Meeting the Healthcare Needs of

Older Adults: Translating Evidence into Policy

Shari M. Ling, MD Deputy Chief Medical Officer

Centers for Medicare and Medicaid Services

HCSRN-OAICs AGING Initiative

July 15, 2020

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Today’s Speaker

Shari M. Ling, MD Deputy Chief Medical Officer

Centers for Medicare and Medicaid Services

Webinar Discussants

Nathan Boucher, DrPH, MPA

Duke University AGING Initiative MCCs

Scholar

Barbara Kivowitz, MSW Stanford Health Care and

Sutter Health AGING Initiative

Patient/Caregiver Advisor

Meeting the Healthcare Needs of Older Adults:

Translating Evidence into Policy

AGING Initiative Webinar

Dr. Shari Ling Deputy Chief Medical Officer

Centers for Medicare & Medicaid Services

Disclaimer

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. No financial conflicts to disclose.

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HHS Department-Level Strategy

a health care system that results in better accessibility, quality, affordability,

empowerment, and innovation

CMS has started a national conversation about improving the health care delivery system, how Medicare can contribute to making the delivery system less bureaucratic and complex, and how we can reduce burden for clinicians, providers and beneficiaries in a way that increases quality of care and decreases costs – making the health care system more effective, simple, and accessible, while maintaining program integrity and preventing fraud

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Evolving Size and Scope of CMS Responsibilities

10,000 New Medicare Beneficiaries Every Day

The number of Americans age 85 and older will increase by 189% between now and 2050

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Size and Scope of CMS Responsibilities

• CMS is the largest purchaser of health care in the world

• Combined, Medicare and Medicaid pay approximately one-third of national health expenditures (approx $800B)

• CMS covers 140 million people through Medicare, Medicaid, the Children’s Health Insurance Program; or roughly 1 in every 3 Americans

• The Medicare program alone pays out over $1.5 billion in benefit payments per day

• Through various contractors, CMS processes over 1.2 billion fee-for-service claims and answers about 75 million inquiries annually

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Co-morbidity among Chronic Conditions

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New CMS Strategy – Putting People First

• Empowering Patients and Clinicians to Make Decisions about Their Healthcare

• Ushering in a New Era of State Flexibility and Local Leadership

• Supporting Innovative Approaches to Improving Quality, Accessibility, and Affordability

• Improving the CMS Customer Experience

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CMS Strategic Priorities for 2020

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Overall CMS Programs & Activities

• National & Local decisions • Mechanisms to support innovation

(CED, parallel review, other) 4

• Advanced Alternative payment models • ACOs, PCMH, Bundles • Multi-payer State agreements • Prevention and Population Health • Rapid Cycle Evaluation

• Provider Enrollment • Fraud, Waste & Abuse Prevention &

Detection • Medical Review • Audits and Investigations

• Hospital Inpatient including IRFs • Hospital Outpatient • In-patient psychiatric hospitals • Cancer hospitals • Nursing homes • Home Health Agencies • Long-term Care Acute Hospitals • In-patient rehabilitation facilities • Hospices

• Hospitals, Home Health Agencies, Hospices, ESRD facilities, Marketplace, Plans

• Parts A, B, C, D • VBP hospitals, SNF, HHA, ESRD • Payment adjustments HAC, hospital RRP • Physician Quality Payment Program (QPP)

• CLIA • Target surveys • Quality Assurance

Performance Improvement CMS

Programs and Activities

States –Center for Medicaid and

CHIP Services Innovation &

Demonstrations

Clinical Standards

Quality & Safety Oversight

Quality & Public Reporting

Payment Coverage

Marketplace

Program Integrity

Quality Improvement

Value- Based Incentive Models

• CMCS 1115 Waivers and demonstrations • CMMI model tests • Innovation Accelerator Program

• Quality Improvement Organizations • Hospital Innovation & Improvement

Networks

Center for Consumer Information and Insurance Oversight (CCIIO); Marketplace

The Preferred Road to Coverage

The incremental information obtained by new diagnostic technology compared to alternatives

Changes physician/clinician recommendations

Resulting in changes in therapy

That improve clinically meaningful health outcomes

A treatment strategy using the new therapeutic technology compared to alternatives

Leads to improved clinically meaningful health outcomes

Diagnostics Therapeutics

Provide adequate evidence that…

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National and Local Coverage Determinations

National Local Definition: Determination by a Medicare Administrative Contractor (MAC) with respect to whether or not a particular item or service is covered in the MAC jurisdictions under §1862(a)(1)(A).

Definition: Determination by the Secretary with respect to whether or not a particular item or service is covered nationally under §1862(a)(1)(A) . CED: §1862(a)(1)(E) in the case of research conducted pursuant to §1142, which is not reasonable and necessary. . Prevention/Screening: Reasonable and necessary for the prevention or early detection of illness or disability under§1861(ddd).

The evidence:

• Sufficient evidence to conclude that the item or service improves clinically meaningful health outcomes for the Medicare population

• Based on a comprehensive review of published evidence

EVIDENCE GAPS REMAIN - OLDER ADULTS ARE NEEDED IN CLINICAL TRIALS

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Medicare • Chronic Care Management

• Annual Wellness Visit & Cognition

• Cognitive Impairment Assessment

• Advance Care Planning

• Coordinated Behavioral Health

• Outpatient Mental Health Counseling

• Home Health

• Hospital

• Short-term Nursing Home Care

• Hospice

• Telehealth

Medicaid • Home and Community-Based Services

• Health Homes

• Targeted Case Management

• Home Health

• Rehabilitative Services

• Programs for All-Inclusive Care

• Hospital

• Short and Long-Term Nursing Home Care

• Hospice

• Telehealth

Some Services That Support People with Serious Illness Fee For Service Payments

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MOVING TO VALUE

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Payment Model Framework

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Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program, that provides two participation tracks:

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MIPS Value Pathways

While there have been incremental changes to the program each year, additional long-term improvements are needed to align with CMS’ goal to develop a meaningful program for every clinician, regardless of practice size or specialty.

CMS is proposing MIPS Value Pathways (MVPs) to create a new participation framework beginning with the 2021 performance year. This new framework would:

• Unite and connect measures and activities across the Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories of MIPS

• Incorporate a set of administrative claims-based quality measures that focus on population health/public health priorities

• Streamline MIPS reporting by limiting the number of required specialty or condition specific measures

Request for Information

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Future State of MIPS (In Next 3-5 Years)

Current Structure of MIPS (In 2020)

New MIPS Value Pathways Framework (In Next 1-2 Years)

Building Pathways Framework MIPS Value Pathways

Clinicians report on fewer measures and activities base on specialty and/or outcome within a MIPS Value Pathway

Moving to Value

Fully Implemented Pathways Continue to increase CMS provided data and feedback to

reduce reporting burden on clinicians

• Many Choices • Not Meaningfully Aligned • Higher Reporting Burden

• Cohesive • Lower Reporting Burden • Focused Participation around Pathways that are Meaningful

to Clinician’s Practice/Specialty or Public Health Priority

• Simplified • Increased Voice of the Patient • Increased CMS Provided Data • Facilitates Movement to Alternative Payment Models (APMs)

2-4 Activities

Improvement Activities

Quality

6+ Measures

Promoting Interoperability

6+ Measures

Cost

1 or More Measures

Cost Quality and IA aligned

Foundation Promoting Interoperability

Population Health Measures

Foundation Promoting Interoperability

Population Health Measures Enhanced Performance Feedback

Patient-Reported Outcomes

Value

Quality Improvement Activities

Cost

We Need Your Feedback on:

Population Health Measures: a set of administrative claims-based quality measures that focus on public health priorities and/or cross-cutting population health issues; CMS provides the data through administrative claims measures, for example, the All-Cause Hospital Readmission measure.

Goal is for clinicians to report less burdensome data as MIPS evolves and for CMS to provide more data through administrative claims and enhanced performance feedback that is meaningful to clinicians and patients. Clinician/Group Reported Data CMS Provided Data

Pathways: What should be the structure and focus of the Pathways? What criteria should we use to select measures and activities?

Participation: What policies are needed for small practices and multi-specialty practices? Should there be a choice of measures and activities within Pathways?

Public Reporting: How should information be reported to patients? Should we move toward reporting at the individual clinician level?

MIPS Value Pathways

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Dementia Quality Measures

• Dementia: Cognitive Assessment (Process) o Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of

cognition is performed and the results reviewed at least once within a 12-month period

• Dementia: Functional Status Assessment (Process) o Percentage of patients with dementia for whom an assessment of functional status was performed at least

once in the last 12 months

• Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management (Process) o Percentage of patients with dementia for whom there was a documented screening for behavioral and

psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months

• Dementia: Education and Support of Caregivers for Patients with Dementia (Process – High Priority)

o Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months

• Dementia: Safety Concern Screening and Follow-up for Patients with Dementia (Process – High Priority)

o Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources

2020 Performance Year

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A New Approach to Improving Outcomes

Launched in 2017, the purpose of the Meaningful Measures initiative is to:

• Improve outcomes for patients

• Reduce data reporting burden and costs on clinicians and other health care providers

• Focus CMS’s quality measurement and improvement efforts to better align with what is most meaningful to patients and clinicians

What is the Meaningful Measures Initiative?

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Domains with Focus Areas

Promote Effective Prevention & Treatment of Chronic Disease

Meaningful Measure Areas • Preventive Care

• Management of Chronic Conditions • Prevention, Treatment, and

Management of Mental Health

• Prevention and Treatment of Opioid and Substance Use Disorders

• Risk Adjusted Mortality

Promote Effective Communication & Coordination of Care

Meaningful Measure Areas

• Medication Management

• Admissions and Readmissions to Hospitals

• Transfer of Health Information and Interoperability

Make Care Affordable

• Appropriate Use of Healthcare

• Patient-focused Episode of Care • Risk Adjusted Total Cost of Care

Meaningful Measure Areas

Strengthen Person & Family Engagement as Partners in their Care

• Care is Personalized and Aligned with Patient’s Goals

• End of Life Care according to Preferences • Patient’s Experience of Care

• Functional Outcomes

Meaningful Measure Areas

Work With Communities to Promote Best Practices of Healthy Living

Meaningful Measure Areas

• Equity of Care

• Community Engagement

Make Care Safer by Reducing Harm Caused in the Delivery of Care

• Healthcare-Associated Infections

• Preventable Healthcare Harm

Meaningful Measure Areas

Meaningful Measures

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• Appropriate use of opioids and avoidance of harm

• Nursing home safety measures

• Interoperability and care transitions

• Appropriate use of services

• Patient-reported outcome measures

Filling the Gaps

Meaningful Measures

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• Developing more APIs for quality measure data submission

• Prototype the use of the FHIR standard for quality measurement

• Interoperable electronic registries – incentivizing use

• Harmonizing measures across registries

• Timely and actionable feedback to providers

• Working with CMMI on use of artificial intelligence to predict outcomes

Advancing Electronic Sources

Meaningful Measures

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TRANSPARENCY

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• Bill passed on September 18, 2014, and signed into law October 6, 2014

• The Act requires the submission of standardized patient assessment data elements by: – Long-Term Care Hospitals (LTCHs): LCDS – Skilled Nursing Facilities (SNFs): MDS – Home Health Agencies (HHAs): OASIS – Inpatient Rehabilitation Facilities (IRFs): IRF-PAI

• The Act specifies that data “… be standardized and interoperable so as to allow for the exchange of such data among such post-acute care providers and other providers and the use by such providers of such data that has been so exchanged, including by using common standards and definitions in order to provide access to longitudinal information for such providers to facilitate coordinated care and improved Medicare beneficiary outcomes…”.

Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014

Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014

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CMS Data Element Library: IMPACT Act

FUNCTION – MOBILITY, SELF-CARE, COGNITION, SYMPTOMS, CARE PLANS

Visit the DEL here: https://del.cms.gov

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IMPACT Act Measure Domains

Measure Domain Measure Name

Functional Status Application of Percent of LTCH Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)

Skin Integrity Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

Medication Reconciliation Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post Acute Care (PAC)

Incidence of Major Falls Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)

Transfer of Health Information Transfer of Health Information to Provider – Post-Acute Care Transfer of Health Information to Patient – Post-Acute Care

Medicare Spending Per Beneficiary Medicare Spending Per Beneficiary-Post Acute Care (PAC)

Discharge to Community Discharge to Community-Post Acute Care (PAC)

Potentially Preventable Hospital Readmissions

Potentially Preventable 30-Day Post-Discharge Readmission Measure

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PATIENTS OVER PAPERWORK

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Patients Over Paperwork

• CMS has established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary, clinician, and provider experience.

• CMS is moving the needle to remove regulatory and policy obstacles that get in the way of providers spending time with patients and healthcare consumers.

• Patient over Paperwork aims to: o Increase the number of customers – clinicians, institutional providers, health

plans, etc. engaged through direct and indirect outreach; o Decrease the hours and dollars clinicians and providers spend on CMS-

mandated compliance; and o Increase the proportion of tasks that CMS customers can do in a completely

digital way.

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Patients Over Paperwork

• We use tools to capture customer perspectives, such as human-centered design • Human-Centered Design (HCD) at CMS is the process we use to

understand the people for which we are writing policies, and creating programs and services.

• At the center of our HCD process is participatory design, where we work directly with clinicians, beneficiaries, third party vendors, federal partners, and CMS employees to collaboratively understand the context of their work and engagement with CMS, as well as the solutions we are creating to support them.

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Patients Over Paperwork Customer Workgroups

Engagement Team Scope

Nursing Home Medicare FFS customer experience from admission to discharge

Beneficiary Transitions of care settings

Clinician Documentation requirements

Hospital Reporting requirements

Hospice First discussion of advanced terminal illness through the provision of bereavement services

Home Health Overall care delivery

Dialysis Facility Early care for Chronic Kidney Disease (CKD); transition into dialysis, and continuous care including coordination between settings

Prior Authorization Improve transparency, efficiency, and standardization of the prior authorization process

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Patients Over Paperwork Beneficiary Care Activities & Transitions

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Patients Over Paperwork Common Challenges for Beneficiary Care Transitions

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Patients Over Paperwork Nursing Home Journey

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Thank You!

Dr. Shari Ling

Deputy Chief Medical Officer

Centers for Medicare & Medicaid Services

Shari.Ling@cms.hhs.gov

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