Federal-State Discourse on Maintaining Momentum for Payment and Delivery System Reform


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Multi-Faceted, State-Led Activities
State Innovation Models (SIM), Round 1: Over $250 million in Model Test awards is supporting six states to implement their State Health Care Innovation Plans. A State Health Care Innovation Plan is a proposal that describes a state’s strategy to use all of the levers available to it to transform its health care delivery system through multi-payer payment reform and other state-led initiatives.
Total: 22
State Innovation Models (SIM), Round 2: In the second round of the State Innovation Models (SIM) Initiative, over $660 million in awards will provide financial and technical assistance to 32 awardees (28 states, three territories, and the District of Columbia) to design and test health care payment and service delivery models to improve health system performance, increase quality of care, and decrease costs for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries—and for all residents of participating states.
Total: 29
Delivery System Reform Incentive Payment (DSRIP) Program: Initiatives are part of broader Section 1115 Waiver programs and provide states with significant funding that can be used to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries.
Total: 10
Accountable Care
Advance Payment ACO Model: The Advance Payment ACO Model is designed for physician-based and rural providers who have come together voluntarily to give high-quality coordinated care to the Medicare patients they serve. Through this model, selected participants will receive up-front and monthly payments, which they can use to make investments in care coordination infrastructure.
Total: 30
Next Generation ACO Model: Building on experience from the Pioneer ACO Model and the Medicare Shared Savings Program, the Next Generation ACO Model offers a new opportunity in accountable care—one that sets predictable financial targets, enables greater opportunities for providers and beneficiaries to coordinate care, and aims to attain the highest quality of care.
Total: 18
Pioneer ACO Model: The Pioneer ACO Model is designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program. The model is designed to work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers, and patients.
Total: 9
ACO Investment Model: The ACO Investment Model is designed for organizations participating as accountable care organizations (ACOs) in the Medicare Shared Savings Program. The ACO Investment Model will test the use of pre-paid shared savings to encourage new ACOs to form in rural and underserved areas, as well as encourage current Medicare Shared Savings Program ACOs to transition to arrangements with greater financial risk.
Total: 47
Comprehensive ESRD Care Model: The Comprehensive ESRD Care (CEC) Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD). Through this model, CMS will partner with health care providers and suppliers to test the effectiveness of a new payment and service delivery model in providing beneficiaries with high-quality, person-centered care.
Total: 13
Episode-Based Payment Initiativesl
BPCI Model 1: The Bundled Payments for Care Improvement initiative is comprised of four broadly defined models of care, which link payments for multiple services that beneficiaries receive during an episode of care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. In Model 1, retrospective bundled payments are made for acute care hospital stays only.
Total: 1
BPCI Model 2: In Model 2, retrospective bundled payments are made for an acute care hospital stay plus post-acute care.
Total: 592
BPCI Model 3: In Model 3, retrospective bundled payments are made for post-acute care only.
Total: 845
BPCI Model 4: In Model 4, prospective bundled payments are made for acute care hospital stays only.
Total: 13
Primary Care Transformation
Transforming Clinical Practices Initiative: The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation. It is designed to support more than 140,000 clinician practices over the next four years in sharing, adapting, and further developing strategies for comprehensive quality improvement.
Total: 132
Graduate Nurse Education Demonstration: Under the Graduate Nurse Education Demonstration, CMS will provide reimbursement to up to five eligible hospitals for the reasonable cost of providing clinical training to advanced practice registered nursing (APRN) students who are added as a result of the demonstration.
Total: 5
Independence at Home Demonstration: Under the Independence at Home Demonstration, the CMS Innovation Center will work with medical practices to test the effectiveness of delivering comprehensive primary care services at home and if doing so improves care for Medicare beneficiaries with multiple chronic conditions. Additionally, the demonstration will reward health care providers that provide high-quality care while reducing costs.
Total: 15
FQHC Advanced Primary Care Practice Demonstration: Participating FQHCs were expected to achieve Level 3 patient-centered medical home recognition, help patients manage chronic conditions, and actively coordinate care for patients. To help participating FQHCs make investments in patient care and infrastructure, they were paid a monthly care management fee for each eligible Medicare beneficiary receiving primary care services. In return, FQHCs agreed to adopt care coordination practices that are recognized by the National Committee for Quality Assurance (NCQA).
Total: 434
Comprehensive Primary Care Initiative: The Comprehensive Primary Care (CPC) initiative is a four-year, multi-payer initiative designed to strengthen primary care. Since CPC’s launch in October 2012, CMS has collaborated with commercial and state health insurance plans in seven U.S. regions to offer population-based care management fees and shared savings opportunities to participating primary care practices in order to support the provision of a core set of primary care functions.
Total: 445
Multi-Payer Advanced Primary Care-Program: Under this demonstration, CMS is participating in multi-payer reform initiatives that are being conducted by states to make advanced primary care practices more broadly available. The demonstration will evaluate whether advanced primary care practice will reduce unjustified utilization and expenditures, while improving the safety, effectiveness, timeliness, and efficiency of health care.
Total: 8
Initiatives Focused on the Medicaid and CHIP Population
Strong Start for Mothers and Newborns Initiative: The Strong Start effort to test new approaches to prenatal care is a four-year initiative to test and evaluate enhanced prenatal care interventions for women enrolled in Medicaid or CHIP who are at risk for having a preterm birth. The goal of the initiative is to determine if these approaches to care can reduce the rate of preterm births, improve the health outcomes of pregnant women and newborns, and decrease the anticipated total cost of medical care during pregnancy, delivery, and over the first year of life for children born to mothers in Medicaid or CHIP.
Total: 175
Medicaid Emergency Psychiatric Demonstration: This demonstration tested whether Medicaid can support higher-quality care at a lower total cost by reimbursing private psychiatric hospitals for certain psychiatric services for which Medicaid reimbursement has historically been unavailable.
Total: 12
Incentives for the Prevention of Chronic Disease in Medicaid Demonstration: The initiatives or programs are to be “comprehensive, evidence-based, widely available, and easily accessible.” An application by a State for a grant under the program must address one or more of the following prevention goals: tobacco cessation, controlling or reducing weight, lowering cholesterol, lowering blood pressure, avoiding the onset of diabetes, or in the case of a diabetic, improving the management of the condition.
Total: 9
Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models
Health Care Innovation Awards, Round 1: The Health Care Innovation Awards are providing up to $1 billion total for applicants across the country that test new payment and service delivery models that will deliver better care and lower costs for Medicare, Medicaid, and/or CHIP enrollees.
Total: 234
Health Care Innovation Awards, Round 2: The second round of Health Care Innovation Awards is funding grants to applicants who are implementing the most compelling new ideas to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), particularly those with the highest health care needs.
Total: 59
Medicare Advantage Value-Based Insurance Design Model: As part of the Health Plan Innovation Initiatives, the Medicare Advantage Value-Based Insurance Design (VBID) Model is an opportunity for Medicare Advantage plans to offer supplemental benefits or reduced cost sharing to enrollees with CMS-specified chronic conditions, focusing on the services that are of highest clinical value to them. The model will test whether these changes can improve health outcomes and lower expenditures for Medicare Advantage enrollees.
Total: 10
Medicare Care Choices Model: Through the Medicare Care Choices Model, CMS will provide a new option for Medicare beneficiaries to receive hospice-like support services from certain hospice providers while also receiving services provided by their curative care providers. CMS will evaluate whether providing these supportive services can improve the quality of life and care received by Medicare beneficiaries, increase patient satisfaction, and reduce Medicare expenditures.
Total: 124
Initiatives to Speed the Adoption of Best Practices
Community-Based Care Transitions Program: The Community-Based Care Transitions Program (CCTP) tests models for improving care transitions from the hospital to other settings, and for reducing readmissions for high-risk Medicare beneficiaries.
Total: 27
Innovation Advisors Program: The Innovation Advisors Program sought to create a network of experts in improving the delivery system for Medicare, Medicaid, and CHIP beneficiaries. The Innovation Center selected 75 individuals from 27 states and the District of Columbia to participate. During 2012, participants undertook activities to deepen key skill sets related to CMS strategy, population health, care redesign, and innovation and improvement science. Seventy-one people completed the program and are Innovation Advisors.
Total: 71