Healthcare Challenges - Current CMS Initiatives Steve McAdoo Deputy Regional Administrator, Dallas Centers for Medicare & Medicaid Services

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 Exam MMA 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.

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 % 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 StateCounty Total Medicare Beneficiaries Total Enrolled in any Drug PlanPercentage TexasAndrews1, % TexasEl Paso88, % TexasHansford % TexasLubbock33, % TexasTaylor19, % TexasTom Green16, % TexasVal Verde6, %

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 StateCounty Total Medicare Beneficiaries Estimate of Benes Entitled to LIS who have not appliedPercentage TexasAndrews1, % TexasEl Paso88,2994, % TexasHansford % TexasLubbock33,0861, % TexasTaylor19, % TexasTom Green16, % TexasVal Verde6, % CMS LIS Toolkit: Social Security Administration:

Medicare Advantage (MA)

Growth in Managed Care Enrollment Rural

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 Rates Selected West Texas Counties StateCounty Total Medicare Beneficiaries Total Enrolled in Medicare AdvantagePercentage TexasAndrews % TexasEl Paso % TexasHansford % TexasLubbock % TexasTaylor % TexasTom Green % TexasVal Verde %

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 Technology II. Reporting on Quality III. Reporting on Prices IV. 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