Accelerating Care and Payment Innovation: The CMS Innovation Center

Accelerating Care and Payment Innovation: The CMS Innovation Center

Thank YouThank You

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• For the care you are providing every day• For the hard work you are doing to improve

your care systems every day• For your commitment to health care reform,

innovation and transformation

Health Care Innovation: One Patient’s Story

Health Care Innovation: One Patient’s Story

“The idea of the program is to keep me healthy, keep me out of the hospital, and keep costs down. I don’t think I would still be here without this program. It has been my lifeline.” – Marie Jones

Marie Jones, a high risk patient, with her dedicated nurse case manager.

New York Times, June 21, 2010 3

We need delivery system and payment transformation

We need delivery system and payment transformation

PUBLICSECTOR

Future State – People-Centered

Outcomes-Driven Sustainable

Coordinated Care Systems

New Payment Systems

Value-based purchasing ACO shared savings Episode-based payments Care management fees Data transparency

Current State – Producer-Centered Volume-Driven

Unsustainable

Fragmented Care Systems

FFS Payment Systems

PRIVATESECTOR

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“The purpose of the [Center] is to test

innovative payment and service delivery

models to reduce program expenditures…

while preserving or enhancing the quality

of care furnished to individuals under such

titles.

- The Affordable Care Act

The CMS Innovation CenterThe CMS Innovation Center

Identify, Test, Evaluate, Scale

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Our Strategy: Conduct many model tests to find out what works

Our Strategy: Conduct many model tests to find out what works

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The Innovation Center portfolio of models will address a wide variety of patient populations, providers, and innovative approaches to payment and service delivery

Tools to Empower Learning and Redesign:Data Sharing, Learning Networks, RECs, PCORI, Aligned Quality Standards

Partnership for Patients

Bundled Payment

Accountable Care OrganizationsComprehensive

Primary Care

Health Care Innovation Awards

Delivery Transformation Continuum

Providers can choose to participate in the testing

of different care delivery transformation models with different amounts of Medicare payments at risk, while benefiting from supports and resources designed to spread best practices and enhance quality.

Delivery Transformation ContinuumDelivery Transformation Continuum

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The Patient-centered Health Care System

of the future

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Providers are Driving TransformationProviders are Driving Transformation

• More than 50,000 providers are or will be providing care to beneficiaries as part of the Innovation Center’s current initiatives

• Over 250 organizations are participating in Medicare ACOs

• More than 4 million Medicare FFS beneficiaries are receiving care from ACOs

• More than 1 million Medicare FFS beneficiaries are participating in primary care initiatives

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Accountable CareAccountable Care

• Medicare Shared Savings Program (Center for Medicare)

• Pioneer ACO Model

• Advance Payment Model

• Comprehensive ESRD Care Initiative

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4 million Medicare beneficiaries having care coordinated by 220 SSP and 32 Pioneers ACOs

(Geographic Distribution of ACO Population)

4 million Medicare beneficiaries having care coordinated by 220 SSP and 32 Pioneers ACOs

(Geographic Distribution of ACO Population)

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The Pioneer ACO ModelThe Pioneer ACO Model

• Designed for health care organizations and providers that are already experienced in coordinating care

• Requires ACOs to create similar arrangements with other payers.

• Option for transition from shared savings to population-based payment in Year 3

• 32 Participating ACOs announced in December 2011

• Over 900,000 aligned beneficiaries

• First performance period began in January 2012.

GOAL: Test payment arrangements with higher risk and reward than MSSP, including partial- and full capitation arrangements, as well as a transition from FFS to population based payments.

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Quality Measurement & Performance for ACOs

Quality Measurement & Performance for ACOs

• 33 Quality measures are separated into the following four key domains:– Better Care

1. Patient/Caregiver Experience2. Care Coordination/Patient Safety

– Better Health3. Preventative Health4. At-Risk Population

• ACOs must meet quality targets to share in savings and the amount of savings shared depends on quality performance 12

• Collaborating with public and private insurers in purchasing high value primary care in communities they serve.

– Requires investment across multiple payers

– individual health plans, covering only their members, cannot provide enough resources to transform primary care delivery.

• Medicare will pay approximately $20 per beneficiary per month (PBPM) then move towards smaller PBPM to be combined with shared savings opportunity.

• The 7 markets selected: Ohio (Dayton), Oklahoma (Tulsa), Arkansas, Colorado, New Jersey, Oregon, New York (Hudson Valley)

Comprehensive Primary Care InitiativeComprehensive Primary Care Initiative

GOAL: Test a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care.

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Comprehensive Primary Care InitiativeComprehensive Primary Care Initiative

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Bundled Paymentsfor Care Improvement

Bundled Paymentsfor Care Improvement

Four models:

1. Acute care hospital stay only

2. Acute care hospital stay plus post-acute care

3. Post-acute care only

4. Prospective payment of all services during inpatient stay

GOAL: Test payment models that link payments for multiple services patients receive during an episode of care for effectiveness in promoting coordination across services and reducing the cost of care.

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Bundled Payments for Care Improvement: All Participants

Bundled Payments for Care Improvement: All Participants

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Model 1 Model 2 Model 3 Model 4

Episode All acute patients, all DRGs

Selected DRGs + post-acute period

Post acute only for selected DRGs Selected DRGs

Services included in the bundle

All Part A DRG-based payments

Part A and B services during the initial

inpatient stay , post-acute period and

readmissions

Part A and B services during the post-acute

period and readmissions

All Part A and B services (hospital,

physician) and readmissions

Payment Retrospective Retrospective Retrospective Prospective

Participants 1 representing 24 health care facilities

53 representing 178 health care

organizations

14 representing 164 health care

organizations

37 representing 76 health care

facilities

Bundled Payments: 4 ModelsBundled Payments: 4 Models

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Health Care Innovation Awards Round TwoHealth Care Innovation Awards Round Two

GOAL: Test new innovative service delivery and payment models that will deliver better care and lower costs for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) enrollees.• Test models in four categories:

1. Reduce Medicare, Medicaid and/or CHIP expenditures in outpatient and/or post-acute settings

2. Improve care for populations with specialized needs3. Transform the financial and clinical models for specific types of

providers and suppliers4. Improve the health of populations

• Letter of Intent due June 28, 2013• Applications due August 15, 2013

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National Outcomes are Improving

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We are starting to see results nationallyWe are starting to see results nationally

Cost trends are down, Outcomes are Improving & Adverse Events are Falling• Total U.S. health spending grew only 3.9 percent in 2011• Medicare 30-day, all-cause readmission rate is estimated to have

dropped 1 percent after being at 19 percent for five years• 70,000 fewer readmissions in 2012 • Expanding coverage with insurance marketplaces gearing up for

2014

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Results: Medicare Per-Capita Spending Growth at Historic Low

Results: Medicare Per-Capita Spending Growth at Historic Low

2008-2009 2009-2010 2010-2011 2011-20120%

2%

4%

6%

Total Medicare

Source: CMS Office of the Actuary, Midsession Review – FY 2013 Budget

Our Ask: Our Ask:

• Continue the work of improving quality and patient safety

• Push your organizations to support this transition to a sustainable patient center healthcare system

• Chose Your Pathways: – ACOs, Models focused on Primary Care, Bundled

Payments for Care Improvement, State Innovation Models

• Make your personal commitment to transformation

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AppendixAppendix

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Multi-payer AdvancedPrimary Care Practice Model

Multi-payer AdvancedPrimary Care Practice Model

• Medicare will participate in existing State multi-payer health reform initiatives.

• Must include participation from Medicaid and private health plans.

• Monthly care management fee for beneficiaries receiving primary care from Advanced Primary Care practices.

• Eight states selected: Maine, Vermont, Rhode Island, New York, Pennsylvania, North Carolina, Michigan and Minnesota.

GOAL: Test the effectiveness of offering providers a common payment method from Medicare, Medicaid, and private health plans.

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Federally Qualified Health Center (FQHC) Advanced Primary Care Demonstration

Federally Qualified Health Center (FQHC) Advanced Primary Care Demonstration

• Open to FQHCs that have provided medical services to at least 200 Medicare beneficiaries in previous 12-month period.

• FQHC receives care management fee for each Medicare beneficiary enrolled.

• 485 FQHCs selected.

• Performance year started Nov 1, 2011.

GOAL: Evaluate impact of the advanced primary care practice model in the Federally Qualified Health Center (FQHC) setting.

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Independence at HomeIndependence at Home

GOAL: Testing the effectiveness of providing chronically ill beneficiaries with home-based primary care.

• Medical practices provide chronically ill beneficiaries with home-based primary care.

• Practices must serve 200 targeted beneficiaries living with multiple chronic diseases to be eligible– Beneficiaries must be living with multiple chronic diseases

• Incentive payments for practices successful in:– meeting quality standards; and – reducing total expenditures

• 15 independent practices and 3 consortia participating26

Graduate Nurse Education DemonstrationGraduate Nurse Education Demonstration

GOAL: To increase the provision of qualified training supply of to Advanced Practice Registered Nursing (APRN) students in order to provide access to primary care services for the increasing number of Medicare beneficiaries.

• 4 year demonstration where participating hospitals will be paid for the reasonable costs of the non-hospital community- based care setting clinical training component of the APRN degree requirements

• Hospitals must partner with schools of nursing and community-based care settings and can partner with other hospitals

• 5 hospitals participating 27

• Financial Alignment Initiative• Initiative to Reduce Avoidable Hospitalizations of

Nursing Facility Residents

Initiatives Focused on Medicare-Medicaid Enrollees

Initiatives Focused on Medicare-Medicaid Enrollees

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Financial Alignment InitiativeFinancial Alignment Initiative

Two Demonstration Models:

• Capitated Model: Three-way contract among State, CMS

and health plan to provide comprehensive, coordinated care

in a more cost-effective way.

• Managed FFS Model: Agreement between State and CMS

under which States would be eligible to benefit from savings

resulting from initiatives to reduce costs in both Medicaid and

Medicare.

Participating states: Massachusetts, Washington, Ohio, Illinois,

California, Virginia

GOAL: Test two models for effectiveness in improving quality of care for Medicare-Medicaid enrollees and reducing costs to Medicare and Medicaid.

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Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility

Residents

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility

Residents

• Participants implement evidence-based interventions at a minimum of 15 Medicare-Medicaid certified nursing facilities.

• 7 organizations selected to participate

• Interventions must:

• Improve beneficiary safety through coordinating management of prescription drugs

• Bring onsite staff to collaborate and coordinate with providers

• Demonstrate a strong evidence base

GOAL: Test evidence-based interventions for their effectiveness in reducing preventable inpatient hospitalizations among residents of nursing facilities.

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Capacity to Spread InnovationCapacity to Spread Innovation

• Partnership for Patients

• Community Based Care Transition Program

• Million Hearts

• Innovation Advisors Program

• Care Innovations Summit

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Partnership for PatientsPartnership for Patients

40% G O A L S :

20%

Reduction in Preventable Hospital-Acquired Conditions1.8 Million Fewer Injuries | 60,000 Lives Saved

Reduction in 30-Day Readmissions1.6 Million Patients Recover without Readmission

partnershipforpatients.cms.gov32

Hospital Engagement NetworksHospital Engagement Networks

• American Hospital Association• Premier• VHA• NC Hospital Assoc• Intermountain HealthCare • GA Hospital Assoc • TX Hospital Assoc • MN Hospital Assoc• NY State Hosp Assoc • IA Healthcare Collaborative • PA Hospital Assoc• WA Hospital Assoc• Dallas Fort Worth Regional

Hospital Assoc

• OH Hospital Assoc • NJ Hospital Assoc • Ascension Health • TN Hospital Assoc • MI Hospital Assoc • National Public Hospital & Health

Institute • Lifepoint • Joint Commission Resources • OH Children’s Hospital • Dignity Healthcare• NV Hospital Assoc • Carolinas Health Care • University Health Care

Collaborative 33

Community-based Care Transitions Program (CCTP)

Community-based Care Transitions Program (CCTP)

GOALS: Test models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries

• Open to community-based organizations partnered with hospitals

• Currently 102 participants

• $300 million in total funding

• Participants in all 10 CMS Regions

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Million Hearts InitiativeMillion Hearts Initiative

Focus, coordinate, and enhance cardiovascular disease prevention activities across the public and private sectors.

• Will scale-up proven clinical and community strategies to prevent heart disease and stroke across the nation.

• Led by Centers for Disease Control and Prevention and Centers for Medicare and Medicaid Services within HHS.

• Partners include: American Heart Association, YMCA, and many other private and public organizations.

GOAL: Prevent 1 million heart attacks and strokes in 5 years

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Initiatives Focused on the Medicaid PopulationInitiatives Focused on the Medicaid Population

• Medicaid Emergency Psychiatric Demonstration

• Medicaid Incentives for Prevention of Chronic Diseases

• Strong Start Initiative

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Medicaid Emergency Psychiatric Demonstration

Medicaid Emergency Psychiatric Demonstration

• Demonstration provides up to $75 million in federal matching funds over 3 years

• Demonstration pays for inpatient services necessary to stabilize the psychiatric emergency

• 11 States – Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington, and West Virginia – and the District of Columbia applied and were selected to participate

GOAL: Test whether Medicaid Beneficiaries aged 21 to 64 who are experiencing a psychiatric emergency (suicidal or homicidal thoughts or gestures) get more immediate, appropriate care when institutions for mental diseases (IMDs) receive Medicaid reimbursement

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Medicaid Incentives for Prevention of Chronic Diseases (MIPCD)

Medicaid Incentives for Prevention of Chronic Diseases (MIPCD)

One or more of the following prevention goals must be addressed:• tobacco cessation• controlling or reducing weight• lowering cholesterol• lowering blood pressure• avoiding the onset of diabetes or in the case of a diabetic,

improving the management of the condition

Grants awarded to:California, Montana, New York, Connecticut, Nevada, Texas,Hawaii, New Hampshire, Wisconsin, Minnesota

GOAL: Testing the impact of providing incentives to Medicaid beneficiaries who participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors.

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Strong Start: Strategy 1Strong Start: Strategy 1

3 primary activities:

1. Promote Awareness – support broad-based awareness efforts in partnership with March of Dimes, American College of Obstetricians and Gynecologists and other organizations.

2. Spread Best Practices – building on efforts of Partnership for Patients to create measureable goals and provide technical assistance in testing and implementing a variety of strategies.

3. Promote Transparency – support efforts to collect performance data and measure success and continuous improvement.

GOAL: Test ways to encourage best practices and support providers in reducing early elective deliveries prior to 39 weeks.

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Strong Start: Strategy 2Strong Start: Strategy 2

• Testing 3 approaches to the delivery of enhanced prenatal care• Targets women receiving Medicaid and at risk for having a

preterm birth• Up to $43 million in funding to 27 awardees (announced February

15, 2013)

• Awards will be located in 32 states, the District of Columbia and Puerto Rico, and will serve more than 80,000 women enrolled in Medicaid or CHIP over the three intervention years

GOAL: Test effectiveness of prenatal care approaches to reduce preterm births for women covered by Medicaid or CHIP who are at risk for preterm births

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Health Care Innovation AwardsHealth Care Innovation Awards

• 107 Projects Awarded in Round 1

• Awards range from approximately $1 million to $30 million for a three-year period.

• Funding activity in all 50 states

• Nearly 3000 applications received

• Applications were accepted from providers, payers, local government, public-private partnerships and multi-payer collaboratives.

GOAL: Test a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs through improvement in communities across the nation.

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Health Care Innovation AwardsHealth Care Innovation Awards

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State Innovation ModelsState Innovation Models

GOALS:

• Partner with states to develop broad-based State Health Care Innovation Plans

• Plan, design, test and support of new payment and service and delivery models in the context of larger health system transformation

• Utilize the tools and policy levers available to states• Engage a broad group of stakeholders in health system

transformation• Coordinate multiple strategies into a plan for health system

improvement43

State Innovation Models AwardeesState Innovation Models Awardees

Model Testing States• Arkansas

• Maine

• Massachusetts

• Minnesota

• Oregon

• Vermont

Model Pre-Testing States• Colorado

• New York

• Washington

Model Design States• California

• Connecticut

• Delaware

• Hawaii

• Idaho

• Illinois

• Iowa

• Maryland

• Michigan

• New Hampshire

• Ohio

• Pennsylvania

• Rhode Island

• Tennessee

• Texas

• Utah

(Announced 2/21/13) 44

State Innovation ModelsState Innovation Models

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Innovation is happening broadly across the country

Innovation is happening broadly across the country

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Thank YouThank You

innovation.cms.gov

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