Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services (2012) / Chapter Skim
Currently Skimming:
1 Essential Considerations and Background
1 Essential Considerations and Background
Pages 19-44
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From page 19... ...
This role has only increased in importance over the years in light of program expansions, the changing demographics and aging of the U.S. population, increasing health care costs, serious pub lic health challenges, and the growing prominence of electronic health records (EHRs)
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CMS manages and supports its prescription drug plans, Medicare Advantage plans, employer-sponsored retiree health care coverage, and various administrative grants. The agency works with various states, regions, and providers to facilitate enrollment of millions of eligible recipients and to develop policies for cost-effective and quality health care." 2 In addition, CMS is responsible for several other key programs such as managing quality standards and training at clinical laboratories, advancing the national e-health agenda, and engaging in research and demon stration projects to improve claims reimbursement and quality of care.
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Major Roles -- Health Insurance Provider and Promoter of Quality Health Insurance Programs CMS provides insurance through the Medicare (Parts A, B, C, and D) , Medicaid, and CHIP programs, and each claims process is administered separately.6 "Collectively, these programs make CMS the largest purchaser of health care in the United States, [covering more than one-third of the U.S.
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Curtis, 2009, "Brief Summaries of Medicare & Medicaid Title XVIII and Title XIX of the Social Security Act," Baltimore, Md.: CMS, available at https://www.cms.gov/MedicareProgramRatesStats/downloads/ MedicareMedicaidSummaries2009.pdf, last accessed July 29, 2011. 12 CMS, 2010, "Key Milestones in CMS Programs," website, available at http://www.cms.
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Some of CMS's efforts toward quality improvement include: • Funding for graduate medical education. To ensure a sufficient number of treatment providers for Medicaid-eligible patients, CMS helps to support graduate medical education programs by making "payments to hospitals that train residents in approved medical residency training programs, based on the number of residents the hospital has on staff." 22 16 CMS, 2009, "State Medicaid Director Letters, May 11, 2009," memorandum, Baltimore, Md.: CMS, available at http://www.cms.gov/SMDL/downloads/SHO051109.pdf, last ac cessed July 29, 2011.
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Slightly fewer than 5 percent of eligible beneficiaries will pay a higher premium based on their income, whereas low-income beneficiaries may be eligible for state assistance in meeting their premiums. Medicare Part B covers physician services and supplies, laboratory services, durable medical equipment, prosthetics and orthotics, outpatient hospital services, and limited home health care services.
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Participants in Part C must also participate in both Medicare Parts A and B, elect coverage under Medicare Part C, and pay required premiums (including Part B premiums, and pos sibly additional Medicare Advantage premiums) .5,6,7 Medicare Part D is a prescription drug program.
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Although CMS has addressed the issue of disparities through QIOs and other program efforts, the agency has now been charged, pursuant to the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009 and the PPACA, to reduce health disparities as a key strategy for ensuring the delivery of quality and equitable care to Medicare and Medicaid beneficiaries.
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They are seeking increased access to clinical-level information (such as aggregate outcomes and events data) for diverse populations as well as more-accurate administrative and claims information to support research on comparative effectiveness and the evaluation of new care-delivery models.28 The involvement of all these stakeholders, and the need for sensitivity to their requirements and the challenges they present, have there 15253, available at http://edocket.access.gpo.gov/2008/pdf/E8-5716.pdf, last accessed September 14, 2011; Agency for Healthcare Research and Quality, 2010, Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement, 10-0058-EF, Rockville, Md.: AHRQ, available at http://www.ahrq.gov/research/iomracereport/, last accessed September 14, 2011; and Institute of Medicine, 2008, Challenges and Successes in Reducing Health Disparities: Workshop Summary, Washington, D.C.: The National Academies Press.
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Requirements in Recent Legislation Recent legislation and policy changes at CMS reflect a growing focus on health care outcomes and quality through the use of data that can serve as indicators of health care quality and equity. Data in this context enable CMS to identify and intervene when providers are performing poorly; to detect and combat fraud and abuse; to increase access to clinical data to improve care when access to such information would help; to enable use of decision support tools by providers; to monitor health disparities and their reduction; and to enable population-wide health.29 In briefings, CMS's goals for data-driven quality improvement were described as follows:30 increase access to safe, effective, and efficient care; ensure greater communication between health care providers and their patients; provide proper and effective stewardship of health care services and expenditures; eliminate redundancy of care; ensure that care is evidencebased and outcome-driven to manage and prevent complications from disease and improve overall outcomes; educate consumers about health 29 See D.J.
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For example, HITECH establishes incentives for the "meaningful use" of electronic health information; the PPACA provides for the creation of "exchanges" wherein the federal government subsidizes the insurance of people whose income is below three to four multiples of the federal poverty levels; and the Improper Payments Elimination and Recovery Act of 2009 amended the 2002 act and expanded current government program auditing processes for agencies such as CMS that are high-volume claims payers. In 2003 Congress created the Medicare Part D prescription drug program to add coverage of prescription drugs for Medicare beneficiaries.
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HITECH meaningful use of electronic health records plus additional oversight tasks. The HITECH provisions of ARRA, consisting of a number of subsections relating to uses of person-specific health information, create additional oversight requirements for CMS (Subtitle D)
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of 200934 amended the 2002 act and expanded current government program auditing processes to better identify programs that are susceptible to improper payments. The 2009 act further specifies that required reporting occur every 3 years and include a statement of whether the reporting agency has sufficient resources with respect to internal controls, human capital, and information systems and other infrastructure to prevent improper payments.
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Specifically, providers are required to adopt a certified electronic health record (EHR) , to use the health record meaningfully, to report quality measures, and to exchange information electronically.
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The program is organized as a collection of objec tives within each area along with measures to determine if the objective has been met. Meaningful use is divided into sequential stages in which objectives evolve from data capture, decision support, and quality measurement, to continuous quality improvement and structured data exchange, to actual quality, safety, and efficiency improvements and patient self-management.
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-- very high impact; • Risk adjustment -- very high impact; • Quality (including quality assessment tools, quality measurement and pay ment initiatives and quality improvement activities) -- high impact; • Medicare integrity -- high impact; • Research, evaluation, and demonstrations -- moderate impact; • Medicaid (including Medicaid operations, integrity, and policy)
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This will be particularly valuable under the new Accountable Care Organizations program. Another opportunity for CMS is to leverage the ICD-10 code set to explore more effective outcomes-based payment and reimbursement policies, including the new health care reimbursement approaches envisioned in the Patient Protection and Affordable Care Act.
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These sources and uses of data are described in greater detail in Chapter 5 and Appendix D Within the government, CMS information is the source for the trustees' annual report on the health of the Medicare program, the Medicare Payment Advisory Commission's "data book" on the current state of the TABLE 1.1 Sources and Content of Some of the Data Held by CMS Source of Data Data Description Claims for Medicare All claims contain basic diagnostic information as well Parts A, B, C, and D as information on date, the type of service provided, and the identity of the prescribing physician.
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Medicare program, and other analyses of the trends in Medicare carried out by agencies such as the Government Accountability Office. Outside researchers also make use of these data sets in materials such as the series of atlases in practice variation produced by Dartmouth.37 CMS currently manages the escalating external demand for its available data files by using an external contractor, the Research Data Assistance Center, which provides support to researchers applying for use of data files.
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See, for example, Vivek Kundra and Richard Spires, 2010, "Update on Federal Data Center Consolidation Initiatives," memorandum, October 1, Washington, D.C.: White House Office of the Chief Information Officer, available at http://www.cio.gov/Documents/ Update-Federal-Data-Center-Consolidation-Initiative.pdf, last accessed July 31, 2011. See also CMS, 2011, CMS 18-Month Plan for Enterprise & Shared Services, July 7.
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To fulfill its core function of paying providers for services to ben eficiaries, CMS processes more than 3 million eligibility inquiries and makes more than $1 billion in fee-for-service payments daily.41 So that it can provide these services, CMS has established a number of informa tion systems families both internal and external to the organization. Each system family consists of a number of existing CMS application systems integrated by means of automated and human processes to meet the requirements of a specific CMS business role or function.
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The systems implementation required setting up connections not only among several federal agencies but also with health insurance plans and pharmacies -- all of which was done quickly and successfully. The Part D implementation also included the deployment of websites that allowed the customers to easily access information about their options, make comparisons among plans, and, after making a selection, proceed to enroll.
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As the country heightens its efforts to improve health care quality and reduce the costs of care, it will rely increasingly on CMS to be at the forefront. Indeed these expectations have been described in recent legislation (see Box 1.2 and the section "Recent Legislation" above)
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This engagement includes communicating to relevant CMS staff what Congress is intending to accomplish. At the same time, the Office of Legislation tries to gather input from CMS program owners and the Office of Information Services 1Jennifer Boulanger and Maria Martino, 2011, "Office of Legislation Perspective," presentation to the committee, April 18.
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• The required change is complex or especially challenging and will involve more extensive disruption to create the necessary system functionality. For example, major Medicare legislative changes can strain the time window for implementing the quarterly update.
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Chapter 2 urges the development of a comprehensive strategic tech nology plan at CMS and presents conceptual underpinnings that empha size the importance of a strategic technology plan that fully recognizes and addresses the centrality of IT as CMS plans to meet its challenges and opportunities. Chapter 3 provides a framework for re-envisioning CMS business and information ecosystems and a meta-methodology for conducting incremental, phased transitions of needed components.
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