Reflecting on Our Journey towards Health Equity

By: Dr. Cara James, Director of the CMS Office of Minority Health

Each April, in recognition of National Minority Health Month, we commemorate past achievements, acknowledge current efforts, and outline our continued journey towards health equity and equality for all. Fifty years ago, our journey included stops in Independence, Missouri where Medicare and Medicaid became law; in Selma and Montgomery, Alabama; and in Washington, D.C. for the signing of the Voting Rights Act and Civil Rights Act.

Since then, there have been many more landmark achievements in health equity. Events such as the publication of the Secretary’s report on Black & Minority Health (the Heckler Report) and the creation of the HHS Office of Minority Health illustrate the increased national attention on the need to address health and health care disparities. The publication of the Agency for Healthcare Research and Quality’s annual National Healthcare Quality and Disparities Report illustrates our commitment to track our progress. The passage of the Affordable Care Act and the enrollment of millions of Americans, including many people of color in health plans, illustrate our continued advancement towards better care and healthier communities.

Five years ago, the Affordable Care Act established three additional offices of minority health within six HHS agencies. While several HHS agencies already had offices of minority health, the Office of Minority Health (OMH) at the Centers for Medicare & Medicaid Services (CMS) was an office newly established through the Affordable Care Act. The principal aim for CMS is better care, healthier people, and smarter spending. To help achieve this aim, the CMS Office of Minority Health ensures that the voices and needs of minority and underserved populations are present in the development, implementation, and evaluation of CMS programs and services. We are dedicated to working on behalf of all CMS beneficiaries, while strategically focusing on racial and ethnic minorities, individuals with disabilities, and Lesbian, Gay, Bi sexual and Transgender (LGBT) minorities. CMS OMH activities include: From Coverage to Care, the CMS Equity Plan for Improving Quality in Medicare, strengthening CMS data collection and analysis, and working across the agency to embed a focus on health equity into new and existing programs and policies.

From Coverage to Care is an ongoing initiative designed to help consumers understand their healthcare coverage and how to access the care they need. Additionally, the CMS Equity Plan for Improving Quality in Medicare is CMS’ first strategic equity plan. Launched in 2015, this equity plan identifies six priorities and provides an action-oriented, results-driven approach for advancing health equity by improving the quality of care provided to racial and ethnic minority and other underserved Medicare beneficiaries. Last month, CMS OMH launched an interactive web based tool for mapping Medicare disparities. The Mapping Medicare Disparities Tool contains health outcome measures for disease prevalence, costs, and hospitalization for 18 specific chronic conditions, emergency department utilization, readmissions rates, mortality and preventable hospitalizations.

We know we cannot achieve health equity on our own. It will take the support of partners from the federal to the community level.  We encourage you to join us on the path to health equity by using the resources discussed in this blog, bookmarking the CMS OMH website, joining our listserv, and of course building on your own health equity activities!

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Our Hopes for the Comprehensive Care for Joint Replacement Model

By Patrick Conway, CMS Principal Deputy Administrator and Chief Medical Officer

Today’s launch of the Comprehensive Care for Joint Replacement Model (CJR) is a major step toward transforming care delivery in Medicare. Why? Because this model looks to improve care and quality for the most common procedures that Medicare beneficiaries have, hip and knee replacements. In 2014, more than 400,000 Medicare beneficiaries received a hip or knee replacement, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers. For instance, the rate of complications, like infections or implant failures, after surgery can be more than three times higher for procedures performed at some hospitals than at others.

The model aligns with what matters to beneficiaries—better outcomes for a whole episode of care. The model includes patient-reported outcomes after surgery and incentivizes better care coordination. One beneficiary said it best when she described that what she cared about for her hip replacement was getting out of the hospital as quickly as possible without an infection or complication and then being able to go back to playing with her grandkids and gardening. The model incentivizes a system that aligns with her goals and the goals of so many beneficiaries.

We are excited about the CJR model’s potential to improve the quality and efficiency of care for Medicare beneficiaries, to contribute toward a health care system that delivers better care, spends our dollars more wisely, and leads to healthier Americans.

How will CJR work? About 800 hospitals located in 67 selected markets will be accountable for the costs and quality of related care from the time of the hip or knee replacement surgery through a post-hospitalization period. They will receive target prices for these joint replacement cases at the beginning of each year. The target price represents expected spending for lower joint replacement episodes, including the initial hospital stay for the procedure and 90 days after discharge from the hospital. If patients receive high quality care and spending is less than the target, a hospital may receive an additional payment from Medicare. If their spending is above the target, hospitals may be required to repay Medicare for a portion of the difference.

We expect this incentive to coordinate the services a patient receives before, during, and after surgery will encourage hospitals and clinicians to partner with nursing facilities, home health agencies and other providers of rehabilitation services to provide seamless, high quality care.

We want hospitals to be successful under this model because success means that Medicare’s beneficiaries will receive better quality care. In the run up to today’s launch, our staff individually contacted the program coordinators at all 800 hospitals to offer data and other resources to assist them on this multi-year journey. CMS will continue to collaborate with hospitals and their physicians and other clinicians to provide support and share best practices.

What will beneficiaries notice? First, beneficiaries will continue to choose their doctor, the hospital where they receive treatment, and the type and location of rehabilitation care they receive. If their hospital is a model participant, they will get a letter explaining the model. Patients whose chosen hospital participates in the model should experience improved care coordination. For instance, we expect that nursing facilities will understand a patient’s needs better before that patient is discharged from the hospital.

The CJR model offers a chance for hospitals, doctors, and other providers to partner with CMS in furthering our shared goal of improving the quality of care for beneficiaries undergoing the most common inpatient surgery, lower extremity joint replacements. The model is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality.

We are excited to begin this groundbreaking initiative and will work with hospitals, physicians, and other providers throughout the model to ensure they have the tools to succeed and improve upon what they do best: provide high quality, coordinated care to beneficiaries.

For more information about the CJR model, please visit: https://innovation.cms.gov/initiatives/cjr.

CMS Invites Quality Innovation Network-Quality Improvement Organizations to Submit Special Innovation Projects to Expand Their Reach in Improving Care Delivery

By: Patrick Conway, MD, MSc
Acting Principal Deputy Administrator
Deputy Administrator for Innovation and Quality
CMS Chief Medical Officer

Kate Goodrich, MD MHS
Director
Center for Clinical Standards and Quality

Jean Moody-Williams, RN, MPP
Deputy Director
Center for Clinical Standards and Quality

Dennis Wagner, MPA
Director, Quality Improvement and Innovation Group
Center for Clinical Standards and Quality

The Centers for Medicare & Medicaid Services’ (CMS) Quality Improvement Organization (QIO) Program is constantly evolving to help ensure that Medicare beneficiaries receive better care, better health, and greater value. Today, CMS is announcing the program’s next evolution: two projects focused on supporting and scaling quality improvement innovations.

With this announcement, Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) can collaborate with health care providers and/or partners to compete for 28 Special Innovation Project (SIP) awards that fall within two topic categories totaling $8 million.

SIPs are two-year quality improvement projects that align with the goals of the CMS Quality Strategy (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html) and emphasize the power of partnerships. There are two categories of SIPs for QIN-QIOs to consider:

1. “Innovations that Advance Local Efforts for Better Care and Smarter Spending,” which will address healthcare quality issues that occur within specific QIN-QIO regions.

2. “Interventions that are Ripe for Spread and Scalability,” which will focus on expanding the scope and national impact of a quality improvement project that has experienced proven but limited success. The expectation is that similar benefits would be experienced on a large scale if spread throughout the greater health care community.

The scalability category aligns with the CMS Strategic Innovation Engine (SIE) (http://sie.qioprogram.org/), a new endeavor launched in August of 2015. The SIE is working to rapidly move innovative, evidence-based quality practices from research to implementation through the QIO Program. In consultation with the SIE Executive Leadership Council, CMS is seeking projects that:

• Streamline patient flow in various health care settings, including hospital units, outpatient clinics, primary care offices, ambulatory surgical centers, and cancer centers resulting in efficiencies, improved satisfaction, decreased mortality, better care, healthier people, and smarter spending.
• Work with health plans and/or care coordination providers to deploy an integrated approach to post-acute care that results in enhanced care management, safe transitions from one care setting to another, improved health outcomes, and reductions in harms.
• Increase value, patient affordability, and appropriate use of specialty drugs by applying evidenced based criteria to prescribing practices and by monitoring effectiveness when providers have a choice(s) among equally effective drugs with differing costs.

• Address acute pain management. For example, more is needed to assist sickle cell patients: from accurate identification of their illness to education of emergency department staff on sickle cell disease while addressing the cultural stigmas often associated with the disease.

• Utilize big data analytics to reduce preventable harm in healthcare.

We encourage those in the larger healthcare community who are leading quality work in these areas, with interventions and proven results, to reach out and explore potential partnerships with QIN-QIOs. Through collaboration with healthcare providers, patients, families, and other key stakeholders, QIN-QIOs have tremendous potential to take those interventions to the national level and improve the health care delivery system by tapping into new settings of care and building upon the knowledge gained by people working on the front line of providing quality health care.

The QIN-QIOs selected to carry out these SIPs will leverage their data-driven approach, extensive partnerships, and the voices of patients and families to positively impact Medicare beneficiaries in their communities and nationwide.

The QIO Program’s 14 QIN-QIOs work with providers, community partners and beneficiaries on multiple data-driven quality improvement initiatives to improve patient safety, reduce harm, engage patients and families, improve clinical care and reduce healthcare disparities. For more information about the CMS QIO Program and for a complete list of QIN-QIOs, please visit the QIO Program website (http://www.qioprogram.org/).

CMS Strong Start for Mothers and Newborns Strategy II Initiative Second Annual Evaluation Report

By Patrick Conway, M.D., CMS Principal Deputy Administrator and Chief Medical Officer

Today, we at the Centers for Medicare & Medicaid Services (CMS) are pleased to announce findings from the second annual evaluation report for the Strong Start for Mothers and Newborns Strategy II Initiative. As noted with the release of our first annual report, Strong Start Strategy II seeks to build on work conducted by the Partnership for Patients and Strong Start Strategy I to improve newborn health through a reduction in early elective deliveries. Babies are generally healthier and have better long-range outcomes when they are born full-term.  Strategy I contributed to a 64.5% nationwide drop in early elective deliveries from 2010 to 2013.

The Strong Start II (hereafter referred to as Strong Start) builds on this success through prenatal care enhancements addressing the psychosocial needs of pregnant women eligible for Medicaid and CHIP.  Strong Start is an important federal initiative geared toward testing innovative approaches to improve maternal and infant health outcomes in low-income families.

Research consistently shows that infants born preterm (before 37 completed weeks of gestation) have higher mortality risks and may endure a lifetime of developmental and health problems when compared to their counterparts born after 37 weeks’ gestation.

Prenatal care enhancements provided through Strong Start are designed to promote overall maternal and infant health and particularly to reduce incidence of preterm birth and low birth weight.  The second annual report presents the progress Strategy II has made since its inception.

Strong Start has continued its partnership with 27 organizations representing nearly 200 provider sites in 32 states, Washington, D.C., and Puerto Rico.  The program continues to provide enhanced services through three approaches:

• Group Care – Group prenatal care that incorporates peer-to-peer support in a facilitated setting for three components: health assessment, education, and support.
• Birth Centers – Comprehensive prenatal care facilitated by midwives and teams of health professionals, including peer counselors and doulas.
• Maternity Care Homes – Enhanced prenatal care at traditional prenatal sites with enhanced continuity of care and expanded access to care coordination, education, and other services.

Enrollment increased dramatically in the second year of program operations, with a total of 23,000 women enrolled from March 2013 to the end of the first calendar quarter of 2015. Enrollment is expected to continue to grow to more than 40,000 participants by the program’s end in February 2017.  Additionally, participants continue to express overwhelming satisfaction, with 90% stating that they were either very satisfied or extremely satisfied with their prenatal care.

In addition to their standard schedule of prenatal care visits, Strong Start participants receive enhanced care visits in accordance with their psychosocial needs.  Enhanced visits provide services such as care coordination, referrals to local resources, prenatal health education, and peer support.

Upon enrollment, Strong Start participants have several risk factors, including many pertaining to psychosocial needs:

• Depression upon enrollment (nearly a quarter of participants report being depressed at intake)
• Unstable housing
• Unemployment
• Unmet mental health and dental needs
• Food insecurity
• Unmarried or unpartnered status

Results from the second year evaluation indicate that, as was found in the first year, Strong Start participants have:

• Lower rates of cesarean section than national averages, though there is wide variation among and within models
• Higher rates of breastfeeding than national averages among similar populations

In addition, the new report finds that Strong Start participants have:

• Overall preterm birth rates similar to national averages despite the high-risk population served
• Lower preterm birth rates than national averages within racial-ethnic groups (Black , White, Hispanic)
• Vaginal birth after cesarean rates that are nearly twice the national average

Although findings must be interpreted with caution because they are descriptive, we are pleased with what we have found thus far. Substantial progress was made during the second evaluation year in developing resources, particularly obtaining state Medicaid claims linked to vital records, which will enable development of a control group and an analysis of costs.  The third annual report is anticipated to contain analysis of further participant-level data, case studies based on site visits, and an initial analysis of linked data from states.

Much work remains to be done to reduce significant risks and complications for pregnant women and infants, but these early results from the Strong Start evaluation show promise for improving pregnancy outcomes.  We remain committed to working together to deliver higher quality care, smarter spending, and better health outcomes for low-income pregnant women and their newborns.

Open Enrollment Trends: Selected HealthCare.gov Statistics prior to the Final Enrollment Deadline

Data as of February 1, 2016

By Niall Brennan

Open Enrollment ended on January 31 with about 12.7 million Americans having selected plans through Health Insurance Marketplaces, including 3.1 million signed up through State-based Marketplaces and over 9.6 million through the HealthCare.gov platform. This does not include about 400,000 people who signed up on the New York and Minnesota Marketplaces for coverage through the Basic Health Program during this Open Enrollment.

Here’s a look at the progress HealthCare.gov states made during Open Enrollment for 2016 coverage:

The Marketplace continues to grow with more than 9.6 million plan selections for 2016. Over 9.6 million people signed up for health coverage through HealthCare.gov. This includes about 4 million new consumers, which means about 42 percent of those who signed up for coverage through HealthCare.gov for 2016 are new to the Marketplace.

New consumers joined the Marketplace earlier this year. Instead of waiting until the last moment, about 2.4 million or 60 percent of our new consumers signed up for coverage that started on January 1, 2016. Compare that with last year when 1.9 million or 40 percent of new consumers signed up for January 1, 2015 coverage. That means 30 percent more new consumers had coverage that started on January 1 this year compared to last year.

Returning Marketplace consumers are more engaged. Of the 5.6 million returning consumers in OE3, 3.9 million or about 70 percent were active returners. This means that a majority of 2015 consumers returning to the Marketplace actively selected a 2016 plan – either their same plan or a new plan – that met their needs. About 1.7 million or 30 percent of returning consumers were automatically re-enrolled into the same or a similar plan for 2016. At the end of OE2, there were 4.1 million returning consumers of which 2.2 million, or 53 percent, actively selected a plan and 2 million who were automatically re-enrolled.

Chart 1: Marketplace Consumers are More Engaged

*Data compares February 1, 2016 plan selection data with data from February 22, 2015.

The majority of consumers who actively renewed their coverage switched plans. Of the 3.9 million active returners during OE3, 61 percent or 2.4 million switched plans. Last year during OE2, of the 2.2 million active returners, 54 percent or 1.2 million switched plans.

Chart 2: Consumers Who Actively Renewed Switched Coverage

*Data compares February 1, 2016 plan selection data with data from February 22, 2015.

More 18-34 year olds join the Marketplace. This year, 2.7 million consumers between the ages of 18-34 selected plans through HealthCare.gov compared to 2.5 million during OE2. In addition, 33 percent of new consumers were 18–34, compared to 31 percent in OE2. The overall percentage of those plan selections for those consumers between the ages of 18-34 remained stable.

Nearly all states have more plan selections at the end of OE3 than in OE2: Of the 37 states using the HealthCare.gov platform in both 2015 and 2016, 34 states have more plan selections at the end of OE3 than they had at the close of OE2. Those states with the largest rates of increases in plan selections between OE3 and OE2 are Oregon (31%), Utah (25%), Iowa (22%), South Dakota (22%) and Nevada (20%). The two states that make up a notably smaller share of plan selections this year than last year, Indiana and Pennsylvania, expanded Medicaid at the beginning of 2015. In these states, consumers with incomes between 100 and 138 percent FPL used to be eligible for Marketplace coverage, but now are eligible for Medicaid instead. Since February 2015, people enrolled in M

Chart 3: Plan Selections in 2016 as a Share of 2015 Plan Selections by State

*Data compares February 1, 2016 plan selection data with data from February 22, 2015.

 Plan selections in the top twenty media markets grew by 15 percent or more: Looking at larger local media markets (defined as having more than 25,000 plan selections), Portland, Oregon had the biggest  percentage increase in plan selections between 2015 and 2016, with 24,000 more consumers selecting plans, a 34 percent increase. Salt Lake City also saw a surge in sign-ups, with 35,000 more consumers selecting plans for a growth rate of 25 percent.

Chart 4: Ratio of New Consumer Plan Selections in 2016 to all 2015 Plan Selections in 20 Large Cities

*Top 20 DMAs with over 25,000 plan selections in 2016. Data compares February 1, 2016 plan selection data with data from February 22, 2015.

Nursing Facility Initiative Annual Report

By Patrick Conway, M.D., CMS Principal Deputy Administrator and Chief Medical Officer

Today we released the annual report summarizing impacts from the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents in 2014. This three-year-old initiative is designed to test ways to reduce avoidable hospitalizations among long-stay nursing facility residents. For such individuals, avoidable hospitalizations can be dangerous, disruptive, and disorienting. CMS research has estimated that 45% of hospitalizations among nursing facility residents could be prevented with well-targeted interventions.

The results in this report are based on experience during the second performance year of the initiative, calendar year 2014. During this period, all seven sites generally showed reductions in Medicare expenditures relative to a comparison group, with statistically significant declines in total Medicare expenditures at two sites. All sites also generally showed a decline in all-cause hospitalizations and potentially avoidable hospitalizations, with four sites showing statistically significant reductions in at least one of the hospitalization measures. These early results are promising.

As we plan for new Medicare payment incentives to reduce hospital readmissions from skilled nursing facilities, these results provide early indications that when the right strategies are in place, they may effectively reduce hospitalization rates and reduce overall Medicare spending.  We anticipate gaining an even more complete understanding of the initiative’s impacts as additional results from this initiative become available.

These promising early results come in tandem with impressive nationwide reductions in inappropriate use of antipsychotics for nursing facility residents through the National Partnership to Improve Dementia Care (http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-09-19.html). These results demonstrate additional progress on the nation’s path to a health system that achieves better care, smarter spending, and healthier people.

The full report is posted on the CMS website: [https://innovation.cms.gov/Data-and-Reports/index.html].

Additional information about the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents is available on the Medicare-Medicaid Coordination Office website: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/ReducingPreventableHospitalizationsAmongNursingFacilityResidents.html