November 7, 2011 For audio, dial: 1-877-668-4490; Meeting/Event Number: 710 239 432 The Integrated Care Resource Center, a joint initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office and the Center for Medicaid, CHIP, and Survey & Certification, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies.
Partnership for Patients & Million Hearts: Achieving the Goals of the National Quality Strategy Paul McGann, MD Co Director, HHS Partnership for Patients Janet Wright, MD Executive Director, HHS Million Hearts Initiative John Michael O Brien, PharmD, MPH Field Director, CMS Innovation Center
Questions to Run On What are the Partnership for Patients and Million Hearts Initiatives? How can states benefit from the initiative? What actions and contributions might states make? What resources or help can CMS provide to States to achieve our bold aims? we want your answers too 3
Partnership for Patients: We are focused on our aims 40% Reduction in Preventable Hospital Acquired Conditions 1.8 Million Fewer Injuries 60,000 Lives Saved 20% Reduction in Preventable 30 Day Readmissions 1.6 Million Patients Recover Without Readmission Potential to save $35 billion in 3 years Now certified by the Office of the Actuary
We Know Major Improvement Is Possible Ascension Health sites participating in a 2007 perinatal safety initiative achieved birth trauma rates that were at or near zero. 150 New Jersey health care facilities reduced pressure ulcers by 70% Rhode Island reported a 42% decrease in Central Line Associated Bloodstream Infections (CLABSI) (2006 2007) 65+ IHI Campaign hospitals reported going more than a year without a ventilator associated pneumonia in at least one unit. The 14 QIO Communities participating in the 9 th SOW Care Transitions Theme achieved significant reduction in readmissions compared to 52 peer communities. 5
How Will Change Actually Happen? There is no silver bullet. We must apply many incentives. We must show successful alternatives. We must offer intensive supports. Help providers and partners with the painstaking work of improvement. 6
Partnership for Patients: Better Care, Lower Costs Up to $500 million to help hospitals and health care organizations to improve patient care to: Provide national-level content for anyone and everyone Support every facility to take part in cooperative learning Establish an Advanced Participants Network for ambitious organizations to tackle all-cause harm Engage patients and families in making care safer Improve measurement and data collection, without adding burdens to hospitals Make data transparent
Areas of Focus Partnership for Patients have indentified nine areas of focus: Adverse Drug Events Catheter-Associated Urinary Tract Infections Central Line Associated Blood Stream Infections Injuries from Falls and Immobility Obstetrical Adverse Events Pressure Ulcers Surgical Site Infections Venous Thromboembolism Ventilator-Associated Pneumonia
National Vision Strong, Public Leadership Commitments The Boards of all Partnership hospitals publically embrace the aims of the initiative and remove barriers to progress. Raise the Floor Every hospital in the nation adopts and completely implements a set of evidence-based interventions. Raise the Bar Vanguard hospitals seek to define and eliminate all-cause harm and preventable readmissions on an extremely ambitious timeframe (making their work transparent to all others with interest). Smooth Transitions between Care Settings Hospitals, communities, patients and families will devote new attention to making sure that transitions out of the hospital are well coordinated.
Why are people readmitted? Provider-Patient interface Unmanaged condition worsening Use of suboptimal medication regimens Return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers No Community infrastructure for achieving common goals 10
Learn from the QIO 9 th SOW: 14 Communities Improving Care Transitions 11
Preliminary Results*: Relative Improvement July 2007 June 2008 compared to July 2009 June 2010 14 Care Transitions Communities vs. 52 Peer Communities 6.00% 5.56% 5.66% 5.00% 4.00% 3.00% 2.00% 2.50% 3.47% Care Transitions Communities Peer Communities 1.00% 0.00% Readmission Relative Improvement Rate Admission Relative Improvement Rate *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs obligations under their CMS contracts. 12
Community Based Care Transitions Program What is it? ACA Section 3026 and part of the Partnership for Patients $500 million to test models for improving care transitions for high risk Medicare beneficiaries 5 year program / potential to expand beyond 5 years based on success! Accepting applications on rolling basis as long as funding is available QIOs can support communities, whether just getting started in care transitions improvement or ready to apply to the CCTP 13
Community Based Care Transitions Program Goals Improve care transitions from inpatient hospital setting to home or other care settings Reduce readmissions for high risk beneficiaries Document measurable savings to the Medicare program 14
Community Based Care Transitions Program The Opportunity Community Based Organizations (CBOs) can actually define and price a new cost effective care transitions service for Medicare patients in their communities tailored to their own unique circumstances and capabilities! 15
Who Could Be a CBO? -- Examples -- Area Agencies on Aging (AAAs) Aging and Disability Resource Centers (ADRCs) Federally Qualified Health Centers (FQHCs) A coalition representing a collaboration of community healthcare providers if a legal entity is formed PAC providers with evidence of board representation that comes from outside of the provider entity. Grantees of Foundations with experience in improving care transitions 16
Who Can Be a Community Based Organization? -- Criteria -- Legal entity, i.e., have a taxpayer ID number, so we can pay them for services provided Governing body with multiple health care stakeholder representation, including consumers Partnership with one or more subsection (d) acute care hospitals Physically located in the community it proposes to serve Can demonstrate ability to provide care transitions for Medicare FFS beneficiaries across health care settings Applicants describe how they will work with other payors including Medicaid 17
Useful Care Transitions Links National Coordinating Center: www.cfmc.org/caretransitions Partnership for Patients: http://www.healthcare.gov/partnershipforpatients Community Based Care Transitions Program: http://go.cms.gov/caretransitions Administration on Aging (AoA) Toolkit, Learning Sessions: http://www.adrc tae.org/tiki index.php?page=caretransitions 18
How Can States Benefit? Achieving the Partnership for Patients HAC reduction goals would result in 271,000 Medicaid patients helped, over 9,000 deaths averted, and $3 billion saved over the next three years (just counting FFS) 252,000 Medicaid readmissions can be averted over the next three years, saving an estimated $2.2 billion dollars These aims will also contribute to improved quality and lower the human & financial costs of harms to all state payors 19
How Can States Contribute? Sign the Pledge at http://www.healthcare.gov/partnershipforpatients urge others to follow your lead. As a powerful payor, get key safety net hospitals to participate aggressively in the improvement work of the partnership. Work with communities applying to the CCTP and with your state s QIO as it recruits communities to improve care transitions Join the full court press by linking state pay for performance programs to the HAC and readmission goals and measures. Convene and engage state safety champions inside government and across the provider, LTC, public health and other communities. 20
How Can CMS Help? Work closely with CMCS, State Medicaid Agencies, and State Health Officials to educate and engage all partners in the work of the Partnership for Patients Hospital Engagement Contractors, Community based Care Transitions Program, and Others Seek and stay aware of ways the Partnership can help States and State funded entities via MSTATs and policy alignment opportunities We want to broadcast your successes and results! 21
Partnership for Patients: The First 200 Days More than 6,500 partners have pledged their commitment to the aims of the Partnership for Patients, including over 3,000 hospitals. 3,079 Hospitals 2,184 Clinicians & Provider Orgs 836 Consumer & Patient Groups 246 Employer, Union & Govt Orgs 110 AAAs & Aging Groups 22
Partnership for Patients: The First 200 Days One third of states of nationwide have over half of their hospitals on board. Every hospital in Iowa and Washington has committed to our aims.
Partnership for Patients: The First 200 Days Every federal agency is in action to leverage and align their policies, programs, expertise and network in support of our aims.
Partnership for Patients: The First 200 Days A number of major partners from across the spectrum of health care stakeholders have made significant commitments aligned to our aims.
Contact Information Paul McGann, MD Paul.mcgann@cms.hhs.gov Dennis Wagner dennis.wagner2@cms.hhs.gov John O Brien John.O Brien@cms.hhs.gov Centers for Medicare and Medicaid Services 7500 Security Blvd. Baltimore, MD 21244 1850 26
27 Elisa Estrella, Special Assistant to the Director, Office of Minority Health
Overview I. Overview of CMS Spending & Health Disparities Costs II. ACA Authorizations that Impact Health Disparities III. CMS Lead Actions for the HHS Health Disparities Plan IV. Next Steps 28
CMS History Medicare s leverage as the largest purchaser and regulator provides opportunities to have a large impact on reducing health disparities. 29
The Annual Cost of Health Disparities to CMS Medicare alone will spend an extra $15.6 billion while private insurers will incur $5.1 billion in additional costs due to elevated rates of chronic illness among African Americans and Hispanics. Estimates indicate the combined total of health disparities costs Medicare and Medicaid is $17 billion a year. Source: Urban Institute 2009 Cost of Health Disparities (Medicaid is less dramatic due to younger status of Medicaid beneficiaries compared to higher per capita spending of Medicare and the second payer status of dual eligible. ) 30
Patient Protection & Affordable Care Act, Section 10334 of PL 111 148 Authorizes the Department of Health and Human Services to establish Offices of Minority Health within six agencies, including CMS. 31
Enrollment Projections by Race/Ethnicity After ACA Pre ACA Medicaid Dual CHIP Eligibility Race/Ethnicity TOTAL TOTAL TOTAL Medicaid Expansion Stand Alone All 64,037,615 10,130,664 10,716,844 2,131,651 8,585,193 Non Hisp White 28,310,000 5,842,071 6,257,845 1,337,864 4,919,981 Non Hisp Black+Hispanic 35,740,000 4,288,593 4,458,999 793,787 3,665,212 Non Hisp Black 16,480,302 2,365,430 1,655,054 359,865 1,295,189 Hispanic 19,256,537 1,923,163 2,803,946 433,923 2,370,023 Post ACA Medicaid Dual Race/Ethnicity TOTAL TOTAL All 86,688,814 7,902,364 Non Hisp White 41,910,000 4,296,886 Non Hisp Black+Hispanic 44,770,000 3,605,478 Non Hisp Black 20,822,951 1,972,175 Hispanic 23,950,646 1,633,303 Note: SPAM is an OACT data set that combines MEPS 2005 7 and reweighted to match 2014 NHE spending and coverage distributions. 32
ACA Authorizations that Impact Health Disparities Section 2001 Expansion of Medicaid income eligibility up to 133% of the Federal Poverty Level. Section 2005 Increase in federal matching rates for Medicaid Section 3021 Authorizes Innovation Models in Medicare/Medicaid (2011 2019) Section 3013 Development, improvement & evaluation of quality measures (2011 2014) Section 3306 Enrollment and outreach to low income populations Section 4302 Requires: Population surveys to collect racial/ethnic subgroup data, Collection/reporting of disparities data in Medicaid and CHIP, Monitoring of health disparities trends in federally funded programs. Section 5405 Sanctions the Primary Care Extension Program (2011 2012) 33
CMS Led Actions for the HHS Health Disparities Plan Goal 1: Transform Health Care Increase the proportion of people with health insurance and provide patient protections in Medicaid, CHIP, Medicare, Health Insurance Exchanges, and other forms of health insurance. Increase the proportion of persons with a usual primary care provider and patient centered health homes. Improve the quality of care provided in the Health Insurance Exchanges. Increase access to dental care for children in Medicaid and CHIP. 34
CMS Led Actions for the HHS Health Disparities Plan Goal 2: Strengthen HHS Workforce and Infrastructure Improve language access in Medicaid. Promote the use of community health workers by Medicare beneficiaries. 35
CMS Led Actions for the HHS Health Disparities Plan Goal 3: Advance the Health, Safety, and Well Being of the American People Implement a multifaceted health disparities data collection strategy across HHS. 36
CMS Led Actions for the HHS Health Disparities Plan Goal 4:Advance Scientific Knowledge and Innovation 37
CMS Led Actions for the HHS Health Disparities Plan Goal 5:Increase Efficiency, Transparency, and Accountability of HHS Programs Monitor and evaluate implementation of the HHS Disparities Action Plan. Goal Level Disparities Monitoring and Surveillance. Strategy Level Evaluation. Ongoing Monitoring/Evaluating and Reporting. 38
Next Steps Formalize CMS Plan to Address Racial and Ethnic Disparities in Health that includes aims consistent with the CMS three part aim: better healthcare, better health and reduced costs through improvement Continue to conduct interagency scans of disparities contracts, programs, and opportunities for incentivizing and better measuring racial and ethnic health outcomes Coordinate and integrate efforts across components Conduct listening sessions Collaborate and share information with private and public partners and leaders 39
Million Hearts Preventing 1 million heart attacks and strokes in 5 years www.millionhearts.hhs.gov
Key components of Million Hearts Clinical Prevention improving the ABCS through Focus simplify and align quality measures; emphasize importance of improved care of the ABCS Health IT use EHRs to improve care and enable quality improvement through clinical decision support, patient reminders, registries, and technical assistance Care innovations teams, med adherence techniques Community prevention Reducing the need for treatment through Prevention of tobacco use Decreased sodium and trans fat consumption
Improved cardiovascular care could save 100,000 lives/year in U.S. Blood Pressure control Cholesterol control Smoking cessation Aspirin prophylaxis Source: Farley TA, et al. Am J Prev Med 2010;38:600-9.
Clinical prevention Increasing focus Improving ABCS is top priority Aligning incentives, communication, clinical measurement, and reporting by physicians, health care facilities, and health care systems Simple, consistent ABCS indicators into Physician Quality Reporting System, EHR meaningful use criteria, community clinic measures, and guidelines from private-sector organizations Medicare Part D & MA/PD Plan Ratings Quality Improvement Organizations
Monitoring progress of Million Hearts Population Metric Baseline 2017 Aspirin for those at high risk 1 ~46% 65% Blood pressure control 2 ~47% 65% Cholesterol control 2 ~33% 65% Smoking prevalence 3 ~19% 17% Average sodium intake 2 ~3.5g/day 20% reduction Artificial trans fat intake 2 ~ 1% of calories 50% reduction Note: Population-wide indicators clinical performance goals higher 1 As measured in NAMCS 2 As measured in NHANES 3 As measured in NHIS
Reasons for hope HRSA Health Centers Collaborative Study increased daily aspirin intake from 53% to 67% KP Colorado High Blood Pressure and Cholesterol Management Program improved from 26% to 73% of patients with cholesterol under control Rhode Island Cardiovascular Chronic Care Collaborative saw an increase in blood pressure control among participants from 20% to 60% Work by Medicaid Massachusetts yielded a drop in smoking rate of over 38% to 28% in 2.5 years
Contact Information Janet Wright, MD Janet.Wright@cms.hhs.gov John Michael O Brien, PharmD, MPH John.O Brien@cms.hhs.gov Centers for Medicare and Medicaid Services 7500 Security Blvd. Baltimore, MD 21244 1850
47 Alice Lind, Center for Health Care Strategies
Countless opportunities for synergy Ideas to foster thought, not a conclusive list Capitated programs will likely have more control over Medicare-covered services Opportunities do exist for managed feefor-service (MFFS) 48
Partnership for Patients Greater synergy when capitated entity financially responsible for Medicare-covered hospital care States may require incentives for hospitals to: - Avoid preventable hospital-acquired conditions and complications immediately following discharge - Implement a computerized physician order entry system or use bar code technology 49
Action Plan to Reduce Health Disparities Dual eligible population is diverse Use Medicaid and Medicare quality measurement data to identify health disparities and areas for improvement States implementing MFFS models, especially health homes, may partner with community-based health teams States developing capitated models in underserved areas may use HRSA s National Health Service Corps (NHSC) to strengthen primary care networks 50
Million Hearts Campaign Include proactive care to prevent heart disease May require primary care providers to report on ABCS indicators (Aspirin for people at risk, Blood pressure control, Cholesterol management, Smoking cessation) Expansion of the HIT Regional Extension Centers and Beacon Communities will support reporting requirements 51
Established by CMS to advance integrated care models for Medicaid beneficiaries with high-cost, chronic needs Provides technical assistance (TA) to help states integrate care for: (1) individuals who are dually eligible for Medicare and Medicaid; and (2) high-need, high-cost Medicaid populations via health homes as well as other emerging models TA coordinated by Mathematica Policy Research and the Center for Health Care Strategies Visit www.integratedcareresourcecenter.com to submit a TA request and/or download resources, including briefs and practical tools to help address implementation, design, and policy challenges 52