1. Overview Sandra M. Foote Senior Advisor, Chronic Care Improvement
Centers for Medicare & Medicaid Services
November 1, 2005

2. Develop and test new programs designed to help
The MHS Challenge
Develop and test new programs designed to help
targeted chronically ill beneficiaries reduce their
health risks
Section 721: “Voluntary Chronic Care Improvement in Traditional Fee-For-Service”of the Medicare Prescription Drug, Improvement and Modernization Act of 2003
First time that Congress has authorized CMS to targeted specific subgroups of chronically ill people and invest millions to help them reduce their health risks
Calling the program Medicare Health Support because that’s in fact what best describes what we’re trying to do—help people stay healthier and avoid costly and debilitating complications.
It also resonates better with the targeted beneficiaries. They want to stay healthy and independent.

3. Fee-For-Service Medicare
Context
Fee-For-Service Medicare
35 million people
$281 billion/year
(projected 2005)
Begin by setting context: Why did Congress take this groundbreaking step and why is this new mandate to CMS so exciting and significant?
1. FFS Medicare is enormous—both in terms of people affecting and how many $$ it drives in the health care system

4. Subgroups Driving Cost
People with chronic diseases drive Medicare costs. The note that costs shown include including all the co-morbidities and complications of the subgroups is an important distinction. Most people in the FFS Medicare population have more than one chronic condition.
NOTE: Spending includes treatment of co-morbidities, by enrollee subgroup, 2002
SOURCE: C. Hogan and R. Schmidt, MedPAC Public Meeting, 03/18/2004

5. Multiple Health Risks
63% of Medicare beneficiaries have 2 or more chronic conditions *
On average, Medicare beneficiaries see 6.4 MDs and fill 20 Rx per year*
23% of beneficiaries have 5 or more chronic conditions**
*Medicare Standard Analytic File, Anderson GF. Testimony on Promoting
Disease Management in Medicare -
**Medicare Standard Analytic File, Anderson GF. N Engl J Med 2005; 353;
In fact, on average they have at least two. They typically see lots of different doctors and fill lots of RX. And note that nearly a quarter of all M beneficiaries have 5+ conditions.

6. Multiple Health Risks On average, beneficiaries with 5 or more
chronic conditions see 14 MDs* and fill 57 Rx per year.** *
** Older Americans, Federal Interagency Task Force on Aging-Related Statistics
Those people—the 23% w/ 5+ conditions – on average see 14 different doctors and fill 57 Rx a year.
What a difficult context they operate in. As Cynthia Boyd and colleagues wrote recently in JAMA: “Comorbidity is associated with poor quality of life, physical disability, high health care use, multiple medications and increased risk of adverse drug events and mortality. Optimizing care for this population is a high priority.” Boyd CM et al., JAMA, 2005, 294:
Percent of Medicare Spending
Johns Hopkins University, Partnership for Solutions: Medicare Standard Analytic File, 2001

7. Phase I: Developmental
8 pilot programs; each to run 3 years
20,000 beneficiaries per program; 10,000 per
control group—randomly assigned
Phase II:Expansion will follow in 2–3.5 years, if
pilots (or components) are successful
So that brings us to the MHS initiative. The statute organized it in 2 phases. Phase I: Developmental to prove we and our awardees can carry out these programs well and cost-effectively; Phase II: Expansion to follow in years if we’re successful.

8. MHS Phase I:Developmental
Phase I Programs
7 of 8 live as of TODAY.
Vastly different geographies, populations, healthcare contexts
Each program is unique. Trying some very interesting models of support.
MHS Phase I:Developmental

9. Who is eligible? Medicare Fee-For-Service only
Pre-selected by CMS through claims review, applying selection criteria (e.g., not in hospice)
All have diabetes and/or congestive heart failure and HCC risk scores of 1.35 or above
Only individuals invited by CMS can participate in Phase I programs
COMMONALITIES: Eligibility same for all the pilots

10. No charge to participants
Key Features
Voluntary
No charge to participants
No change in Medicare benefits, choice of providers or claims payment
Supportive, not restrictive
Not a substitute for current care
All pilots are an OVERLAY to FFS Medicare. They don’t change key tenets of FFS M ( We hope this overlay approach will encourage beneficiaries’ willingness to participate.)

11. Personalized Support Beneficiary Health Risk Reduction Medical
Care
Support
Coordination
&
Communication
Beneficiary
Self-Care
Support
Personalized and HOLISTIC approach
What we’re doing is exactly what IOM recommended – self-care support and assistance dealing with fragmentation.
Examples: Self-care: 590 blood sugar story; Communication: Russian speakers; MCS: 2 different antihypertensives
Health Risk Reduction

12. Rx Therapy Management Participant self-report of medications
Part D Rx claims data – plan to start April, 2006
Statutory obligation for Part D plans to coordinate Rx therapy management with MHS programs for MHS targeted beneficiaries *
*Federal Register, January 28, 2005, (d)(4)
“The MTMP must be coordinated with any care management plan established for a targeted individual under a CCIP
Under Section 1807 of the Act. A Part D sponsor must provide drug claims data to CCIPs in a manner specified by CMS.” FR 1/28/2005, (d)(4)
Exactly how deal with MTM and coord w Part D plans? Yet to be determined

13. New Population-Based Model
Fees at risk: QI, $, satisfaction
Targeted
Beneficiaries
MHS
Organization
CMS
Beneficiaries’
Physicians
NEW POPULATION BASED BUSINESS MODEL will encourage aggressive attention to optimizing MTM.
Fees at risk for QI, satisfaction, $$
Part D Plans
Data exchange
Fee per person/month

14. Flexibility to customize and innovate
Advantages of Model
Flexibility to customize and innovate
Incentives for regional collaborations
Emphasis on cost-effectiveness
Savings measured across provider “silos”
Sufficient scale to detect significant impacts
on population health
Advantages of this NEW MODEL notable because so different from other CMS disease management and P4P initiatives.
CMS-ASSIGNED POPULATION—not in older DM initiatives. FEES AT RISK for population outcomes: Not in other initiatives. SAVINGS to Medicare across all provider types, all diseases (not just within MD or RX)
Regional and VERY LARGE SCALE

15. National Organizations Helping to Promote Understanding of MHS
…AND MANY OTHERS!

16. Emerging Partnerships
Many new national and regional alliances
developing with awardees
Examples:
American College of Physicians
American College of Cardiology
American Academy of Family Physicians
American Geriatric Society
“ACP recognizes the opportunity for the CCIP to improve continuity of care, improve patient health knowledge, reinforce adherence to physician care plans and improve quality of life for seniors living with chronic conditions," said ACP Chief Executive Office and Senior Vice President John Tooker, MD, MBA, FACP. “
1/21/05

17. Expected Results Improved health and quality of life
Lower average Medicare costs
Reduced complications, emergencies and hospital
admissions
Increased adherence to evidence-based care
Better coordination of care through use of new health information and communication technologies
To summarize…

18. More Envisioned Results
Programs well accepted by physicians
Focus on total health, not selected diseases
Adaptable, scalable and replicable nationally
Quality and cost outcomes sustainable over time
Administrative model works
Business model (fees at risk) successful
Programs effective in dually eligible populations

19. Where is MHS leading?
New strategies to improve chronic care cost-effectively on a national scale
Focus on prevention
New partnerships
Fostering innovation
Accountability for performance

20. More Information Website: http://www.cms.hhs.gov/medicarereform/ccip/
Contact information: