Medicare Advantage Chronic Care Improvement
Program
Training for Medicare Advantage Organizations
Marsha Davenport, MD MPH
CAPT, USPHS Chief Medical Officer
and
Karla Taylor, PharmD
Medicare Drug and Health Plan Contract Administration
Group
April 11, 2012
1
Presentation Overview: Part I
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QI Program Overview
Background
Million Hearts Campaign
Disease Management
Components of a CCIP
Case Studies
Discussion
Brief break/Stretch
2
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
3
QUALITY IMPROVEMENT (QI)
PROGRAM OVERVIEW
4
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
5
QI Program -21. 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
6
QI Program -33. 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
7
QI Program -46. Include a program review process for the formal evaluation
of the QI Program that addresses at least the following
areas on an annual basis:
•
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Impact
Effectiveness
7. Take remedial action to correct problems identified using
ongoing quality improvement
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Defining Quality
9
BACKGROUND
10
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
11
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
12
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
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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
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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
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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%
─
3.5g/day
20% ↓
─
Average artificial trans fat intake 1% of calories/day 50% ↓
─
Average sodium intake
Source: Million Hearts Campaign 2012
1 Population-wide indicators
2 Clinical systems
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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?
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Improve safety and quality of care
Improve access to care
Improve patient self-management
Decrease costs
Provide health improvement based on plan on population
31
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
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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
36
Collaborative Care Model
• Structured interdisciplinary team
• Patient centered CCIP
• Designed to provide best possible outcomes
37
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
39
Routine Reporting/Feedback Loop
• Process of communication
• Keeps all care team members and patient in the loop
40
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
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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
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Relevant to the program
Specific
Measureable
Positive effect on health outcomes
Attainable
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Interventions
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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
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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
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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
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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
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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
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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•
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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•
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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
100
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
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