June 20, 2018
By Seema Verma, Administrator, Centers for Medicare & Medicaid Services
Working Together for Value
Over the past year, the Centers for Medicare & Medicaid Services (CMS) has engaged with the provider community in a discussion about regulatory burden issues. This included publishing a Request for Information (RFI) soliciting comments about areas of high regulatory burden. One of the top areas of burden identified in the over 2,600 comments received was compliance with the physician self-referral law (often called the “Stark Law”) and its accompanying regulations. In response to these concerns, CMS undertook a review of the existing regulations to determine where the agency could consider potential areas for burden reduction. In coordination with HHS Deputy Secretary Eric Hargan, CMS is now soliciting specific input on a range of issues identified with the Stark Law to help the agency better understand provider concerns and target its regulatory efforts to address those concerns.
The Stark Law was enacted in the 1980s to help protect Medicare and its beneficiaries from unnecessary costs and other harms that may occur when physicians benefit from referring patients to health care entities with which they have a financial relationship. The law prohibits a physician from making referrals for certain health care services to an entity with which he or she (or an immediate family member) has a financial relationship. There are statutory and regulatory exceptions, but in short, a physician cannot refer a patient to any service or provider in which they have a financial interest.
Stark also prohibits the entity from filing claims with Medicare for services resulting from a prohibited referral and Medicare cannot pay if the claims are submitted. In its current form, the physician self-referral law may prohibit some relationships that are designed to enhance care coordination, improve quality, and reduce waste.
To achieve a truly value-based, patient-centered health care system, doctors and other providers need to work together with patients. Many of the recent statutory and regulatory changes to payment models are intended to help incentivize value based care and drive the Medicare system to greater value and quality. This has been a priority of CMS and HHS and is reflected in many of our current ongoing initiatives. Medicare’s regulations must support this close collaboration. The Stark Law and regulations, in its current form, may hinder these types of arrangements. To help better understand the impediments to better coordinated care caused by existing regulatory efforts, this RFI seeks to obtain input about how to address those concerns.
We invite you to share your ideas and suggestions as we work together for coordinated care and a better health care system for all Americans. The RFI can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/.
June 11, 2018
CMS Opioids Roadmap
Although some progress has been made in efforts to combat the opioid epidemic, the latest data from the Centers for Disease Control and Prevention indicate the crisis is not slowing down. However, it is important for our beneficiaries across the country to know that the Centers for Medicare & Medicaid Services (CMS) is exploring all of our options to address this national crisis.
As evidence of our commitment to the health and well-being of patients, CMS is publishing a roadmap outlining our efforts to address this issue of national concern. In this roadmap, we detail our three-pronged approach to combating the opioid epidemic, focusing in on prevention of new cases of opioid use disorder (OUD), the treatment of patients who have already become dependent on or addicted to opioids, and the utilization of data from across the country to target prevention and treatment activities.
Current estimates show that over two million[i] people suffer from opioid use disorder, with a prevalence in Medicare of 6 out of every 1,000 beneficiaries.[ii] In order to decrease that number, it is crucial that Medicare beneficiaries and providers are aware that there are options available for both prevention of developing new cases of OUD and the treatment of existing cases. CMS is working to ensure that beneficiaries are not inadvertently put at risk of misuse by closely monitoring prescription opioid trends, strengthening controls at the time of opioid prescriptions, and encouraging healthcare providers to promote a range of safe and effective pain treatments, including alternatives to opioids. We are also working on communications with beneficiaries to explain the risks of prescription opioids and how to safely dispose of them, so they are not misused by others. These are just some of the ways we are looking to protect and care for people with Medicare.
CMS also recognizes that the opioid epidemic has affected people covered by Medicaid across the country in different ways – an estimated 8.7 out of 1,000 Medicaid beneficiaries are impacted by OUD. We believe one crucial effort to help on the treatment front is encouraging states to tailor programs to their populations by taking advantage of flexibilities that are available through Medicaid Section 1115 substance use disorder (SUD) demonstrations that improve OUD treatment. CMS has worked with seven new states since October 2017 to approve waivers to tackle the opioid epidemic in their state. With each state having a unique population, we recognize the challenges that states face in creating programs to help, and we are committed to providing the support necessary to help states achieve positive results for their populations.
Beyond Medicare and Medicaid, CMS is also looking across our other programs to use all the tools at our disposal to address the opioid crisis. We are working to ensure that the private plans offering coverage on the Health Insurance Exchanges also provide options for treating OUD, and we are examining our quality standards across our programs to encourage providers to follow best practice guidelines related to opioid misuse diagnosis and treatment. Further, while we have initiatives specific to Medicare and Medicaid, we are also reviewing all of our programs to find solutions that are working at the local level with states, providers, and payers so that we can disseminate successful ideas as quickly as possible to help our partners know that they do not have to solve this alone.
CMS believes we can make progress in addressing the many aspects of the opioid epidemic in partnership with states and other stakeholder organizations. Every day this crisis claims the lives of loved ones and, in many areas in our country, we have yet to turn the tide. This roadmap is only a start, and as we begin to implement many of our plans and programs, it will continue to evolve. But the roadmap is also a demonstration of CMS’ commitment to explore and offer viable options to address the crisis, to share the information we collect with other agencies and organizations, and to protect our beneficiaries and communities affected by the crisis.
By: Administrator, Seema Verma, Centers for Medicare & Medicaid Services
In his first 500 days in office, President Donald J. Trump has achieved results both at home and abroad for the American people, working to ensure government is more accountable to the American people. One of the many promises the Trump Administration has made and kept is improving accountability and transparency in Medicaid.
Medicaid provides healthcare for more than 75 million Americans, including many of our most vulnerable citizens, at an annual cost of over $558 billion. It has grown significantly over the years, consuming an every greater share of our public resources – from 10 percent of state budgets in 1985 to nearly 30 percent in 2016. Medicaid should improve the lives of those it serves by delivering high quality health care and services to eligible individuals at a maximum value to American taxpayers. As the administrators of the program, states, along with their local healthcare professionals who care for their neighbors, know best the unique healthcare needs of their community. Our success on delivering on Medicaid’s promise hinges on the critical role they play in managing the precious state and federal resources with which we are entrusted.
That’s why we have committed to resetting the state-federal partnership by ushering in a new era of state flexibility. We’ve approved groundbreaking Medicaid demonstration projections, including reforms to test how Medicaid can be designed to improve health outcomes and lift individuals from poverty by connecting coverage to community engagement. We are streamlining our internal processes and breaking down regulatory barriers that force states to commit too much of their time and resources to administrative tasks rather than focusing on delivering better care.
But with that commitment to flexibility must come an equal pledge to improve transparency and accountability. Too often we have struggled to articulate our collective performance in executing on our immense responsibility. This is best reflected in the fact that Medicaid is responsible for approximately half of the nation’s births, yet no one will argue that we are achieving the birth outcomes our future generations deserve. As we return power to states, we must shift our oversight role at CMS to one that focuses less on process and more on holding us all collectively accountable for achieving positive outcomes.
That is precisely why, last November, I announced that we would create the first ever CMS Medicaid and CHIP Scorecard to increase public transparency about the programs’ administration and outcomes. The data offered within the Scorecard begins to offer taxpayers insights into how their dollars are being spent and the impact those dollars have on health outcomes. The Scorecard includes measures voluntarily reported by states, as well as federally reported measures in three areas: state health system performance; state administrative accountability; and federal administrative accountability. As states continue to seek greater flexibility from CMS, the Scorecard will serve as an important tool in ensuring that CMS is able to report on critical outcome metrics.
The first version of the Scorecard is foundational to CMS’s ongoing efforts to enhance Medicaid and CHIP transparency and accountability. We’ve begun this initiative by publishing selected health and program indicators that include measures from the CMS Medicaid and CHIP Child and Adult Core Sets along with federal and state accountability measures. For the first time, we are publicly publishing measures that show how we are doing in the business of running these immense programs, including things like how quickly we review state managed care rate submissions or approve state section 1115 Medicaid demonstration projects. Our stakeholders, including beneficiaries, providers, and advocates, deserve to have this information available to them.
And we’re just getting started. Public reporting of meaningful quality and performance metrics is an important and ongoing responsibility of states and the federal government given Medicaid’s vital role in covering nation’s children and as the single greatest payer for long-term care services for the elderly and people with disabilities.
That’s why, in future years, the Scorecard will be updated annually with new functionality and new metrics as data availability improves, including measures that focus on program integrity as well as opioid and home and community-based services quality metrics. Over time, we plan to add the ability for users of the Scorecard to generate year-to-year comparisons on key metrics, as well as to compare states on measures of cost and program integrity. While some variation may be inherent based on geographic, population, reporting or programmatic differences, the public should have access to information that allows them to understand how and why costs and outcomes can vary from state to state for the same populations. Then we can begin to ask important questions about what may really be driving differences in quality and efficiency.
CMS recognizes that continued insight from our state partners is a critical component in the maintenance of the Scorecard. I want to thank all the states for their assistance in the creation of this first iteration, particularly the 14 states that served on the National Association of Medicaid Director’s workgroup over the last six months. Many of the measures are only possible because of the commitment from states to collect and report on these important metrics. Through this partnership with states, CMS will continue to advance policies and projects that increase flexibility, improve accountability and enhance program integrity and are designed to fulfill Medicaid’s promise to help Americans lead healthier, more fulfilling lives.
By: Administrator, Seema Verma, Centers for Medicare & Medicaid Services
Quality Payment Program Exceeds Year 1 Participation Goal
I’m pleased to announce that 91 percent of all clinicians eligible for the Merit-based Incentive Payment System (MIPS) participated in the first year of the Quality Payment Program (QPP) – exceeding our goal of 90 percent participation. Remarkably, the submission rates for Accountable Care Organizations and clinicians in rural practices were at 98 percent and 94 percent, respectively. What makes these numbers most exciting is the concerted efforts by clinicians, professional associations, and many others to ensure high quality care and improved outcomes for patients.
Meeting the Challenges Ahead
Even with this high rate of participation, we are committed to removing more of the regulatory burdens that get in the way of doctors and other clinicians spending time with their patients. After only eight months, we’ve made significant progress through our Patients over Paperwork initiative: streamlining our regulations, increasing efficiencies, and improving care for patients. At the same time, we continue to put patients first by protecting the safety of our beneficiaries and strengthening the quality of healthcare they receive.
For example, we reviewed many of the MIPS requirements and developed policies for 2018 that continue to reduce burden, add flexibility, and help clinicians spend less time on unnecessary requirements and more time with patients.
In particular we have:
Under the Bipartisan Budget Act of 2018 we have additional authority to continue our gradual implementation of certain requirements for three more years to further reduce burden in areas of MIPS.
We’re also eager to improve the clinician and patient experience through our Meaningful Measures initiative so that clinicians can spend more time providing care to their patients and improving the quality of care their patients receive. Within MIPS, we are adopting measures that improve patient outcomes and promote high-quality care, instead of focusing on processes.
Working with the Healthcare Community
We want to express our gratitude to all of the clinicians who collaborated with us as part of the voluntary Clinician Champions Program and the Clinician Voices initiative. We also want to thank all of you who participated in our various listening sessions and user groups throughout the year. Your input and feedback opened a dialogue, highlighted opportunities for improvement, and helped us identify ways to continue to reduce burden within the Quality Payment Program.
We deeply appreciate the contributions professional associations, consumer advocates and other important stakeholders have made to help engage their members and prepare them for success. We also want to acknowledge the networks supporting the free technical assistance available to clinicians, specifically the Small, Underserved, and Rural Support initiative, Quality Innovation Networks, and the Transforming Clinical Practice Initiative, who worked tirelessly to help clinicians familiarize themselves with the program so they can successfully participate. Together with our stakeholders and technical assistance networks, we hosted over 6,000 Quality Payment Program events last year. We used these events to describe requirements, offer tips, listen to you, and act on your feedback.
And, we’re proud to announce that our free technical assistance received a 99.8 percent customer satisfaction rating by over 200,000 clinicians and practice managers. The technical assistance networks also responded to 98.7 percent of initial referrals for additional support from the Quality Payment Program Service Center and Centers for Medicare & Medicaid Services (CMS) Regional Offices within 1-business day. We believe that there is an obligation to respond quickly, so clinicians can spend less time trying to figure out the program and more time with their patients.
Additionally, our Quality Payment Program Service Center complemented the technical assistance effort by fielding more than 130,000 inquiries and delivering world class customer support.
Better yet, all of the free and customized support from the technical assistance networks and the Quality Payment Program is still available to clinicians in the 2018 performance year!
Moving Forward Together
While we’re proud of what has been accomplished, there is more work to be done. CMS remains committed to listening to the healthcare community and exploring ways to reduce clinician burden, strengthen quality, introduce new payment models, develop meaningful measures including for patient safety, and promote interoperability. We look forward to continuing to hearing from you to make sure that we focus on patients, not paperwork.
By CMS Administrator Seema Verma
Nationally expanded performance-based payment model now enrolling service suppliers
The Centers for Medicare & Medicaid Services (CMS) in April expanded the Medicare Diabetes Prevention Program (MDPP), a national performance-based payment model offering a new approach to type 2 diabetes prevention in eligible Medicare beneficiaries with an indication of pre-diabetes. For the first time, both traditional healthcare providers and community-based organizations can enroll as Medicare suppliers of health behavior change services. This innovative model promotes patient-centered care and continues to test market-driven reforms to drive quality of care and improve outcomes for America’s seniors, more than a quarter of whom have type 2 diabetes.
CMS recognizes that prevention is a critical part of creating an affordable healthcare system that puts patients first, and we encourage eligible suppliers to partner with us on this shared goal by participating in the national expansion of the MDPP.
As the CMS Innovation Center’s first preventive services model test to expand nationally, the MDPP is a key example of how we’re putting innovation to work. The model launched in 2012 as a small, voluntary model test at 17 sites across the country in partnership with the YMCA-USA, Centers for Disease Control and Prevention (CDC), and other public and private partners. Now, CMS is expanding this set of services nationwide based on promising results. In the initial model test, 45 percent of beneficiaries met the 5 percent weight loss target, which translates to a clinically meaningful reduction in the risk of developing type 2 diabetes.
Through the MDPP, trained community health workers and other health professionals empower beneficiaries at high risk of developing type 2 diabetes to take ownership of their health through curriculum-driven coaching and proven behavior change strategies for weight control. As a new preventive service for qualifying Medicare beneficiaries, MDPP services are available without a referral or co-payment.
The MDPP is not only a good value for our beneficiaries. Investing in prevention through performance-based payments and market-based incentives, this promising model will save the Medicare program more than $180 million by keeping beneficiaries healthy and averting new cases of diabetes[i].
One of the critical innovations in the MDPP is its approach to care delivery: For the first time, community-based organizations can enroll in Medicare to provide evidence-based diabetes prevention services after achieving preliminary or full recognition through the CDC. These organizations can enroll in Medicare to become an MDPP Supplier today, and CMS will continue to accept supplier applications on a rolling basis. Eligible organizations can begin the screening and enrollment process to become an MDPP Supplier by using the Provider Enrollment Chain and Ownership System (PECOS) or submitting the paper CMS-20134 Form. For information on the steps to enrollment, please refer to the MDPP Enrollment Fact Sheet.
Diabetes exerts an unacceptable toll on our beneficiaries, their families, and the Medicare program, which spends more than $104 billion every year treating patients with this preventable disease. The Medicare Diabetes Prevention Program is leveraging innovation to bring valuable preventive services to our beneficiaries, and I urge eligible organizations across the country to enroll today in this exciting performance-based payment opportunity.
[i] Federal Register. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program; Final Rule. November 15, 2017. [pg. 53355 – 53356] https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
March 2, 2018
By Kate Goodrich, MD
Director, CMS Center for Clinical Standards and Quality & CMS Chief Medical Officer
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity:Measure Development for the Quality Payment Program
CMS is pleased to announce a new funding opportunity for the development, improvement, updating, and expansion of quality measures for use in the Quality Payment Program. CMS will be partnering directly with clinicians, patients, and other stakeholders to provide up to $30 million of funding and technical assistance in development of quality measures over three years.
Cooperative agreements provide a unique opportunity for CMS to partner with external entities, such as clinical specialty societies, clinical professional organizations, patient advocacy organizations, educational institutions, independent research organizations, and health systems, in developing, improving, updating, and expanding quality measures for the Quality Payment Program. By giving external entities needed resources to help guide their measure-development efforts though this funding opportunity, CMS can leverage the unique perspectives and expertise of these external entities, such as clinician and patient perspectives, to advance the Quality Payment Program measure portfolio. The cooperative agreements will allow CMS to collaborate with stakeholders to address essential topics such as: clinician engagement, burden minimization, consumer-informed decisions, critical measure gaps, quality measure alignment, consumer-informed decisions, clinician engagement, and efficient data collection that minimizes health care provider burden.
The priority measures developed, improved, updated or expanded under the cooperative agreements will be aligned with the CMS Quality Measure Development Plan. The CMS Quality Measure Development Plan provides a strategy for filling clinician and specialty area measure gaps and for recommendations to close these gaps in order to support the Quality Payment Program, and identifies the following initial priority areas for measure development: Clinical Care, Safety, Care Coordination, Patient and Caregiver Experience, Population Health and Prevention, and Affordable Care. The gap areas include, but not limited to: Orthopedic Surgery, Pathology, Radiology, Mental Health and substance use conditions, Oncology, Palliative Care, and Emergency Medicine.
More broadly than the CMS Quality Measure Development Plan, which is specific for the Quality Payment Program, CMS measures work is guided by the Meaningful Measurement framework which identifies the highest priorities for quality measurement and improvement. The Meaningful Measure Areas serve as the connectors between CMS goals under development and individual measures/initiatives that demonstrate how high quality outcomes for our Medicare, Medicaid, and CHIP beneficiaries are being achieved. They are concrete quality topics which reflect core issues that are most vital to high quality care and better patient outcomes.
Through these cooperative agreements, CMS aims to provide the necessary support to help external entities expand the Quality Payment Program quality measure portfolio with a focus on clinical and patient perspectives and minimizing burden for clinicians. Focusing on patient perspectives will ensure measures focus on what is important to patients and drive the improvement of patient outcomes. To accomplish this, the cooperative agreements prioritize the development of: outcome measures, including patient reported outcome and functional status measures; patient experience measures; care coordination measures; and measures of appropriate use of services, including measures of overuse.
For more information, search for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program on Grants.gov or visit our website, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html.
By: Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS Chief Medical Officer
Medicare and other payers are rapidly moving toward a healthcare system that rewards high quality care while spending more wisely. Foundational to the success of these efforts is having quality measures that are meaningful to patients, consumers, and providers alike. CMS recently announced the “Meaningful Measures” initiative to identify the most impactful areas for quality measurement and improvement and reflect core issues that are most vital to high quality care and better individual outcomes. Each year, CMS publishes a list of quality and cost measures that are under consideration for Medicare quality reporting and value-based purchasing programs, and collaborates with the National Quality Forum (NQF) to get critical input from multiple stakeholders, including patients, families, caregivers, clinicians, commercial payers and purchasers, on the measures that are best suited for these programs. Ultimately, these measures may help patients choose the nursing home, hospital, or clinician that is best for them, and can help providers to provide the highest quality of care across care settings.
I am happy to announce that CMS posted the Measures under Consideration (MUC) List for 2018 pre-rulemaking on the CMS website and has sent it to NQF in preparation for multi-stakeholder input.
This year’s MUC List contains 32 measures that have the potential to drive improvement in quality across numerous settings of care, including clinician practices, hospitals, and dialysis facilities. CMS is considering new measures to help quantify healthcare outcomes and track the effectiveness, safety and patient-centeredness of the care provided. At the same time, CMS is taking a new approach to coordinated implementation of meaningful quality measures focused on the most critical, highly impactful areas for improvement while reducing the burden of quality reporting on all providers so they can spend more time with their patients. In addition to other factors, CMS evaluated the measures on the MUC list to ensure that measures considered for adoption in a CMS program through rulemaking as necessary, focus on clearly defined, meaningful measure priority areas that safeguard public health and improve patient outcomes. For example, to generate this year’s MUC list, CMS considered 184 measures submitted by stakeholders during an open call for measures. Considering the meaningful measurement areas, CMS narrowed the list to 32 measures (17% of the original submissions) which focus CMS efforts to achieve goals of high quality healthcare and meaningful outcomes for patients, while minimizing burden. CMS will continue to use the Meaningful Measures approach to strategically assess the development and implementation of quality measure sets that are the most parsimonious and least burdensome, that are well understood by external stakeholders, and are most likely to drive improvement in health outcomes.
This year, approximately 40% of measures on the MUC list are outcome measures, including patient-reported outcome measures, which will help empower patients to make decisions about their own healthcare and help clinicians to make continuous improvements in the care provided. In addition, this year there are eight episode-based cost measures proposed that were developed by incorporating the insight and expertise of clinicians and specialty societies. CMS is committed to working with clinicians, consumers, and other stakeholders on the development and use of measures that are most meaningful to patients and clinicians and our programs.
We invite you to review the MUC List in detail and to participate in the public process. We believe it is critical to hear a wide range of voices in the selection of quality and efficiency measures that are used for accountability and transparency purposes and look forward to another successful pre-rulemaking season. For more information regarding the NQF Measure Applications Partnership public stakeholder review meeting purpose, meetings, 2017 MUC List deliberations and voting, visit the NQF website at http://www.qualityforum.org/map/.
By Kate Goodrich, MD
Director, CMS Center for Clinical Standards and Quality & CMS Chief Medical Officer
CMS is actively working to move the needle on improving quality in healthcare without additional burden to those providers on the frontlines. CMS recently launched a new initiative, ‘Meaningful Measures,’ which will streamline current measure sets – so providers can focus on the measures that are most impactful – and will move from process measures to outcome measures where possible. A great deal of attention has also been focused on alignment of quality measures within CMS and with commercial payers, and we are committed to working towards alignment of these measures to ensure delivery of high quality care to all Americans while minimizing burden on providers.
I am pleased to announce that CMS is deploying an innovative tool that provides all stakeholders improved visibility into the portfolio of CMS measures. The CMS Measures Inventory Tool (CMIT), an interactive web-based application that contains the same information that is currently included on the Excel spreadsheet, provides a comprehensive list of measures that are currently under development, implemented for use, and have been removed from a CMS quality program or initiative. The intuitive and user-friendly functions allow you to find measures quickly and to compile and refine sets of related measures. The tool increases transparency and can be used to identify measures across the continuum of care and will help coordinate measurement efforts across all conditions, settings, and populations. We have expanded the information contained in the inventory to better answer questions we have heard from the public; the CMIT lists each measure by program, dates of measure consideration and implementation, and measure specifications including, but not limited to, numerator, denominator, exclusion criteria, measure type, and National Quality Forum (NQF) endorsement status.
CMIT is an innovative approach that will help to promote the goal of increased alignment across programs and with other payers. We believe it is an easy to use valuable resource to various stakeholders, including commercial payers, clinicians, patients and measure developers.
For more information about CMIT and to access the tool, please visit the CMS.gov website.
November 16, 2017
By: Seema Verma, CMS Administrator @SeemaCMS
Today, CMS is celebrating National Rural Health Day by commemorating our partners who provide quality care to the nearly one in five Americans who reside in rural communities. CMS recognizes the unique challenges facing rural America, and we are taking action to improve access and quality for healthcare providers serving rural patients.
This fall, I have been visiting communities throughout the country to learn more about issues critical to improving access to rural healthcare. I travelled to Kansas City and visited the headquarters of the National Rural Health Association to talk with key leadership and stakeholders to hear how CMS can reduce the challenges rural communities face. CMS is committed to evaluating our policies and looking at each of them through a rural lens to ensure rural providers greater flexibility and less regulatory burden.
New technologies are emerging that have strong promise to address access issues in rural communities. CMS is trying to modernize the Medicare program so that beneficiaries can make use of the new technology. For example, CMS recently released new telehealth payment codes in Medicare so more services can be accessed in rural areas. This is only the beginning of our overall strategy to update our programs and improve access to high quality services.
Rural hospitals also face challenges in recruiting physicians. CMS is addressing this challenge by placing a two-year moratorium on the direct supervision requirement for outpatient therapeutic services at Critical Access Hospitals and small rural hospitals. This policy helps to ensure access to outpatient therapeutic services for Medicare beneficiaries living in rural communities and provides regulatory relief to America’s small rural hospitals. In Medicare Advantage plans, we are working to ensure network standards offer the flexibility needed to provide greater health care plan choices to rural beneficiaries. These reforms are in line with our focus on improving the beneficiary experience.
In response to feedback received from Critical Access Hospitals and other rural stakeholders, CMS recently announced that Critical Access Hospitals should no longer expect to receive medical record reviews related to the 96-hour certification requirement absent concerns of probable fraud, waste, or abuse.
We are also now providing technical assistance and greater flexibilities to small and rural clinicians to help facilitate their participation in the Quality Payment Program (QPP). These efforts are aligned with our goal of reducing regulatory burden so clinicians are able to spend more time on patient care and healthier outcomes, and less time on paperwork. One way we have done this is to provide free and customized technical assistance to support small and rural clinicians every step of the way, as well as assistance through our Service Center, Regional Offices, and the QPP page on cms.gov.
We have finalized several policies to reduce burdens and help clinicians in small practices successfully participate in the QPP program. Some of these include:
In our effort to consider a new direction that promotes patient-centered care and test market-driven reforms, the CMS Innovation Center is currently seeking suggestions on improving rural healthcare by way of a recently released Request for Information (RFI). The opportunity to provide recommendations for the new direction closes November 20 and if you have not already, we hope you will share your thoughts.
CMS has also developed a number of resources to help rural providers and other stakeholders. To improve the customer experience and further empower our rural providers, we are centralizing rural healthcare resources into a single website which you can find here.
And finally, CMS does not operate in a vacuum. We work closely with other federal partners including the Health Resources and Services Administration, the Office of the National Coordinator, and the Centers for Disease Control and Prevention, among others, to ensure our efforts to improve care in rural America are consistent with those agencies’ rural initiatives. CMS will continue to listen to, work with, and value the input from rural stakeholders. Together, we can improve care in rural America. Happy National Rural Health Day!
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November 15, 2017
By Kimberly Brandt, Principal Deputy Administrator for Operations (@cms.hhs.gov)
The Centers for Medicare & Medicaid Services (CMS) is committed to reducing improper payments in all of its programs, as evidenced by improper payment reduction efforts contained in the Fiscal Year 2018 President’s Budget. CMS’s new leadership is re-examining existing corrective actions and exploring new and innovative approaches to reducing improper payments, while minimizing burden for its partners. Due to the successes of actions we’ve put into place to reduce improper payments, the Medicare Fee-For-Service (FFS) improper payment rate decreased from 11.0 percent in 2016 to 9.5 percent in 2017, representing a $4.9 billion decrease in estimated improper payments. The 2017 Medicare FFS estimated improper payment rate represents claims incorrectly paid between July 1, 2015 and June 30, 2016. This is the first time since 2013 that the Medicare FFS improper payment rate is below the 10 percent threshold for compliance established in the Improper Payments Elimination and Recovery Act of 2010.
Improper payments are not always indicative of fraud, nor do they necessarily represent expenses that should not have occurred. For example, instances where there is insufficient or no documentation to support the payment as proper are cited as improper payments under current Office of Management and Budget guidance. The majority of Medicare FFS improper payments are due to documentation errors where CMS could not determine whether the billed items or services were actually provided, were billed at the appropriate level, and/or were medically necessary. A smaller proportion of Medicare FFS improper payments are payments for claims CMS determined should not have been made or should have been made in a different amount, representing a known monetary loss to the program.
Figure 1 provides information on Medicare FFS improper payments that are a known “monetary loss” to the program (i.e. medical necessity, incorrect coding, and other errors). The estimated known “monetary loss” improper payment rate is 3.0 percent, representing an estimated known monetary loss of $11.3 billion out of the total estimated improper payments of $36.2 billion. In the figure, “unknown” represents payments where there was no or insufficient documentation to support the payment as proper or a known monetary loss. In other words, when payments lack the appropriate supporting documentation, their validity cannot be determined. These are payments where more documentation is needed to determine if the claims were payable or if they should be considered monetary losses to the program.
Figure 1: FY 2017 Medicare FFS Improper Payments (in Millions) and Percentage of Improper Payments by Monetary Loss and Type of Error
CMS continues to implement tools and work with law enforcement partners and other key stakeholders to help focus on prevention, early detection, and data sharing to prevent and reduce improper payments in Medicare FFS. Although documentation errors are the largest cause of improper payments, CMS employs multi-layered efforts to target all root causes of improper payments, with an emphasis on prevention-oriented activities.
CMS is pleased to have achieved this reduction in the improper payment rate, but we still have work to do. We remain committed to collaborating across CMS and with stakeholders to address potential vulnerabilities and continuing to strengthen our program integrity efforts, while minimizing burden for our partners.
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