The Integrated Care Resource Center, a joint initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office and the Center for Medicaid, CHIP, and Survey & Certification, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies.

November 7, 2011

For audio, dial: 1-877-668-4490; Meeting/Event Number: 710 239 432

Partnership for Patients & Million Hearts:Achieving the Goals of the National Quality Strategy

Paul McGann, MDCo‐Director, HHS Partnership for PatientsJanet Wright, MDExecutive Director, HHS Million Hearts InitiativeJohn Michael O’Brien, PharmD, MPHField Director, CMS Innovation Center

Questions to Run On 

• What are the Partnership for Patients and Million Hearts Initiatives?

• How can states benefit from the initiative?• What actions and contributions might states make?

• What resources or help can CMS provide to States to achieve our bold aims?

…we want your answers too

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• 40% Reduction in Preventable Hospital Acquired Conditions– 1.8 Million Fewer Injuries– 60,000 Lives Saved

• 20% Reduction in Preventable 30‐Day Readmissions– 1.6 Million Patients Recover Without Readmission

• Potential to save $35 billion in 3 years– Now certified by the Office of the Actuary

Partnership for Patients: We are focused on our aims

We KnowMajor Improvement Is Possible

• Ascension Health sites participating in a 2007 perinatal safety initiative achieved birth trauma rates that were at or near zero. 

• 150 New Jersey health care facilities reduced pressure ulcers by 70%• Rhode Island reported a 42% decrease in Central Line‐Associated 

Bloodstream Infections  (CLABSI) (2006‐2007)• 65+ IHI Campaign hospitals reported going more than a year without 

a ventilator‐associated pneumonia in at least one unit.• The 14 QIO Communities participating in the 9th SOW Care 

Transitions Theme achieved significant reduction in readmissions compared to 52 peer communities. 

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How Will Change Actually Happen?

• There is no “silver bullet.”• We must apply many incentives.• We must show successful alternatives.

• We must offer intensive supports.– Help providers and partners with the painstaking work of improvement.

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Up to $500 million to help hospitals and health care organizations to improve patient care to:

• Provide national-level content for anyone and everyone• Support every facility to take part in cooperative learning• Establish an Advanced Participants Network for ambitious organizations

to tackle all-cause harm• Engage patients and families in making care safer• Improve measurement and data collection, without adding burdens to

hospitals• Make data transparent

Partnership for Patients:Better Care, Lower Costs

Areas of Focus

• Partnership for Patients have indentified nine areas of focus:

• Adverse Drug Events• Catheter-Associated Urinary Tract Infections• Central Line Associated Blood Stream Infections• Injuries from Falls and Immobility• Obstetrical Adverse Events• Pressure Ulcers• Surgical Site Infections• Venous Thromboembolism• Ventilator-Associated Pneumonia

National Vision

• Strong, Public Leadership Commitments – The Boards of all “Partnership” hospitals publically embrace the aims of the initiative and remove barriers to progress.

• “Raise the Floor” – Every hospital in the nation adopts and completely implements a set of evidence-based interventions.

• “Raise the Bar” – Vanguard hospitals seek to define and eliminate all-cause harm and preventable readmissions on an extremely ambitious timeframe (making their work transparent to all others with interest).

• Smooth Transitions between Care Settings – Hospitals, communities, patients and families will devote new attention to making sure that transitions out of the hospital are well coordinated.

Why are people readmitted?

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No Community infrastructure for achieving common goals

Unreliable system supportLack of standard and known processesUnreliable information transferUnsupported patient activation during transfers

Provider-Patient interfaceUnmanaged condition worseningUse of suboptimal medication regimensReturn to an emergency department

Learn from the QIO 9th SOW: 14 Communities Improving Care Transitions

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Preliminary Results*: Relative Improvement July 2007‐June 2008 compared to July 2009‐June 2010

14 Care Transitions Communities vs. 52 Peer Communities

5.56% 5.66%

2.50%

3.47%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Readmission Relative Improvement Rate Admission Relative Improvement Rate

CareTransitionsCommunitiesPeerCommunities

*Results were developed to help guide the Care Transitions Theme.  These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

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Community‐Based Care Transitions ProgramWhat is it? 

• ACA Section 3026 and part of the Partnership for Patients• $500 million to test models for improving care transitions for 

high risk Medicare beneficiaries• 5‐year program / potential to expand beyond 5 years based on 

success!• Accepting applications on rolling basis as long as funding is 

available• QIOs can support communities, whether just getting started in 

care transitions improvement or ready to apply to the CCTP

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Community‐Based Care Transitions Program‐‐ Goals ‐‐

• Improve care transitions from inpatient hospital   setting to home or other care settings

• Reduce readmissions for high risk beneficiaries

• Document measurable savings to the Medicare program

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Community‐Based Care Transitions Program‐‐ The Opportunity ‐‐

Community Based Organizations (CBOs) can actually  define and price a new cost‐effective care transitions service for Medicare patients in their communities

…tailored to their own unique circumstances and capabilities!

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• Area Agencies on Aging (AAAs)• Aging and Disability Resource Centers (ADRCs)• Federally Qualified Health Centers (FQHCs)• A coalition representing a collaboration of community 

healthcare providers ‐ if a legal entity is formed• PAC providers ‐ with evidence of board representation that 

comes from outside of the provider entity.• Grantees of Foundations with experience in improving care 

transitions

Who Could Be a CBO?-- Examples --

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• Legal entity, i.e., have a taxpayer ID number, so we can pay them for services provided

• Governing body with multiple health care stakeholder representation, including consumers

• Partnership with one or more subsection (d) acute care hospitals

• Physically located in the community it proposes to serve• Can demonstrate ability to provide care transitions for Medicare FFS beneficiaries across health care settings

• Applicants describe how they will work with other payors including Medicaid

Who Can Be a Community Based Organization?-- Criteria --

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Useful Care Transitions Links

National Coordinating Center: www.cfmc.org/caretransitions

Partnership for Patients: http://www.healthcare.gov/partnershipforpatients

Community‐Based Care Transitions Program: http://go.cms.gov/caretransitions

Administration on Aging (AoA) Toolkit, Learning Sessions: http://www.adrc‐tae.org/tiki‐index.php?page=CareTransitions

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How Can States Benefit?

• Achieving the Partnership for Patients HAC reduction goals would result in 271,000 Medicaid patients helped, over 9,000 deaths averted, and $3 billion saved over the next three years  (just counting FFS)

• 252,000 Medicaid readmissions can be averted over the next three years, saving an estimated $2.2 billion dollars

• These aims will also contribute to improved quality and lower the human & financial costs of harms to all state payors

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How Can States Contribute?

• Sign the Pledge at http://www.healthcare.gov/partnershipforpatients –urge others to follow your lead.

• As a powerful payor, get key safety net hospitals to participate aggressively in the improvement work of the partnership.

• Work with communities applying to the CCTP and with your state’s QIO as it recruits communities to improve care transitions

• Join the “full court press” by linking state pay for performance programs to the HAC and readmission goals and measures.

• Convene and engage state safety champions inside government and across the provider, LTC, public health and other communities.

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How Can CMS Help?

• Work closely with CMCS, State Medicaid Agencies, and State Health Officials to educate and engage all partners in the work of the Partnership for Patients– Hospital Engagement Contractors, Community‐based Care Transitions Program, and Others

• Seek and stay aware of ways the Partnership can help States and State‐funded entities via MSTATs and policy alignment opportunities

• We want to broadcast your successes and results!

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3,079Hospitals

2,184Clinicians & Provider Orgs

110AAAs & 

Aging Groups

836Consumer & Patient Groups

246Employer, Union & Govt Orgs

Partnership for Patients: The First 200 Days

More than 6,500 partners have pledged their commitment to the aims of the Partnership for Patients, including over 3,000 hospitals.

Partnership for Patients: The First 200 Days

One‐third of states of nationwide have over half of their hospitals on board. Every hospital in Iowa and Washington has committed to our aims.

Partnership for Patients: The First 200 Days

Every federal agency is in action to leverage and align their policies, programs, expertise and network in support of our aims.

Partnership for Patients: The First 200 Days

A number of major partners from across the spectrum of health care stakeholders have made significant commitments aligned to our aims.

Contact Information

Paul McGann, MDPaul.mcgann@cms.hhs.gov

Dennis Wagnerdennis.wagner2@cms.hhs.gov

John O’BrienJohn.O’Brien@cms.hhs.gov

Centers for Medicare and Medicaid Services7500 Security Blvd.

Baltimore, MD  21244‐1850

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Elisa Estrella, Special Assistant to the Director, Office of Minority Health

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Overview

I. Overview of CMS Spending & Health Disparities Costs

II. ACA Authorizations that Impact Health Disparities

III. CMS‐Lead Actions for the HHS Health Disparities Plan

IV. Next Steps

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CMS’ History 

• Medicare’s leverage as the largest purchaser and regulator provides opportunities to have a large impact on reducing health disparities.

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The Annual Cost of Health Disparities to CMS

• Medicare alone will spend an extra $15.6 billion while private insurers will incur $5.1 billion in additional costs due to elevated rates of chronic illness among African Americans and Hispanics.

• Estimates indicate the combined total of health disparities costs Medicare and Medicaid is $17 billion a year.

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Source: Urban Institute 2009 Cost of Health Disparities(Medicaid is less dramatic due to younger status of Medicaid beneficiaries compared to higher per capita spending of Medicare and the second payer status of dual eligible.”)

Patient Protection & Affordable Care Act, Section 10334 of PL 111‐148

• Authorizes the Department of Health and Human Services to establish Offices of Minority Health within six agencies, including CMS.

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Enrollment Projections by Race/Ethnicity After ACA

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Pre‐ACA Medicaid Dual CHIP Eligibility

Race/Ethnicity TOTAL TOTAL TOTALMedicaid Expansion Stand‐Alone

All 64,037,615  10,130,664  10,716,844  2,131,651  8,585,193 

Non‐Hisp White 28,310,000  5,842,071  6,257,845  1,337,864  4,919,981 

Non‐Hisp Black+Hispanic 35,740,000  4,288,593  4,458,999  793,787  3,665,212 Non‐Hisp Black 16,480,302  2,365,430  1,655,054  359,865  1,295,189 Hispanic 19,256,537  1,923,163  2,803,946  433,923  2,370,023 

Post‐ACA Medicaid Dual

Race/Ethnicity TOTAL TOTALAll 86,688,814  7,902,364 

Non‐Hisp White 41,910,000  4,296,886 

Non‐Hisp Black+Hispanic 44,770,000  3,605,478 Non‐Hisp Black 20,822,951  1,972,175 Hispanic 23,950,646  1,633,303 

Note: SPAM is an OACT data set that combines MEPS 2005‐7 and reweighted to match 2014 NHE spending and coverage distributions.

ACA Authorizations thatImpact Health Disparities

• Section 2001 ‐ Expansion of Medicaid income eligibility up to 133% of the Federal Poverty Level. 

• Section 2005 ‐ Increase in federal matching rates for Medicaid• Section 3021 ‐ Authorizes Innovation Models in Medicare/Medicaid 

(2011‐2019)• Section 3013 ‐ Development, improvement & evaluation of quality 

measures (2011‐2014)• Section 3306 ‐ Enrollment and outreach to low‐income populations• Section 4302‐ Requires:

– Population surveys to collect racial/ethnic subgroup data,– Collection/reporting  of disparities data in Medicaid and CHIP,– Monitoring  of health disparities trends in federally‐funded 

programs.• Section 5405‐ Sanctions the Primary Care Extension Program (2011‐

2012)

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CMS‐Led Actions for theHHS Health Disparities Plan

Goal 1: Transform Health CareIncrease the proportion of people with health insurance and provide patient protections in Medicaid, CHIP, Medicare, Health Insurance Exchanges, and other forms of health insurance.Increase the proportion of persons with a usual primary care provider and patient‐centered health homes.Improve the quality of care provided in the Health Insurance Exchanges.Increase access to dental care for children in Medicaid and CHIP. 

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CMS‐Led Actions for theHHS Health Disparities Plan

Goal 2: Strengthen HHS Workforce and InfrastructureImprove language access in Medicaid.Promote the use of community health workers by Medicare beneficiaries.

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CMS‐Led Actions for theHHS Health Disparities Plan

Goal 3: Advance the Health, Safety, and Well‐Being of the American People

Implement a multifaceted health disparities data collection strategy across HHS.

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CMS‐Led Actions for theHHS Health Disparities Plan

Goal 4:Advance Scientific Knowledge and Innovation

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CMS‐Led Actions for theHHS Health Disparities Plan

Goal 5:Increase Efficiency, Transparency, and Accountability of HHS Programs

Monitor and evaluate implementation of the HHS Disparities Action Plan.Goal‐Level Disparities Monitoring and Surveillance.Strategy‐Level Evaluation.Ongoing Monitoring/Evaluating and Reporting.

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Next Steps

Formalize “CMS Plan to Address Racial and Ethnic Disparities in Health” that includes aims consistent with the CMS three‐part aim: better healthcare, better health and reduced costs through improvementContinue to conduct interagency  scans of disparities contracts, programs, and opportunities for incentivizing and better measuring racial and ethnic health outcomesCoordinate and integrate efforts across componentsConduct listening sessions Collaborate and share information with private and public partners and leaders

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Million Hearts

Preventing 1 million heart attacks and strokes in 5 years

www.millionhearts.hhs.gov

Key components of Million Hearts

• Clinical Prevention – improving the ABCS through– Focus – simplify and align quality measures; emphasize

importance of improved care of the ABCS– Health IT – use EHRs to improve care and enable quality

improvement through clinical decision support, patient reminders, registries, and technical assistance

– Care innovations – teams, med adherence techniques• Community prevention – Reducing the need for

treatment through– Prevention of tobacco use– Decreased sodium and trans fat consumption

Improved cardiovascular care could save 100,000 lives/year in U.S.

Source: Farley TA, et al. Am J Prev Med 2010;38:600-9.

Smoking cessation

Blood Pressure control

Cholesterol control

Aspirin prophylaxis

Clinical preventionIncreasing focus

• Improving ABCS is top priority • Aligning incentives, communication, clinical

measurement, and reporting by physicians, health care facilities, and health care systems

• Simple, consistent ABCS indicators into– Physician Quality Reporting System, – EHR meaningful use criteria, community clinic

measures, and guidelines from private-sector organizations

– Medicare Part D & MA/PD Plan Ratings– Quality Improvement Organizations

•

Monitoring progress of Million Hearts

Population Metric Baseline 2017Aspirin for those at high risk1 ~46% 65%

Blood pressure control2 ~47% 65%

Cholesterol control2 ~33% 65%

Smoking prevalence3 ~19% 17%

Average sodium intake2 ~3.5g/day 20% reduction

Artificial trans fat intake2 ~ 1% of calories 50% reduction

1As measured in NAMCS2As measured in NHANES3As measured in NHIS

Note: Population-wide indicators – clinical performance goals higher

Reasons for hope

• HRSA Health Centers Collaborative Study increased daily aspirin intake from 53% to 67%

• KP Colorado High Blood Pressure and Cholesterol Management Program improved from 26% to 73% of patients with cholesterol under control

• Rhode Island Cardiovascular Chronic Care Collaborative saw an increase in blood pressure control among participants from 20% to 60%

• Work by Medicaid Massachusetts yielded a drop in smoking rate of over 38% to 28% in 2.5 years

Contact Information

Janet Wright, MDJanet.Wright@cms.hhs.gov

John Michael O’Brien, PharmD, MPHJohn.O’Brien@cms.hhs.gov

Centers for Medicare and Medicaid Services7500 Security Blvd.

Baltimore, MD  21244‐1850

Alice Lind, Center for Health Care Strategies

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• Countless opportunities for synergy• Ideas to foster thought, not a conclusive

list• Capitated programs will likely have more

control over Medicare-covered services • Opportunities do exist for managed fee-

for-service (MFFS)

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Partnership for PatientsGreater synergy when capitated entity financially responsible for Medicare-covered hospital care

States may require incentives for hospitals to:

- Avoid preventable hospital-acquired conditions and complications immediately following discharge

- Implement a computerized physician order entry system or use bar code technology

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Action Plan to Reduce Health DisparitiesDual eligible population is diverseUse Medicaid and Medicare quality measurement data to identify health disparities and areas for improvementStates implementing MFFS models, especially health homes, may partner with community-based health teams States developing capitated models in underserved areas may use HRSA’s National Health Service Corps (NHSC) to strengthen primary care networks

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Million Hearts CampaignInclude proactive care to prevent heart diseaseMay require primary care providers to report on ABCS indicators (Aspirin for people at risk, Blood pressure control, Cholesterol management, Smoking cessation) Expansion of the HIT Regional Extension Centers and Beacon Communities will support reporting requirements

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Established by CMS to advance integrated care models for Medicaid beneficiaries with high-cost, chronic needsProvides technical assistance (TA) to help states integrate care for: (1) individuals who are dually eligible for Medicare and Medicaid; and (2) high-need, high-cost Medicaid populations via health homes as well as other emerging modelsTA coordinated by Mathematica Policy Research and the Center for Health Care StrategiesVisit www.integratedcareresourcecenter.com to submit a TA request and/or download resources, including briefs and practical tools to help address implementation, design, and policy challenges