Healthcare Challenges -Current CMS Initiatives

Steve McAdooDeputy Regional Administrator, DallasCenters for Medicare & Medicaid Servicessteve.mcadoo@cms.hhs.gov214-767-6427

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”physical exam

Bone mass measurement

Cardiovascular screening

Colorectal cancer screening

Diabetes screening, services, and supplies

Glaucoma screening Pap test and pelvic exam

with clinical breast exam Prostate cancer screening Screening mammogram Smoking cessation

counseling Influenza, Pneumococcal

and Hepatitis B immunization

“Welcome to Medicare” Physical ExamMMA Section 611

Initial preventive physical exam 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

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 RatesSelected West Texas Counties

State County

Total Medicare Beneficiaries

Total Enrolled in any Drug Plan 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 PenetrationSelect West Texas Counties

State County

Total Medicare Beneficiaries

Estimate of Benes Entitled to LIS who have not applied

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

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

2005

350,000

2006

520,000

2007

780,000

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: 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 RatesSelected West Texas Counties

State County

Total Medicare Beneficiaries

Total Enrolled in Medicare Advantage 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. Health Information TechnologyII. Reporting on QualityIII. Reporting on PricesIV. 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. 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