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ACTonAlzheimer’sHealthCareLeadershipSummit

ANa%onalPerspec%veonHealthcareQuality

ShariLing,MDSeptember29,2016

Disclaimers&DisclosureThispresenta,onwaspreparedasatooltoassistprovidersandisnotintendedtograntrightsorimposeobliga,ons.Althougheveryreasonableefforthasbeenmadetoassuretheaccuracyoftheinforma,onwithinthesepages,theul,materesponsibilityforthecorrectsubmissionofclaimsandresponsetoanyremi=anceadvicelieswiththeproviderofservices.Thispresenta,onisageneralsummarythatexplainscertainaspectsoftheMedicareandMedicaidPrograms,butisnotalegaldocument.Theofficialprogramprovisionsarecontainedintherelevantlaws,regula,ons,andrulings.Policychangesfrequently,andlinkstothesourcedocumentshavebeenprovidedwithinthedocumentforyourreferenceTheCentersforMedicare&MedicaidServices(CMS)employees,agents,andstaffmakenorepresenta,on,warranty,orguaranteethatthiscompila,onofinforma,oniserror-freeandwillbearnoresponsibilityorliabilityfortheresultsorconsequencesoftheuseofthisguide.Nofinancialconflictstodisclose.

•  CMSisthelargestpurchaserofhealthcareintheworld•  Ourprogramscurrentlyprovidehealthcarecoveragetoroughly

125millionbeneficiariesinMedicare,Medicaid,andCHIP;about1inevery3Americans

•  20Millionaddi,onallivesarenowcoveredthroughtheHealthInsuranceMarketplace,authorizedthroughtheAffordableCareAct

•  Throughvariouscontractors,CMSprocessesover1.2billionfee-for-serviceclaimsannually

•  Combined,MedicareandMedicaidpayapproximatelyone-thirdofna,onalhealthexpenditures(approximately$816B),about23%oftheFederalbudget

•  Implementthelaw

SizeandScopeofCMSResponsibili?es

DeliverySystemReformwillresultinbeCercare,smarterspending,andhealthierpeople

Keycharacteris?cs!  Producer-centered!  Incen,vesforvolume!  Unsustainable!  FragmentedCare

SystemsandPolicies!  Fee-For-ServicePayment

Systems

Keycharacteris?cs!  Person-centered!  Incen,vesforoutcomes!  Sustainable!  Coordinatedcare

SystemsandPolicies!  Value-basedpurchasing!  AccountableCareOrganiza,ons!  Episode-basedpayments!  Medical/HealthHomes!  Quality/costtransparency

PublicandPrivateSectors

EvolvingfuturestateHistoricalstate

!  SMARTERSPENDING:Healthcarecostsconsumeasignificantpor,onofstate,federal,family,andbusinessbudgets,andwecanfindwaystospendthosedollarsmorewisely

!  HEALTHIERPEOPLE:Givingproviderstheopportunitytofocusonperson-centeredcareandtobeaccountableforqualityandcostmeanskeepingpeoplehealthierlonger

!  BETTERCARE:Wehaveanopportunitytorealigntheprac,ceofmedicinewiththeidealsoftheprofession—keepingthefocusonpa,enthealthandthebestcarepossible.

DeliverySystemReform

5

ThePersonIsCentraltotheProvisionofCareinEverySeOng

TheNa?onalAlzheimer’sProjectAct(NAPA)

•  CreatesandmaintainsanintegratedNa,onalPlantoaddressAlzheimer'sdisease

•  CoordinatesAlzheimer'sdiseaseresearchandservicesacrossFederalagencies

•  Acceleratesthedevelopmentoftreatmentsthatwouldprevent,halt,orreversethecourseofAlzheimer'sdisease

•  Improvesearlydiagnosisandcoordina,onofcareandtreatment

•  Decreasesdispari,esinAlzheimer'sdiseaseforethnicandracialminoritypopula,onsathigherrisk

•  Coordinateswithinterna,onalbodiestofightAlzheimer'sdiseaseglobally

•  EstablishedanAdvisoryCouncilonAlzheimer'sResearch,Care,andServicesandrequirestheSecretaryoftheDepartmentofHealthandHumanServices,collabora,ngwiththeCouncil,tocreateandmaintainaNa,onalPlantoovercomeADRD

Informa,onat:h=ps://aspe.hhs.gov/na,onal-alzheimers-project-act

CMSAuthorizedPrograms&Ac,vi,es

CMS

ClinicalStandards

Survey&Cert.

Payment*

Value-basedPurchasing*

Quality&Public

Repor,ng*

QualityImprovement*

Coverage

CMMI

MedicaidPhysicianFeeScheduleTelehealthHospiceHospitalReadmissionsReduc?onProgramHealthCareAssociatedCondi?onsProgram

ESRDQIPHospitalVBPPhysicianvaluemodifierSkilledNursingFacili?esHomeHealthAgenciesQualityPaymentProgram

TransformingClinicalPrac?ceIni?a?ve(TCPI)QIOs,HENsESRDNetworksHealthcarePayment&LearningAc?onNetworks

HospitalInpa?entQualityHospitalOutpa?entIn-pa?entpsychiatrichospitalsCancerhospitalsPost-acutecare(HomeHealthAgencies,Hospices,Long-termCareAcuteHospitals,In-pa?entrehabilita?onfacili?es,SkilledNursingFacili?es)Nursinghomes

AccountableCareOrganiza?onsCaremodeldemonstra?ons&projectsValue-basedinsurancedesignAccountableHealthCommuni?es

Hospitals,HomeHealthAgencies,Hospices,ESRDfacili?es,LongtermCarefacili?es

Na?onal&LocaldecisionsMechanismstosupportinnova?on(CED,parallelreview,other)

TargetsurveysQualityAssurancePerformance

Improvement

StateInnova?onModelsInnova?onAcceleratorProgram1115Waivers

Dualeligibledemonstra?onprojects

QualityMeasurementandADRD

TheCMSQualityStrategy

NeurologyMeasures

•  NQFhasendorsed15measures(sixofwhichareendorsedwithareservestatusdesigna,on)andapprovedonemeasurefortrialuserelatedtoneurologicalcondi,ons

•  Twoaredemen,ameasures:#2111,An(psycho(cUseinPersonswithDemen(a,PharmacyQualityAlliance,Endorsed#2872,Demen(a-Cogni(veAssessment,PCPI,Endorsed

•  NQFalsoreleasedaFinalReportonADRDin2014,“PrioritySemngforHealthcarePerformanceMeasurement:AddressingPerformanceMeasureGapsforDemen,a”:

h=p://www.qualityforum.org/priority_semng_for_healthcare_performance_measurement_alzheimers_disease.aspx

TheFutureofQualityMeasurement

•  Qualitymeasuresarebroad-based,meaningful,andperson-centered

•  Measureconceptsarepriori,zedbasedonpopula,on-wideeffects,andthereareendorsedmeasuresforcaredomainswheregapscurrentlyexist

•  Measuresarealigned,person-centered,andspanacrossallsemngsofcare

•  Qualityiscapturedatthreemainlevels:provider,group-facility/popula,on-community

•  Thereisacommonmeasurementplapormforelectronichealthrecords,healthinforma,ontechnologyisinteroperable,andburdenisminimized

PatrickConway,FarzadMostashari,CarolynClancy,2013,“TheFutureofQualityMeasurementforImprovementandAccountability”

QualityMeasureDevelopmentatCMS

•  CMS,ameasuredeveloper,regularlysolicitscommentonqualitymeasuresandmeasureconcepts

•  TheAgencyrecentlysolicitedcommentformeasurementofcogni?vefunc?onandmentalstatus

•  Thecommentperiodisnowclosed,butCMSwills,lltakecomments(althoughtheywillnotbepubliclylogged)

•  Seearchivedmaterialsbetween8/18-9/142016:h=ps://www.cms.gov/Medicare/Quality-Ini,a,ves-Pa,ent-Assessment-Instruments/MMS/CallforPublicComment.html

QualityMeasurementDevelopment(con?nued)

•  CMSistakingpubliccommentsonmeasurespecifica,onsandjus,fica,oninthefollowingareasun(lOctober7:

•  MeasuresforbeneficiariesduallyeligibleforMedicareandMedicaidandMedicaidonly,includingthosereceivinglong-termservicesandsupportsthroughmanagedcareorganiza,onsorfee-forservicedeliverymodels;peoplewithcomplexneedsandhighcosts(e.g.demen,a);andbeneficiariesreceivinghomeandcommunity-basedservices

Informa,onat:h=ps://www.cms.gov/Medicare/Quality-Ini,a,ves-Pa,ent-Assessment-Instruments/MMS/CallforPublicComment.html

HomeandCommunity-BasedServicesQuality

•  Mostpeoplewanttoremainathomeintheircommuni,esastheyageorbecomedisabled

•  CMS’sMoneyFollowsthePersonDemonstra,onandtheIndependenceatHomeDemonstra,onhaveshowngainsinbeneficiarysa,sfac,on,quality,andcost,augmentedby30yearsofsuccessfulHCBSprogramsinMedicaid

•  TwoyearsagoHHScontractedwiththeNa,onalQualityForum(NQF)todefineHCBS,examinequalitymeasurementinHCBS,andiden,fygapsinHCBSmeasurement

•  MeasuringqualityinHCBSsemngs,wherefewendorsedmeasuresexist,hasbecomeincreasinglyimportantinthenewcross-semnghealthcareparadigm

•  CMSrecentlyreceivedCAHPS®endorsementfortheHCBSExperienceofCareSurvey,andNQF’sPersonandFamilyCenteredCareCommi=eehasrecommendedthesurveymeasures(#2967)

•  NQFissuedafinalreportyesterdayonHCBSQualitythatoutlinesmeasurementdomainsandwillguidefuturemeasuredevelopmentefforts

Informa,onat:h=p://www.qualityforum.org/Measuring_HCBS_Quality.aspx

Bi-par,sanbillintroducedinMarch,U.S.House&Senate;passedonSeptember18,2014andsignedintolawbyPresidentObamaOctober6,2014RequiresStandardizedPa?entAssessmentDatathatwillenable:

–  AssessmentandQMuniformity–  Qualitycareandimprovedoutcomes–  ComparisonofqualityacrossPACsemngs–  Improvedischargeplanning–  Interoperability–  Facilitatecarecoordina,on

RequiresassessmentdatatobestandardizedandinteroperableforexchangeamongPACprovidersandotherproviderstoallowaccesstolongitudinalinforma,ontofacilitatecoordinatedcareandimprovebeneficiarypa,entoutcomes,includingthedischargeplanningprocess.

ImprovingMedicarePost-AcuteCareTransforma?on(IMPACT)Actof2014

16

DataIsStandardized,CareisIndividualized

17

InformationFollowsthePerson

Long Term CareInstitutional and

Home and Community-Based Services (HCBS)

Person-centered care: Prevention, Mitigation, Risk Reduction, Continuity of Care & Care Coordination

Acute Care Post-Acute Care Home HealthPerson

PCP

EMR

EHR EHR EHR EHR

QualityImprovement

Na?onalPartnershiptoImproveDemen?aCareAn?psycho?cMedica?onUseTrendUpdate

•  SincethestartoftheNa,onalPartnershiptoImproveDemen,aCarein2012,therehasbeena28.8%reduc,oninthena,onaluseofan,psycho,cmedica,onsamonglong-staynursinghomeresidents

•  In201223.9%oflong-stayresidentswereonan,psycho,c

medica,ons.Bytheendof2015,thepercentagedroppedto17.0%

•  SuccesshasvariedbystateandCMSregion,withsome

statesandregionsrecordinggreaterreduc,onsInforma,onat:h=ps://www.cms.gov/Medicare/Provider-Enrollment-and-Cer,fica,on/SurveyCer,fica,onGenInfo/Downloads/Survey-and-Cert-Le=er-16-28.pdf

“AddressingNeuropsychiatricSymptomsinPa?entswithDemen?a”

•  InJuneCMSsponsoredaMedscapecon,nuingeduca,onopportunity•  Theprogramprovidesasummaryoftreatmentgoalsforcomprehensive

demen,acare,addressesneuropsychiatricsymptommanagementincludingaDICE(describe,inves,gate,create,evaluate)approachtodifficultbehaviors,providesforacutehospitalmanagement,andlistsclinicalandadministra,veresources

•  Thefocusisonimprovingandmaintainingqualityoflifeofpeoplewithdemen,a,includingsupportforfamiliesandcaregiversacrosssemngsofcare

•  Con,nuingMedica,onEduca,onCreditisvalidthrough06/09/2017•  CMSisexploringproducingotherlearningproductsondemen,a-related

topics

Overthepastthreemonthstheprogramhasbeenviewednearly9,000learners!!!!

h=p://www.medscape.org/viewar,cle/863605?src=acdmpart_hhs_863605

Payment

ProposedChangestothe2017MedicarePhysicianFeeSchedule

•  APFSbillingcodesetthatmoreaccuratelyrecognizestheworkofprimarycareandothercogni,vespecial,estoaccommodatethechangingneedsofMedicarebeneficiaries

•  Separatepaymentsforcertainexis,ngCurrentProceduralTerminology(CPT)codesdescribingnon-face-to-faceprolongedevalua,onandmanagementservices

•  Re-evalua,onofexis,ngCPTcodesdescribingface-to-faceprolongedservices•  Separatepaymentsusingnewcodestodescribethecomprehensiveassessmentandcare

planningforbeneficiarieswithcogni,veimpairment(e.g.,demen,a)•  AdvanceCarePlanningdeliveredthroughtelehealth•  Separatepaymentsusingnewcodestopayprimarycareprac,cesthatuseinter-professional

caremanagementresourcesforbeneficiarieswithbehavioralhealthcondi,ons•  SeparatepaymentsforcodesdescribingChronicCareManagementforbeneficiarieswithgreater

complexity•  Changestoreduceadministra,veburdenassociatedwithfurnishing/billingtheChronicCare

ManagementservicecodesPleaseseetheproposedregula?onfordetails(commentsarenowclosed):

h=ps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-

Federal-Regula,on-No,ces-Items/CMS-1654-P.html

CMSCodesforBeneficiaryManagement

Procedure CMSCodeAnnualwellnessvisit,firstvisitAnnualwellnessvisit,subsequentvisitaWelcometoMedicareexama

HCPCSG0438andG0439HCPCSG042

Chroniccaremanagementa

CPTcode99490–cannotbebilledduringsamemonthas:Transi,onalCareManagement–CPT99495and99496HomeHealthcareSupervision–HCPCSG0181HospiceCareSupervision–HCPCSG9182CertainESRDservices–CPT90951-90970

Caretransi,onsb

CPTCode99495–communica,onwiththepa,entorcaregiverwithintwobusinessdaysofdischarge.Thiscanbedonebyphone,e-mail,orinperson.Itinvolvesmedicaldecisionmakingofatleastmoderatecomplexityandaface-to-facevisitwithin14daysofdischargeCPTCode99496–communica,onwiththepa,entorcaregiverwithintwobusinessdaysofdischarge.Thiscanbedonebyphone,e-mail,orinperson.Itinvolvesmedicaldecisionmakingofhighcomplexityandaface-to-facevisitwithinsevendaysofdischarge

Advancedcareplanningc CPTcode99497tobebilledforthefirst30minutes,and99498foreachaddi,onal30minutes

a.AAPwebsite;b.HHS-CMSwebsite;c.HHS-CMSwebsite.

CMSDemonstra?onModelsandADRD

TheCMSInnova?onCenterwascreatedbytheAffordableCareActtodevelop,test,andimplementnewpaymentanddeliverymodels

“Thepurposeofthe[Center]istotestinnova,vepaymentandservicedeliverymodelstoreduceprogramexpenditures…whilepreservingorenhancingthequalityofcarefurnishedtoindividualsundersuch,tles”

Threescenariosforsuccess1.   Qualityimproves;costneutral2.   Qualityneutral;costreduced3.   Qualityimproves;costreduced(bestcase)

Ifamodelmeetsoneofthesethreecriteriaandotherstatutoryprerequisites,thestatuteallowstheHHSSecretarytoexpandthedura?onandscopeofamodelthroughrulemaking

ComprehensivePrimaryCarePlus(CPC+)CMS’slargest-everini(a(vetotransformhowprimarycareisdeliveredandpaidforinAmerica

GOALS PARTICIPANTSANDPARTNERS

CARETRANSFORMATIONFUNCTIONS PAYMENTREDESIGNCOMPONENTS

1.  Strengthenprimarycarethroughmul,-payerpaymentreformandcaredeliverytransforma,on.

2.  Empowerprac,cestoprovidecomprehensivecarethatmeetstheneedsofallpa,ents.

3.  Improvequalityofcare,improvebeneficiaries’health,andspendhealthcaredollarsmorewisely.

Accessandcon,nuity

Caremanagement

Comprehensivenessandcoordina,on

Personandcaregiverengagement

Plannedcareandpopula,onhealth

•  5yearmodel:2017-2021•  Upto5,000prac,cesinupto20regions•  Twotracksdependingonprac,cereadinessfortransforma,onandcommitmenttoadvancedcaredeliveryforpa,entswithcomplexneeds

•  PublicandprivatepayersinCPC+regions•  HITvendors(officialpartnersforTrack2only)

PBPMrisk-adjustedcaremanagementfees

Performance-basedincen,vepaymentsforquality,experience,andu,liza,onmeasuresthatdrivetotalcostofcare

ForTrack2,hybridofreducedfee-for-servicepaymentsandup-front“ComprehensivePrimaryCarePayment”toofferflexibilityindeliveringcareoutsidetradi,onalofficevisits

ComprehensivePrimaryCarePlus(con?nued)

•  Enrolledbeneficiarieswithcomplexneeds(e.g.cogni,veimpairment,chroniccondi,ons,frailty)willbebe=erabletoachievetheirgoalsandbecomeengagedincare,have24houraccess,andreceivepreven,veservicesandcarecoordina,on

•  Toensurebeneficiarieswithdemen,aareiden,fiedandflexiblycaremanaged,CPC+Track2prac,cesarepaid$100PB-PMforpa,entswithdemen,adiagnoses:h=ps://innova,on.cms.gov/Files/x/cpcplus-prac,ceslidepres.pdf

•  CPC+CareDeliveryrequirements2.2and2.6areespeciallyrelevantforpeoplewithdemen,a:h=ps://innova,on.cms.gov/files/x/cpcplus-prac,cecaredlvreqs.pdf

Informa,onat:h=ps://innova,on.cms.gov/ini,a,ves/comprehensive-primary-care-plus

MedicareAdvantageValue-BasedInsuranceDesignModel(VBID)

•  TheVBIDmodelwilltestthehypothesisthatgivingMAplansflexibilitytooffersupplementalbenefitsorreducedcostsharingtoenrolleeswithspecifiedchroniccondi,onsinordertoencouragetheuseofservicesthatareofhighestvaluetothemwillleadtohigher-qualityandmorecost-efficientcare

•  Clinically-nuancedVBIDapproacheshavegenerallynotbeenincorporatedintotheplansun,lnow

•  Inthesecondyearofthemodel,beginningJanuary1,2018,CMSwilladddemen,atotheclinicalcategoriesforwhichpar,cipantsmayofferbenefits

•  Inaddi,ontodevelopinginterven,onstargetedatallenrolleesinoneormoreoftheabovecategories,par,cipa,ngMAplanswillhavetheflexibilitytoiden,fyspecificcombina,onsofthelistedchroniccondi,onsforoneormore“mul,pleco-morbidi,es”groupsandestablishtailoredVBIDinterven,onsforeachgroup.

Informa,onat:h=p://innova,on.cms.gov/ini,a,ves/VBID

HealthCareInnova?onAwards(HCIA)

•  Goal – to identify and support 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

•  RoundOneFundingPeriod:July2012–June2015

–  1stAnnualReportavailableat•  h=p://innova,on.cms.gov/Files/reports/HCIA-DS-FirstEvalRpt.pdf

–  TrusteesofIndianaUniversity–  RegentsoftheUniversityofCalifornia,LosAngeles

•  h=p://innova,on.cms.gov/Files/reports/HCIA-CHSPT-FirstEvalRpt.pdf–  UniversityofArkansasforMedicalSciences,–  UniversityofNorthTexasHealthScienceCenter–  UniversityofRhodeIsland

–  2ndAnnualReport-released:h=ps://innova,on.cms.gov/ini,a,ves/Health-Care-Innova,on-Awards/

–  3rdAnnualReportan,cipatedrelease:Early2017

HCIA Round One Projects - People with Dementia Awardee Brief Description

Regents of the University of California, Los Angeles

Coordinated, comprehensive, patient and family-centered program. Five key components: (1) patient recruitment and a dementia registry; (2) structured needs assessments of patients and their caregivers; (3) creation and implementation of individualized dementia care plans; (4) monitoring and revising care plans as needed; and (5) providing access 24/7, 365 days a year for assistance and advice.

Trustees of Indiana University

The Aging Brain Care program incorporates the common features of several evidence-based collaborative care models into one program designed to deliver high quality, efficient medical care to older adults suffering from dementia and or depression.

University of Rhode Island

The Living Rite Innovations project is delivering holistic coordinated care through the project’s two Living Rite Centers. The Centers provide comprehensive chronic care management in order to coordinate services between multiple community providers, improve health and decrease unnecessary hospitalizations and ER visits.

University of Arkansas for Medical Sciences

Project is providing enhanced training of both family caregivers and the direct-care workforce in order to improve care for elderly patients requiring long-term care services, including Medicare beneficiaries qualifying for home healthcare services and Medicaid beneficiaries who receive homemaker and personal care assistant services.

University of North Texas Health Science Center

The awardee in partnership with Brookdale Senior Living (BSL), is developing and testing the Brookdale Senior Living Transitions of Care Program, which is based on an evidenced-based assessment tool called Interventions to Reduce Acute Care Transfers (INTERACT) for residents living in independent living, assisted living and skilled nursing facilities. The goal of the program is to prevent the progress of disease, thereby reducing complications, improving care, and reducing the rate of avoidable hospital admissions for older adults.

HCIA Round 2 Awardees Serving People with Dementia

Awardee Brief Description

The Regents of the University of California, San Francisco

This project will test a model to provide high quality dementia care. The model consists of four specific modules targeting caregivers, decision-making, medications, and functional monitoring.

Johns Hopkins University

This project will test a comprehensive care management program for patients with Alzheimer's disease/Dementia designed to help patients remain in their homes.

Forthe2ndroundofHCIA,proposalsweresolicitedin4specificcategoriesofcare,including“improvecareforpopula,onswithspecializedneeds,”whichdesignatedproposalsthattargetcareforpersonswithADasaprioritypopula,on

2awardsfundedaroundADRDFundingPeriod:Sept1,2014toAug31,2017.

WhereWeareHeading

HHSGoalsforValue-BasedPaymentsinMedicare

During2016,the30%goalwasachievedoneyearaheadofschedule!

"  A better, smarter Medicare for healthier people "  First step to a fresh start "  We’re listening and help is available "  Pay for what works to create a Medicare that is enduring "  Health information needs to be open, flexible, and user-centric

Quality Payment Program as Proposed TheMedicareAccessandCHIPReauthoriza?onActof2015(MACRA)

The Merit-based Incentive

Payment System (MIPS)

Advanced Alternative

Payment Models (APMs)

or

"  Repeals the Sustainable Growth Rate (SGR) Formula

"  Streamlines multiple quality reporting programs into the new Merit-based Incentive Payment System (MIPS)

"  Provides incentive payments for participation in Advanced Alternative Payment Models (APMs)

TransformingClinicalPrac?ceIni?a?ve(TCPI)

•  TCPIisdesignedtosupportmorethan140,000clinicianprac,cesinsharing,adap,nganddevelopingcomprehensivequalityimprovementstrategiesthroughpayment/prac,cereform,carecoordina,on,community-basedhealthteamssuppor,ngchroniccaremanagement,andaprac,cetransforma,oncollabora,ve

•  Ofnoteisthe“TCPIChangePackage,”acompila,onoftestedinterven,onsthatincludesimprovementtac,csbasedonthreepillars–personandfamily-centeredcare,datadrivequalityimprovement,andsustainablebusinessprac,ces:h=ps://www.acponline.org/prac,ce-resources/business-resources/payment/transforming-clinical-prac,ce-ini,a,ve

TheHealthcareCommuni?esTCPIPortal:www.healthcarecommuni?es.org

•  MaincommunityforTCPIpar(cipants

andstakeholders•  Sub-communi(esforeachPrac(ce

Transforma(onandSupportAlignmentNetwork

•  Publicpagefornewsandresults•  Announcements•  EventCalendarwithregistra(onand

reminders•  Shareresourcesandtools-advanced

searchfunc(on•  Subscribetodocumentupdates•  Hear/Viewothers’stories•  Gethelp–SingleSolu(onsCenter

Connectwithotherslocallyandna(onallyandbytopic–Listservs,BlogsandForums

•  Shareresultsandsuccess

36

ShariLingshari.ling@cms.hhs.gov

Whatdata,research,evidenceisneededtogainmoreac,ononana,onallevel?Whatofthesewouldbemosthelpfultomovethedialforsystem/policychange?Ifstakeholdersweretoinvestlocaldollarstogeneratethisinforma,on-whatshouldwefocuson?Whatarethebiggestdata,evidence,researchgapsfromCMS’sperspec,ve?

TheCMSQualityStrategy

#  Focusontheaimsofbe=ercare,smarterspending,andhealthierpeople

#  Maximizethequalityofcareyoudeliver

#  Learnaboutqualitymeasurement

#  Investinneededinfrastructure

#  Focusondatacollec,onandperformancetransparency

#  HelpCMSdevelopnewpaymentandservicedeliverymodels

#  Engageinalterna,vepaymentandintegratedcaremodels

#  Testinnova,ons,scalesuccess,andshareyourresults

#  Par?cipateinopportuni,esforpubliccomment

WhatCanYouDotoImproveCareQuality?

Makingcaresaferbyreducingharmcausedinthedeliveryofcare.

Source:PartnershipforPa(ents

PartnershipforPa?entsModelTestFocusedonTwoBreakthroughAims

“40/20by‘14”

Ensuringthateachpersonandfamilyareengagedaspartnersintheircare.

•  HowcanwebesthelppeoplewithADRDandtheircaregiverspriortohavingtherightinfrastructureandcaremodelinplace?

•  Itseemswhenpa,entsgettothenursinghomewithobviouscogni,veimpairment...whenwediscussdemen,a,itseemslikethefirst,methefamilyhasheardaboutit...itseemsprimarycareandhospitalprovidersarenottalkingabouttheelephantintheroom.Howcanweaddressthisissue?

Promo(ngeffec(vecommunica(onandcoordina(onofcare.

•  Howdowecon,nuetoalignpolicy,programs,andpaymenttosupportdemen,acare?

•  Whatwillittaketoinvolvelocalmedicalsystems?•  Howcanwebesuretoalignallqualityandcasemanagementexpecta,onstoavoid

confusionandduplica,on?

•  HowdoesCMSenvisionpayingforthewraparoundservicesrequiredtosupportdemen,apa,entsandtheircaregivers,outsideofthefeeforserviceworld?

•  Isthereateambasedmodelforreimbursementofdemen,acareintheambulatorysemng?

•  HowcanCMSu,lizetheInnova,onCenterand/orthedualsofficetointegratedemen,acareacrosssemngs(e.g.,includingclinic,behavioral,hospital,managedlong-termservicesandsupports,homehealth,homeandcommunity-basedservices,assistedliving),andacrossdisciplines?

•  Howcanwepromotethevalueofcarecoordina,onwithpaymentmodelstosupport?

•  Howdoyouseethefutureofreimbursementandapplica,onoftelehealthenhancingdemen,acare?

•  ArethereanyplansforMedicaretoengageinacaregivertrainingpilot?

Promo(ngthemosteffec(vepreven(onandtreatmentprac(cesfortheleadingcausesofmortality,star(ngwithcardiovasculardisease.

•  Howcanweimprovedetec,onofdemen,ainabusyprac,ceeffec,velyandefficiently?•  HowcanCMSdrivedetec,on?•  HowcanCMShelptopriori?zedetec?onandmanagementofdemen?ainprimarycare?•  Alzheimer'sisacomplexdiseasetoassessanddiagnose,yettheassessmenttoolsarenotreimbursedforphysicians

whotake,metoimplementthem.Inordertoimproveoutcomes,weneedtoenablehealthcareprac,,onerstobereimbursedandmake,meforathoroughassessment.Howcanthisbeimplemented?

•  Thehealthcaresystemcurrentlyrewardsprocedure-basedspecial,es,andtradi,onally,specialistsindemen,acareareviewedasaliabilityintermsofearningpoten,al.HowwillCMSincen,vizethecounselingworkthatisinvolvedindemen,acareandmanagementacrossprovidertypes?

•  Howdoyousuggestweusealliedhealthproviderstobe=erimprovecaretopeoplewithdemen,a(pharmacists,OT,PT)?

•  HowcanCMSuseitsdatatounderstanddispari,esindetec,on,diagnosisandmanagement?•  Whatcanwedotoincreaseawarenessofthelinkbetweendemen?aandco-morbiddisorders?•  Howcanweencouragepromotethereasonsforearlydetec,on,careplanning,andreferral?•  Howdowemakedemen,acarepartofmedicalcare?Howdowemaketrea,ngbrainfailureliketrea,ngcancer,

heartfailure,kidneyfailure,etc.?•  Therearecurrentlymul?pleproblemsassociatedwiththeprimarycarephysician’scurrentencounterswiththe

demen?apa?ent-thedura?onofvisits,financialincen?vesassociatedwithcare,anddelayeddiagnosisinthispa?entpopula?on.ArethereanyplansfromaCMSperspec?vetobeCersupportprimarycareprovidersinthemanagementofdemen?a?

•  ForamyloidimagingtobereimbursedthroughMedicare,wouldbothprimaryendpoints(e.g.decisionmakingandreducedhealthcarecosts)needtobemetorwoulditbesufficienttomerelyshowanimpactonphysiciandecision-making?

•  Whatwouldyouencourageasthefirststepforhealthplanstoconsiderwhendevelopingafocusondemen?a?

Workingwithcommuni(estopromotewideuseofbestprac(cestoenablehealthyliving.

•  Howcanweencourageclinicianstobe=ercoordinatecarefortheirpa,ents,andu,lizethenewCMScarecoordina,onpaymentcodetobereimbursed?

•  IfyoucouldchangeonethingatCMStoencourageearlydetec,onanddiagnosisofdemen,a,whatwouldthatbe?•  ThecurrentMedicareWellnessExamdoesnotspecifythediagnos,ctoolstobeusedincogni,vescreening.Canwe

expectthemandateofevidencebaseddiagnos,ctools?•  Onceabenefitisimplemented(e.g.AnnualWellnessVisit),underwhatcircumstancesmightitbediscon,nued?•  HowdoesCMSuseclinicianinputindesigningnewbenefits?•  Isitpossibletomakedemen,aaqualitycareindicatorforpa,ents>65yearsold?•  WhatrolemightMedicarereviewersplayinhelpingimprovedetec,onanddiagnosis?•  Howwouldyoudescribeidealdemen,acare,andwhatpolicychangeswouldneedtohappenforthistypeofcare

tobefinanciallysustained?•  Howdoesdemen,arankonthena,onalprioritylist?ForCMS?

•  WhatmechanismsdoesCMShavetoeducateprovidersandbeneficiariesaboutgoalsandimplementa,onofspecificbenefits?

•  Whatadvicedoyouhaveinsuppor,ngsmallruralprac,cesinimprovingtheirdemen,adetec,on,diagnosis,treatment,andcare?

•  CanwecreateCentersofExcellenceOlderAdultswithCMSfunds?•  InAugust,SecretaryClintonannouncedaplantointegratementalandphysicalhealthcaresystems.Herplan

encompassestheintegra,onofmentalandphysicalhealthcaresystems,includinganexpansionofreimbursementstructuresinMedicareandMedicaid,taskingtheCMSInnova,onCentertocreateandimplementthenewpaymentmodels.HowdoyouseetheAlzheimer’sDiseasecommunityfimngintothisproposedagenda?

TelehealthHistory

•  Medicarecoverageandpaymentforservicesdeliveredthroughtelecommunica,onssystemswasauthorizedbytheCongressnearly20yearsagowhenitadded‘MedicareReimbursementforTelehealthServices’totheSocialSecurityAct

•  In2000statutoryrequirementsamendedtheActbyaddinganewsec,on,‘PaymentforTelehealthServices,’whichallowsMedicaretomakeapaymentforalimitednumberofPartBserviceswhenfurnishedbyaneligiblephysicianorprac,,onertoaneligibleMedicarebeneficiaryviaatelecommunica,onsystem

•  TheActlimitsMedicare’spaymentauthoritytoonlythetypesoftelehealthservicesdefinedinthestatute

•  Medicaredoesnotcurrentlyhavepaymentauthorityforservicesfurnishedviamobilehealth(mhealth)orelectronichealth(ehealth)methods,aswellaspaymentforothertechnologicalandwebbasedadvancementsincarethatwerenotcontemplatedinthestatutedecadesago

Telehealth(con?nued)•  TheActdefinesMedicaretelehealthservicestoincludeconsulta,ons,officevisits,office

psychiatryservices,andanyaddi,onalservicespecifiedbytheHHSSecretary,whenfurnishedviaatelecommunica,onssystem

•  CMSfinalizedaprocessthatprovidesthepublicwiththeopportunitytosubmitrequestsforconsidera,onofaddi,onaltelehealthservicesiftheservicefallsintooneoftwocategories:Category1:Servicesthataresimilartoprofessionalconsulta(onsandofficevisitsthatarecurrentlyincludedonthelistofeligibleMedicaretelehealthservicesandCategory2:ServicesthatarenotsimilartoservicescurrentlyonthelistofeligibleMedicaretelehealthservices,butwheretherequestincludesanassessmentoftheserviceanddocumentsthatwhentheserviceisfurnishedviatelehealthaclinicalbenefitforthepa(entisdemonstrated

•  CMShasfurnishedguidanceonthetypesofbenefitsthatareacceptablewhenconsideringtheappropriatenessoffurnishingaprofessionalserviceviatelehealthincludingoninterven,onsincarethatreducenega,vehealthoutcomesandrestora,onandpromo,onofbeneficiarywell-being

Forinforma,ononsubmimngatelehealthservicerequesttoCMSforconsidera,onintheannualtelehealthupdateprocess:h=ps://www.cms.gov/Medicare/Medicare-General-Informa,on/Telehealth/Criteria.htmlFactSheeton2016Telehealthcoverage:h=ps://www.cms.gov/Outreach-and-Educa,on/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publica,ons-Items/CMS1243327.html

MedicaidTes?ngExperienceandFunc?onalToolsGrants

h=ps://www.medicaid.gov/medicaid-chip-program-informa,on/by-topics/delivery-systems/grant-programs/te�-program.html