Centers for Medicare & Medicaid Pay for Performance Updates

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Jeff Flick Regional AdministratorCMS, Region IXFebruary 7, 2006

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Big Changes in Medicare

New orientation toward prevention

Personalized help for people with special conditions and chronic healthcare issues

Assistance for Low-Income Beneficiaries

Push for Healthcare IT- PHRs & EHRs

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Changes in MedicareKeeping up with Today’s Healthcare

Medicare is converting from a bill paying bureaucracy and a one sized fits all program, to an agency providing personalized help and benefits to beneficiaries.

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Traditionally, Medicare has not communicated with beneficiaries, it has been a standard set of national benefits focused on paying for complications. New focus on prevention and avoiding complications of chronic illness.

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Personalizing Medicare Services

The drug benefit is the first big step in personalizing services. There are a lot of choices and benefits that can be tailored uniquely to beneficiaries

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Personalizing Medicare Services

It is not enough to just change the benefits. We must help educate beneficiaries to understand the new benefits and to use them wisely

Much of the education and communication with beneficiaries will be accomplished by working through providers, hence the need for pay for performance

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Improving Performance

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Medicare has a fundamental interest in re-structuring the payment system.

Medicare is no longer going to pay based purely on volume; the days of the more you do the more you get paid are about to end.

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Medicare intends to become a value based purchaser

• Medicare will measure performance

• Medicare will pay at least partially based on performance

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Medicare Today

We pay for the wrong care much of the time (45%)

We pay for inappropriate care

We pay for unnecessary care

We pay for mistakes and errors

We pay for many duplicative diagnostic studies

We must do better- we cannot afford to continue on this path

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Medicare Today

Medicare wants to pay for the right care for every patient every time

Medicare wants to pay for all of the care needed by beneficiaries that is supported by science

Medicare wants to pay for all of the appropriate preventative care for all beneficiaries based on scientific standards

P4P is not cost control in disguise, Medicare wants to pay for performance

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Performance is…

Measuring patients experience of care

Measuring and rewarding based on efficiency and eliminating waste and unnecessary costs

Measuring ability to use evidence based care

Measuring appropriate use of preventive care

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Paying for Performance through Demonstrations

CMS currently pays for quality through a series of demonstrations (all must be budget neutral)

A large number of quality demonstrations were mandated in MMA

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Current P4P Demonstrations

Premier Hospital Reporting

DOQ-IT (Sec 649)

CCIP / Medicare Health Support

BIPA Disease Management / Heart Partners

Physician Group Practice Demonstration

High Cost Beneficiaries

Medicare Health Care Quality (Sec 646)

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What CMS Really Needs

We need a good Medicare Advantage model for doing P4P inside the expanding MA program.

Is anyone here aware of a good P4P program?

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Stay Informed ThroughRegion IX Stakeholder Call

Every 3rd Thursday of the Month, 2-3pm PST

Next call March 16, 2006

Toll Free: 888-452-0273

Pass Code: Stakeholder Call

Leader: Jeff Flick

Register for “CMS Region IX Stakeholder” ListServ for notification and details about calls through:

http://www.cms.hhs.gov/apps/mailinglists/

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Thank You!

Jeff Flickjeffreyflick@cms.hhs.gov

415-744-3501

Centers for Medicare & Medicaid Pay for Performance Updates

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