News and Updates for Healthcare Professionals

NIH-funded tool may improve clinical trial design and aid in treatment development.

A proposed measurement framework for diagnostic quality and safety developed by the National Quality Forum has been posted for public comment. Comments will inform recommendations for the development of priority measures to address measurement gaps in diagnostic accuracy. Public comment on this draft report and measurement framework is open through July 12. Please submit your comments on the project page.

By Anne Elixhauser, Ph.D.
As an AHRQ researcher, I get to dive into topics that matter to the American people using one of the most comprehensive health care databases – AHRQ’s Healthcare Cost and Utilization Project, or HCUP. HCUP is the Nation’s most complete source of hospital-based data, including information on hospitalizations and emergency department (ED) visits for all patients, including those paid by government and private insurance as well as the uninsured.

Learning about data trends to help improve lives can mean swimming through very scary waters. Take the opioids crisis, for instance. There has been widespread attention given to opioid-related deaths in the media. A New York Times article recently estimated that nearly 60,000 people died from using an opioid drug in 2016 . On the other hand, the New York Times also wrote that opioid prescriptions have declined for the first time in two decades. These articles illustrate two very important aspects of the opioid crisis. But what about the people who don’t die or are still being prescribed too many pills? And what about those who turn to heroin or other illicit opioids and overdose, but survive thanks to a visit to the hospital or emergency department (ED)?

It’s hard to defeat a problem like the opioid epidemic until you know how bad the problem really is and what subgroups are affected disproportionately. That is what AHRQ is uniquely suited to provide—data on opioid hospitalizations and ED visits for specific population subgroups from our HCUP Fast Stats database. HCUP allows Secretary Price, other HHS agencies, policymakers, and frontline providers to best define the challenge, and ultimately, begin to measure how opioid addiction treatment and reduction efforts are working.

So what are the numbers? We highlighted some in a press release that is based on data in a new statistical brief on opioid-related hospitalizations and ED visits, by patient sex and age (PDF, 343 KB). The data are sobering:

• Men and women were hospitalized at virtually the same rate nationwide in 2014—about 225 hospitalizations per 100,000 people. That’s a 75 percent increase for women between 2005 and 2014, compared to only a 55 percent increase for men.
• An infographic shows that in three-quarters of all States with available data, women had a higher rate of an opioid-related hospitalization than men in 2014.
• However, men were still more likely to make opioid-related ED visits in 2014.
• Individuals 25–44 years had the highest opioid-related ED visit rate in every State. But people 65 and older had the largest increases in opioid-related hospital stays and ED visits.

In July, we plan to release another statistical brief on opioid-related hospitalizations and ED visits by patient residence and income. This may also be a disturbing read, as the data will show, for example, that opioid-related ED visits increased the most in the lowest income communities from 2005 to 2014.

While none of these data are very encouraging, it is critical to have a better idea of why women are being hospitalized more than men or why 25–44 year-olds are visiting the ED more than other age groups, especially since we have 2015 and 2016 data for many States in the database and we are continuing to see the trend line for hospitalizations and ED visits going up.

That’s why I am heartened by Secretary Price’s request for additional funding for opioid abuse research. Recently, the Secretary awarded more than $70 million in grants to help prevent opioid overdose deaths. About $28 million of the grant money will go to medication-assisted treatment (MAT). AHRQ is investing about $12 million over 3 years in grants to explore how best to deliver MAT opioid abuse in rural areas and remove barriers to using MAT. Also, the recently enacted 21st Century Cures Act authorized the Substance Abuse and Mental Health Services Administration to award $485 million in grants for opioid abuse prevention, treatment, and recovery.

All these grants show HHS’ dedication to halt the opioid epidemic. AHRQ will continue to play an important role monitoring the national and State data for opioid-related hospitalizations and ED visits—because that’s our job.

Dr. Elixhauser is a Senior Researcher at AHRQ. She has worked with HCUP data for more than 20 years and is the author of more than 200 articles and reports.

Data details health care spending for residents by service and major payer

Today, the Centers for Medicare & Medicaid Services’ (CMS) Office of the Actuary (OACT) released state-level health care spending data for the period 1991-2014. The data shows that while most states experienced faster growth in 2014 due to Medicaid expansion and enrollment in Exchange plans, per capita health spending in Medicaid expansion and non-expansion states grew at similar rates. The report also found that the most recent economic recession, which ended in 2009, and modest recovery since then, had a sustained impact on health spending and health insurance coverage. Every state experienced slower growth in per capita personal health care spending from 2010-2013 than experienced during the period 2004-2009.

David Lassman, the lead author of the report noted that, “recent economic and health sector factors have had clear impacts by state, both by payer and in the rates of overall per capita personal health care expenditure growth; however, during the 2009 to 2014 period, the variation in spending between the lowest and highest states was virtually unchanged.”

The report, published as a web first in Health Affairs, offers vital context for understanding how health spending varies across states. The analysis updates previous estimates published in 2011 and examines personal health care spending (or the health care goods and services consumed) through a resident-based view. These estimates are also presented both by type of goods and services (such as hospital services and retail prescription drugs) and by major payer (including Medicare, Medicaid, and private health insurance) for the individuals who reside in a state.

The topline findings from the report include:

• Considerable regional variation on personal health care spending:
  • In 2014, the New England and Mideast regions had the highest levels of total per capita personal health care spending ($10,119 and $9,370, respectively), or 26 and 16 percent higher than the national average ($8,045).
  • In contrast, the Rocky Mountain and Southwest regions had the lowest levels of total personal health care spending per capita in 2014 ($6,814 and $6,978, respectively) with average spending roughly 15 percent lower than the national average.
• Similar growth in Medicaid expansion and non-expansion states: While most states experienced faster growth in 2014 compared to 2013 due to Medicaid expansion and enrollment in Health Insurance Exchange plans, per capita health spending in Medicaid expansion and non-expansion states grew at similar rates, 4.4 and 4.5 percent respectively. The similar growth in per capita spending for expansion and non-expansion states was due largely to two effects:
  • Faster growth in the use of healthcare goods and services in expansion states relative to non-expansion states due to a larger increase in the percent of people insured in those states.
  • Faster growth in spending per insured person in non-expansion states relative to expansion states.
• Impact of recent economic recession and recovery: The most recent economic recession, which ended in 2009, and modest recovery since then, had a sustained impact on health spending and health insurance coverage.
  • For 2010-2013, per capita personal health spending grew at a rate of 2.8 percent per year on average, substantially slower than during 2004-2009, when spending averaged 5.2 percent growth per year.
  • During 2010-2013, every state experienced slower growth in per capita personal health care spending with an average deceleration of just over two percentage points compared to the 2004-2009 period.
• Three Major Payers:
  • Medicare: States with above average per enrollee Medicare spending were generally located in the eastern United States while states with the lowest spending were generally in the western United States.
    • The State with the highest per enrollee Medicare spending in 2014 was New Jersey ($12,614) with spending levels roughly 15 percent above the national average ($10,986).
    • In 2014, Montana was the State with the lowest per enrollee Medicare spending, at $8,238 per enrollee (25 percent below the national average per enrollee).
  • Medicaid: The recent trends in per enrollee spending were driven by the Medicaid coverage expansion, which increased the share of relatively less expensive enrollees relative to the previous Medicaid beneficiary population mix in expansion states.
    • Total Medicaid spending increased 12.3 percent from 2013 to 2014 for states that expanded Medicaid, compared with 6.2 percent for states that did not expand Medicaid.
    • However, on a per enrollee basis Medicaid spending declined considerably for the expansion states (-5.1 percent) in 2014, because of the enrollment of relatively less expensive enrollees, whereas per enrollee Medicaid spending in the non-expansion states increased 5.1 percent.
  • Private Health Insurance: Per enrollee private health insurance spending was $4,551 in 2014, an average annual increase of 3.3 percent since 2009 ($3,872).
    • Total private health insurance spending grew more rapidly in states that did not expand Medicaid eligibility by 2014 than in states that did expand eligibility, at rates of 6.8 percent and 4.6 percent, respectively.
    • A majority of this difference reflects faster private health insurance enrollment growth in non-expansion states (3.2 percent) compared to that for expansion states (1.9 percent).

Unusual case provides insight into leading cause of acute illness worldwide.

After decades of increases in the obesity rate among U.S. adults and children, the rate recently has dropped among some populations, particularly young children. What are the factors responsible for these changes? How can promising trends be accelerated? What else needs to be known to end the epidemic of obesity in the United States?

To examine these and other pressing questions, the Roundtable on Obesity Solutions, of the National Academies of Sciences, Engineering, and Medicine, …

Dr. Lynn Webster of Utah recently produced a documentary about pain treatment. The documentary, “The Painful Truth,” can be found online and on public television stations across the country and provides insight into the difficulties patients run into when trying to find effective treatment for chronic pain.

The patients featured in “The Painful Truth” include some who are fearful of losing access to opioid treatment, as well as those who say some doctors have refused to treat them and pharmacies have balked at filling their prescriptions. The apprehension among some pain patients that they won’t be able to get opioids has been reported in several media outlets, including STAT.

Webster acknowledged that several of the patients in his documentary are “miserable” even while taking opioids, and the documentary makes the point that better treatments are desperately needed. For now, however, he said opioid medications are often the best of several flawed options.

“With all of the focus on opioid addiction, we are forgetting many people with pain who have benefited,” he said. “It’s the only thing that keeps them from suicide.”

Critical Article from STAT

I was a fan of the author David Armstrong when he wrote for Wall Street Journal. However, his recent article on Lynn Webster’s documentary starts out with guilt by association. Roughly a year ago, Lynn called me and asked for advice on how to promote this documentary. At that time, he was passionate about the way pain management patients and their physicians are being unfairly shunned by society.

Armstrong notes that Dr. Webster and several of the experts he quotes in the program have long-standing financial relationships with pain medicine makers. When asked why these relationships are not disclosed to viewers, Webster told STAT that he did not receive any drug industry funding for the documentary. He said it was funded entirely by himself and his wife.

“I am cognizant of that issue, but I think I dealt with it as carefully as I could,” he said in an interview. If viewers want to know whether any of the individual doctors associated with the documentary have financial relationships with pharmaceutical makers, Webster said they can search for that information on the web.

Dr. Webster Paid for the Documentary Himself

I encourage the media to call Lynn and hear why he did this documentary and paid for it out of his own pocket. Yes, Lynn worked for industry but that is by no means his primary motivation to do this documentary. Go spend some time in a pain clinic and meet some patients who are truly in pain, this is by no means a binary issue.

“There are dozens of important stories about people with opioid addiction almost daily but rarely is there a story about people in pain,” Webster said in an email to STAT.

Does the Media Own Some Part of the Opioid Crisis?

It hit me recently that the Media needs to take some responsibility for the Opioid crisis, in 2004 when the Cox 2 inhibitors were slammed as “unsafe” there was no thought to what other alternative therapies that were available to alleviate pain. Had the media or the medical community for that matter, paid just a little attention and thought, the best Cox 2 inhibitors would have been hugely successful and companies would have reaped the benefit, but the opioid crisis might never have happened.

Comments from Tom Fogarty, MD

We reached out to Tom Fogarty, Founder of the Fogarty Institute and inventor of the catheter, who stated,

Opioid addiction is a serious and worldwide problem that is ever increasing. The reasons are multi-factorial, unfortunately a minority of physicians are responsible for this. A doctor’s sole purpose is to relieve pain and suffering and the vast majority adhere to that doctrine. The minority who knowingly do not, should be investigated and corrected. Continued excessive use of opioid prescriptions (easily documented) should be followed by fines and some other forms of punishment imposed upon the responsible physician. Chronic addiction to opioids and other drugs should be handled by specialists in the field of pain management. Dr. Lynn Webster and others should be looked to for resolution of these problems. The majority should not be punished, that is our patients, by inappropriate laws or recommendations.

Viewpoints Should Not Be Discounted Because of Past Work History

It always bothers me when I see someone’s viewpoints discounted simply because they have worked for industry in the past. The author is capable of doing better work.

Further, Aaron Pruitt, director of content at MontanaPBS, said he was “not aware” of any financial connections between Webster and companies that make opioid pain relievers. “If there is some evidence of that, I have seen nothing,” he said. After being directed to public disclosures of those relationships, Pruitt wrote in an email, “As far as I can tell, he has been working with companies to find safer, less addictive treatments for patients.”

In a pitch to television stations offered the documentary, the distributors write that “NETA and MontanaPBS have carefully reviewed The Painful Truth, and the credentials of Dr. Webster. We have found Dr. Webster to be one of the country’s experts on pain treatment, a past president of the American Academy of Pain Medicine, and an advocate for the safe prescription of opioids.”

Disclosure: the company I own, Rockpointe, receives grants from pharmaceutical and device manufacturers for accredited educational programs.

Accelerating learning and innovation in health care delivery is what AHRQ does—every day. AHRQ tools take the “what” and translate it into the “how” by providing research-backed, practical tools that doctors and nurses can use to improve care.

Many people worry about becoming forgetful as they age. They think it is the first sign of Alzheimer’s disease. But forgetfulness can be a normal part of aging. Check out this infographic to see examples of mild forgetfulness versus signs of serious memory problems, like Alzheimer’s disease. Be sure to talk to your doctor if you have concerns.

By: Judy Sarasohn, HHS (Public Affairs)

During National Public Health Week, April 3-9, we celebrate the progress we’ve made helping people live healthier lives and those public health professionals who have helped us make that progress. But one hallmark of public health is life expectancy, and the United States just experienced a drop in overall life expectancy for the first time since 1993. This was due in part to increases in two of the nation’s most heart-breaking and yet preventable public health issues facing us: the increasing rate of suicide and the increasing misuse of opioid drugs.

This week the Health and Human Services Department launched a new page on HHS.gov highlighting the regulatory and administrative actions the Department is taking to relieve the burden of the current healthcare law and support a patient-centered healthcare system.

“We’re taking action to improve choices for patients, stabilize the individual and small-group insurance markets, and expand access to more affordable coverage,” said Secretary Tom Price, M.D. “This page will be the place to go for updates on our ongoing efforts.”

The actions are part of a broader plan to repeal and replace the Affordable Care Act.

New measures will be announced as soon as is allowable by law. In particular, future actions will:

Lower costs and increase choices by providing relief from the burdensome regulations and fostering competition in insurance markets;
Work to ensure a stable transition period;
Offer states greater flexibility of their Medicaid programs to meet the needs of their most vulnerable populations; and
Increase the opportunities for patients to get the care they need when they need it.

NQP’s Case Study, Integrating Personal Preferences in Advanced Illness Care, follows Hazel, a 63-year-old-woman diagnosed with advanced lung cancer as she transitions through the healthcare system, from inpatient and post-acute care to palliative and hospice care. The case study illustrates how measures can support the six key preferences of person-centered advanced illness care identified in the NQP issue brief. More than 400 people participated in the March 15 launch of this case study. Listen to and share the virtual forum recording.

According to JAMA, 68% of physicians report feeling inadequately trained to discuss end-of-life care with patients. NQP’s Fact Sheet, Strategies for Change—A Collaborative Journey to Transform Advanced Illness Care, gives physicians, clinicians, and other providers questions to help guide conversations with patients, their families, and caregivers and further support person-centered advanced illness care.

NQP’s Advanced Illness Care Action Team (PDF) has issued a national call to action for healthcare systems, communities, policymakers, and other stakeholders to ensure that individuals with advanced illness, their families, and caregivers are at the center of care decisions.

Health and Human Services Secretary Tom Price, M.D., released the following statement today on the Congressional Budget Office (CBO) report on the American Health Care Act:

“The CBO report’s coverage numbers defy logic. They project that zeroing out the individual mandate – allowing Americans to choose whether to have insurance – will result in 14 million Americans opting out of coverage in one year. For there to be the reductions in coverage they project in just the first year, they assume five million Americans on Medicaid will drop off of health insurance for which they pay very little, and another nine million will stop participating in the individual and employer markets. These types of assumptions do not translate to the real world, and they do not accurately estimate the effects of this bill.

“The CBO report also does not incorporate two-thirds of the healthcare reform plan President Trump has called for – specifically the regulatory relief HHS can provide and the additional legislative reforms Congress is and will be pursuing. Our three-pronged approach will free patients to purchase coverage that works best for them at a price they can afford. Doctors and patients understand that, especially under current law, having coverage is not the same thing as having access to the care one wants or needs. Our approach will provide Americans with relief from the collapsing healthcare law, which never delivered on the benefits projected by the Congressional Budget Office in the first place.”

Today, the Department of Health and Human Services (HHS), in partnership with the Department of the Treasury, suggested ways to help foster healthcare innovation by giving states greater flexibility.

“States need the flexibility to develop innovative healthcare models that will improve patient access to care, increase affordability and choices offered, lower premiums, and improve market stability,” said Health and Human Services Secretary Tom Price, M.D. “Today’s letter highlights State Innovation Waivers as opportunities for states to modify existing laws or create something entirely new to meet the unique needs of their communities.”

NIH statement from Dr. Griffin P. Rodgers, Director, National Institute of Diabetes and Digestive and Kidney Diseases.

The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) will be hosting a co-led webinar on Wednesday, March 22nd from 1:00-2:00 p.m. EDT. The webinar will provide an overview of Medicare Diabetes Prevention Program Model (MDPP) expansion and the CDC Diabetes Prevention Recognition Program (DPRP), the requirements for pending and full CDC DPRP recognition, review the CDC recognition in the 2017 Physician Fee Schedule (PFS), and next steps for organizations thinking of offering MDPP. Registration is now open.

The Veterans Administration and Department of Defense issue a clinical practice guideline regarding opioid therapy for chronic pain in veterans.

AHRQ’s EvidenceNow, an initiative that supports smaller primary care practices’ efforts to improve heart health, has found that participating practices regularly provide evidence-based care while recognizing the potential to improve on one or more of the heart health clinical services known as the ABCS: Aspirin use for high-risk individuals, Blood pressure control, Cholesterol management, and Smoking cessation counseling. EvidenceNOW provides support services typically not available to smaller primary care practices to help them improve the care they deliver. Baseline data from more than 1,000 primary care practices participating in EvidenceNOW indicate that while an average of more than 50 percent of patients are receiving each of the ABCS services, many practices have not yet reached the EvidenceNOW goal of 70 percent.

MarkVCID brings team science approach to small vessel disease biomarkers in the brain.

April 27th, 2016 executive notice by the US Department of Health and Human Services issued key provisions to the Medicare Access and Summary CHIP Reauthorization Act of 2015, (MACRA). MACRA replaced the 1997 Sustainable Growth Rate formula for determining Medicare reimbursement. MACRA provides a new approach in Medicare reimbursement based on value and quality care. MACRA legislation is guided by the Quality Payment Program, directing two paths for Medicare reimbursement: The Merit-based Incentive Payment System (MIPS), or the Advanced Alternative Payment Model (APM). Nurse Practitioners, require knowledge and information to prepare for MIPS and APM to begin January 1, 2017.

Heart disease is the leading cause of death for men and women in the United States. February is American Heart Month, a great time for health care providers to share the facts about heart health with their patients, especially those who may be at high risk of heart attacks.

AHRQ has fact sheets for primary care health professionals to help their high-risk patients adopt the ABCS of heart disease prevention: Aspirin use by high-risk individuals, control their Blood pressure, lower their Cholesterol, and quit Smoking.

To download these free materials go to: Aspirin Use, Control Blood Pressure, Lower Cholesterol, and Quit Smoking.

The tribal elder at Fort Berthold Reservation in western North Dakota had struggled with his diabetes for years. His blood glucose level was about twice what’s considered normal, his blood pressure was dangerously high, and he was overweight.

His health care provider talked to him about the need to address his diabetes and he was included in the tribal clinic’s diabetes registry, so they wouldn’t lose track of him. But he just didn’t take the steps necessary to manage his condition. Until one day, it apparently clicked.

Jared Eagle, Director of the Indian Health Service’s Special Diabetes Program for Indians (SPDI) at the reservation in New Town, said the man finally started taking advantage of the resources and care provided through the clinic. He started walking more; lost 20 to 30 pounds; and reduced his blood glucose and blood pressure levels.

“You can see him walking every day. He’s walking his dog every day, even in the winter,” Eagle said.

The story of this elder of the Mandan, Hidatsa and Arikara Nation (also known as the Three Affiliated Tribes) reflects the significant progress being made in Indian Country where Native Americans have a greater chance of having diabetes and kidney failure resulting from diabetes than any other U.S. racial or ethnic group, according to the Centers for Disease Control and Prevention. Nonetheless, the CDC also reported recently that kidney failure among Native Americans dropped by 54 percent between 1996 and 2013, the fastest rate for any racial or ethnic group in the U.S.

In January 2016, the Centers for Medicare & Medicaid Services issued a final rule reimbursing physicians and other providers for discussing advanced care planning with patients and their families. However, studies show that nearly two-thirds of physicians feel inadequately trained to engage in end-of-life counseling. A new issue brief from National Quality Partners (NQP) helps healthcare providers better navigate these conversations through the lens of six key preferences of high-quality, person-centered advanced illness care.

NQP’s Advanced Illness Care Action Team—which includes more than 25 patient advocates, physicians, hospital systems, and other stakeholders from the public and private sectors—identified purpose and connection, physical comfort, emotional and psychological well-being, family and caregiver support, financial security, and peaceful death and dying as key preferences of individuals with advanced illness. By placing individuals at the center as the guiding North Star of all healthcare decisions, this initiative calls on the nation to transform advanced illness care and to engage patients, families, and caregivers as true partners in care planning.

Download the issue brief now to explore these key preferences in depth, along with snapshots of organizations that have embraced one or more of these preferences. Register for NQP’s March 15 webinar to delve into case studies demonstrating how physicians, nursing homes, and home health agencies can integrate these preferences into existing quality efforts.

The Centers for Medicare & Medicaid Services (CMS) today finalized rules governing home health agencies that will improve the quality of health care services for Medicare and Medicaid patients and strengthen patients’ rights. These Medicare and Medicaid Conditions of Participation are the minimum health and safety standards a home health agency must meet in order to participate in the Medicare and Medicaid programs.

Home health care allows patients to receive needed health care services within the comfort and safety of their own homes. Patients receive coordinated services ranging from skilled nursing to physical therapy to medical social services, all under the direction of their physician. Currently, there are more than 5 million Medicare and Medicaid beneficiaries receiving home health care from nearly 12,600 Medicare and Medicaid-participating home health agencies nationwide.

“Our priority is to ensure that Medicare and Medicaid beneficiaries who receive health services at home get the highest level of patient-centered care from home health agencies,” said Kate Goodrich, MD, CMS Chief Medical Officer and Director of the Center for Clinical Standards and Quality for CMS. “Today’s announcement is the first update in many years to Medicare and Medicaid home health agency rules and reflects current best practices for in-home care, based on recommendations from stakeholders and medical evidence.”

These changes are an integral part of CMS’ overall effort to improve the quality of care furnished through the Medicare and Medicaid programs, while streamlining requirements for providers. The final rule includes:

• A comprehensive patient rights condition of participation that clearly enumerates the rights of home health agency patients and the steps that must be taken to assure those rights.
• An expanded comprehensive patient assessment requirement that focuses on all aspects of patient wellbeing.
• A requirement that assures that patients and caregivers have written information about upcoming visits, medication instructions, treatments administered, instructions for care that the patient and caregivers perform, and the name and contact information of a home health agency clinical manager.
• A requirement for an integrated communication system that ensures that patient needs are identified and addressed, care is coordinated among all disciplines, and that there is active communication between the home health agency and the patient’s physician(s).
• A requirement for a data-driven, agency-wide quality assessment and performance improvement (QAPI) program that continually evaluates and improves agency care for all patients at all times.
• A new infection prevention and control requirement that focuses on the use of standard infection control practices, and patient/caregiver education and teaching.
• A streamlined skilled professional services requirement that focuses on appropriate patient care activities and supervision across all disciplines.
• An expanded patient care coordination requirement that makes a licensed clinician responsible for all patient care services, such as coordinating referrals and assuring that plans of care meet each patient’s needs at all times.
• Revisions to simplify the organizational structure of home health agencies while continuing to allow parent agencies and their branches.
• New personnel qualifications for home health agency administrators and clinical managers.

Without ACA protections, more than half of non-elderly Americans could face discrimination in health care

Since the Affordable Care Act (ACA) became law, millions of Americans no longer face coverage denials, higher costs, or coverage carve outs because of their medical histories. A new analysis from the U.S. Department of Health and Human Services provides a first look at what happened to uninsured rates for Americans with pre-existing health conditions when the ACA’s major insurance market reforms took effect in 2014. It finds that, between 2010 and 2014, the share of Americans with pre-existing conditions who went without health insurance all year fell by 22 percent, meaning 3.6 million fewer people with pre-existing conditions went uninsured.

While data for individuals with pre-existing conditions are available only through 2014, the uninsured rate for all Americans has fallen by an additional 22 percent through mid-2016, and Americans with pre-existing conditions have likely seen similar additional gains.

“Today, thanks to Affordable Care Act protections, the uninsured rate is at its lowest level in history and millions of Americans with pre-existing conditions like asthma or cancer no longer have to worry about being denied coverage because of their medical history,” said HHS Secretary Sylvia M. Burwell. “This is clear and measurable progress, and we shouldn’t turn the clock back to a time when people were denied coverage.”

The new analysis estimates that 51 percent of non-elderly Americans, or 133 million people, have a pre-existing health condition under the definition insurers used for underwriting purposes before the ACA. Among the most common pre-existing conditions are: high blood pressure (46 million people); behavioral health disorders (45 million people); asthma or chronic lung disease (34 million people); heart conditions or heart disease (16 million people); diabetes (13 million people); and cancer (11 million people). Because the likelihood of having a pre-existing condition increases with age, the ACA’s protections are especially important to middle-aged and older Americans. Up to 84 percent of Americans between age 55 and 64, and up to 75 percent of Americans between age 45 and 54 have a pre-existing condition that could have been the basis for insurer discrimination prior to 2014.

Today’s analysis confirms that the ACA’s insurance market reforms are having a major impact on coverage for Americans with pre-existing conditions. After passage of the Affordable Care Act, uninsured rates declined by almost 20 percent or more among non-elderly Americans with high blood pressure, behavioral health disorders, asthma or chronic lung disease, and osteoarthritis.

The analysis also sheds light on proposals that would restrict pre-existing condition protections to people who meet standards for continuous coverage, rather than protecting anyone who signs up during an annual open enrollment period. The analysis finds that tens of millions of people with pre-existing conditions go uninsured for at least short spells due to job changes, other life transitions, or periods of financial difficulty. In the two-year period beginning in 2013, almost one third of people (44 million) with pre-existing conditions went uninsured for at least one month.

The Affordable Care Act achieved dramatic improvements in coverage for people with pre-existing conditions through three fundamental reforms: first, requiring insurance companies to cover people with pre-existing conditions; second, providing financial assistance linked to premiums and income to help make coverage more affordable; and third, by requiring all Americans to get coverage if they can afford it. Prior to the Affordable Care Act, states that tried to protect people with pre-existing conditions without other measures such as financial assistance and an individual responsibility requirement saw premiums skyrocket as not enough healthy people entered the risk pool. Under the Affordable Care Act, the number of people in the individual market has grown, and most HealthCare.gov enrollees can select a plan for less than $75 per month in premiums.

We have made great progress in recent years on reforming our system into one that delivers better quality of care for patients and pays for care in a smarter way, including investing more in prevention and primary care.

Before 2010, there had been only modest efforts to improve care and reduce costs. Medicare – the country’s largest health care insurance program – was largely paying for health services based on volume – where providers were paid for every service they ordered or performed – which didn’t necessarily improve the health of beneficiaries or preserve the program for future generations. To improve our health care system, the largest payer of health care stepped up to partner with providers, doctors and other clinicians, states, private payers, consumers, and others to spur innovation. The market and people in communities across the nation have responded this initiative in extraordinary ways and delivered better care to patients.

This has been the mission of the Center for Medicare and Medicaid Innovation (CMS Innovation Center), to align incentives, partner with others to improve the health system, and implement best practices for coordinating patient care. Since opening its doors in late 2010, the CMS Innovation Center has worked tirelessly to enhance the quality of health care delivered while not increasing costs for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. The CMS Innovation Center takes locally-driven approaches – approaches from doctors and other health care partners providing care to patients every day – and gives them the platform to be tested through a collaborative process.

Today, based on the successful work of the CMS Innovation Center and countless public and private sector partners, we can now say that health care delivery system reform addressing both quality and cost has become part of the fabric of Medicare, Medicaid, and the health care sector nationwide. According to a new report to Congress prepared by the CMS Innovation Center:

• Over 30 new payment models have been launched over the past six years.
• Investments in electronic medical records and a data and analytics infrastructure are sparking a new set of innovative companies.
• The CMS Innovation Center’s portfolio of models has attracted participation from a broad array of health care providers, states, payers, and other partners. An estimated 18 million individuals, including CMS beneficiaries and individuals with private insurance included in multi-payer models, have been impacted by, have received care, or will soon be receiving care furnished by more than 207,000 health care providers participating in CMS Innovation Center payment and service delivery models and initiatives. These models are delivering care to people in every state across the nation.
• Medicare exceeded – earlier than predicted – the goal to tie more than 30 percent of fee-for-service payments by the end of 2016 through alternative payment models to quality and cost metrics. Medicare is on pace to reach 50 percent by the end of 2018.

The Innovation Center has partnered with Medicare, Medicaid, and private health plans in the commercial market on new models of care and innovation. And, a number of exciting initiatives will be coming to more beneficiaries over the next few years:

• The Medicare Diabetes Prevention Program expanded model, set to begin in 2018, will pay for services to prevent the onset of diabetes to all eligible Medicare beneficiaries, improving their health and that of the Medicare program both now and in the future. This is important because we estimate that Medicare spent $42 billion in 2016 on fee-for-service, non-dual eligible, over age 65 beneficiaries with diabetes.
• Three new payment models—the Acute Myocardial Infarction Model, the Coronary Artery Bypass Graft Model, and the Cardiac Rehabilitation Incentive Payment Model—will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation.
  Through the Comprehensive Primary Care Plus Model, primary care doctors can care for their patients the way they think will deliver the best outcomes, and they’ll get paid for achieving results and improving care.
• One new payment model—the Surgical Hip and Femur Fracture Treatment Model—will support clinicians in providing care to patients who undergo surgery after a hip or femur fracture beyond hip replacement. In addition, we finalized updates to the Comprehensive Care for Joint Replacement Model, which began in April 2016.
• The Accountable Health Communities Model, beginning in 2017, will test whether increased awareness of and access to services addressing health-related social needs will impact total health care costs and improve health and quality of care for Medicare and Medicaid beneficiaries in selected communities. This model will address a critical gap between clinical care and community services in the current delivery system.
• Thirty-eight states and territories are engaged in the State Innovation Models initiative where they are testing their own best ideas to improve health, quality of care, and lower costs. Additionally, Vermont and Maryland have entered into global payment arrangements to improve care for the whole state’s population.
• And, already, investments in patient safety from the CMS Innovation Center, including through the Partnership for Patients, have contributed to an estimated 125,000 lives saved, over 3 million infections and adverse events avoided, and $28 billion in savings. We expect to see these numbers and savings continue to grow in the coming years.
• These exciting approaches are the result of careful design, thorough and rigorous evaluation, and close collaboration with patients, doctors, and other stakeholders to achieve real, measurable, and significant results in improving health and lowering spending. CMS conducts an independent evaluation of every CMS Innovation Center model and releases those findings publicly. These reports provide stakeholders with information on the impact of the model as a whole on health care expenditures and utilization, beneficiary and health care provider experiences with care, and, where feasible, health outcomes. The reports also often provide site-specific results.

Using the CMS Innovation Center to advance better, smarter health care has become even more important over time. Since the passage of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the CMS Innovation Center has been instrumental to its implementation. The Quality Payment Program, which implements provisions of MACRA, includes a five percent incentive payment for physicians and other clinicians sufficiently participating in Advanced Alternative Payment Models. The CMS Innovation Center is the mechanism to create new Advanced Alternative Payment Models in the future. In fact, the CMS Innovation Center has recently announced more than five new or re-opened opportunities for clinicians to join Advanced Alternative Payment Models. CMS expects 125,000 to 250,000 clinicians to be participating in Advanced Alternative Payment Models by 2018. The CMS Innovation Center looks forward to partnering with doctors, clinicians, patients, and others on new models.

The CMS Innovation Center continues to work on behalf of current and future Medicare, Medicaid, and CHIP beneficiaries. After more than six years, the health care system is objectively safer while making Medicare more financially secure for future generations. Such significant progress is possible because we have worked with Congress and stakeholders to listen, adapt, and advance proven ideas. Our work in developing and expanding new payment models will continue to be guided by the following core principles:

• Supporting innovative payment and service delivery models with strong potential to improve health care quality and lower costs.
• Engaging with and listening to consumers, providers, and other stakeholders allowing for open and transparent dialogue, including through the appropriate use of notice-and-comment rulemaking and ombudsmen.
• Evaluating results based on appropriately scoped and sized demonstrations and advancing best practices based on their impact on quality and cost.

Together we can continue to strive to achieve better care, healthier people, and smarter spending.

The CMS Innovation Center has released its third Report to Congress, as mandated by section 1115A(g) of the Social Security Act. It focuses on activities between October 1, 2014 and September 30, 2016, but also highlights a number of important activities started during that time period that were announced between September 30, 2016 and December 31, 2016. The CMS Innovation Center’s portfolio of models and initiatives has attracted participation from health care providers, states, payers, and other stakeholders in all 50 states, the District of Columbia, and Puerto Rico. During this period, the CMS Innovation Center has tested or announced 39 payment and service delivery models and initiatives authorized under section 1115A authority. To improve care and value, these model tests focus on reducing program expenditures while improving the quality of care.

Today, the Centers for Medicare & Medicaid Services (CMS) announced the Medicare-Medicaid Accountable Care Organization (ACO) Model, a new initiative designed to improve the quality of care and lower costs for beneficiaries who are enrolled in both Medicare and Medicaid.

The Medicare-Medicaid ACO Model builds on the current Medicare Shared Savings Program and advances efforts to partner with states in transforming the health care delivery system.

“This model aims to provide improved care coordination for those enrolled in both Medicare and Medicaid, allowing providers to focus more on providing care for their patients rather than administrative work,” said Dr. Patrick Conway, CMS acting principal deputy administrator. “CMS continues to partner with and leverage the best ideas from states to transform our health care system to improve quality and care coordination. In the long run, this partnership will result in healthier people and smarter spending.”

In current Medicare ACO initiatives, beneficiaries who are Medicare-Medicaid enrollees may be attributed to ACOs. However, Medicare ACOs often do not have financial accountability for the Medicaid expenditures for those beneficiaries. The Medicare-Medicaid ACO Model will allow Medicare Shared Savings Program ACOs to take on accountability for the quality of care and both Medicare and Medicaid costs for Medicare-Medicaid enrollees.

CMS is accepting letters of intent from states that wish to work with CMS to design certain state-specific elements of the model. The Medicare-Medicaid ACO Model is open to all states and the District of Columbia that have a sufficient number of Medicare-Medicaid enrollees in fee-for-service Medicare and Medicaid. CMS will enter into participation agreements with up to six states with preference given to states with low Medicare ACO saturation. Once a state is approved to participate in the model, a request for application will be released to ACOs and health care providers in that state.

The Medicare Shared Savings Program and other ACO initiatives were created to change the incentives for how medical care is delivered and paid for in the United States, moving away from a system that rewards the quantity of services to one that rewards the quality of health outcomes. ACOs are groups of doctors, hospitals, and other health care providers who voluntarily come together to develop and execute a plan for a patient’s care and share information, putting the patient at the center of the health care delivery system.

The Affordable Care Act, through the creation of the Center for Medicare and Medicaid Innovation, allows for the testing of innovative payment and service delivery models, such as the Medicare-Medicaid ACO Model. Today’s announcement is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality.

In March 2016, the Administration announced that it met the ambitious goal – eleven months ahead of schedule – of tying an estimated 30 percent of Medicare payments to quality and value through alternative payment models by 2016. The Administration’s next goal is tying 50 percent of Medicare payments to alternative payment models by 2018. The Health Care Payment Learning and Action Network established in 2015 continues to align efforts between government, private sector payers, employers, providers, and consumers to broadly scale these efforts to achieve better care, smarter spending, and healthier people.

Today’s announcement is one in a series of Innovation Center initiatives that will expand opportunities for clinicians to participate in Advanced Alternative Payment Models under MACRA. Our work in developing and expanding new payment models will continue to be guided by the following core principles:

• Supporting innovative payment and service delivery models with strong potential to improve health care quality and lower costs.
• Engaging with and listening to consumers, providers, and other stakeholders allowing for open and transparent dialogue, including through the appropriate use of notice-and-comment rulemaking and ombudsmen.
• Evaluating results based on appropriately scoped and sized demonstrations and advancing best practices based on their impact on quality and cost.

We look forward to continuing to work with our many stakeholders to achieve better care for patients, better health for our communities, and lower costs through improvement for our health care system.

At the Centers for Medicare & Medicaid Services (CMS), we are working with numerous partners to transform our health care delivery system to one that delivers better health outcomes while spending dollars more wisely. In November of 2015, we updated the CMS Quality Strategy, incorporating the ongoing work to shift Medicare from paying for the number of services provided to paying for better outcomes for patients. We know that a key strategy to achieving better outcomes is to meaningfully engage patients as partners in decisions about their health care. Therefore, one of the six goals outlined in this strategy is: Strengthen person and family engagement as partners in care. Today, we are excited to announce the release of the CMS Person and Family Engagement Strategy, which we believe can lead to significant progress toward this important goal.

What does person and family engagement mean? We view this as patients and families being part of the health care team by working collaboratively with their doctor or other health care professional to be active partners when making decisions about their health.

Why is this important? Because consideration of the health, values, and goals of the individual in consultation with the entire health care team leads to an improved experience and better care. When people feel responsible for their own health and are partners with their providers in goal-setting and decision-making, they are much more likely to achieve their health care goals.

• If individuals feel their beliefs, desires, and culture are considered in their care, they are more likely to follow their care plan.
• If individuals are able to communicate effectively with their providers and have a prominent role in making health care decisions, they will receive better care, can more effectively manage their health, and may receive appropriate preventive care while relying less on emergency or urgent care[1].

The CMS Person and Family Engagement Strategy will serve as a guide for the implementation of person and family engagement principles and strategies throughout CMS programs. This strategy will expand the awareness and practice of person and family engagement by providing the following goals and objectives:

• Goal 1: Actively encourage person and family engagement along the continuum of care within the broader context of health and well-being in the communities in which people live.
• Goal 2: Promote tools and strategies that reflect person and/or family values and preferences and enable them to actively engage in directing and self-managing their care.
• Goal 3: Create an environment where persons and their families work in partnership with their health care providers to develop their health and wellness goals informed by sound evidence and aligned with their values and preferences.
• Goal 4: Develop meaningful measures and tools aimed at improving the experience and outcomes of care for persons, caregivers, and families. Also, identify person and family engagement best practices and techniques in the field that are ready for widespread scaling and national integration.

This Strategy emphasizes that person and family engagement goes beyond informed consent. It is about including the patients voice in policy and program planning. It is about proactive, effective communication and partnered decision-making with patients, families, and caregivers. It is about building a care relationship based on trust and inclusion of patients’ beliefs, values, preferences, and culture which can even lead to a reduction in health care disparities. Health care decision-making should not always be limited to the patient and provider. It is essential to include family members, care-givers, and close friends in the conversation about health when the patient desires inclusion of others. As delivery system reform efforts move the nation to focus on the quality of care and not the quantity of care received, person and family engagement is an essential part of a health care system that delivers high quality care, spends dollars more wisely, and improves the health of people in their communities.

[1] Epstein RM, Street RL, Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.

The Centers for Medicare & Medicaid Services is sharing a new Health Affairs article by Secretary Burwell outlining her vision for the future of health care. In it, she touts collaboration with stakeholders like you in advancing crucial Delivery System Reform efforts — including ongoing Center for Medicare and Medicaid Innovation initiatives.