1. 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

2. Presentation Overview: Part I
QI Program Overview
Background
Million Hearts Campaign
Disease Management
Components of a CCIP
Case Studies
Discussion
Brief break/Stretch

3. 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

4. QUALITY IMPROVEMENT (QI) PROGRAM OVERVIEW

5. Quality Improvement (QI) Program
42 Code of Federal Regulations (CFR) §
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

6. 1. Chronic care improvement program (CCIP)
QI Program -2-
1. Chronic care improvement program (CCIP)
Meet the requirements of 42CFR § (c)
Addresses populations identified by CMS based on review of current quality performance
2. Quality improvement projects (QIPs)
Meet the requirements of 42CFR § (d)
Expected to have a favorable effect on health outcomes and enrollee satisfaction
Address areas identified by CMS

7. QI Program -3-
Develop and maintain a health information system
Encourage providers to participate in CMS and Health & Human Services (HHS) QI initiatives
Contract with an approved Medicare CAHPS vendor to conduct the Medicare CAHPS satisfaction survey

8. QI Program -4-
Include a program review process for the formal evaluation of the QI Program that addresses at least the following areas on an annual basis:
Impact
Effectiveness
Take remedial action to correct problems identified using ongoing quality improvement

9. Defining Quality

10. BACKGROUND

11. QIPs may be clinical or non-clinical
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

12. 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

13. 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

14. 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

15. MILLION HEARTS CAMPAIGN

16. 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

17. 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

18. CVD Leading Cause of Shorter Life Expectancy Among African Americans
Source: Million Hearts Campaign 2012

19. Source: Million Hearts Campaign 2012
Improving CVD Care
Aspirin
Blood pressure
Cholesterol
Smoking
Source: Million Hearts Campaign 2012

20. Source: Million Hearts Campaign 2012
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

21. 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

22. 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

23. Medical System Messages
Clinicians
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

24. Medical System Messages -2-
Insurers
Measure and incentivize performance on the ABCS; collect and share data for quality improvement; empower consumers
Individuals
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

25. Source: Million Hearts Campaign 2012
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

26. Source: Million Hearts Campaign 2012
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

27. Million Hearts: Getting to the Goal
Population metric
Baseline
20171
Clinical target2
Aspirin for those at high risk
~50%
65%
~70%
Blood pressure control
Cholesterol control
~33%
Smoking prevalence
~20%
17% ─
Average sodium intake
3.5g/day
20% ↓
Average artificial trans fat intake
1% of calories/day
50% ↓
Source: Million Hearts Campaign 2012
1 Population-wide indicators
2 Clinical systems

28. Take the Pledge at http://millionhearts.hhs.gov/

29. DISEASE MANAGEMENT

30. What is Disease Management?
Supports physician/patient plan of care
Emphasis on prevention
Outcomes evaluated continuously
Disease management is a program designed to target a disease or condition which is not curable but can be improved or maintained through pharmaceutical therapy, education, and patient self management. Disease Management Programs support and encourage the practitioner and patient relationship. Emphasis is placed on the prevention of disease deterioration and complications by using evidence based guidelines and empowering the patient to self manage their condition. Keep in mind the goal is to improve overall health. Evaluation of the clinical, humanistic, and the economic outcomes are done on an ongoing basis.

31. What Can Disease Management Do?
Improve safety and quality of care
Improve access to care
Improve patient self-management
Decrease costs
Provide health improvement based on plan on population

32. 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

33. 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

34. Disease Management: Six Required Elements
Population identification
Evidence based guidelines
Collaborative care
Patient self-management
Process and outcome measures
Routine reporting/feedback loop

35. Population Identification
Process of identification
Data sources
Target population

36. Evidence Based Guidelines
Set of actions based on clinical research
Effectively manage or improve outcomes
Ensures consistency in treatment

37. Collaborative Care Model
Structured interdisciplinary team
Patient centered CCIP
Designed to provide best possible outcomes

38. Patient Self-Management
Systematic provision of education and supportive interventions
Increase patient skills and confidence in managing their health

39. Process and Outcome Measures
Determines program stability
Reflects the impact on health status of the targeted population

40. Routine Reporting/Feedback Loop
Process of communication
Keeps all care team members and patient in the loop

41. COMPONENTS OF THE CHRONIC CARE IMPROVEMENT PROGRAM

42. Required CCIP Disease Selection
New for 2012
Cardiovascular Disease focus
Must still be individualized to meet the needs of the MA plan’s population

43. Components of the CCIP
Disease state selection
Six disease management elements
Anticipated outcomes
Goal(s)
Interventions

44. Anticipated Outcomes
Determining what the program will achieve
Must positively improve health outcomes
Important factor in evaluation of the CCIP

45. Goals
Relevant to the program
Specific
Measureable
Positive effect on health outcomes
Attainable

46. Interventions
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

47. CASE STUDIES

48. 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

49. Diabetes

50. Diabetes -2-

51. Diabetes -3-

52. QUESTIONS

53. BRIEF BREAK/STRETCH

54. CCIP REPORTING PROCESS

55. Plan-Do-Study-Act (PDSA) Quality Model
Identify disease state, plan the program Do
Implementation of the program
Study
Data collection and analysis
Act
Next Steps

57. 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

58. Submitted in two sections
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

59. WORKING WITH CMS REGIONAL OFFICE (RO) ACCOUNT MANAGERS (AMs)

60. 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

61. REVIEW OF THE CCIP REPORTING TOOL

62. THE PLAN SECTION

63. A. Basis for Selection
A1. Disease State (not scored)
A2. Rationale for Selection
A3. Relevance to the Plan Population
A4. Anticipated Outcomes

64. 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

65. 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

66. 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

67. 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

68. B1. Population Identification Process
B. Program Design
B1. Population Identification Process
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)

69. B2. Evidence Based Medicine B3. Care Coordination Approach
B. Program Design -2-
B2. Evidence Based Medicine
B3. Care Coordination Approach
B4. Education
B4(a). Patient Self-Management
B4(b). Provider Education

70. B5. Outcome Measures and Interventions B(5a). Goal B5(b). Benchmark
B. Program Design -3-
B5. Outcome Measures and Interventions
B(5a). Goal
B5(b). Benchmark
B5(c). Goal and Benchmark indicators
B5(d). Intervention

71. B5. Outcome Measures and Interventions (cont’d)
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)

72. B1. Population Identification Process
B1(a): Describe the target population
Inclusion criteria
Exclusion criteria
Incidence rate among the members related to the inclusion criteria

73. 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

74. 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

75. 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

76. B3. Care Coordination Approach
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

77. 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

78. 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

79. 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

80. 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

81. 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

82. 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

83. 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

84. 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

85. 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

86. 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

87. THE “DO” SECTION

88. E. Program Implementation, Review, Revision
E1. Education
E1(a). Patient Self-Management
E1(b). Provider Education
E2. Intervention
E3. Results or Findings
E4. Barriers Encountered
E5. Mitigation Plan for Risk Assessment
E6. Anticipated Impact on the Goal and/or Benchmark

89. THE “STUDY” SECTION

90. F. Results
F1. Goal
F2. Benchmark
F3. Timeline
F4. Dates of Implementation
F5. Sample Size or Percent of Total Population

91. F. Results -2-
F6. Numerator
F7. Denominator
F8. Total Percent or Results
F9. Other Data or Results
F10. Analysis of Results or Findings

92. THE “ACT” SECTION

93. 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

94. G. The Next Steps -2-
G6. Expand the program
G7. Identify additional interventions
G8. Re-evaluate data and criteria
G9. Other

95. SUMMARY

96. 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

98. 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

99. 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

100. 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

101. Diabetes

102. Diabetes -2-

103. Diabetes -3-

104. Marsha Davenport, MD, MPH CAPT, USPHS Chief Medical Officer
Contact Information
Marsha Davenport, MD, MPH
CAPT, USPHS
Chief Medical Officer
Medicare Drug and Health Plan Contract Administration Group (MCAG)