioid crisis is especially destructive,” said HHS Secretary Alex Azar. “The MOM model will support state Medicaid agencies, front-line providers and healthcare systems to help ensure that mothers and infants afflicted by the opioid epidemic get the care they need.”

Substance use-related illness and death is now a leading cause of maternal death.  Pregnant and postpartum women who misuse substances are at high risk for poor maternal outcomes, including preterm labor and complications related to delivery; these problems are frequently exacerbated by malnourishment, interpersonal violence, and other health-related social needs. Infants exposed to opioids before birth are at greater risk for negative health outcomes such as higher risk of being born preterm, having a low birth weight, and experiencing the effects of neonatal abstinence syndrome (NAS), a group of conditions caused when an infant withdraws from certain drugs s/he is exposed to in the womb. In addition, Medicaid pays the largest portion of hospital charges for maternal substance use, as well as a majority of the $1.5 billion annual cost of NAS.

The primary goals of the model are to:

  • Improve quality of care and reduce expenditures for pregnant and postpartum women with OUD as well as their infants;
  • Increase access to treatment, service-delivery capacity, and infrastructure based on state-specific needs; and
  • Create sustainable coverage and payment strategies that support ongoing coordination and integration of care.

The CMS Innovation Center will execute up to 12 cooperative agreements with states, whose Medicaid agencies will implement the model with one or more “care-delivery partners” in their communities. The MOM model will serve pregnant Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries with OUD who have elected to participate, during the prenatal, peripartum (i.e., surrounding labor and delivery), and postpartum periods. Awardees will be responsible for ensuring that beneficiaries participating in the model have access to a set of essential physical and behavioral health services, such as medication-assisted treatment (MAT) for OUD, maternity care, relevant primary care services, and other mental and behavioral health  services beyond MAT.

The MOM model will have a five-year period of performance with different types of funding. Specifically, implementation funding, transition funding, and the opportunity for milestone funding will be provided in three distinct model periods: Pre-implementation (Year 1), Transition (Year 2), and Full Implementation (Years 3-5).

Care delivery will begin in Year 2, or the Transition Period, of the model. During this year, funding for care-delivery services that are not otherwise covered by Medicaid will be provided by Innovation Center funds. By Year 3, the start of the Full Implementation Period, states must implement coverage and payment strategies. This overall structure seeks to balance rapid model initiation and state flexibility, while minimizing administrative burden. In particular, the MOM model design supports each awardee’s ability to quickly begin delivering coordinated and integrated care to pregnant and postpartum women with OUD during the Transition Period, while supporting states in developing a long-term coverage and payment strategy that aligns with their state Medicaid program.

CMS anticipates releasing a Notice of Funding Opportunity (NOFO) in early 2019 to solicit cooperative agreement applications to implement the MOM model. The state Medicaid agency will be expected to complete the application, which must demonstrate that it has partnered with at least one care-delivery partner. A maximum of $64.6 million will be available across up to 12 state awardees over the course of the five-year model. The NOFO will contain all model requirements and eligibility criteria for potential applicants.

In August, CMS announced the Integrated Care for Kids (InCK) Model, a child-centered local service delivery and state payment model aimed at reducing expenditures and improving the quality of care for children covered by Medicaid and CHIP through prevention, early identification, and treatment of priority health concerns like behavioral health challenges, including substance abuse. The model will empower states and local providers to better address these needs through care integration across all types of healthcare providers. CMS anticipates releasing a NOFO for the InCK Model at the same time as it does for the MOM Model.

For more information, please visit https://innovation.cms.gov/initiatives/maternal-opioid-misuse-model/ or the fact sheet: https://www.cms.gov/sites/drupal/files/2018-10/10-23-2018%20Fact%20Sheet%20Maternal%20Opioid%20Misuse%20%28MOM%29%20Model%20%28FINAL%29.pdf

PHC4 Embargoed Release: Financial Analysis 2017 Volume Two

Posted October 11, 2018

The Pennsylvania Health Care Cost Containment Council (PHC4) will release Financial Analysis 2017 Volume Two on Thursday, October 11, 2018.  The report includes statewide and facility-specific information about the financial health of Pennsylvania’s ambulatory surgery centers for fiscal year 2017.

Click HERE to access the embargoed report and press release. 


Please
Joe Martin if you have any questions.

Joe Martin
Executive Director
PA Health Care Cost Containment Council
Commonwealth of Pennsylvania
Suite 400 | 225 Market Street
Harrisburg, PA 17101
Phone: 717-232-6787 | Fax: 717-232-3821

Centers for Medicare & Medicaid Services (CMS) Measures Management System Update

Posted October 10, 2018

Measures Management and You

Centers for Medicare & Medicaid Services

October 2018 [Volume 3, Edition 10]

Welcome! 

This month’s newsletter provides an overview of the Qualified Clinical Data Registry (QCDR). Every edition includes links to the CMS Blueprint (the version in use at the time of publication), as well as a calendar of upcoming events and opportunities.

We hope you find this newsletter useful and we welcome any feedback or suggestions to make it even better. Please send comments or suggestions for future newsletters to MMSSupport@battelle.org.

Qualified Clinical Data Registry (QCDR) Overview

A Qualified Clinical Data Registry (QCDR) is a Centers for Medicare & Medicaid Services (CMS) approved third-party intermediary that is defined at 42 CFR 414.1305 and generally in the business of improving health care quality. QCDRs may include specialty societies, regional health collaboratives, large health systems, or software vendors working in collaboration with one of these medical entities. One of the ways QCDRs can help to improve the quality of care patients receive is by collecting clinical data from clinicians and reporting this data to CMS on their behalf for purposes of MIPS. QCDRs differ from Qualified Registries because, in addition to collecting and reporting data, they can develop QCDR measures. In addition to submitting this data for purposes of the Quality performance category under MIPS, QCDRs may also submit data on behalf of clinicians for two additional MIPS performance categories: the Promoting Interoperability and Improvement Activities performance categories.

QCDR measures are to be developed in accordance with the Blueprint, but do not need to go through the Pre-Rulemaking process.

Annually, CMS puts out a call for QCDR self-nomination. The 2019 Self-Nomination Toolkit for QCDRs and Qualified Registries is now available. QCDRs must self-nominate annually, even if previously approved.

There are several benefits of using a QCDR to submit measures under MIPS. For example, because many QCDRs are specialty-based, QCDR measures may be more meaningful and applicable to the eligible clinician. QCDRs may also streamline data collection and manage the submission of the three MIPS performance categories for which data is required to be submitted to CMS. Eligible clinicians may be able to earn bonus credit in multiple performance categories. The clinicians may receive benchmark information so they can see how they are performing in comparison with their peers. QCDRs generally provide quarterly feedback reports to their participating clinicians, which provides the clinicians the opportunity to make rapid changes to improve quality of care. For more information about QCDRs, see the full article on the Measures Management System (MMS) website.

Special Announcements

Updated CMS Measures Inventory Tool (CMIT)

We are excited to share the latest update for the CMS Measures Inventory Tool (CMIT)! This update reflects measure information from the proposed and final Federal Rules for 20 programs published between June 1 through August 20, 2018. The CMS Measures Inventory currently includes 2,179 unique measures from 37 programs/initiatives and spans the measurement lifecycle including Measures under Development (MUD), those that have been published on a Measures under Consideration (MUC) List, and measures that are currently used in or have been removed/retired from a program.

A few of CMIT’s new features and functions:

  • Lists similar measures for each measure in the inventory

  • An improved filtering interface that will help you refine your search for relevant measures

  • Shows “Upcoming Status Changes” for measures in specific programs

  • Assists you in identifying gaps via a measure comparison tool

  • Application of common synonyms when searching; for example, a search for “juvenile” will also find measures that mention “adolescents”

  • The ability to view and export tables that count measures by category in the Measure Summary view; for example, by program and current status or by program and meaningful measure area

Visit cmit.cms.gov today to check it out!

We always welcome feedback on the CMS Measures Inventory – for any questions or comments, please contact MMSSupport@battelle.org.

Cooperative Agreements Announcement

On September 21, 2018, the Centers for Medicare & Medicaid Services selected seven applicants to receive cooperative agreements through the “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program.” The awardees and the measure(s) they are developing, improving, updating, or expanding can be found at https://go.cms.gov/1Gb6GDL . Thank you to the applicants that applied. We look forward to continuing to engage with the healthcare community to improve the quality and value of healthcare delivered to our beneficiaries.

All times shown are Eastern Time zone

  • The Measure Authoring Tool and Bonnie Training

    • Register for the training session on October 11, 2018 at 11:00 AM here

    • Register for the training session on October 15, 2018 at 2:00 PM here

  • Leveraging Patient-Centered Clinical Decision Support: Addressing the National Opioid Crisis and Beyond on October 15, 2018

    • Register for event here

  • Patient Relationship Categories and Codes Webcast on October 17, 2018 at 1:30-3:00 PM

    • Register for event here

  • Physician Compare: Preview Period and Public Reporting Webcast on October 30, 2018 at 1:30-3:00 PM

    • Register for event here

  • Cooking with CQL: or How to Incorporate CQL into HQMF for eCQMs on October 25, 2018 at 4:00 PM

    • Register for event here

Upcoming Opportunities

Opportunities for Public Comment on quality measures

Currently there are no open public comments. Please check the CMS Quality Measures Public Comment Web Page for current Public Comment announcements and summary reports.

Opportunities to participate in a Technical Expert Panel (TEP)

  • Development of Two Outpatient Outcome Measures for the Merit-based Incentive Payment System (MIPS)

    • The Clinician Committee nomination period opened on September 25, 2018 and closes on October 10, 2018.

  • Impact Assessment of CMS Quality and Efficiency Measures 

    • The TEP nomination period opened on September 27, 2018 and closes on November 2, 2018.

  • MACRA Episode-Based Cost Measures – Call for Clinical Subcommittee

    • The TEP nomination period closed on March 20th, but nominations are being accepted on a continuous basis.

Please check the CMS Quality Measures Call for TEP Web Page for current TEP membership lists and meeting summaries.

New to the listserv or missed a month? Find all our announcements as well as printer-friendly versions of past newsletters here.

Please send comments and suggestions to MMSSupport@battelle.org.

CMS to Strengthen Oversight of Medicare’s Accreditation Organizations

Posted October 8, 2018

FOR IMMEDIATE RELEASE
October 4, 2018

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

CMS to Strengthen Oversight of Medicare’s Accreditation Organizations
Agency’s website will increase transparency into Accrediting Organization performance, and CMS will streamline and strengthen the validation of Accrediting Organization surveys

Today, the Centers for Medicare & Medicaid Services (CMS) took action to improve quality and safety in healthcare facilities and empower patients with information to make decisions about where to receive care.

“Today we are taking action to improve our oversight of Accrediting Organizations, including by increasing transparency for patients on the organizations’ performance,” said CMS Administrator Seema Verma.  “The public trusts CMS to ensure the quality and safety of patient care, and we take this responsibility very seriously.  Today's changes will bolster the processes for overseeing how effective Accrediting Organizations, who work on CMS’ behalf, are in evaluating healthcare facilities.”

Currently, Medicare-participating healthcare providers and suppliers are surveyed either by State survey agencies or by Accrediting Organizations (AOs) to ensure that they meet CMS’ quality and safety standards. AOs receive deeming authority from CMS, which affirms that AOs’ health and safety standards meet or exceed those of Medicare. Only facilities and suppliers that have been deemed by state or AO surveyors to meet CMS’ standards may receive payments from Medicare. There are currently 10 CMS-approved AOs, each of which surveys one or more different types of facilities.

CMS will enhance and strengthen its oversight and quality transparency of AOs in three ways:  1) the public posting of AO performance data; 2) a redesigned process for AO validation surveys and 3) the release of the Annual Report to Congress. Taken together, these efforts will provide important insights to the public and assist AOs, providers, and suppliers in ensuring patient health and safety. 

Posting AO Performance Data Online

To increase transparency for consumers, CMS will post new information on the CMS.Gov website, including:  The latest quality-of-care deficiency findings following complaint surveys at facilities accredited by AOs; a list of providers determined by CMS to be out of compliance, with information included on the provider’s AO; and overall performance data for AOs themselves. To view AO performance data, visit: https://qcor.cms.gov/hosp_cop/HospitalCOPs.html

Today, the public relies on accreditation status as a way to gauge providers’ and suppliers’ quality of care. By posting more detail—accredited hospitals’ complaint surveys, out-of-compliance information, and performance data for AOs themselves—CMS will offer the public more nuanced information than accreditation status alone provides.  The agency is currently prohibited by law from disclosing the actual surveys done by AOs, except for surveys of home health agencies and surveys related to an enforcement action.

Pilot Testing Direct Observation for AO Validation Surveys

CMS is testing a more streamlined, efficient way to assess AOs’ ability to ensure that facilities and suppliers comply with CMS requirements.

CMS evaluates the ability of AOs to accurately assess providers’ and suppliers’ compliance with health and safety standards through a validation survey process. Historically, CMS has measured the effectiveness of AOs by choosing a sample of facilities, performing state-conducted assessment surveys within 60 days following AO surveys, and comparing results of the state surveys with the AO surveys. In a pilot test, CMS will eliminate the second state-conducted validation survey and instead use direct observation during the original AO-run survey to evaluate AOs’ ability to assess compliance with CMS’s Conditions of Participation.

Direct observation will enable CMS not only to evaluate AO performance more effectively, but also to suggest improvements and address concerns with AOs immediately. This approach will relieve providers from having to undergo the burden of a state’s follow up assessment.  The approach is another example of the wide-ranging effort at CMS to eliminate duplication and relieve burden, reducing the amount of time that healthcare facilities must spend on compliance activities.

CMS will also analyze and incorporate State complaint investigations of accredited facilities as part of the agency’s strengthened validation program. This work will focus on identifying and monitoring accredited facilities that are out of compliance with Medicare health and safety requirements. CMS will use this information as an additional indicator of AO performance.

Posting the Most Recent Annual Report to Congress Regarding AO Performance

CMS has also posted the most recent annual Report to Congress, the “Review of Medicare’s Program for Oversight of Accrediting Organizations and the Clinical Laboratory Improvement Validation Program Fiscal Year 2017,” on the CMS website.  As the changes announced today inform and bolster our oversight of AOs, CMS will continue to publish this report online annually to demonstrate the impact of these changes on the oversight of AOs and to provide greater transparency for the public. The FY 2017 Report to Congress is posted online: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

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SHO: Key Provisions of Legislation Extending Federal Funding for CHIP

Posted October 5, 2018

Today, the Centers for Medicare & Medicaid Services (CMS) issued a letter to state Health Officials describing some key provisions of the HEALTHY KIDS and ACCESS Acts that are related to the Children’s Health Insurance Program (CHIP) as well as other children’s coverage and quality provisions.

The letter can be accessed on Medicaid.gov at https://www.medicaid.gov/Federal-Policy-Guidance/Federal-Policy-Guidance.html. For more information on CHIP, visit https://www.medicaid.gov/chip/index.html

CMS Blog: Better Data Will Serve as the Foundation in Modernizing the Medicaid Program

Posted October 3, 2018

CMS BLOG

https://www.cms.gov/blog/better-data-will-serve-foundation-modernizing-medicaid-program

October 2, 2018
By Seema Verma, Administrator, Centers for Medicare & Medicaid Services


Better Data Will Serve as the Foundation in Modernizing the Medicaid Program

Between 2013 and 2016, Federal spending on Medicaid grew by over $100 billion. The program is often the first or second largest line item in state budgets. Just recently, CMS’ independent Office of the Actuary released their Medicaid financial report, confirming what we have already known for quite some time – that our healthcare spending, particularly in Medicaid – is forecast to continue growing, averaging 5.7% annually over the next 10 years to reach over $1 trillion by 2026.

Yet as program costs have continued to rise, we have failed to deliver a level of transparency and accountability for achieving positive outcomes commiserate with our significant investment. But this is finally beginning to change. Over the last several years, CMS has collaborated with states to improve how we collect and use data to modernize and measure the Medicaid and CHIP program. Through strong data and systems, CMS and states can drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP. These efforts will provide the foundation that enables CMS to deliver on its commitment to usher in a new era of Medicaid centered on state flexibility, stronger accountability, and improved program integrity.

As one example, CMS has worked with stakeholders to identify two core sets of health care quality measures that can be used to assess the quality of health care provided to children and adults enrolled in Medicaid and CHIP.  These core sets are tools states can use to monitor and improve the quality of health care provided to Medicaid and CHIP enrollees. Under statute, state reporting on these measure sets is voluntary. In the future, we aim to increase the number of states reporting on a uniform set of measures and to support states in using these measures to drive quality improvement for the beneficiaries they serve. And ultimately, this move toward greater transparency will start an important conversation about how and when states should be held accountable for the outcomes their programs produce.

Last week, we released the latest Federal Fiscal Year 2017 quality measurement data from the Medicaid and CHIP Child and Adult Core Sets that states have voluntarily reported to CMS. We greatly appreciate the work our state partners have endured to report these measures. CMS recognizes that quality reporting can present a significant administrative burden for both states and providers, and has taken steps to reduce this burden through our Meaningful Measures initiative.  In the future, we hope to leverage existing and more automated data reporting systems to generate these Medicaid measures on behalf of states, thereby reducing reporting burden while also improving data consistency, comparability, and comprehensiveness. 

States have worked with CMS over the last few years to modernize the way in which administrative data is collected by moving from the Medicaid Statistical Information System (MSIS) to the Transformed-MSIS (T-MSIS).  T-MSIS modernizes and enhances the way states submit operational data about beneficiaries, providers, claims, and encounters.  It is the foundation of a national analytic data infrastructure to support programmatic and policy improvements and program integrity efforts and will help advance reporting on outcomes. It also enhances the ability to identify potential fraud and improve program efficiency.

I am pleased to say that all states, the District of Columbia, and Puerto Rico are now successfully submitting T-MSIS data, marking a significant and exciting milestone in the history of the Medicaid program.

With these data in hand, we are shifting our efforts to continuous data quality review and improvement--a collaboration we will sustain with states. CMS’ ongoing goal is to use advanced analytics and other innovative solutions to both improve T-MSIS data and maximize its potential for performance measurement, health care quality improvement, and program integrity, all while reducing state reporting burden.  

I appreciate our continued partnership with states. Programs as important as Medicaid and CHIP require robust, timely, and accurate data in order to ensure the highest financial and program performance, support policy analysis and ongoing improvement, identify potential fraud or waste, and enable data-driven decision making. 

We are committed to collaborating with states on improving their data submissions.

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CMS announces new streamlined user experience for Medicare beneficiaries

Posted October 3, 2018

CMS NEWS

FOR IMMEDIATE RELEASE
October 1, 2018

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

CMS announces new streamlined user experience for Medicare beneficiaries

Today, the Centers for Medicare & Medicaid Services (CMS) announced a multi-year initiative that will empower patients and update Medicare resources to meet beneficiaries’ expectation of a more personalized customer experience. The eMedicare initiative will modernize the way beneficiaries get information about Medicare and create new ways to help them make the best decisions for themselves and their families.

The eMedicare initiative’s goal is to provide a seamless online health care experience to meet the growing expectations for this generation of Medicare beneficiaries. CMS has a cohesive, multi-year strategy of consumer data integration and web product development to modernize Medicare.gov and improve access to personal health care data. The road map for this program will enhance opportunities to go digital, offer additional self-serve options, and create a seamless multi-channel customer service experience.

“Since day one, President Trump has been committed to strengthening the Medicare program—eMedicare puts his leadership into action by giving Medicare beneficiaries a simpler, more intuitive customer experience,” CMS Administrator Seema Verma said. “Our intent is not to replace traditional channels that beneficiaries trust and depend on, but to improve and enhance them with the emerging digital options to create a user-centered, seamless consumer experience.”

Some of the new eMedicare initiatives that CMS is launching ahead of Medicare Open Enrollment are:

  • An improved coverage wizard to help beneficiaries compare options at a deeper level as a way to decide if Original Medicare or Medicare Advantage is right for them;
  • A stand alone, mobile optimized out of pocket cost calculator that will provide information on both overall costs and prescription drug costs;
  • A simplified log in for the Medicare Plan Finder (https://www.medicare.gov/find-a-plan/questions/home.aspx) tool using their online account (instead of the current process of entering 5 pieces of information to authenticate);
  • A webchat option, which will be available within the Medicare Plan Finder for some beneficiaries; and
  • New easy to use surveys available across Medicare.gov so beneficiaries can continue to tell us what they want.

These changes are building on previous improvements including:

CMS launched the initiative with a new video (https://youtu.be/YUiHOnmun8s) that includes insights from Medicare beneficiaries on what they expect from Medicare and remarks from Administrator Verma outlining her vision for modernized program. Approximately 10,000 people join Medicare each day. The Medicare population is expected to increase to more than 80 million beneficiaries in 2030, up from 54 million in 2015. As of 2016, about two-thirds of Medicare beneficiaries indicate they use the Internet daily or almost daily (65%).

Read a Medicare.gov blog about eMedicare: https://www.medicare.gov/blog/emedicare-another-step-to-strengthening-medicare.

For a royalty-free, downloadable image of the updated Medicare.gov homepage to use for republishing, please visit:
https://www.cms.gov/sites/drupal/files/MGOV-hmpg-highres-press_1.png

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EMBARGOED: PHC4 Research Brief: Breast Cancer Surgery in PA

Posted October 2, 2018

The Pennsylvania Health Care Cost Containment Council (PHC4) will release a Research Brief, Breast Cancer Surgery in Pennsylvania on Tuesday, October 2, 2018. This brief examines breast cancer surgeries performed in Pennsylvania hospitals and ambulatory surgery centers in 2017. Included are trends between 2008-2017, age and payer breakdowns, and surgery rates by county.

Click here to access the embargoed report and press release. 

Please contact Joe Martin if you have any questions.

Joe Martin
Executive Director
PA Health Care Cost Containment Council
Commonwealth of Pennsylvania
Suite 400 | 225 Market Street
Harrisburg, PA 17101
Phone: 717-232-6787 | Fax: 717-232-3821
www.phc4.org

Remarks by Administrator Seema Verma at the 2018 Medicaid Managed Care Summit

Posted September 28, 2018

Speech
FOR IMMEDIATE RELEASE
September 27, 2018
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

Remarks by Administrator Seema Verma at the 2018 Medicaid Managed Care Summit
(As prepared for delivery – September 27, 2018)

It is great to be back in front of a room full of professionals dedicated to improving the lives of Medicaid beneficiaries. For me, it’s a little like coming home. I see the faces of the people out working on the front lines, of transforming the American health care system, working to making Medicaid a stronger and more sustainable program.

Medicaid is more than a safety-net program. It’s our nation’s commitment to care for our most vulnerable citizens. And I believe that societies, throughout history, should not just be judged by their wealth and influence, but they should also be judged by how they treat those who are less fortunate. Since its inception Medicaid has served as a powerful tool in making sure that our nation’s most vulnerable can get the care they need.

People tell me that I am a realist. I guess you have to be to take on this job.

And the reality at CMS … is pretty refreshing right now. We are making great progress on a goal I set nearly a year ago as I outlined an aggressive agenda aimed at transforming Medicaid…the largest program at CMS serving more than 80 million beneficiaries. Our strategy is centered on 3 key pillars:

  • Flexibility
  • Accountability, and
  • Integrity

Those central themes have been our guiding strategy as we’ve worked to deliver on our early commitments to ushering in a new day in the Medicaid program.

So let’s begin with Flexibility. Giving states the flexibility is more than just paying for health care – it’s empowering them to act on what works best for the citizens in their community. And this is necessary if we are truly serious about improving the health outcomes of the most vulnerable Americans. State and local officials know much more about the unique needs of their friends and neighbors than Washington DC does.

To this end, we are proposing modifications to a few of our regulations; including the Medicaid Access to Care Rule and the Medicaid Managed Care Rule, and with each of these proposed rules, we have worked closely with states in an unprecedented manner to promote individual choice and local control – leading to better health outcomes for Americans on Medicaid.

But we cannot regulate our way to innovation.

To elicit meaningful reform, the best thing that CMS can do is create a fertile ground for states to serve as the laboratories of innovation in Medicaid policy...and then get out of their way. And that’s why we’ve opened opportunities for states to seek demonstrations to test new and exciting reforms.
And under our more flexible approach to waivers, CMS has approved 10 additional Substance disorder demonstrations – these include:
Indiana
New Jersey
Kentucky
Utah
Louisiana
Illinois
Vermont
New Hampshire
Pennsylvania and
Washington state

– which with the prior approvals means that more than a quarter of the states have committed to building out a more complete continuum of services to help individuals fighting addiction.

Additionally, in January, we released a groundbreaking new demonstration opportunity in response to state requests to test work and community engagement incentives among able-bodied adult beneficiaries. This guidance was followed by four approvals of innovative Medicaid demonstrations.

We are committed to this issue and we are moving closer to approving even more state waivers.

As such, I’m happy to share with you today that we have finalized the terms for our next innovative community engagement demonstration, which we expect to deliver to the state very soon. So stay tuned!

But this is not a policy that is without controversy. I have heard the criticisms… and felt the resistance…but I reject the premise, and here is why: it is not compassionate to trap people on government programs, or create greater dependency on public assistance as we expand programs like Medicaid.

True Compassion is giving people the tools necessary for self-sufficiency… allowing able-bodied, working age adults to experience the dignity of a job, of contributing to their own care, and gaining a foothold on the path to independence.

From my experience working directly with indigent patients in the early phases of my career, I saw first-hand that no one sets out in life with the goal of relying on the government. Personal responsibility and self-sufficiency are bedrock American values.

And there is clear evidence that people are happier and healthier when they are working and leading independent, self-sufficient lives. Arthur Brooks of the American Enterprise Institute, wrote a book about the concept of earned success. The idea that we value what we earn much more than we value what is given to us. The drive to earn propels us to new heights, whereas dependency limits us.

The problem too often is that the most well-meaning government policies trap people in a hopeless cycle of poverty, making it too difficult to escape, and too easy to become more dependent.  Instead, we ought to insist that the able-bodied participate in earning benefits.

To quote from Arthur’s Book, the Conservative Heart:

“Work gives people something welfare never can. It’s a sense of self-worth and mastery, the feeling that we are in control of our lives. This is a source of abiding joy. There’s a reason that Aristotle wrote “happiness belongs to the self-sufficient.”

Community engagement requirements are not some subversive attempt to just kick people off of Medicaid. Instead, their aim is to put beneficiaries in control with the right incentives to live healthier independent lives.

When you consider that, less than 5 years ago, Medicaid was expanded to nearly 15 million new working-age adults, it’s fair that states want to add community engagement requirements for those with the ability to meet them. It’s easier to give someone a card, it’s much harder to build a ladder to help people climb their way out of poverty. But even though it is harder, it’s the right thing to do.

Between the years 2000 and 2017, the overall work rate for non-disabled working age adults fell by 3.4 percentage points. Over half of this decline occurred before the Great Recession even began.

Historically, childless working age adults were working at a rate much higher than the overall rate for working age, able bodied adults – as you might expect. But that is changing. In 1979, the employment rate for childless adults under 50 was almost 10 percentage points higher than the overall rate. By 2017, it was only 2.6 percentage points higher, and, not surprisingly, this group also experienced the largest increase in welfare.

Put simply, even before the Recession began, childless adults under 50 were on a disturbing trajectory…Depending less on work and self-sufficiency, and more on government assistance.

It is therefore no surprise that, as this group continues on an unsustainable trajectory, states have looked to the Medicaid program to help reverse this trend, increase self-sufficiency, and break the chains of welfare dependence. 

And this motivation comes at an incredible time of opportunity. Under President Trump’s leadership, we are now experiencing among the lowest rates of unemployment we’ve seen in over 50 years. The Trump administration has created a booming American economy. Not only are job opportunities on the rise, but wages grew at the fastest rate in August since the Great Recession.

But despite these promising signs, we also know that there is often a skills gap between those needing employment, and the available jobs.  Too many live in the shadows of opportunity, instead of its light, because they don’t have 21st century skills. That’s why this effort is also about helping those individuals find new hope through education and job training opportunities.

And these policies are not blunt instruments. We’ve worked carefully to design important protections to ensure that states exempt individuals who have disabilities, are medically frail, serve as primary caregivers, or have an acute medical condition that prevent them from successfully meeting the requirement. Some have argued that a Medicaid demonstration can never advance the program’s objectives if the project ultimately reduces Medicaid enrollment or spending.

But I prefer to think of it more like President Reagan, who said, “We should measure welfare’s success by how many people leave welfare, not by how many people are added.”

As our economy thrives, it can lift up as many Americans as possible, and lift millions off of programs like Medicaid and instead onto private insurance. There will always be a need for a safety net and programs like Medicaid. We want it to be there for those who need it most.

Others believe that any consequences for failing to comply with a program requirement, like disenrollment or periods of non-eligibility, shouldn’t be allowed. There is no basis for that contention. CMS has approved demonstrations that include those exact type of incentives for failure to comply with requirements like monthly premiums going back across several federal administrations. Even the Children’s Health Insurance Program – or CHIP - allows states to impose premiums and consequences for failure to pay them in certain circumstances.

Some have argued that these demonstrations are unnecessary because nearly all Medicaid beneficiaries are already working. To that I say – great. Then this policy won’t impact them, and in fact if you look at Arkansas the vast majority of adults subject to the requirement were ultimately exempted from the monthly reporting requirement because of their steady employment. Nothing to argue about there!

We’ve also heard that the costs associated with implementing community engagement are too high, in terms of updating eligibility systems and providing the necessary supports. But we view these as important investments, not unlike those we have made in other aspects of the program, that help build capacity for states to address the whole human needs of their beneficiaries, and one that can pay dividends as we aim to end cycles of generational poverty. We have taken steps to ensure that appropriate protections have been designed to shield against unintended consequences.

We’ve strongly encouraged states to align their Medicaid requirements with similar policies in SNAP and TANF, and to take steps to ensure that if an individual is meeting the requirements of one program, they aren’t having to do something different in another.

One of the most encouraging outcomes that I’ve seen emerge in states participating in this initiative is the level of engagement and partnership between stakeholders.

When I was in Arkansas this spring to hand deliver their signed waiver, I heard directly from these groups about some of the unique work happening to help lift people out of poverty. There, the state is working with community colleges and technical schools to connect Medicaid beneficiaries with new educational opportunities, including partnerships with nursing homes to provide free job training for enrollees.

In July, Arkansas became the first state to go live with their community engagement program. And a few weeks ago, Governor Hutchinson reported that more than 1,000 Arkansas Works enrollees have found jobs since the program began in July. Imagine the impact that this has had on the lives of those individuals and their families. One specific example he cited, was a woman in Harrison, Arkansas. She visited a Workforce Specialist and is now enrolled in LPN school at North Arkansas Community College with financial assistance. In addition to taking classes, she is also gaining real world experience by working at a long-term care facility one day a week.

Governor Hutchinson also described a gentleman in Rogers, Arkansas, who came into a workforce center after receiving his notice in the mail. There, he received an assessment and a referral for employment, and after nearly a year of being unemployed, is now earning over $17 an hour.
This is earned success. It is not granted by government, but realized through sweat, toil and initiative.

These are only a couple of examples – but the fact is that these two lives, and potentially many more, have been steered onto a pathway out of poverty. Over time, the woman in Harrison and the man in Rogers may begin to earn their health insurance through their employer, and no longer rely on government assistance, and we should all join with them in hoping for this brighter future.

Let me be clear, there is no shame in receiving extra help when it’s needed – that’s why we have a safety net to care for folks on hard times. But our default position must always be to help and encourage those who are able to lift themselves up and find their footing again.

There is dignity and pride that is derived from work…for paying one’s own way…and I believe it is the desire of nearly every American to achieve financial independence.

In America we believe we can be anything we want to be, never dictated by one’s station at birth. The migrant farmer still dreams of one day owning the farm. The waiter still aspires to one day own the restaurant. We don’t ascribe to the artificial barriers posed by class…because we believe through hard work, we can realize our biggest dreams.

While we've ushered in a new era of state flexibility, we are also committed to enhancing our collective accountability for delivering results on behalf of beneficiaries and taxpayers. So that brings me to our next pillar – Accountability. Despite growing from 10% of state budgets in 1985 to nearly 30% in 2016, Medicaid has never developed a cohesive system of accountability that allows the public to easily measure and check our results.

If we are going to be good stewards of taxpayer dollars and good servants to the 80 million Americans who depend on Medicaid and CHIP, we must be honest with ourselves and honest with all of our stakeholders about how well we are doing. I agree with oversight bodies like the GAO – we need to do better. That’s why we’ve been working to enhance how we evaluate state demonstration projects, including standardizing how certain common types of waivers get evaluated, developing standardized metrics across waivers, and using consistent monitoring and evaluation protocols.

This will hold true for community engagement demonstrations, where we will be closely monitoring their implementation and ensuring thorough independent evaluations are conducted. But we also will not draw rash conclusions after only a few months of data and information.

As we drive toward value across the entire health care delivery system, we believe that greater transparency creates stronger accountability, and we were very excited earlier this summer to publish the first-ever CMS Medicaid & CHIP Scorecard.

If you haven't had a chance to take a look at that yet I strongly suggest you do. We’ve had about 14 states that have spent six months working diligently with us on crafting this version of the Scorecard.

In addition to displaying health outcome and quality metrics in areas like well-child visits and chronic health conditions, you’ll see for the first time public reporting on our administrative performance.

This includes both state and federal performance measures in areas like the speed of processing managed care rate reviews or state plan amendments. Soon the scorecard will begin to reflect some of the real progress we are making on this front. For example, between 2016 and the first quarter of 2018, we saw a 23% drop in the average approval time for Medicaid state plan changes.

84% of those requested changes were approved within the first 90-day period in the first quarter of 2018, a 20% increase over 2016.
And over that same time period, the average time to approve renewals for home and community based waivers decreased by 38%.

And this version of the Scorecard is only the first step in this project. We are already hard at work on the next iteration, which we hope to update annually with new features and expanded measures. Future updates will include additions like the ability to generate year-to-year comparisons and understand differences in state and regional performance.

We are also working to develop more measures, including ones that look at the areas of cost, program integrity, and beneficiary satisfaction. And, I’d be remiss, if I didn’t mention a group to whom we should hold ourselves accountable for serving better – and that is the 12 million Americans who are dually eligible for Medicaid and Medicare. It’s essential that we give states and health plans the tools to better integrate the full array of services these individuals rely on.

It is particularly critical that we address this given the facts that dually eligible individuals are among our most expensive beneficiaries for both programs. Despite accounting for 20% of Medicare enrollees and 15% of Medicaid enrollees, they consume 34% of Medicare spending and 33% of Medicaid spending, respectively.

Less than 10% of duals are enrolled in any form of integrated care, and instead have to navigate alone across disconnected delivery and payment systems to get the care they need. We have to change that.

Earlier this year Congress challenged us to do more to promote integrated care through dual eligible special needs plans. Our work is well underway. In the coming year, we will support new models and opportunities for additional states to test innovations to better serve this population. Additionally, we will challenge ourselves and the states to be better business partners to health plans and providers. The administrative burdens and inefficiencies to serving dually eligible beneficiaries are unacceptable. It’s time to achieve a level of operational excellence that older Americans deserve.

Which brings us to our final pillar: Program Integrity.

Federal spending on Medicaid has ballooned, growing by over $100 billion between 2013 and 2016, and it often sits at the number 1 or 2 spot in state budgets. We have a responsibility to make sure that taxpayer dollars are spent only on qualified services for those who are truly eligible, even as we return greater control of the Medicaid program to the states.

And just last week, CMS’ independent Office of the Actuary released their financial report on the Medicaid program. It confirmed, what we have already known for quite some time – that our healthcare spending, particularly in Medicaid is forecasted to grow at an alarming pace. Since Day One, my top priority has been to ensure programs, such as Medicaid, will always be around to serve those that truly need the program, and that means slowing the growth of spending.

Additionally, in June we launched our new Medicaid Program Integrity strategy that will bring CMS into a new era of enhancing the accountability of how we manage taxpayer dollars. This strategy includes several important new initiatives:

First, we will take a close review of State eligibility determinations. And second, we will take steps to strengthen our oversight of state financial claiming and rate setting.

We are also working to build a stronger regulatory framework to ensure transparency and accountability in Medicaid supplemental payments, with a particular emphasis on promoting integrity in the equity partnership we share with states by ensuring that states put up their fair share of state matching funds only from permissible sources.

Transparency must also extend to our health plan partners. This room understands well that nearly all newly eligible individuals in Medicaid are served through managed care organizations. I’m putting you on notice now - CMS will begin targeted audits to ensure that provider claims for actual health care spending matches what the health plans are reporting financially.

Finally, we are working to strengthen how we use data in the oversight of the program.

For the first time, every state, D.C., and Puerto Rico are now submitting data on their programs to the Transformed Medicaid Statistical Information System (known as T-MSIS), and over the course of the coming months we will be validating the quality and completeness of that data, so that its use for program integrity purposes can be expanded and realized, including plans to release analytic files for research purposes beginning next year.

And as a part of our MyHealthEData Initiative, we have called on everyone who holds patient data, whether it be hospitals, insurers, or Medicaid Managed Care Plans, to give patients control of their records, so that they can be the chief drivers of value in our healthcare system.

I truly believe that best ideas, attuned to the distinct needs of local communities, come from those communities - not DC.

And I greatly appreciate the role that our health plan partners play in delivering quality care to Medicaid beneficiaries all across the country. I have seen firsthand the value that you bring to your partnership with states, and the resources that you can often bring to bear to serve the needs of our enrollees on the front lines.

We must continue to work together, allowing state innovation to drive improvements in services. We must foster greater collaboration among…and between…state agencies, providers, advocates, and beneficiaries - to chart a path forward - because we recognize that what works in Montana won't be a good fit for Rhode Island, but we can all learn from our individual and shared experiences.

But I have said before and I will say it again - until we move away from an open ended entitlement program, and only when states are held accountable to a defined budget - can the federal government finally end our practice of micromanaging every administrative process. I believe that it’s our imperative to instead focus on measuring the actual results on the program while unleashing the power of local innovation - so you will see more from us soon on new opportunities to do just that. So stay tuned.

We want every individual to have the opportunity to achieve earned success, and we must encourage every American to strive for better health and well-being. These efforts must be supported, evaluated, and shared – not shunned. Prosperity can never be handed out as a government benefit, but our programs can play an important part in helping people get off the sidelines of American life and find independence and a sense of purpose. Thank you.

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Medicare Advantage premiums continue to decline while plan choices and benefits increase in 2019

Posted September 28, 2108

CMS NEWS
FOR IMMEDIATE RELEASE
September 28, 2018
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

Medicare Advantage premiums continue to decline while plan choices and benefits increase in 2019
Enrollment projected to increase while plans offer new types of supplemental benefits
Today, the Centers for Medicare & Medicaid Services (CMS) announced that, on average, Medicare Advantage premiums will decline while plan choices and new benefits increase. In addition, Medicare Advantage enrollment is projected to reach a new all-time high with more than 36 percent of Medicare beneficiaries projected to be enrolled in Medicare Advantage in 2019. This news comes as the agency releases the benefit and premium information for Medicare health and drug plans for the 2019 calendar year.

“Medicare Part D and Medicare Advantage demonstrate the successes possible when we harness consumer choice and private-sector innovation to improve care and lower cost,” said HHS Secretary Alex Azar. “Efforts to strengthen negotiation and competition in Medicare Part D are bearing fruit in the form of lower drug costs for American seniors, a key priority for President Trump. Meanwhile, the significant steps taken to maximize competition among Medicare Advantage plans and support and empower Medicare beneficiaries are a crucial piece of allowing patients to define and drive value, which the Trump Administration has made a priority.”

“The steps that the Trump Administration has taken to improve and drive competition in Medicare Advantage means more savings, more benefits, and lower costs for seniors,” said CMS Administrator Seema Verma. “The popularity of programs, such as Medicare Advantage, and with the various new supplemental benefits and policy changes that have been adopted, we expect plan choices to be even more robust moving forward.”
The Medicare Advantage average monthly premium continues to steadily decline, and will be the lowest in the last three years. On average, Medicare Advantage premiums in 2019 is estimated to decrease by six percent to $28.00, from an average of $29.81 in 2018. Nearly 83 percent of Medicare Advantage enrollees remaining in their current plan will have the same or lower premium in 2019. Approximately 46 percent of enrollees in their current plan will have a zero premium.

Medicare Advantage will be offering approximately 600 more plans in 2019. The number of plans available to individuals to choose from across the country is increasing from about 3,100 to about 3,700 – and more than 91 percent of people with Medicare will have access to 10 or more Medicare Advantage plans, compared to nearly 86 percent in 2018. Access to the Medicare Advantage program remains strong, with about 99 percent of people with Medicare having access to a Medicare Advantage plan.

Medicare Advantage enrollment is projected to increase to an all-time high from the current enrollment of 20.2 million to 22.6 million in 2019, an 11.5 percent increase compared to 2018.

As a result of the new flexibilities on supplemental benefits available for the first time in 2019, about 270 plans are providing nearly 1.5 million enrollees with access to the following new types of benefits:

  • Expanded health related supplemental benefits, such as adult day care services, in-home support services, caregiver support services, home-based palliative care and therapeutic massage; and
  • Reduced cost sharing and additional benefits for enrollees with certain conditions, such diabetes and congestive heart failure, due to the agency’s reinterpretation of uniformity.

The access to new supplemental benefits is a positive start for 2019, and CMS expects continued growth in 2020, as plans take advantage of these new flexibilities to attract new beneficiaries. In addition, more Medicare Advantage enrollees are projected to have greater access to important supplemental benefits such as dental, vision, hearing, over-the-counter items, meals, nursing hotlines and transportation for medical services (for example, doctor visits).

Access to the Medicare Part D prescription drug program remains universal in 2019 with 100 percent of beneficiaries having access to a stand-alone prescription drug plan. Earlier this year, CMS announced that, for a second year in a row, the average monthly basic Part D premiums are expected to fall from $33.59 this year to $32.50 next year. The agency had announced several changes in the Part D program to provide Part D plans with additional tools to strengthen negotiations with drug manufacturers to lower the cost of prescription drugs.

As the 2019 Medicare Open Enrollment period approaches, CMS is continuing to improve the Medicare.gov website for Medicare plan selection, so beneficiaries can more easily compare options and choose the plan that best fit their needs. Medicare Open Enrollment for 2019 Medicare health and drug plans begins on October 15, 2018, and ends December 7, 2018. Plan costs and covered benefits can change from year to year, so people with Medicare should look at their coverage choices and decide on the options that best fits their health needs. They can visit Medicare.gov (https://www.medicare.gov), call 1-800-MEDICARE, or contact their State Health Insurance Assistance Program. Those people with Medicare who do not wish to change their current coverage do not need to re-enroll in order to keep their current coverage.

For a fact sheet on Medicare Advantage and Part D in 2019, please visit: https://www.cms.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-prescription-drug-program-landscape.

To view the premiums and costs of 2019 Medicare health and drug plans, please visit: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/index.html.

For state-by-state information on Medicare Advantage and Part D in 2019, please visit: https://www.cms.gov/Outreach-and-Education/Reach-Out/Find-tools-to-help-you-help-others/MA-Part-D-Landscape-State-by-State.pdf

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Patients Over Paperwork Newsletter

Posted September 28, 2018

In this seventh issue of our Patients over Paperwork newsletter, we are giving you an update on our ongoing work to reduce administrative burden and improve the customer experience while putting patients first. In this edition, we highlight our progress on burden reduction efforts:

  • Give you an overview of how we are reducing burden in 2018.
  • Update you on our Requests for Information (RFI) process, including our progress in addressing comments.
  • Describe how we are engaging with customers through our customer centered workgroups.
  • Update you on our proposed and final rules that aim to save money and reduce burden hours.
  • Update you about our documentation simplification efforts.
  • Highlight our other initiatives that reduce burden.

How are we reducing burden?

Over the past few years, stakeholders have been telling us about regulatory burden and that paperwork is increasing. We have listened and made a thoughtful plan, the Patients over Paperwork initiative, to address burden across our programs. Patients over Paperwork’s goals are to:

  • Reduce unnecessary burden.
  • Increase efficiencies.
  • Improve the patient experience.

First, we tried to fully understand providers’ concerns about burden, especially where they were feeling burden the most. We did this in 2 parts through Requests for Information (RFIs) and customer engagement. Last year, we issued 9 RFIs to solicit comments on burden. We received 2,800 comments and have been working over the past 6 months to address them. 

We also realized that RFIs alone were not enough to understand the burden providers feel when they are delivering care.  We established 4 customer centered workgroups and traveled across the country to visit health care facilities and speak directly with care providers, beneficiaries, and patients.
Second, we addressed burden through the Federal Rulemaking process. As of September 2018, we have proposed and finalized a number of rules that directly reduce burden and give providers more time with patients.  We estimate that across rules finalized in 2017 and 2018 and current proposed rules CMS projects savings of nearly $5.2 billion and a reduction of 53 million hours through 2021. That means saving 6,000 years of burden hours over the next 4 years!

Recently, we released a proposed rule to lift unnecessary regulations and ease burden on providers.  The updates collectively would save health care providers an estimated $1.12 billion annually. Many of the proposed provisions simplify and streamline the Medicare Conditions of Participation and Requirements for Participation for facilities so that health and safety standards can be met more efficiently.  You can get more information in our fact sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-proposed-regulatory-provisions-promote-program-efficiency-0.
You can also electronically submit comments through our e-Regulation website here: https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking

What did we learn from our RFIs?
To reduce burden, we had to understand:

  • Where providers felt the most burden.
  • What their big pain points were.
  • How we could solve them.

Last year, we issued RFIs to solicit comments on burden reduction, flexibilities, and efficiencies through the annual rulemaking process for 9 Medicare Fee-for-Service payment rules. We received over 2,800 RFI responses from 7 stakeholder groups: Beneficiary/Consumer, Clinician/Individual Provider, Institutional Provider, Government Entity, Health Plan, Supply Chain, and Others.

Our policy analysts spent hundreds of hours reviewing comments and identified 3,040 mentions of burden. We synthesized and consolidated the 3,040 comments into 1,146 burden topics. Examples of burden topics include: time intensive auditing/compliance practices across provider settings, time-consuming prior authorization requirements, lack of uniformity in home health eligibility documentation requirements, and Repetitive Medicare Secondary Payer Questionnaire (MSPQ) process.

As of July 2018, we identified 284 actions we have taken or are taking in response to the RFI burdens, addressing 624 (55%) of the 1,146 burden topics. An additional 185 burden topics (16%) remain under consideration, and 337 (29%) were either referred to another agency or decided they didn’t require further action.

RFI Data Analysis Work Stream

 RFI Data Analysis Work stream 

Burden Topic Action Status


 Burden Topic Action Status 

For example:
Burden identified in RFI comment: Program compliance costs, such as those associated with beneficiary notices and requirements to deliver, explain, log, and continually support related provider-patient interactions, sometimes outweigh the clinical value of the policy or program.
Recommendation: Consider revisiting notice requirements and condensing them into fewer, more concise notices that redirect beneficiaries to other resources. Maintain most information in the beneficiary manual (Medicare and You), provided to all beneficiaries.¬
Action taken:  In January 2018, we released a newly revised Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), which eliminated the need for the 5 SNF Denial Letters and the Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (NEMB-SNF).

What did we learn from our customer centered workgroups?
While we were reviewing RFI comments about burden, we were also busy looking for ways to reduce burden for consumers.  To start, we focused on 4 customer segments:
1.      Nursing homes
2.      Beneficiaries
3.      Clinicians
4.      Hospitals.
To understand the customer experience, we left Washington and went into the field.  Over the past year, we have traveled the United States engaging customers in various health care delivery settings.

We met with providers, beneficiaries, family members, caretakers, and health care clinical and support staff.  We conducted 21 site visits, nearly 300 customer interviews and 97 Subject Matter Expert interviews, and held 73 listening sessions and other engagement activities. From this, we were able to learn from our customers in a fuller way how our policies impact care delivery and innovations they are trying to advance.

What we heard:

  • “Clinicians have become data entry staff.  We spend twice the amount of time entering data in the electronic medical record than the time we actually spend seeing and treating our patients. We hire people to deal with paperwork. DEATH BY A THOUSAND CLICKS!” (Clinician)
  • “Continue this open dialogue from staff allowing us to identify issues.  Involve many different job titles, including [physicians].  Know that we appreciate what you [are] doing [with Patients over Paperwork] and we want to work together to make healthcare better.” (Hospital Executive)
  • “Streamline it. Streamline the measures. Streamline the consistency. Streamline the process. Consistency. Why do all the measures have to be different ways, different times, different periods? Have some consistency in time frames, reporting methodology. Streamline the methodology. And realize that this electronic reporting is not all necessarily labor-free.” (Hospital Executive)

Some ways we addressed concerns:
You said: Requiring teaching physicians to re-document most updates made by medical students in the patient record as part of a billable Evaluation and Management (E/M) service created burden.
We listened and acted: As of January 1, 2018, a teaching physician may rely on the medical student documentation and verify it rather than re-documenting the (E/M) service. In those cases, Medicare Administrative Contractors shall consider the documentation requirement met if the teaching physician signs and dates the medical student’s entry in the medical record.
You said:  Facilities spend countless hours requiring duplicative questionnaires be answered at the time of admission and reviewing and documenting where in the medical record required information can be found.
We listened and acted:  We are reducing burden by removing the admission order documentation requirement in an effort to reduce duplicative documentation requirements.  We believe this requirement will continue to be appropriately addressed through the enforcement of the hospital conditions of participation, as well as the hospital admission order payment requirements.

How has regulatory action helped?
We have issued a number of proposed and final rules that, in part, aim to reduce burden and have made a lot of progress.  We estimate that across rules finalized in 2017 and 2018 and current proposed rules CMS projects savings of nearly $5.2 billion and a reduction of 53 million hours through 2021. That means saving 6,000 years of burden hours over the next 4 years!

Burden Reduction Impact:
Total projected savings from rules finalized in 2017 and 2018
Savings reflected from 2018-2021 equals $5.2 billion and 53 million hours

image  

Regulatory action taken to reduce burden:

You said: Stakeholders maintain that CMS evaluation and management documentation guidelines are outdated, complex, ambiguous, and that they fail to distinguish meaningful differences among code levels.

We listened:  CMS acknowledged that the current guidelines create an administrative burden and increased audit risk for some providers. We proposed a number of recommendations for E/M visits to begin the discussion. Currently, we are in the process of reviewing each and every comment and suggestion we received.  We thank the clinician and provider community for engaging with us in this process.

This rule incorporates a variety of changes in response to stakeholders’ suggestions about ways to reduce burden for hospitals. Overall, the rule will reduce the number of hours hospitals spend on paperwork by about 2 million hours.  For example: Removing the requirement that certification statements detail where in the medical record the required information can be found.

The Skilled Nursing Facility PPS final rule reduces unnecessary burden on providers by easing documentation requirements and offering more flexibility. As part of our actions to modernize Medicare, the SNF PPS rule makes an innovative new classification system, the Patient Driven Payment Model (PDPM).  The PDPM ties skilled nursing facility payments to patients’ conditions and care needs rather than volume of services provided. PDPM simplifies complicated paperwork requirements for performing patient assessments by significantly reducing reporting burden (approximately $2.0 billion over 10 years), helping to create greater contact between health care professionals and their patients.   

The rule finalizes a variety of changes in response to suggestions from the public on ways to reduce burden for IRFs. In addition to policies that reduce the number of measures IRFs are required to report, we are reducing burden by easing documentation requirements and providing flexibility in several areas. The final rule will reduce regulatory burden for IRF providers by well over 300,000 hours.

This rule enables more efficient use of Hospice Compare data in the Hospice Quality Reporting Program by no longer directly displaying the 7 component measures from which a composite measure is calculated on Hospice Compare. We would still provide the public the ability to view these component measures in a manner that avoids confusion on Hospice Compare.

In an effort to reduce unnecessary burdens for physicians, we are proposing to eliminate the requirement that the certifying physicians estimate how much longer skilled services are required when recertifying the need for continued home health care. This proposal is responsive to industry concerns about regulatory burden reduction and could reduce claims denials that solely result from an estimation missing from the recertification statement. We estimate that this proposal would result in annualized savings to

This proposed rule takes significant steps forward by strengthening quality incentives and reducing administrative burden. Based on stakeholder feedback, we plan to reduce ESRD facility-related documentation burdens for certain payment adjustments so that requirements are more consistent with other payment systems. We are also proposing to update the measure set for the ESRD Quality Incentive Program so that it’s more closely aligned with the quality priorities the agency has adopted as part of the Meaningful Measures Initiative.

What is the Documentation Requirement Simplification Initiative?
We are simplifying Medicare documentation requirements so clinicians spend less time on paperwork, including confusing and time-consuming claims documentation, allowing for more time with patients. We have made some important changes already: In the past year, we completed 9 sub-regulatory documentation requirements simplifications.

Here are some of our most recent simplifications:

  1. Simplified the requirements for preliminary/verbal Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule (DMEPOS) orders.
    Before: Our instructions were not clear about whether preliminary (verbal) orders for DMEPOS items were conditions of payment.                   

    After: Suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician. However, Medicare medical review contractors will look to the signed, written order to see if the item meets our payment requirements.

    View the change request for more information.
  2. Clarified DMEPOS written order prior to delivery date requirements.
    Before: There was confusion about whether contractors needed to verify that a written order was received by checking for a fax transmittal date or a date stamp.                                                                                                              

    After: If the written order is dated the day of or prior to delivery there is no need for affirmative documentation of its being “received.”

    View the change request for more information.

What are our cross-cutting initiatives?
We are committed to reducing burden across our whole agency.  We have launched several initiatives that make up Patients over Paperwork and they all have the same goal: making patients our top priority.

Meaningful Measures

Our Meaningful Measures initiative is centered on: patient safety, quality of care, transparency, and making sure the measure sets providers are asked to report make the most sense. The modernizing proposals to advance our Meaningful Measures Initiative have or will eliminate 105 measures resulting in projected savings of $178 million and an anticipated reduction of 4.6 million burden hours!

  • In the Inpatient Prospective Payment System and Long-Term Care Hospital (IPPS/LTCH) PPS final rule, we are removing unnecessary, redundant, and process-driven measures from several pay-for-reporting and pay-for-performance quality programs. The final rule eliminates a number of measures acute care hospitals are currently required to report across the four hospital pay-for-reporting and value-based purchasing quality programs. It also “de-duplicates” certain measures that are in multiple programs, keeping them in the program where they can best incentivize improvement and maintaining transparency through public reporting. In all, these changes will remove 18 measures from the programs and de-duplicate another 25 measures.
  • We are making a variety of other changes to reduce the hours providers spend on paperwork through hospital quality and value measures. This new flexibility will allow hospitals to spend more time providing care to their patients, thereby improving the quality of care their patients receive. Overall, changes in the hospital quality and value measures across the four programs will eliminate more than 2 million burden hours for hospitals impacted by the IPPS/LTCH PPS rule, saving them about $75 million annually after these changes take effect.

My HealthEdata & Interoperability

MyHealthEdata aims to empower patients by ensuring that they control their health care data and can decide how their data is going to be used, all the while keeping the information safe and secure.

  • To further spur innovation in this era of digital health, CMS has recently released Medicare Advantage data sets and next year we expect to make Medicaid and Children’s’ Health Insurance Program (CHIP) data available. These data sets will provide researchers and innovators with data on a new population of 74 million beneficiaries.
  • We believe the future of interoperability centers on digital health and the implementation of APIs.  We are committed to requiring that providers begin using 2015 Edition certified electronic health record (EHR) technology starting in 2019 because this version opens APIs.
  • Recently, we overhauled the Meaningful Use programs changing the name to the “Promoting Interoperability” programs. This is more than a name change, it is a change in direction for the programs – from programs that support the adoption of health IT, to programs that promote interoperability and patient access to data.
  • When we announced MyHealthEData, we also unveiled Blue Button 2.0. -- a developer-friendly, standards based API, which will allow a majority of Medicare beneficiaries to connect their claims data to third party applications, services, and research programs. There are now 600 developers signed up to experiment with this API, more than doubling participation since March of this year.
How can I learn more?
Learn more about Patients over Paperwork.

Join our listserv to get this newsletter and any other Patients over Paperwork updates.  You can also find our past newsletters.

Office of Minority Health

Posted September 26, 2018

NEW! Connected Care Toolkit for Health Care Professionals and Communities

Connected Care: the Chronic Care Management Resource updated its toolkits for health care professionals and community partners into one combined toolkit.
 
Connected Care is an educational initiative to raise awareness of the benefits of chronic care management services for Medicare beneficiaries with multiple chronic conditions and to provide health care professionals with support to implement CCM programs.
 
The Connected Care Toolkit: Chronic Care Management Resources for Health Care Professionals and Communities has been revised based on partner feedback to provide better clarity and add informative resources about CCM services. This version includes current care coordination information for Rural Health Clinics and Federally Qualified Health Centers.
 
Download the toolkit by clicking here: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CCM-Toolkit-Updated-Combined-508.pdf.
 
Connected Care has several resources to help patients and health care professionals understand chronic care management (CCM) services. To learn more and see all available materials, please visit our website: go.cms.gov/CCM.

New CMS Model Launch October 1st

Posted September 26, 2018

The CMS Innovation Center is excited about the launch of the new BPCI Advanced Model on October 1, 2018. 
BPCI Advanced aims to support healthcare providers who invest in practice innovation and care redesign, to better coordinate care, improve quality of care, and reduce expenditures. The Model qualifies as an Advanced Alternative Payment Model (APM). Eligible clinicians who meet threshold levels for participating in BPCI Advanced, will receive a five percent APM Incentive Payment under the Quality Payment Program.
The BPCI Advanced Model 5-year Performance Period will begin on October 1, 2018 and run through December 31, 2023.

Model Overview

  • Voluntary bundled payment model
  • Single retrospective payment and risk track 
  • 90-day episode period
  • 29 Inpatient Clinical Episodes
  • 3 Outpatient Clinical Episodes
  • Qualifies as Advanced Alternative Payment Model (Advanced APM)
  • Payment is tied to performance on quality measures 
  • Preliminary Target Prices provided prospectively, prior to the start of each Model Year

Patient Engagement is Crucial to Success in the Model

The BPCI Advanced team created two Patient Vignettes that illustrate how the patient experience changes within the context of the BPCI Advanced Model versus the traditional Fee-For-Service payment structure.
View the Patient Medical Vignette at: https://downloads.cms.gov/media/innovations/bpciadvanced-vignette1-ffsbp-cardiology.mp4
View the Patient Surgical Vignette at: https://downloads.cms.gov/media/innovations/bpciadvanced-vignette2-ffsbp-surgical.mp4

Bundled Payments Goals is to:

  • Improve the Patient Experience
  • Seamless, streamlined experience
  • Avoid complications
  • Reduce readmissions
  • Achieve better outcomes

Beneficiary Notification Letter

The BPCI Advanced Model Participation Agreement requires that Participants, their Episode Initiators and Participating Providers, provide a Beneficiary Notification Letter to Medicare beneficiaries who meet the eligibility criteria of the Model's Clinical Episodes. CMS will provide a template for this document that may not be modified by Participants, Episode Initiators, or Participating Providers. The purpose of this letter is to educate beneficiaries that they still have all the same Medicare rights and protections, including the right to choose their hospital, doctor, or other health care provider. However, if the beneficiary does not wish to receive care under the BPCI Advanced Model, he or she must choose a health care provider that does not participate in the Model.

Implementation of the Model

Model Year 1:    10/1/18 - 12/31/18*
Model Year 2:    1/1/19 - 12/31/19
Model Year 3:    1/1/20 - 12/31/20
Model Year 4:    1/1/21 - 12/31/21
Model Year 5:    1/1/22 - 12/31/22
Model Year 6:    1/1/23 - 12/31/23
*Note that Model Year 1 is truncated

Next Application Opportunity for Model Year 3 (2020) 
CMS will provide an additional opportunity for organizations to apply to participate in the Model during the spring of 2019. This second Cohort will commence participation on January 1, 2020, for Model Year 3. Application materials will be posted on the BPCI Advanced website. At this time, there are no additional application periods planned for Model Years 4 or 5.

We will send a bulletin to all subscribers of the BPCI Advanced listserv with updates on the Model.

Sign up for the BPCI Advanced listserv.

Questions?
Contact the BPCI Advanced Team at:
BPCIAdvanced@cms.hhs.gov

Proposed Rule Removes Unnecessary Regulations, Eases Burden

Posted September 24, 2018


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CMS Proposes to Lift Unnecessary Regulations and Ease Burden on Providers

Posted September 18, 2018

Proposed rule driven by agency’s Patients Over Paperwork initiative, expected to save U.S. healthcare facilities $1.12 billion per year

Today, the Centers for Medicare and Medicaid Services (CMS) announced a proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities. Collectively, these updates would save healthcare providers an estimated $1.12 billion annually. Taking into account policies across rules finalized in 2017 and 2018 as well as this and other proposed rules, savings are estimated at $5.2 billion.
CMS developed the proposed rule in response to President Trump’s charge to federal agencies to “cut the red tape” and reduce burdensome regulations.  In addition, feedback from Requests for Information (RFIs) the agency issued seeking stakeholder input on regulatory burdens helped inform this proposed rule, with particular attention to comments and anecdotal insights from clinicians serving Medicare beneficiaries.

“We are committed to putting patients over paperwork, while at the same time increasing the quality of care and ensuring patient safety and bolstering program integrity,” said CMS Administrator Seema Verma. “With this proposed rule, CMS takes a major step forward in its efforts to modernize the Medicare program by removing regulations that are outdated and burdensome. The changes we’re proposing will dramatically reduce the amount of time and resources that healthcare facilities have to spend on CMS-mandated compliance activities that do not improve the quality of care, so that hospitals and healthcare professionals can focus on their primary mission: treating patients.”

Many of the proposals simplify and streamline Medicare’s conditions of participation, conditions for coverage, and other requirements for participation for facilities, so they can meet health and safety standards more efficiently. This proposal ensures continued protection for patient health and safety.

A key provision would reduce burden and promote efficiency to support patients who need organ transplants. The rule would eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare. Re-approval has led to transplant programs avoiding performing transplants for certain patients, causing some organs to go unused. CMS will maintain other requirements in order to continue to monitor outcomes and quality of care in transplant programs after initial Medicare approval.       

Additional provisions in the proposed rule would, for example:
•    Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
•    Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
•    Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
•    Remove duplicative ownership disclosure requirements for Critical Access Hospitals.

Patients Over Paperwork

Following President Trump’s leadership in his “Cut the Red Tape Initiative,” today’s proposed rule is the latest in a series of steps that are reducing unnecessary burden on facilities, generating efficiencies and giving healthcare providers more time to spend with their patients.

Since CMS’s Patients Over Paperwork initiative began in 2017, the agency has led a robust RFI process, held interviews with diverse stakeholder groups, visited healthcare facilities across the country and organized work groups. Stakeholders that participated include: beneficiaries/consumers, clinicians/individual providers, institutional providers, government entities, health plans and members of the supply chain. These efforts to better engage with stakeholders yielded 3,040 mentions of burden, which CMS categorized as related to 1,146 different issues.

To date, CMS has taken action to address 55 percent (624) of the burden topics raised, while approaches to 16 percent (185) of the topics remain under consideration and 29 percent (337) were either referred to another agency or did not require further action.
Across rules finalized in 2017 and 2018 and current proposed rules to address these topics, CMS projects savings of nearly $5.2 billion and a reduction of 53 million hours through 2021. That results in saving 6,000 years of burden hours over the next three years.

   Burden Reduction ($)
 Burden Reduction (Hours)
 2018  $ 183 million
 10.8 million
 2019  $ 1.6 billion
 12.6 million
 2020  $ 1.7 billion
 15.3 million
 2021  $ 1.7 billion
 14.3 million
 Total:  $ 5.2 billion
 53 million

Moreover, many of the policies produce ongoing annual savings not captured in this total. CMS also remains focused on ways to reduce burden through reforms to the Stark Law and Evaluation and Management Codes. Even beyond the burden reduction captured in these rules, we have been working at all levels to streamline and modernize our programs, such as by reducing the administrative burden providers associated with provider audits.  This Administration has awarded new Recovery Audit Contracts (RAC) with checks and balances in place to ensure providers are not adversely impacted from reviews; modified its traditional medical review process to move to a targeted review and education process; and streamlined and clarified documentation requirements in payment manuals.

Experts agree that reducing unnecessary burden is critical to improving patient care.  Burden hours represent the amount of time healthcare providers spend complying with federal regulations. A study published in the Annals of Internal Medicine found that for every hour providers spend seeing patients, nearly two additional hours are spent on paperwork.

Meaningful Measures

CMS has heard from providers that overly burdensome and redundant measures have taken time away from patients, which is why CMS launched the Meaningful Measures initiative. Under this initiative CMS is closely examining all measures, and proposing to eliminate ones that are outdated, are duplicative, are overly burdensome, or are not strongly linked to patient outcomes.

A recent Health Affairs study reported that U.S. physicians and their staff in four common specialties spend, on average, 15.1 hours per week and more than $40,000 per year reporting quality measures. This equates to 785 hours per physician and more than $15.4 billion annually. The vast majority - 81 percent - of practices reported that they now spend more effort dealing with quality measures than three years ago, and only 27 percent said current measures are representative of the quality of care.

A Family Practice Management review notes that the proliferation of quality measures and the pay-for-performance (P4P) systems that use them have led to significant administrative burdens and unintended consequences, often devaluing the patient-physician relationship and contributing to clinician burnout.

Through several proposed rules, including this one, CMS seeks to eliminate reporting requirements for 105 out of 416 measures across the agency’s programs, saving healthcare providers $178 million over the next two years.

Feedback Welcome

CMS looks forward to feedback on the proposal and will accept comments until XXX, 2018. Comments may be submitted electronically through our e-Regulation website.

To learn more about the proposed rule, please visit the Federal Register.

Read the CMS fact sheet on the proposed rule; an “at a glance” overview of Medicare Burden Reduction can be found here.

Get CMS news at https://www.cms.gov/Newsroom/Newsroom-Center.html, sign up for CMS news via email and follow CMS on Twitter @CMSgov

CMS Publishes Updates to eCQM Value Sets for 2019 Reporting and Performance Periods

Posted September 18, 2018

The Centers for Medicare & Medicaid Services (CMS) and the National Library of Medicine (NLM) published updates to the electronic clinical quality measure (eCQM) value sets to align with the most recent releases to terminologies, including, but not limited to, International Classification of Diseases (ICD)-10 Clinical Modification (CM) and Procedure Coding System (PCS), SNOMED CT, LOINC, and RxNorm.

What programs are affected by the addendum?

CMS published an addendum to the eCQMs (published in May 2018) to update relevant eCQM value sets for the 2019 reporting/performance year. This addendum affects the electronic reporting of eCQMs for the following programs:
•    The Quality Payment Program: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs)
•    Comprehensive Primary Care Plus (CPC+)
•    CMS Hospital Inpatient Quality Reporting (IQR)
•    Medicare and Medicaid Promoting Interoperability (PI) Programs

What changes are included in the addendum?

Changes only affect the value sets for eCQMs. The Health Quality Measure Format (HQMF) specifications, the value set object identifiers (OIDs), and the measure version numbers for 2019 eCQM reporting will not change.

The changes to the value sets consist of (1) deletion of expired codes, (2) addition of relevant replacement codes, and (3) addition of newly available codes that represent concepts consistent with the intent of the value set and corresponding measure(s).

Where is the addendum posted?

All changes to the eCQM value sets are available through the NLM’s Value Set Authority Center download tab. The value sets are available as a complete set, as well as value sets per measure. 

Updated measure information, including revised technical release notes, are available on the eCQI Resource Center website.

What do I need to do?

Measure implementers should review these changes to ensure their submissions comply with the updated requirements.

Where do I go for assistance?

Measure implementers can report questions regarding the addendum, eCQM value sets, and appropriateness of mapping to the ONC eCQM Issue Tracker. Visit the eCQI Resource Center to review additional frequently asked questions and answers regarding the addendum.


New Resources Available on the Medicare Diabetes Prevention Program Website

Posted September 18, 2018

The following resources have been recently added to go.cms.gov/MDPP:

MDPP Billing and Claims Fact Sheet: This fact sheet is for organizations and providers that are enrolled as MDPP suppliers who want to better understand how to bill for MDPP services. It includes MDPP billing practices, the claims submission process, and where to get help along the way.

MDPP Supplier Crosswalk Guidance: MDPP suppliers are required to maintain a crosswalk file that lists beneficiary identifiers used for performance data submissions to the Centers for Disease Control and Prevention (CDC), and the corresponding Medicare identifiers for each beneficiary who receives MDPP services. This document provides guidance on the form and manner in which the MDPP supplier must maintain the crosswalk file, including:

•    Crosswalk file submission dates
•    Beneficiaries to include in the crosswalk file
•    Data required in crosswalk file 

Can't find the answer to your question on the MDPP website? Visit our FAQs or email the MDPP Mailbox at MDPP@cms.hhs.gov.

CMS Updates 2017 MIPS Performance Feedback

Posted September 18, 2018

Recently, CMS released performance feedback for clinicians included in the Merit-based Incentive Payment System (MIPS) during the 2017 performance year. As we’ve previously announced, we saw a very high 91 percent participation rate for the first performance year (2017) of MIPS. Over the last several weeks, individual clinicians, groups, and eligible clinicians in certain Alternative Payment Models (APMs) have had access to this feedback on the Quality Payment Program website, which provides a comprehensive overview of their MIPS final score, performance category details, and 2019 MIPS payment adjustment.
Along with releasing performance feedback, we launched a process known as targeted review. A targeted review provides the opportunity for clinicians, groups, or those participating in certain APMs to request that we review their MIPS payment adjustment factor(s), if they believe there is an error with the 2019 MIPS payment adjustment calculation.

The requests that we received through targeted review caused us to take a closer look at a few prevailing concerns. Those concerns included the application of the 2017 Advancing Care Information (ACI) and Extreme and Uncontrollable Circumstances hardship exceptions, the awarding of Improvement Activity credit for successful participation in the Improvement Activities (IA) Burden Reduction Study, and the addition of the All-Cause Readmission (ACR) measure to the MIPS final score. Based on these requests, we reviewed the concerns, identified a few errors in the scoring logic, and implemented solutions. The targeted review process worked exactly as intended, as the incoming requests quickly alerted us to these issues and allowed us to take immediate action.
Addressing and correcting for the above elements resulted in changes to the 2017 MIPS final score and associated 2019 MIPS payment adjustment for the clinicians who were impacted by the identified issues. Additionally, in order to ensure that we maintain the budget neutrality that is required by law under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), some clinicians will see slight changes in their payment adjustment as a result of the reapplication of budget neutrality.  These revisions were made to the performance feedback on the Quality Payment Program website on September 13, 2018. We encourage you to sign-in to the Quality Payment Program website as soon as possible to review your performance feedback. If you believe an error still exists with your 2019 MIPS payment adjustment calculation, the targeted review process is available for you.

To offer additional time for clinicians, groups, and APM entities and their participants to access and review their performance feedback, we are extending the targeted review deadline to October 15, 2018 at 8:00pm (EDT). We also have a number of resources available on our Quality Payment Program Resource Library to help you understand your performance feedback and the targeted review process. If you are in-need of additional assistance, please reach out to the Quality Payment Program Service Center by phone at 1-866-288-8292, (TTY) 1-877-715-6222 or by email at QPP@cms.hhs.gov, or contact your local technical assistance organization for no-cost support.

From the onset of the Quality Payment Program, our goals have included creating a program that is fully transparent and provides accurate information. We believe that the above steps are essential to achieving that goal for the first performance year (2017), also referred to as the “transition” year. We will continue to work closely with the clinician community to learn from one another and ensure operational excellence in implementation.

New MIPS Resources are Now Available in the Quality Payment Program Resource Library

Posted September 18, 2018

CMS has posted the following new Merit-based Incentive Payment System (MIPS) resources on CMS.gov:
•    2019 Virtual Groups Toolkit: Includes an overview fact sheet, which details what virtual groups are and how to participate in a virtual group in 2019; an election process fact sheet that describes the process for forming a virtual group; a sample virtual group election submission email; and a virtual group agreement template.  
•    2018 Cost Performance Category Fact Sheet (updated): Offers an overview of the Cost performance category including how the cost performance category is weighted and scored.
•    2018 Claims Data Submission Fact Sheet: Provides details on how to submit Quality performance category data through claims for the 2018 performance year.
•    2018 MIPS Specialty Measures Guides for Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs), Cardiologists, and Radiologists: Highlights a non-exhaustive list of measures and activities for the Quality, Cost, Improvement Activities and Promoting Interoperability performance categories that may apply to anesthesiologists and CRNAs, cardiologists, and radiologists in 2018.
•    MIPS Data Validation Criteria: Includes an overview fact sheet and the 2018 criteria used to audit and validate data submitted in the Quality, Improvement Activities, and Promoting Interoperability performance categories.
•    2018 Eligible Measure Applicability (EMA) Resources: Provides an overview of the Eligibility Measure Applicability (EMA) process and lists individual quality measures for both registry and claims data submission.
For More Information
•    Visit the Quality Payment Program Resource Library on CMS.gov to review new and existing QPP resources.
•    Contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222).

Learn About New Influenza Vaccine Code

Posted September 14, 2018

News & Announcements
•    Help Your Medicare Patients Avoid and Report Scams
•    Hospice Provider Preview Reports: Review Your Data by October 5
•    IRF Provider Preview Reports: Review Your Data by October 8
•    LTCH Provider Preview Reports: Review Your Data by October 8
•    Open Payments: Key Thresholds for Program Year 2019 Reporting
•    Open Payments: Program Year 2019 Teaching Hospital List
•    Hand in Hand: A Training Series for Nursing Homes
•    Quality Payment Program: Other Payer Advanced APM Resources
•    Mapping Medicare Disparities Tool: Hospital View
•    Physician Compare: Public Reporting Webinar Materials
•    Prostate Cancer Awareness Month

Provider Compliance
•    Bill Correctly for Device Replacement Procedures - Reminder

Upcoming Events
•    Dementia Care: Opioid Use & Impact for Persons Living with Dementia Call — September 18
•    Medicare Diabetes Prevention Program: New Covered Service Call — September 26
•   Final Modifications to the Quality of Patient Care Star Rating Algorithm Call — October 3
•    Comparative Billing Report on Psychologists Webinar — October 17

Medicare Learning Network® Publications & Multimedia
•    Billing Requirements Implemented for non-OPPS Providers MLN Matters® Article — New
•    Annual Clotting Factor Furnishing Fee: 2019 Update MLN Matters Article — New
•    ASC Payment System: October 2018 Update MLN Matters Article — New
•    Influenza Vaccine Payment Allowances: Annual Update MLN Matters Article — New
•    Influenza Virus Vaccine Code: January 2019 Update MLN Matters Article — Revised
•    Certification Statement Policies MLN Matters Article — Revised
•    Telehealth Billing Requirements for Distant Site Services MLN Matters Article — Revised
•    Complying with Documentation Requirements for Laboratory Services Fact Sheet — Revised
•    Global Surgery Booklet— Revised
•    Medicare Provider-Supplier Enrollment National Educational Products — Reminder

Administrative Simplification Basics: Electronic Funds Transfer and Electronic Remittance Advice (EFT and ERA)

Posted September 12, 2018

Administrative Simplification Basics: Electronic Funds Transfer and Electronic Remittance Advice (EFT and ERA)

CMS Administrative Simplification includes standards and operating rules for common health care electronic transactions. Widespread use of standards and operating rules for administrative transactions—where everyone uses the same language, format, and codes—can lead to substantial savings across the health care community.
Today, we’ll review two of these common transactions: electronic funds transfer (EFT) and remittance advice (ERA).

Electronic Funds Transfer


Electronic Funds Transfer (EFT) is the electronic transaction health plans use to transfer funds to a provider’s account to pay for health care services. An EFT message includes:

  • Amount being paid
  • Name and identification of the health plan and provider
  • Bank accounts of the health plan and provider
  • Routing numbers
  • Date of payment

Electronic Remittance Advice

Electronic Remittance Advice (ERA) is the insurance claim payment message sent from a health plan to a provider. It explains how a health plan has adjusted claim charges based on factors like:

  • Contract agreements
  • Secondary payers
  • Benefit coverage
  • Copays and co-insurance

Standards and operating rules for EFT and ERA transactions offer many benefits. They can help providers and health plans save time and money by streamlining the payment process, speeding up provider revenue cycles, and automatically posting payments to accounts.

Visit the EFT and ERA section of the CMS Administrative Simplification website to learn more.

Medicare Diabetes Prevention Program: New Covered Service Call

Posted September 6, 2018

Date: Wednesday, September 26
Time: 2 to 3 pm ET
Audience: Medicare fee-for-service providers
 
Register here for Medicare Learning Network events.
 
The 2019 Medicare and You Handbook includes information on the Medicare Diabetes Prevention Program, a new Medicare-covered service. Help your patients prevent or delay Type 2 diabetes and understand their treatment options. During this call, learn about the service, eligibility requirements, and how to refer your patients. A question and answer session follows the presentation.

Register Now for the 2019 MIPS Performance Period Self-Nomination Virtual Office Hours Session

Posted September 5, 2018

Join CMS on 9/20 for a Virtual Office Hours Session Regarding the 2019 MIPS Self-Nomination Process

During the 2019 Performance Period Self-Nomination period, CMS will offer a 2019 Merit-Based Incentive Payment System (MIPS) Performance Period Self-Nomination Virtual Office Hours session. The purpose of this session is to allow current and potential Qualified Clinical Data Registries (QCDRs) and Qualified Registries the opportunity to participate in a question and answer session regarding the self-nomination process and its related tasks.

Qualified Registries and QCDRs are CMS-approved vendors that collect clinical data on behalf of clinicians for data submission to CMS for the MIPS program. Please note that eligible clinicians wishing to report for the 2019 performance period of the MIPS program via the Qualified Registry or QCDR reporting mechanism do NOT need to self-nominate. Only entities wishing to participate (and who meet the requirements) as a Qualified Registry and/or QCDR need to complete and submit the self-nomination form. Please attend the session on Thursday, September 20 from 1-2:30 pm ET if your organization plans to self-nominate as a Qualified Registry or QCDR and you have questions regarding the Self-Nomination process and its related tasks. Participation in this session is optional.

Webinar Details

  • Title: Self-Nomination Virtual Office Hours Session Webinar
  • Date: Thursday, September 20, 2018 
  • Time: 1-2:30 p.m. ET 
  • Description: During this session, CMS will provide a Question & Answer Session regarding the self-nomination process and related tasks. 
  • Audience: EHR Vendors, Qualified Registries, QCDRs, Vendor Technology Product Leads, Regional Collaboratives, Specialty Societies, or Large Healthcare Systems 
  • Event Registration: Click here to register.

The audio portion of this webinar will be broadcast through the web. You can listen to the presentation through your computer speakers. If you cannot hear audio through your computer speakers, please contact CMSQualityTeam@ketchum.com. Phone lines will be available for the Q&A portion of the webinar.

For More Information

Visit the Quality Payment Program Resource Library on CMS.gov to learn more about the QCDR and Qualified Registry self-nomination process for vendors.

Register for September 12 All-Payer Combination Option Overview Webinar

Posted September 5, 2018

Join CMS for 9/12 Webinar on All-Payer Combination Option Overview

CMS is hosting a webinar on Wednesday, September 12, 2018 at 2:00 PM ET to provide an overview of the All-Payer Combination Option, which allows clinicians to become a Qualifying APM Participant (QP), and therefore eligible for the 5% APM Incentive payment, through participation in a combination of Medicare Advanced Alternative Payment Models (APMs) and Other-Payer Advanced APMs, including Medicaid, Medicare Advantage and commercial payers.
During the webinar, CMS will discuss:

  • Overview of APMs and Advanced APMs
  • All-Payer Combination Option Basics
  • Determinations of Other Payer Advanced APMs (Payer and Eligible Clinician Initiated Processes)
  • Determinations for QPs under the All-Payer Combination Option
  • Frequently Asked Questions
  • Additional Resources

CMS will address questions from participants at the end of the webinar, as time allows.

Webinar Details

The audio portion of this webinar will be broadcast through the web. You can listen to the presentation through your computer speakers. CMS will open the phone line for the Q&A portion. If you cannot hear audio through your computer speakers, please contact CMSQualityTeam@ketchum.com.

New MDPP resources now available

Posted September 5, 2018

New Resources Available on the Medicare Diabetes Prevention Program Website
The following resources have been recently added to go.cms.gov/mdpp:

  • Beneficiary Eligibility Fact Sheet: Provides details on beneficiary eligibility requirements and tips for MDPP suppliers to verify eligibility.
  • Coach Eligibility Fact Sheet: Lists the eligibility requirements for coaches and tips to help individuals become lifestyle coaches. 
  • Link to MDPP Supplier List: We have added a link to the data.cms.gov webpage that lists all current MDPP suppliers. It provides the same information as the MDPP Supplier Map, but in a downloadable format. You can export the file and view comprehensive MDPP supplier data, including locations, contact information, and National Provider Identifier (NPIs). This list will be updated biweekly.

Can't find the answer to your question on the MDPP website? Visit our FAQs or email the MDPP Mailbox at MDPP@cms.hhs.gov.

Centers for Medicare & Medicaid Services (CMS) Marketplace Quality Initiatives Update

Posted September 5, 2018

The updated and final 2018 Quality Rating System (QRS) quality ratings and QHP Enrollee Survey results will be available for a second preview period beginning September 10th at 9am ET through September 14th at 6pm ET. During the initial preview period (August 13th – 24th), CMS was notified of an improper data submission and an error in the denominator criteria applied to two survey measures: Access to Care and Care Coordination. CMS will correct these issues and hold a second preview period for QHP issuers to preview their final 2018 ratings. QHP issuers and Marketplace administrators will be able to preview the corrected QRS preview reports and proof sheets for their respective reporting units in the CMS’ Health Insurance Oversight System Marketplace Quality Module (HIOS-MQM).
QHP issuers will also be able to view their updated QHP Enrollee Survey Quality Improvement (QI) Reports. During the initial preview period, CMS was notified that the scores for the Enrollee Experience with Cost composite and the questions within the composite (Questions 51-54) were not presented in the QI reports appropriately (these scores should have been inverted when converting the mean scores into a 0-100 scale). CMS will update the Enrollee Experience with Cost composite scores in the QI Reports.  This change does not impact Overall QHP scores or QRS scores and ratings.
 
Access to HIOS-MQM is required to preview the QRS rating information and QHP Enrollee Survey results. Please navigate to the HIOS-MQM Quick Reference Guide for details about registering and accessing the HIOS-MQM. Inquiries regarding the preview results should be submitted to the CMS help desk, CMS_FEPS@cms.gov, by September 14th.  Please note it may take one to three business days to respond to inquiries
.

Register Now for the 2019 Performance Period MIPS Self-Nomination JIRA Demonstration on August 30th

Posted August 28, 2018


Join CMS on August 30th to Learn More about the Qualified Registry and Qualified Clinical Data Registry (QCDR) 2019 Performance Period MIPS Self-Nomination Process and QCDR Measure Submission Template

As the 2019 Performance Period Self-Nomination period approaches, CMS will offer a 2019 Performance Period MIPS Self-Nomination JIRA Demonstration. The purpose of this demonstration is to provide a walk-through of both the Registry and Qualified Clinical Data Registry (QCDR) 2019 Performance Period Self-Nomination forms in the JIRA application as well as the QCDR Measure Submission Template for those submitting QCDR measures. Qualified Registries and QCDRs are CMS-approved vendors that collect clinical data on behalf of clinicians for data submission. Please note that eligible clinicians wishing to report for the 2019 performance period of the Merit-Based Incentive Payment System (MIPS) program via the Qualified Registry or QCDR reporting mechanism do NOT need to self-nominate. Only entities wishing to participate (and who meet the requirements) as a Qualified Registry and/or QCDR vendor need to complete the self-nomination form. Please attend the webinar on August 30th from 2-3:30pm ET if your organization plans to self-nominate as a Qualified Registry or QCDR. Participation in this demonstration is optional.

Webinar Details

  • Title: 2019 Performance Period MIPS Self-Nomination JIRA Demonstration for Qualified Registries and QCDRs
  • Date: Thursday, August 30, 2018 
  • Time: 2-3:30 p.m. ET 
  • Description: During this webinar, CMS will provide:
  • Self-Nomination Process walk-through in JIRA
  • QCDR Measure Submission Template walk-through
  • Question & Answer Session
    • Audience: EHR Vendors, Qualified Registries, QCDRs, Vendor Technology Product Leads, Regional Collaboratives, Specialty Societies, or Large Healthcare Systems 
    • Event Registration: Click here to register.


The audio portion of this webinar will be broadcast through the web. You can listen to the presentation through your computer speakers. If you cannot hear audio through your computer speakers, please contact CMSQualityTeam@ketchum.com. Phone lines will be available for the Q&A portion of the webinar.

For More Information

Visit the Quality Payment Program Resource Library on CMS.gov to learn more about the QCDR and Qualified Registry self-nomination process for vendors
.

2018 Merit-based Incentive Payment System (MIPS) Improvement Activities (IA) Performance Category Call for TEP

Posted August 28, 2018

This is a notice regarding a current call for nominations for the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) Improvement Activities (IA) Technical Expert Panel (TEP).

As part of its improvement activity development process, CMS is seeking feedback from a group of stakeholders, consumers, patients and experts who can contribute direction and thoughtful input on the improvement activities during development and maintenance. HealthInsight is a subcontractor on this project and is working to convene a TEP around the effectiveness and accuracy of the improvement activities (IAs) included in Year 2 (2018) of the Quality Payment Program under MIPS IA performance category.

We are seeking a TEP of approximately 10-12 clinicians and individuals with the following perspectives and areas of expertise:

  • Subject matter/clinical expertise with IAs
  • Consumer/patient/family (non-medical caregiver)
  • Healthcare disparities
  • Performance measurement
  • Quality improvement

The nomination period closes at 5:00 pm PST on September 22, 2018.

For more information, or to download the TEP Nomination Form, review the full posting on the Technical Expert Panels page at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/TEP-Currently-Accepting-Nominations.html#456.
For questions or assistance, please email ImprovementActivitiesTEP@healthinsight.org

2019 Eligible Clinician Electronic Clinical Quality Measure Flows

Posted August 28, 2018

The Centers for Medicare & Medicaid Services (CMS) developed and published the 2019 performance period electronic clinical quality measure (eCQM) flows for eligible clinicians and eligible professionals (EPs) to the eCQI Resource Center. The eCQM flows are designed to assist in interpretation of the eCQM logic and calculation methodology for performance rates. eCQM flows provide an overview of each of the population criteria components and associated data elements that lead to the inclusion or exclusions into the eCQM’s quality action (numerator).

eCQM flows supplement eCQM specifications for eligible clinicians and EPs for the following programs:

  • Quality Payment Program: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs)
  • Comprehensive Primary Care Plus (CPC+)
  • The Promoting Interoperability Program

These flows are intended to be used as an additional resource when implementing eCQMs and should not be used in place of the eCQM specification or for reporting purposes.
CMS plans to publish flows for eligible hospital and critical access hospital (CAH) eCQMs in September. This will be a new resource for EH and CAH eCQMs for 2019 reporting, developed in response to stakeholder feedback.

Questions on the eCQM flows should be directed to the ONC eCQM Issue Tracker available at http://jira.oncprojectracking.org/browse/CQM/.


CMS announces new model to address impact of the opioid crisis for children

Posted August 24, 2018

CMS announces new model to address impact of the opioid crisis for children
Model to focus on children in Medicaid and CHIP who have physical and behavioral health needs, including substance use

On August 23, 2018, the Centers for Medicare & Medicaid Services (CMS) announced a new Innovation Center payment and service delivery model as part of a multi-pronged strategy to combat the nation’s opioid crisis. The Integrated Care for Kids (InCK) Model aims to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and the Children’s Health Insurance Program (CHIP) through prevention, early identification, and treatment of behavioral and physical health needs. The model will empower states and local providers to better address these needs through care integration across all types of healthcare providers.

The InCK Model will help state Medicaid agencies and their local health and community-based partners identify and address risk factors for behavioral health conditions, understanding that the earliest signs of a problem may present outside of clinical settings—such as in schools or at home—and may be known not to clinicians but rather to teachers and to child welfare and foster care programs. The interventions outlined in the InCK Model are designed to respond to this crisis by supporting state Medicaid agencies and local health and community-based partners to increase access to behavioral health for vulnerable children and build capacity in communities to provide more effective, efficient, and affordable care through home- and community-based services.

While the existing, required Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is comprehensive, variation remains among states in how and when children receive behavioral health screening, diagnostic and treatment services. In addition, despite the variety of federal, state, and local services that do exist to support children’s health, limited information sharing and differing eligibility and enrollment processes have created barriers to putting children and families at the center of their care and coordinating across services.

InCK Model participants will benefit from systematic integration, coordination, and management of core child services, including clinical care, school-based health services, housing, and other health-related supports. The InCK Model aims to positively impact the health of the next generation through early identification and treatment of behavioral health risk factors of children up to age 21 covered by Medicaid and CHIP in selected states. Testing the use of a state-specific payment model to cover integrated care coordination and case management, the InCK Model will be tailored to the unique challenges faced by providers and patients at the local level, ultimately leading to long-term improvements in child health services and health outcomes.

The CMS Innovation Center anticipates releasing a detailed Notice of Funding Opportunity in Fall 2018 with additional details on how state Medicaid agencies and local health and community-based organizations can apply to participate in the model. CMS intends to award funding for up to 8 states at a maximum of $16 million each in as early as Spring of 2019 to implement the seven-year model.

The CMS Innovation Center was established by section 1115A of the Social Security Act to test innovative healthcare payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or CHIP benefits.

For a fact sheet on the InCK Model, please visit: https://www.cms.gov/newsroom/fact-sheets/integrated-care-kids-inck-model.
For more information on the InCK Model, please visit: https://innovation.cms.gov/initiatives/integrated-care-for-kids-model/.   


The Deadline to Submit a MIPS Targeted Review Request is 40 Days Away

Posted August 23, 2018

The Deadline to Submit a MIPS Targeted Review Request is 40 Days Away

If you participated in the Merit-based Incentive Payment System (MIPS) in 2017, your MIPS final score and performance feedback are available now on the Quality Payment Program website. The payment adjustment you will receive in 2019 is based on this final score. A positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished under the Medicare Physician Fee Schedule in 2019.

 MIPS eligible clinicians or groups (along with their designated support staff or authorized third-party intermediary), including those who are subject to the APM scoring standard, may request for CMS to review their performance feedback and final score through a process called targeted review. The deadline to submit your request is October 1, 2018 at 8:00 PM (EDT) – which is just 40 days away.

When to Request a Targeted Review
If you believe an error has been made in your 2019 MIPS payment adjustment calculation, you can request a targeted review until October 1, 2018 at 8:00 PM (EDT). The following are examples of circumstances in which you may wish to request a targeted review: 

  • Errors or data quality issues on the measures and activities you submitted
  • Eligibility issues (e.g., you fall below the low-volume threshold and should not have received a payment adjustment)
  • Being erroneously excluded from the APM participation list and not being scored under APM scoring standard
  • Not being automatically reweighted even though you qualify for automatic reweighting due to the 2017 extreme and uncontrollable circumstances policy

This is not a comprehensive list of circumstances. CMS encourages you to contact the Quality Payment Program if you believe a targeted review of your MIPS payment adjustment (or additional MIPS payment adjustment) is warranted. We’ll help you to determine if you need to submit a targeted review request.

How to Request a Targeted Review
You can access your MIPS final score and performance feedback and request a targeted review by:

  • Going to the Quality Payment Program website
  • Logging in using your Enterprise Identity Management (EIDM) credentials; these are the same EIDM credentials that allowed you to submit your MIPS data. Please refer to the EIDM User Guide for additional details.

When evaluating a targeted review request, we will generally require additional documentation to support the request. If your targeted review request is approved, CMS will update your final score and associated payment adjustment (if applicable), as soon as technically feasible. CMS will determine the amount of the upward payment adjustments after the conclusion of the targeted review submission period. Please note that targeted review decisions are final and not eligible for further review.

For More Information
To learn more about the steps for requesting a targeted review, please review the following:

  • How to Request a Targeted Review Demo Video
  • Targeted Review of 2019 MIPS Payment Adjustment User Guide
  • Targeted Review of the 2019 Merit-based Incentive Payment System Payment Adjustment Fact Sheet


Questions?
If you have questions about your MIPS performance feedback or final score, or whether you should submit a targeted review request, please contact the Quality Payment Program by:
Phone: 1-866-288-8292/TTY: 1-877-715-6222; or
Email: QPP@cms.hhs.gov

The 2016 Physician Quality Reporting System (PQRS) Experience Report and the 2018 Value Modifier Experience Report Are Now Available

Posted August 21, 2018

The 2016 Physician Quality Reporting System (PQRS) Reporting Experience Including Trends (2007 – 2016) (commonly referred to as the 2016 PQRS Experience Report) provides a summary of the reporting experience of individual eligible professionals (EPs) and group practices who participated during the 2016 PQRS reporting period. This report provides historical trends on eligibility, participation, payment incentives and adjustments, and measure performance broken down by specialty and state. It gives a snapshot of this program and shows who participated, including the type of EP and their specialty, as well as what methods they used to participate.

In 2018, the PQRS payment adjustment is applied under the Medicare Physician Fee Schedule (PFS) for individual EPs and group practices based on submitted 2016 quality data. The final data submission timeframe for reporting 2016 PQRS quality date (to avoid the 2018 PQRS downward payment adjustment) was January 1, 2017 through March 31, 2017.

For the full 2016 PQRS Experience Report, visit the PQRS Analysis and Payment webpage.

Highlights of this year’s report include:

  • In 2016, nearly 1.39 million EPs were eligible to participate in PQRS, compared to 1.36 million in 2015.
  • Of those eligible, 72% (1,001,731 EPs) participated in 2016. This is a 7% increase in reporting from 2015, when 69% (938,939 EPs) participated.
  • Of those eligible in 2016, 69% (962,974 EPs) were successful and avoided the 2018 payment adjustment.
  • Of all EPs that were eligible in 2016, 31% (435,111) will receive a payment adjustment of -2% in 2018. Almost 85% of those subject to the adjustment did not attempt to participate in the program (that is, did not submit any data).
  • EPs were more likely to be subject to payment adjustments if they were a part of a smaller practice, had lower PFS allowed charges, or had lower beneficiary volume.
  • 71% of all EPs who received the payment adjustment were from practices with fewer than 25 EPs.
  • 68.8% of those EPs who received the payment adjustment had 100 or fewer Medicare beneficiaries.
  • 69.5% of those EPs who received the payment adjustment had PFS charges that were $30,000 or less and 48% had PFS charges that were $10,000 or less.

The 2018 Value-Based Payment Modifier Program Experience Report highlights characteristics of the practices subject to the Value Modifier in 2018 and compares program results across 2015, 2016, 2017, and 2018. In 2018, the Value Modifier applies upward, downward, and neutral payment adjustments at the practice level to Medicare PFS payments to physicians, nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs) based their performance in 2016. For the full 2018 Value Modifier Experience Report and the factsheet on the 2018 Value Modifier Results, visit the 2016 QRUR and 2018 Value Modifier webpage.

Questions

  • Questions regarding PQRS and related topics, such as reporting requirements, downward payment adjustments, and feedback reports can be directed to the QualityNet Help Desk at 1-866-288-8912 (TTY: 1-877-715-6222) between the hours of Monday–Friday; 7:00 a.m.–7:00 p.m. Central Time.
  • Questions regarding the Value Modifier and Quality and Resource Use Reports (QRURs) can be directed to the Physician Value Help Desk at pvhelpdesk@cms.hhs.gov or 888-734-6433 (select option 3) between the hours of Monday–Friday; 7:00 a.m.–7:00 p.m. Central Time.

Moving Forward with Quality Reporting

These are the final Experience Reports for the PQRS and Value Modifier programs, as both programs sunset December 31, 2018.

Many elements of PQRS transitioned to the Quality Performance Category of the Merit-based Incentive Payment System (MIPS). MIPS is one of two paths under the Quality Payment Program. The first MIPS performance period was January through December 2017 for the 2019 payment year. Clinicians could choose how they wanted to participate in the Quality Payment Program based on factors including their practice size, specialty, location, or patient population. The clinician types eligible to participate in the first two years of MIPS do not include all the clinician types that were required to participate under PQRS. The MIPS low-volume threshold additionally reduces the number of clinicians included initially in MIPS. Further, MIPS has been designed to reduce burden and complexity in the reporting requirements, as compared to prior years under the PQRS. No-cost technical assistance is available for all clinicians, including a specific focus on small practices in an effort to increase program success.

MIPS is a new approach to paying for Medicare Part B PFS items and services in which clinicians may receive an increase, decrease, or no change in their payments based on their performance. Performance is measured in four areas - Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. Clinicians report data in the first three areas, while the Cost area is calculated by CMS based on claims submitted. MIPS is designed to update and consolidate previous programs, including: Medicare EHR Incentive Program, PQRS, and the Value-based Payment Modifier. CMS will continue its collaboration with the clinician community to inform policy and offer a simpler, sustainable Medicare program. For more information about MIPS, please visit qpp.cms.gov. To receive reminders for important program deadlines and information, sign up for the Quality Payment Program listserv by entering your email address in the "Subscribe to Updates" area at the bottom of the page. The Resource Library includes program resources to help you learn more about the Quality Payment Program and how to participate.

QPP Resource

Virtual Groups Toolkit for 2019 MIPS Performance Year Now Available

Posted August 17, 2018

If you’re interested in forming a virtual group for the 2019 Merit-based Incentive Payment System (MIPS) performance year, you must follow an election process and submit your election to CMS via e-mail between October 1 and December 31, 2018

CMS has posted the 2019 Virtual Groups Toolkit to help you understand the election process to participate in MIPS as a virtual group in 2019. The toolkit includes:

  • 2019 Virtual Groups Overview Fact Sheet – Provides an overview of what a virtual group is, who can participate in a virtual group, how virtual groups collect and submit data, and how virtual groups are scored.
  • 2019 Virtual Groups Election Process – Details the two-stage election process for forming a virtual group, and what needs to be included in a virtual group agreement.
  • Virtual Group Election Submission E-mail – A sample e-mail that can be used for a virtual group election submission.
  • Virtual Agreement Template – A template that can be used to develop a virtual group agreement.

Upcoming 2019 Virtual Groups Webinar

CMS is hosting a webinar on Monday, August 27, 2018 at 2:00 PM ET to provide information about how clinicians can participate in MIPS as a virtual group for the 2019 performance year. Register today to secure your spot.

Webinar Details
Title: Quality Payment Program Virtual Groups Webinar
Date: Monday, August 27, 2018
Time: 2:00 – 3:00 PM ET
Registration Link: https://engage.vevent.com/rt/cms/index.jsp?seid=1179
 
Learn More

Patients Over Paperwork

Posted August 15, 2018

Updated 2019 Medicare PFS Proposed Rule Presentation; Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session – August 22

Patients Over Paperwork – Updated 2019 Medicare Physician Fee Schedule (PFS) Proposed Rule Presentation
The Patients Over Paperwork web page is your resource for learning more about how the Centers for Medicare and Medicaid Services (CMS) is putting patients first by reviewing and streamlining our regulations. CMS has recently updated the page to include a new 2019 Medicare Physician Fee Schedule (PFS) proposed rule presentation.

Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session – August 22

Wednesday, August 22 from 1:30 to 3 pm

Register for Medicare Learning Network events.

Proposed changes to the CY 2019 Physician Fee Schedule would increase the amount of time doctors and other clinicians spend with their patients by reducing the burden of Medicare paperwork.  During this listening session, CMS experts will briefly cover three provisions from the proposed rule and address your clarifying questions to help you formulate your written comments for formal submission:

  • Streamlining Evaluation and Management (E/M) payment and reducing clinician burden
  • Advancing virtual care
  • Continuing to improve the Quality Payment Program to reduce clinician burden, focus on outcomes, and promote interoperability

We encourage you to review the proposed rule prior to the call, as well as the following materials on the provisions to be covered:

Note: Feedback received during this listening session will not be considered formal comments on the rule. See the proposed rule for information on submitting these comments by September 10, 2018.

Target Audience: Medicare Part B fee-for-service clinicians; office managers and administrators; state and national associations that represent healthcare providers; and other stakeholders.


August 2018 CMS National Training Program Update

Posted August 15, 2018

August is National Immunization Month:

Preventing Pneumonia is Easy
Medicare can help protect you from pneumococcal infections. The pneumococcal shot is the best way to help prevent these infections. Medicare Part B covers the shot and a second shot one year later. Learn more about Medicare-covered vaccines by watching our video.

New / Updated CMS Publications
Information Partners Can Use on Reassignment
Medicare Coverage of Ambulance Services

Newly Posted Training Materials

Module 6: Medicare for People with End-Stage Renal Disease
Module 10: Medicare and Medicaid Fraud and Abuse Prevention
Module 11: Medicare Advantage Plans

Did You Know?
Physician Compare helps you find doctors who accept Medicare, so you can make an informed decision for your health care needs.

New Medicare cards are being mailed. To learn more about the new card or to check the mailing status of your new card, go to Medicare.gov/newcard/.

Registration is still OPEN
for the 2018 CMS National Training Program (NTP) Workshop in Denver, Colorado from September 11-13, 2018. For more information and to register, go to CMS.seiservices.com/cms2018/.

2017 MIPS Performance Feedback and Payment Adjustment Update

Post August 10, 2018

If you submitted 2017 Merit-based Incentive Payment System (MIPS) data through the Quality Payment Program website, you can now view your performance feedback and MIPS final score.

CMS originally displayed a single payment adjustment amount, which included an additional adjustment for exceptional performance available to MIPS eligible clinicians and groups with a final score of 70 or greater. However, based on feedback from various clinicians and groups, we have updated the system so that your MIPS payment adjustment, and if applicable, your additional adjustment for exceptional performance, are now displayed separately. The system will continue to display your total MIPS payment adjustment, which is a sum of your MIPS performance and exceptional performance.

How to Access Your Final Score and Feedback

You can access your 2017 MIPS performance feedback and final score by:

  • Going to the Quality Payment Program website
  • Logging in using your Enterprise Identity Management (EIDM) credentials; if you don’t have an EIDM account, refer to this guide

Upcoming Office Hours
CMS will be hosting an office hours session on August 14 to provide a brief overview of MIPS 2017 performance feedback and targeted review and to answer frequently asked questions.

Title:  Performance Feedback and Targeted Review Office Hours Session
Date: Tuesday, August 14, 2:00 – 3:00 p.m. ET
Register: https://meetingconnect.webex.com/meetingconnect/onstage/g.php?MTID=e91df49e0f68fa7073866f0307f82b53b

Resources
•    2017 Performance Feedback Fact Sheet and User Guide
•    2017 Performance Feedback Instructional Videos
•    2019 MIPS Payment Adjustment Fact Sheet and Infographic

Questions?
If you have questions about your performance feedback or MIPS final score, please contact the Quality Payment Program by:
•    Phone: 1-866-288-8292/TTY: 1-877-715-6222 or
•    Email: QPP@cms.hhs.gov

Quality Payment Program Exception Applications are Now Available on QPP.CMS.GOV

Posted August 10, 2018


The 2018 Quality Payment Program Exception Applications for the Promoting Interoperability (PI) performance category and for Extreme and Uncontrollable Circumstances for the Merit-based Incentive System (MIPS) are now available on the Quality Payment Program website.

Promoting Interoperatability Hardship Exceptions

If you’re participating in MIPS during the 2018 performance year as an individual, group, or virtual group—or participating in a MIPS Alternative Payment Model (APM)—you can submit a Quality Payment Program Hardship Exception Application for the PI performance category, citing one of the following specified reasons for review and approval:

  • MIPS-eligible clinicians in small practices (new for 2018)
  • MIPS-eligible clinicians using decertified EHR technology (new for 2018)
  • Insufficient Internet connectivity
  • Extreme and uncontrollable circumstances
  • Lack of control over the availability of certified electronic health record technology (CEHRT)

An approved Quality Payment Program Hardship Exception will:

  • Reweight your PI performance category score to 0 percent of the final score
  • Reallocate the 25 percent weighting of the PI performance category to the Quality performance category

Please note that simply not using CEHRT does not qualify you for reweighting of your PI performance category.

You must submit a hardship exception application by December 31, 2018 for CMS to reweight the PI performance category to 0 percent.

Extreme and Uncontrollable Circumstances

MIPS eligible clinicians who are impacted by extreme and uncontrollable circumstances may submit a request for reweighting of the Quality, Cost, and Improvement Activities performance categories.

"Extreme and uncontrollable circumstances" are defined as rare events (highly unlikely to occur in a given year) entirely outside your control and the facility in which you practice.

These extreme and uncontrollable circumstances would cause you to be unable to collect information necessary to submit for a performance category, or to submit information that would be used to score a performance category for an extended period of time (for example, 3 months unable to collect data for the Quality performance category). In your application, you must indicate the performance categories that were subject to an extreme and uncontrollable circumstance and how the circumstance affected your ability to collect or submit data for the 2018 MIPS performance year.
The application for extreme and uncontrollable circumstances must be submitted by December 31, 2018 for the 2018 MIPS performance year.

For More Information:

CMS Finalizes Changes to Empower Patients and Reduce Administrative Burden

Posted August 3, 2018

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 
Changes in the Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System final rule will advance price transparency and electronic health records .

Thursday, August 2, 2018, the Centers for Medicare & Medicaid Services (CMS) finalized a rule to empower patients and advance the White House MyHealthEData initiative and the CMS Patients Over Paperwork initiative. This final rule and others issued earlier this week will help improve access to hospital price information, give patients greater access to their health information and allow clinicians to spend more time with their patients.

Individually and collectively, these final rules put patients first, ease provider burden, and make significant strides in modernizing Medicare. The final rule issued on August 2, 2018 makes updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) that will incentivize value-based, quality care at these facilities. CMS also issued final rules this week on fiscal year (FY) 2019 Medicare payments and policies for the Skilled Nursing Facility (SNF) PPS, Inpatient Psychiatric Facility (IPF) PPS, Inpatient Rehabilitation Facility (IRF) PPS, and the Hospice Wage Index and Payment Rate Update.

“We’re excited to make these changes to ensure care will focus on the patient, not on needless paperwork,” said CMS Administrator Seema Verma. “We’ve listened to patients and their doctors who urged us to remove the obstacles getting in the way of quality care and positive health outcomes. Today’s final rule reflects public feedback on CMS proposals issued in April, and the agency’s patient-driven priorities of improving the quality and safety of care, advancing health information exchange and usability, and removing outdated or redundant regulations on healthcare providers to make way for innovation and greater value.”

Along with policy changes, the FY 2019 IPPS/LTCH PPS final rule provides acute care hospitals an average payment increase of approximately 3 percent, which reflects rate updates required by law and payments for new technologies and uncompensated care.

The IPPS/LTCH PPS final rule also updates geographic payment adjustments for IPPS hospitals. CMS looks forward to continuing to work on geographic payment disparities, particularly for rural hospitals, to the extent permitted under current law and appreciates responses to our request for public input on this issue. By allowing the imputed wage index floor to expire for all-urban states, CMS has begun the process of making geographic payments more equitable for rural hospitals.

In addition, CMS is updating the LTCH PPS standard federal payment rate by 1.35 percent. Overall, under the changes included in the final rule, CMS projects that LTCH PPS payments will increase by approximately 0.9 percent, or $39 million in FY 2019. In addition, CMS is finalizing the proposal to eliminate the 25 percent threshold policy in a budget neutral manner.

MyHealthEData and Interoperability: The policies in the FY 2019 IPPS/LTCH PPS final rule will bring us closer to the agency’s goal of creating a patient-centered healthcare system by increasing price transparency and fluid information exchange — essential components of value-based care — while also significantly lifting the administrative burden on hospitals so they can operate with greater flexibility and patients have the information they need to make decisions about their own care. CMS received stakeholder feedback on solutions for achieving interoperability, or the sharing of healthcare data between providers, through responses to a Request for Information (RFI) issued in April in the IPPS/LTCH PPS proposed rule.

While CMS previously required hospitals to make publicly available a list of their standard charges or their policies for allowing the public to view this list upon request, CMS has updated its guidelines to specifically require hospitals to post this information on the Internet in a machine-readable format. The agency is considering future actions based on the public feedback it received on ways hospitals can display price information that would be most useful to stakeholders and how to create patient-friendly interfaces that allow consumers to more easily access relevant healthcare data and compare providers.

The policies released today begin implementing core pieces of the White House-led MyHealthEData initiative through several steps to strengthen interoperability. In the IPPS/LTCH PPS final rule, CMS overhauls the Medicare and Medicaid Promoting Interoperability Programs (formerly known as the “Meaningful Use” program or Medicare and Medicaid Electronic Health Record Incentive Programs) to:

  • Make the program more flexible and less burdensome
  • Emphasize measures that require the exchange of health information between providers and patients 
  • Incentivize providers to make it easier for patients to obtain their medical records electronically

In addition, the final rule reiterates the requirement for providers to use the 2015 Edition of certified electronic health record technology in 2019 as part of demonstrating meaningful use to qualify for incentive payments and avoid reductions to Medicare payments. This updated technology includes the use of application programming interfaces (APIs), which have the potential to improve the flow of information between providers and patients. APIs can enable patients to collect their health information from multiple providers and incorporate it into a single portal, application, program or other software. This will support a patient’s ability to share their information with another member of their care team or with a new doctor, which can reduce duplication and encourage continuity of care.

Meaningful Measures and Transparency: CMS’s Meaningful Measures initiative is centered on patient safety, quality of care, transparency and ensuring that the measure sets providers are asked to report make the most sense. In the IPPS/LTCH PPS final rule, CMS is removing unnecessary, redundant and process-driven measures from several pay-for-reporting and pay-for-performance quality programs. The final rule eliminates a number of measures acute care hospitals are currently required to report across the four hospital pay-for-reporting and value-based purchasing quality programs. It also “de-duplicates” certain measures that are in multiple programs, keeping them in the program where they can best incentivize improvement and maintaining transparency through public reporting. In all, these changes will remove a total of 18 measures from the programs and de-duplicate another 25 measures while still ensuring meaningful measures of hospital quality and patient safety. In addition to the changes that apply to acute care hospitals, the final rule eliminates three measures in the LTCH Quality Reporting Program. Lastly, CMS is making a variety of other changes to reduce the hours providers spend on paperwork. This new flexibility will allow hospitals to spend more time providing care to their patients, thereby improving the quality of care their patients receive. Overall, changes in the hospital quality and value measures across the four programs will eliminate more than 2 million burden hours for hospitals impacted by the IPPS/LTCH PPS rule, saving them about $75 million annually after these changes are implemented.

Similarly, the Skilled Nursing Facilities (SNF) PPS, Inpatient Psychiatric Facility (IPF) PPS and Inpatient Rehabilitation Facility (IRF) PPS final rules establish policies that ensure the measures those providers must report are patient-centered and outcome-driven rather than process-oriented. Where applicable, these changes will allow providers to work with a smaller set of more meaningful healthcare measures and spend more time on patient care.
CMS is also advancing Meaningful Measures through the Hospice Wage Index and Payment Rate Update. This final rule will make Hospice Compare public data easier and more efficient to use.

Patients Over Paperwork: The SNF PPS final rule incorporates the agency’s Patients Over Paperwork initiative through avenues that reduce unnecessary burden on providers by easing documentation requirements and offering more flexibility. As part of the agency’s actions to modernize Medicare, the SNF PPS rule establishes an innovative new classification system, the Patient Driven Payment Model (PDPM), which ties skilled nursing facility payments to patients’ conditions and care needs rather than volume of services provided. The new model will better incentivize treating the needs of the whole patient, rather than focusing on the amount of services for that patient, which requires substantial paperwork to track over time. The PDPM approach advances CMS’s efforts to build a patient-driven healthcare system starting with innovation throughout Medicare’s payment systems. Under this new SNF payment model, patients will have more opportunity to choose a skilled nursing facility that offers services tailored to their condition and preferences, as the payment to these facilities will be based more on the patient’s condition rather than the specific services each skilled nursing facility provides.

Modernizing Medicare in additional ways to benefit patients, today’s final IRF PPS rule adopts advances in telecommunications technology and removes obstacles that may prevent rehabilitation physicians from conducting certain meetings without being physically in the room. The rule also removes overly prescriptive documentation requirements for admission orders for these rehabilitation facilities.

For a fact sheet on the FY 2019 IPPS/LTCH PPS final rule (CMS-1694-F), please visit:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-08-02.html

To view the FY 2019 IPPS/LTCH PPS final rule (CMS-1694-F), please visit:
https://www.federalregister.gov/public-inspection/

For a fact sheet on the FY 2019 SNF PPS final rule (CMS-1696-F), please visit:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-31-3.html

To view the FY 2019 SNF PPS final rule (CMS-1696-F), please visit:
https://federalregister.gov/d/2018-16570

For a fact sheet on the FY 2019 IPF PPS final rule (CMS-1690-F), please visit:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-31.html

To view the FY 2019 IPF PPS final rule (CMS-1690-F), please visit:
https://federalregister.gov/d/2018-16518

For a fact sheet on the FY 2019 IRF PPS final rule (CMS-1688-F), please visit:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-31-2.html

To view the FY 2019 IRF PPS final rule (CMS-1688-F), please visit:
https://federalregister.gov/d/2018-16517

For a fact sheet on the FY 2019 Hospice Wage Index and Payment Rate Update final rule (CMS-1692-F), please visit:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-08-01-2.html

To view the FY 2019 Hospice Wage Index and Payment Rate Update final rule (CMS-1692-F), please visit:
https://federalregister.gov/d/2018-16539


CMS Announces Updates to eCQM Value Sets for 2019 Reporting and Performance Periods

Posted August 2, 2018

The Centers for Medicare & Medicaid Services (CMS) and the National Library of Medicine (NLM) will publish updates to the electronic clinical quality measure (eCQM) value sets to align with the most recent releases to terminologies, including, but not limited to, International Classification of Diseases, 10th revision (ICD-10), Clinical Modification and Procedure Coding System, SNOMED CT, LOINC, RxNorm, and Current Procedural Terminology.

When will the addendum be published and what programs are affected by the addendum?

In September 2018, CMS will publish an addendum to the eCQMs (published in May 2018) to update relevant eCQM value sets for the 2019 reporting/performance year. This addendum will affect the electronic reporting of eCQMs for the following programs:

  • The Quality Payment Program: Merit-based Incentive Payment System and Advanced Alternative Payment Models
  • Comprehensive Primary Care Plus 
  • CMS Hospital Inpatient Quality Reporting 
  • Medicare and Medicaid Promoting Interoperability Programs

What changes are included in the addendum?

Changes will only affect the value sets for eCQMs. The Health Quality Measure Format specifications, the value set object identifiers, and the measure version numbers for 2019 eCQM reporting will not change.
The changes to the value sets consist of (1) deletion of expired codes, (2) addition of relevant replacement codes, and (3) addition of newly available codes that represent concepts consistent with the intent of the value set and corresponding measure(s).

Where will CMS and the NLM post the addendum?
All changes to the eCQM value sets will be available through the NLM’s Value Set Authority Center download tab. The value sets will be available as a complete set, as well as value sets per measure. 
Updated measure information, including revised technical release notes, will be available on the eCQI Resource Center website.

What do I need to do?
Measure implementers should review these changes to ensure their submissions comply with the updated requirements.

Where do I go for assistance?

Measure implementers can report questions regarding the addendum, eCQM value sets, and appropriateness of mapping to the ONC eCQM Issue Tracker. Visit the eCQI Resource Center to review additional frequently asked questions and answers regarding the addendum.


Quality Payment Program

Posted August 1, 2018

Help CMS Improve the Quality Payment Program Website
Are you interested in providing feedback on the Quality Payment Program website to the Centers for Medicare & Medicaid Services (CMS) as we continue to improve the Quality Payment Program experience? Email the QPP User Research Lead to participate in our feedback sessions.


CMS Announces Updates to eCQM Value Sets for 2019 Reporting and Performance Periods
CMS and the National Library of Medicine (NLM) will publish updates to the electronic clinical quality measure (eCQM) value sets to align with the most recent releases to terminologies, including, but not limited to, International Classification of Diseases (ICD)-10 Clinical Modification (CM) and Procedure Coding System (PCS), SNOMED CT, LOINC, RxNorm, and Current Procedural Terminology (CPT).

When will the addendum be published and what programs are affected by the addendum?
In September 2018, CMS will publish an addendum to the eCQMs (published in May 2018) to update relevant eCQM value sets for the 2019 reporting/performance year. This addendum will affect the electronic reporting of eCQMs for the following programs:

  • The Quality Payment Program: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs)
  • Comprehensive Primary Care Plus (CPC+)
  • CMS Hospital Inpatient Quality Reporting (IQR)
  • Medicare and Medicaid Promoting Interoperability (PI) program

What changes are included in the addendum?
Changes will only affect the value sets for eCQMs. The Health Quality Measure Format (HQMF) specifications, the value set object identifiers (OIDs), and the measure version numbers for 2019 eCQM reporting will not change.

The changes to the value sets consist of (1) deletion of expired codes, (2) addition of relevant replacement codes, and (3) addition of newly available codes that represent concepts consistent with the intent of the value set and corresponding measure(s).

Where will CMS and NLM post the addendum?
All changes to the eCQM value sets will be available through the NLM’s Value Set Authority Center download tab. The value sets will be available as a complete set, as well as value sets per measure.

Updated measure information, including revised technical release notes, will be available on the eCQI Resource Center website.

What do I need to do?
Measure implementers should review these changes to ensure their submissions comply with the updated requirements.

Where do I go for assistance?
Measure implementers can report questions regarding the addendum, eCQM value sets, and appropriateness of mapping to the ONC eCQM Issue Tracker. Visit the eCQI Resource Center to review additional frequently asked questions and answers regarding the addendum.

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