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Medicare Advantage Chronic Care Improvement Program

Training for Medicare Advantage Organizations

Marsha Davenport, MD MPHCAPT, USPHS Chief Medical Officer

and

Karla Taylor, PharmD

Medicare Drug and Health Plan Contract Administration Group

April 11, 2012

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Presentation Overview: Part I

• QI Program Overview• Background• Million Hearts Campaign• Disease Management• Components of a CCIP• Case Studies• Discussion• Brief break/Stretch

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Presentation Overview: Part II

• CCIP Reporting process• Plan-Do-Study-Act (PDSA)• CY2011 and CY2012 submissions

• Role of Central Office Quality Team• Role of Regional Office (RO) Account Managers (AM) and

Clinicians• Review CCIP Reporting Tool• Case Studies• Questions and Wrap up

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QUALITY IMPROVEMENT (QI)PROGRAM OVERVIEW

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Quality Improvement (QI) Program

• 42 Code of Federal Regulations (CFR) § 422.152

• Applies to all MAOs, including SNPs• Seven components of the QI Program• Serves to integrate and coordinate all of the assessment

tools and reporting requirements

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QI Program -2-

1. Chronic care improvement program (CCIP)• Meet the requirements of 42CFR §422.152(c)• Addresses populations identified by CMS based on review of

current quality performance

2. Quality improvement projects (QIPs)• Meet the requirements of 42CFR §422.152(d)• Expected to have a favorable effect on health outcomes and

enrollee satisfaction• Address areas identified by CMS

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QI Program -3-

3. Develop and maintain a health information system

4. Encourage providers to participate in CMS and Health & Human Services (HHS) QI initiatives

5. Contract with an approved Medicare CAHPS vendor to conduct the Medicare CAHPS satisfaction survey

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QI Program -4-

6. Include a program review process for the formal evaluation of the QI Program that addresses at least the following areas on an annual basis:• Impact• Effectiveness

7. Take remedial action to correct problems identified using ongoing quality improvement

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Defining Quality

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BACKGROUND

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Background

• Identified need to improve reporting tools for both the CCIPs and the QIPs• Follow the QI cycle of Plan, Do, Study, Act• More focused on interventions and outcomes• Participate in national health initiatives

• CCIPs must be clinical• QIPs may be clinical or non-clinical

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Background -2-

• CMS is involved in several important Department of Health and Human Services (HHS) Initiatives

• Want to ensure that our beneficiaries enrolled in the Medicare Advantage (MA) program have the opportunity to benefit from these initiatives

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Background -3-

• The required topic for the CY 2012 CCIPs is reducing risks for cardiovascular disease

• This topic is the focus of the national Million Hearts Campaign

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Background -4-

• The required topic for the CY 2012 QIPs is decreasing plan all cause readmissions

• Current HEDIS® measure• One of the goals of the national CMS Partnership for Patient

Initiative

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MILLION HEARTS CAMPAIGN

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Heart Disease and Strokes

• Also referred to has cardiovascular disease (CVD)• Over 2 million heart attacks and strokes each year• Leading killers in the U.S.

• Cause 1 of every 3 deaths ~ 800,000 deaths• Leading cause of preventable death in people < 65

Source: Million Hearts Campaign 2012

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Heart Disease and Strokes -2-

• Billions of dollars (~ $444 ) in health care costs and lost productivity

• Treatment accounts for ~ $1 of every $6 spent• Greatest differences in racial disparities for life expectancy

Source: Million Hearts Campaign 2012

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CVD Leading Cause of Shorter Life Expectancy Among African Americans

Source: Million Hearts Campaign 2012

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Improving CVD Care

• Aspirin• Blood pressure• Cholesterol• Smoking

Source: Million Hearts Campaign 2012

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Status of the ABCS

Aspirin People at increased risk of cardiovascular disease who are taking aspirin

47%

Blood pressure

People with hypertension who have adequately controlled blood pressure

46%

Cholesterol People with high cholesterol who have adequately controlled hyperlipidemia

33%

Smoking People trying to quit smoking who get help 23%

Source: Million Hearts Campaign 2012

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Million Hearts Outcomes

• 10M more people with HBP controlled• 20M more people with high

cholesterol controlled• 4M fewer people will smoke • 20% drop in average sodium intake• 50% drop in average trans fat intake

Source: Million Hearts Campaign 2012

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Key Components of Million Hearts

Community Prevention• Reduce the number of people who need treatment

Clinical Prevention• Optimize care for those people who do need treatment

Source: Million Hearts Campaign 2012

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Medical System Messages

• Clinicians • Emphasize power of prevention• Create systems to get an “A” in the ABCS• Use decision supports and registries to drive performance• Deploy teams

• Pharmacists• Monitor and influence refill patterns• Work in teams• Teach adherence

Source: Million Hearts Campaign 2012

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Medical System Messages -2-

• Insurers • Measure and incentivize performance on the ABCS; collect

and share data for quality improvement; empower consumers

• Individuals • Know your numbers—and goals • Take aspirin, if advised • Get aggressive with BP and Cholesterol• Cut sodium and trans fats• If you smoke, quit

Source: Million Hearts Campaign 2012

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Community Messages -2-

• Retailers and Employers• Offer blood pressure monitoring and educational resources• Focus on improving ABCS care in retail and worksite clinics

• Advocacy groups • Monitor and demand progress toward goal• Promote actions that prevent heart attacks and strokes

Source: Million Hearts Campaign 2012

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Community Messages

• Government • Support community and systems transformation to reduce

tobacco use and improve nutrition• Provide data for action

• Foundations • Support consumer and provider outreach and activation

Source: Million Hearts Campaign 2012

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Million Hearts: Getting to the Goal

Population metric Baseline 20171 Clinical target2

Aspirin for those at high risk ~50% 65% ~70%

Blood pressure control ~50% 65% ~70%

Cholesterol control ~33% 65% ~70%

Smoking prevalence ~20% 17% ─

Average sodium intake 3.5g/day 20% ↓ ─

Average artificial trans fat intake 1% of calories/day 50% ↓ ─

1 Population-wide indicators2 Clinical systems

Source: Million Hearts Campaign 2012

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Take the Pledge at http://millionhearts.hhs.gov/

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DISEASE MANAGEMENT

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What is Disease Management?

• Supports physician/patient plan of care• Emphasis on prevention• Outcomes evaluated continuously

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What Can Disease Management Do?

• Improve safety and quality of care• Improve access to care• Improve patient self-management• Decrease costs • Provide health improvement based on plan on population

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Disease State Selection

• Determine incidence and prevalence• Identify data sources• What data do I have to use to track and monitor progress for

the patients• Is the disease relevant to the patients• Are there gaps in the current program

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Disease State Selection -2-

• Is the disease clinically manageable• What is the current impact for the MA plan members• Will changing how the disease is managed have a positive

impact

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Disease Management: Six Required Elements

• Population identification• Evidence based guidelines• Collaborative care• Patient self-management• Process and outcome measures• Routine reporting/feedback loop

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Population Identification

• Process of identification• Data sources• Target population

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Evidence Based Guidelines

• Set of actions based on clinical research• Effectively manage or improve outcomes• Ensures consistency in treatment

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Collaborative Care Model

• Structured interdisciplinary team• Patient centered CCIP• Designed to provide best possible outcomes

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Patient Self-Management

• Systematic provision of education and supportive interventions

• Increase patient skills and confidence in managing their health

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Process and Outcome Measures

• Determines program stability• Reflects the impact on health status of the targeted

population

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Routine Reporting/Feedback Loop

• Process of communication • Keeps all care team members and patient in the loop

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COMPONENTS OF THE CHRONIC CARE IMPROVEMENT PROGRAM

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Required CCIP Disease Selection

• New for 2012• Cardiovascular Disease focus• Must still be individualized to meet the needs of the MA

plan’s population

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Components of the CCIP

• Disease state selection• Six disease management elements• Anticipated outcomes• Goal(s)• Interventions

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Anticipated Outcomes

• Determining what the program will achieve• Must positively improve health outcomes• Important factor in evaluation of the CCIP

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Goals

• Relevant to the program• Specific• Measureable• Positive effect on health outcomes• Attainable

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Interventions

• Relates to the both the disease state selected and the goals• Designed to reach the goal• Some questions to consider• Can this intervention improve health outcomes• Can the impact of the intervention be measured• Is the intervention sustainable

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CASE STUDIES

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Case Study #1: Diabetes

• Develop a Diabetes CCIP• Walk through the components of the CCIP• Provide specific examples for disease management

elements and the CCIP components

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Diabetes

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Diabetes -2-

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Diabetes -3-

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QUESTIONS

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BRIEF BREAK/STRETCH

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CCIP REPORTING PROCESS

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Plan-Do-Study-Act (PDSA) Quality Model

• Plan

Identify disease state, plan the program• Do

Implementation of the program• Study

Data collection and analysis• Act

Next Steps

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CY 2011 CCIP Submissions

• The CCIPS submitted later this Spring are based on what health plans worked on in CY 2011

• Will report using the new templates• Submitted from May 1-15, 2012• CCIPs will be scored by a contractor• New HPMS module• Training on HPMS module in late April

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CY 2012 CCIP Submissions

• Submitted in two sections• Plan section due June 11-July 31• Do-Study-Act sections will be required to be submitted in early

2013

• MAOs must work with the AMs to have the Plan section approved

• Cannot begin CCIP without the AM’s approval• Completed within HPMS using new template

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WORKING WITH CMS REGIONAL OFFICE (RO) ACCOUNT MANAGERS (AMs)

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Regional Office (RO) Account Managers (AMs)

• Will provide day-to day monitoring of the QI Program• Provide technical assistance (TA) to health plans to improve

their overall QI program• Review and approve the Plan Sections of the CCIPs and the

QIPs

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REVIEW OF THE CCIP REPORTING TOOL

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THE PLAN SECTION

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A. Basis for Selection

• A1. Disease State (not scored)• A2. Rationale for Selection• A3. Relevance to the Plan Population• A4. Anticipated Outcomes

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A2. Rationale for Selection

• The rationale for selecting the specific disease state• How the data sources showed the gap in the current care

that confirms the need for a specialized program• Incidence and/or prevalence of the disease within the MA

Plan population supported by the data sources

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A3. Relevance to the Plan Population

• How the program is relevant to the MA Plan population through incidence and/or prevalence of the disease

• The impact the disease currently has on the members• How filling the gap in care identified in A2 will improve health

outcomes

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A4. Anticipated Outcomes

• The expected outcome of the program• How the members will be impacted by the outcome• A brief description of the evidence based guidelines

considered and how these will be effective in producing improved health outcomes

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A5. Data Sources

• Section is not scored but critical to the development of the CCIP

• MAOs may chose to use data sources other than the ones listed in the CCIP reporting tool

• Incorporate information from as many of the data sources that make sense into the CCIP

• Understand the link between the data and the CCIP

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B. Program Design

• B1. Population Identification Process• B1(a). Describe the Target Population• B1(b). Method of identifying members (not scored)• B1(c). Risk Stratification (not scored)• B1(d). Enrollment method (not scored)

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B. Program Design -2-

• B2. Evidence Based Medicine• B3. Care Coordination Approach• B4. Education

• B4(a). Patient Self-Management• B4(b). Provider Education

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B. Program Design -3-

• B5. Outcome Measures and Interventions• B(5a). Goal• B5(b). Benchmark• B5(c). Goal and Benchmark indicators• B5(d). Intervention

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B. Program Design -4-

• B5. Outcome Measures and Interventions (cont’d)• B5(e). Rationale for specific intervention related to goal or

benchmark• B5(f). Measurement Methodology• B5(g)Timeline

• B6. Communication Sources (not scored)

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B1. Population Identification Process

• B1(a): Describe the target population • Inclusion criteria• Exclusion criteria• Incidence rate among the members related to the inclusion

criteria

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B1. Population Identification Process -2-

• B1(a): Describe the target population (cont’d)• The illness severity level of the members included• The demographics and clinical variables used to identify

members appropriate for inclusion in the program

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B2. Evidence Based Medicine

• The evidence based medical guidelines chosen from a credible and authoritative institution

• Why the guidelines were chosen including how their use will impact health outcomes

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B2. Evidence Based Medicine -2-

• How the guidelines will be applied to the program including • How they will be applied across different demographics

and• Different illness severity levels (with an example

provided)

• The source and date of the guidelines

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B3. Care Coordination Approach

• The internal and external team members• The team’s approach for the program• The roles and responsibilities of the team members• The model of care (MOC) or care plan• Culturally competent care

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B3. Care Coordination Approach -2-

• How the team will communicate and work together to support the member and the goal (with an example)

• How the individual member’s goals and outcomes will be assessed and addressed with an example provided

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B4(a). Education: Patient Self-Management

• Description of the planned methods and educational topics used for training, support, monitoring, and follow-up of members

• The methods are varied and take into consideration the different demographics, socioeconomic status, and cultural backgrounds of the members

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B4(a). Education: Patient Self-Management -2-

• The educational topics that support improvement in health outcomes and are designed for different acuity levels, demographics, socioeconomic status and cultural backgrounds of the members

• Training, support, monitoring, and follow up are addressed

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B4(b). Education: Provider Education

• Provider training on the applicable evidence based guidelines for the identified condition

• Methods for providing appropriate support for the members in managing their condition and monitoring of the member

• Methods and frequency for follow up of the member

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B5(a). Goal

• A goal that is specific and relevant to the program• The evidence or factors considered that show how

achieving the goal will impact health outcomes• How the goal is measureable and attainable in the set

timeframe

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B5(b). Benchmark

• A valid, reliable benchmark that is relevant to the goal of the program

• How it relates to the demographics of the target population• How use of it reflects the complexity of the disease state the

program is targeting• The current date of the benchmark

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B5(d). Intervention

• The planned intervention• How it is measureable and capable of effecting improved

health outcomes• How the intervention relates to the goal • How it is sustainable over time

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B5(e). Rationale for Specific Intervention

• The reason the intervention was chosen• How it relates to the goal and benchmark• The factors or evidence considered when developing the

intervention that demonstrates its validity • How health outcomes are anticipated to be impacted

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B5(f). Measurement Methodology

• The specific valid and reliable data that will be collected for measurement

• How the measure relates to the intervention, the goal, and the benchmark

• The systematic method in which that data will be collected• Frequency of data collection and analysis

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B5(g). Timeline

• Exact beginning and ending dates for the measurement cycle

• An explanation of how the timeline reflects an appropriate amount of time to complete the planned intervention

• The rationale for the expected timeline

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THE “DO” SECTION

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E. Program Implementation, Review, Revision

• E1. Education• E1(a). Patient Self-Management• E1(b). Provider Education

• E2. Intervention• E3. Results or Findings• E4. Barriers Encountered• E5. Mitigation Plan for Risk Assessment• E6. Anticipated Impact on the Goal and/or Benchmark

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THE “STUDY” SECTION

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F. Results

• F1. Goal• F2. Benchmark• F3. Timeline• F4. Dates of Implementation• F5. Sample Size or Percent of Total Population

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F. Results -2-

• F6. Numerator• F7. Denominator• F8. Total Percent or Results• F9. Other Data or Results• F10. Analysis of Results or Findings

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THE “ACT” SECTION

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G. The Next Steps

• G1. Continue the program with no changes• G2. Continue the program with changes• G3. Develop a QIP to study one or more aspects of the

program• G4. Discontinue the program• G5. Re-evaluate and change the goal or benchmark

selected

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G. The Next Steps -2-

• G6. Expand the program• G7. Identify additional interventions• G8. Re-evaluate data and criteria• G9. Other

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SUMMARY

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Summary

• Identify requirements of QI Program and CCIPs• Explain how CCIPs improve health outcomes and quality of

care• Describe disease management • Understand the CCIP Reporting Tool

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Disease Management and the CCIP Reporting tool

• Population identification• Plan sections A1-4• Plan section B1

• Evidence based guidelines• Plan section B2

• Collaborative Care• Plan section B3

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Disease Management and the CCIP Reporting tool -2-

• Patient self-management• Plan section B4(a)• Do section E1(a)

• Process and outcomes measures• “Plan” section B5• “Do” section E3• “Study” section

• Reporting and feedback loop• “Act” section

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Case Study #1: Diabetes

• Develop a Diabetes CCIP• Walk through the components of the CCIP• Provide specific examples for disease management

elements and the CCIP components

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Diabetes

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Diabetes -2-

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Diabetes -3-

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Contact Information

Marsha Davenport, MD, MPH

CAPT, USPHS

Chief Medical Officer

Medicare Drug and Health Plan Contract Administration Group (MCAG)

MAQuality@cms.hhs.gov

410-786-0230