Transcript Steve McAdoo Center for Medicare & Medicaid Services

Healthcare Challenges Current CMS Initiatives
Steve McAdoo
Deputy Regional Administrator, Dallas
Centers for Medicare & Medicaid Services
[email protected]
214-767-6427
CMS Initiatives
 Preventive Services Covered by Medicare
 Medicare Part D – The Drug Benefit
 Medicare Advantage (MA)
 The Value Driven Healthcare Initiative
(VDHC)
 The Physician Quality Reporting Initiative
(PQRI)
Medicare Preventive Services
Services to Help You Stay Healthy
 “Welcome to Medicare”  Glaucoma screening
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physical exam
Bone mass
measurement
Cardiovascular
screening
Colorectal cancer
screening
Diabetes screening,
services, and supplies
 Pap test and pelvic exam
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with clinical breast exam
Prostate cancer screening
Screening mammogram
Smoking cessation
counseling
Influenza, Pneumococcal
and Hepatitis B
immunization
“Welcome to Medicare” Physical Exam
MMA Section 611
 Initial preventive physical exam
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
Height, weight, blood pressure, and EKG
Education, counseling, and referral for other
preventive services
 Within first 6 months of Part B coverage
 20% copayment after Part B deductible in Original
Medicare Plan

When provider accepts assignment
Preventive Services – The Problem
 Pneumococcal covered since 1981 – only
69% report getting it.
 Flu vaccine – Only about 65% got the flu shot
last year.
 Mammogram – Less than half of eligible
women get the test.
 Similar utilization rates with most preventive
services.
www.MyMedicare.gov
 You may use MyMedicare.gov to:
 View claim status (excluding Part D claims),
 Order a duplicate Medicare Summary Notice (MSN) or
replacement Medicare card,
 View eligibility, entitlement and preventive services
information,
 View enrollment information including prescription drug
plans,
 View or modify your drug list and pharmacy information,
 View address of record with Medicare and Part B
deductible status, and
 Access online forms, publications and messages sent to
you by CMS.
Medicare Part D
The Drug Benefit
Part D – A Status Report
 Competition & choice resulted in an average monthly
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premium of $24 for 2007, the same as 2006.
83% of beneficiaries in PDPs have access to plans
that cost less than their previous coverage.
Average number of drugs included on formularies
increased 13%.
More plans with coverage for preferred brands and/or
generics in the coverage gap (at least one in each
state).
Beneficiaries are saving an average of $1,200
annually on their drug costs.
Five separate opinion surveys show beneficiaries are
overwhelmingly satisfied with their plan.
Part D Enrollment Rates
Selected West Texas Counties
Total
Medicare
Beneficiaries
Total Enrolled
in any Drug
Plan
State
County
Percentage
Texas
Andrews
1,885
1403
74.43%
Texas
El Paso
88,299
61932
70.14%
Texas
Hansford
840
600
71.43%
Texas
Lubbock
33,086
23182
70.07%
Texas
Taylor
19,373
12657
65.33%
Texas
Tom Green
16,852
11206
66.50%
Texas
Val Verde
6,416
4268
66.52%
The Drug Benefit in Rural America
 Help with Costs Leads to Better Health and
Lower Risk of Complications
 Geography and Access to Pharmacies
 CMS efforts to continue to enroll eligible
Medicare beneficiaries who have never
enrolled, will focus on rural areas this fall.
 Special focus on beneficiaries entitled to
extra help.
Targeted LIS Audience (%)
Low Income Subsidy Penetration
Select West Texas Counties
Total Medicare
Beneficiaries
Estimate of Benes
Entitled to LIS who
have not applied
State
County
Percentage
Texas
Andrews
1,885
82
4.350%
Texas
El Paso
88,299
4,321
4.894%
Texas
Hansford
840
36
4.286%
Texas
Lubbock
33,086
1,246
3.766%
Texas
Taylor
19,373
914
4.718%
Texas
Tom Green
16,852
936
5.554%
Texas
Val Verde
6,416
403
6.281%
CMS LIS Toolkit: http://www.cms.hhs.gov/Partnerships/Toolkits/
Social Security Administration: 1-800- 772-1213
Medicare Advantage (MA)
Growth in Managed Care Enrollment
Rural
900,000
800,000
2007
700,000
780,000
600,000
500,000
2006
400,000
520,000
300,000
2005
200,000
350,000
100,000
0
Medicare Advantage
 The Medicare Modernization Act (MMA)
vastly expanded the options for
managed care in Medicare.
 Medicare Advantage – HMOs & PPOs
 Special Needs Plans
 Private Fee For Service Plans
MA Expansion Impact on Rural Areas
 Expanding insurance to rural areas and areas
previously underserved by plans
 Significant legislation:
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Risk Corridors
Stabilization Fund
Essential Hospital Payments
 Growth in enrollment in PFFS plans
 PFFS are available in 96% of rural counties
 59% of all rural beneficiaries in MA are in PFFS
plans
Medicare Managed Care Enrollment
Managed Care
Enrollment Rates
MA Enrollment Rates
Selected West Texas Counties
Total Medicare
Beneficiaries
Total Enrolled
in Medicare
Advantage
State
County
Percentage
Texas
Andrews
1885
92
4.88%
Texas
El Paso
88299
19424
22.00%
Texas
Hansford
840
18
2.14%
Texas
Lubbock
33086
1984
6.00%
Texas
Taylor
19373
1211
6.25%
Texas
Tom Green
16852
679
4.03%
Texas
Val Verde
6416
532
8.29%
The Value Driven Healthcare
Initiative (VDHC
Value-Driven Health Care System
The goal of VDHC is to provide public information
about the quality and cost of services delivered by
health care providers.
 Consumers cannot adequately compare on the
basis of quality and cost.
 Practitioners cannot compare performance to
standards of practice.
Public reporting is the surest way to achieve
better health care at lower cost.
Value Driven Healthcare Initiative
(VDHC)
I.
II.
III.
IV.
Health Information Technology
Reporting on Quality
Reporting on Prices
Incentives for Quality and Value
 Community Leaders
 Value Exchanges
The Physician Quality Reporting
Initiative (PQRI)
Physician Quality Reporting Initiative
(PQRI)
 Voluntary quality reporting program
 Doctors and other medical professionals may
participate.
 Participants may receive a 1.5% bonus on
allowed charges.
 On selected procedures participants report
procedure codes, plus a quality code.
PQRI and Rural Practitioners
 Historical impact of Medicare reimbursement
methodologies.
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Reasonable charge reimbursement
Physician fee schedule
Pay for performance
 Initial emphasis is on reporting of quality
factors and bonus payments are based on
reporting alone.
 All feedback to participants will be
confidential.
TrailBlazer Health Chosen as Medicare
Administrative Contractor
• Award for Jurisdiction 4 made on August
2, 2007
• One of 15 new MAC jurisdictions to be
awarded by 2009
•Recompeted every 5 years.
•Full transition to be implemented no later
than Spring 2008
•The transition will affect approximately
3,855,000 beneficiaries, being served by
831 hospitals and 106,000 physicians and
other health professionals.
•The jurisdiction accounts for
approximately 9.4% of the national
Medicare claims workload.
Conclusion