# Presentation: 383713

## Overview

- Sandra M. Foote
- Senior Advisor, Chronic Care Improvement
- Centers for Medicare & Medicaid Services
-  October 24, 2005

##     The MHS Challenge

- Develop and test new programs designed to help
- targeted chronically ill beneficiaries reduce their
- health risks

- Section 721: “Voluntary Chronic Care Improvement in Traditional Fee-For-Service”of the Medicare Prescription Drug, Improvement and Modernization Act of 2003

**Notes:**
First time ever that Congress has authorized CMS to invest millions in large-scale regional programs for targeted subgroups of chronically ill people that CMS identifies as having modifiable health risks
Calling the program Medicare Health Support because that’s in fact what best describes what we’re trying to do—help people stay healthier and avoid costly and debilitating complications.

##   Phase I: Developmental

-  8 pilot programs; each to run 3 years
-  20,000 beneficiaries per program; 10,000 per
-    control group—randomly assigned
-  Phase II:Expansion will follow in 2–3.5 years, if
-    pilots (or components) are successful

**Notes:**
2 phases: Developmental to prove we and our awardees can carry out these programs well and cost-effectively;
Expansion will follow in 2-3.5 years if we’re successful.

## Voluntary
No charge to participants
No change in Medicare benefits, choice of providers or claims payment
Supportive, not restrictive
Not a substitute for current care
Individualized and holistic health support 

- No charge to participants
- No change in Medicare benefits, choice of providers or claims payment
- Supportive, not restrictive
- Not a substitute for current care
- Individualized and holistic health support

**Key Features**

**Notes:**
This initiative is an OVERLAY to FFS Medicare. It does not CHANGE FFS Medicare’s core tenets. Services are highly customized to individual needs and preferences.

## Flexible Interventions

**  ****Medical **
**    ****Care **
**  ****Support**

**  ****Beneficiary**
**Self-Care**
**Support**

**Coordination **
**& **
**Communication**

-            **Health Risk Reduction**

**Flexible Interventions**

**Notes:**
This is exactly what IOM recommended – They said that in order to reduce health risks among chronically ill people, we’ve got to address problems of insufficient self-care support and fragmentation of care  

##  CMS

**Beneficiaries’**
**Physicians**

**Targeted**
** ****Beneficiaries**

** ****MHS**
**    ****Organization**

-  **CMS**

**Fees at risk: QI,  $,** **satisfaction**** **

**Data exchange**

**     ****Fee per person/month**

**New Population-Based Model**

## Advantages of Model

- Flexibility to customize and innovate
- Incentives for regional collaborations
- Emphasis on cost-effectiveness
- Savings measured across provider “silos”
- Sufficient scale to detect significant impacts
-     on population health

## MHS Phase I:Developmental

**Phase I Programs**

## ...AND MANY OTHERS!

**...****AND MANY OTHERS!**

**National Organizations Helping ****to Promote Understanding of MHS**

**Emerging Partnerships**

- Many new national and regional alliances
-     developing with awardees

**Examples:  **
- American College of Physicians
- American College of Cardiology
- American Academy of Family Physicians
- American Geriatric Society

## Who is eligible?

- Pre-selected by CMS through claims review,  applying selection criteria (e.g., not in hospice)
- All have diabetes and/or congestive heart failure
- Only individuals invited by CMS can participate in Phase I programs

**Who is eligible?**

## Subgroups Driving Cost

- NOTE:  Spending includes treatment of co-morbidities, by enrollee subgroup, 2002
- SOURCE: C. Hogan and R. Schmidt, MedPAC Public Meeting, 03/18/2004

**Subgroups Driving Cost**

## 63% of Medicare beneficiaries have 2 or more chronic conditions *

On average, Medicare beneficiaries see 6.4 MDs and fill 20 Rx per year*

23% of beneficiaries have 5 or more chronic conditions** 

*Medicare Standard Analytic File, 1999. Anderson GF. Testimony on Promoting 
Disease Management in Medicare -www.partnershipforsolutions.com/statistics/
**Medicare Standard Analytic File, 2001. Anderson GF. N Engl J Med 2005; 353; 305-309

- On average, Medicare beneficiaries see 6.4 MDs and fill 20 Rx per year*
- 23% of beneficiaries have 5 or more chronic conditions**
- *Medicare Standard Analytic File, 1999. Anderson GF. Testimony on Promoting
- Disease Management in Medicare -www.partnershipforsolutions.com/statistics/
- **Medicare Standard Analytic File, 2001. Anderson GF. N Engl J Med 2005; 353; 305-309

**     ****Multiple Health Risks**

##        Multiple Health Risks

- Johns Hopkins University, Partnership for Solutions:    Medicare Standard Analytic File, 2001

**Percent of Medicare Spending**

**       ****Multiple Health Risks**

- *http://partnershipforsolutions.com/DMS/files/Medicare_fact_sheet.pdf
- ** _Older Americans, 2004._ Federal Interagency Task Force on Aging-Related Statistics

- On average, beneficiaries
- with 5 or more
- chronic conditions see 14 MDs* and fill 57 Rx per year.**

**Notes:**
“Comorbidity is associated with poor quality of life, physical disability, high health care use, multiple medications and increased risk of adverse drug events and mortality. Optimizing care for this population is a high priority.”

Boyd CM et al., JAMA, 2005, 294: 716-724.

## Enable better care planning 
Create Personal Health Records from multiple sources 
Add valuable data (e.g., health status monitoring)  
Apply algorithms incorporating multiple Clinical Practice Guidelines 
Help beneficiaries communicate more effectively

Support beneficiary follow-through on care plans
Coach and reinforce
Track progress
Generate preventive care reminders and medical care alerts

Link caregivers in ways EMRs (and RHIOs) do not

Monitor clinical quality for targeted populations

- Create Personal Health Records from _multiple sources_
- Add valuable data (e.g., health status monitoring)
- Apply algorithms incorporating multiple Clinical Practice Guidelines
- Help beneficiaries communicate more effectively
- Support beneficiary follow-through on care plans
- Coach and reinforce
- Track progress
- Generate preventive care reminders and medical care alerts
- Link caregivers in ways EMRs (and RHIOs) do not
- Monitor clinical quality for targeted populations

**MHS Value Added **

**Notes:**
1650 active Clinical Practice Guidelines (CPGs) in National Guideline Clearing House in July, 2005*

“Ideally CPGs would help physicians select from among multiple evidence-based recommendations those with the greatest benefit to a given patient.”*

 Need EMR to compute priorities and MD to evaluate with patients in context of their personal goals   

O’Connor PJ. JAMA, 2005, 294:741-743.

## Improved health and quality of life 

Lower average Medicare costs

Reduced complications, emergencies and hospital 
     admissions 

Increased adherence to evidence-based care

Better coordination of care through use of new health information and communication technologies

- Lower average Medicare costs
- Reduced complications, emergencies and hospital
-      admissions
- Increased adherence to evidence-based care
- Better coordination of care through use of new health information and communication technologies

**Envisioned Results**

## Programs well accepted by physicians 

Focus on total health, not selected diseases 

Adaptable, scalable and replicable nationally

Quality and cost outcomes sustainable over time

Administrative model works 

Business model (fees at risk) successful

Programs effective in dually eligible populations

- Focus on total health, not selected diseases
- Adaptable, scalable and replicable nationally
- Quality and cost outcomes sustainable over time
- Administrative model works
- Business model (fees at risk) successful
- Programs effective in dually eligible populations

**More Envisioned Results**

## CMS Program Management  

**Contractor**

**CMS**

**MHS **
**Organization**

**Performance Monitoring**
**Contractor**

**System Integrity**
**Contractor**

**Outreach Support **
**Contractor**

**Independent**
**Evaluator**

**CMS Program Management  **

**Financial Reconciliation**
**Contractor**

## 
New strategies to improve chronic care cost-effectively on a national scale

Focus on prevention
New partnerships
Fostering innovation
Accountability for performance

- New strategies to improve chronic care cost-effectively on a national scale
- Focus on prevention
- New partnerships
- Fostering innovation
- Accountability for performance

** ****Where is MHS leading?**

## More Information

- Website:
- http://www.cms.hhs.gov/medicarereform/ccip/
- Contact information:
- sandra.foote@cms.hhs.gov

**More Information**