ACHIEVING A TRANSFORMED AND MODERNIZED HEALTH CARE SYSTEM FOR THE 21ST CENTURY Centers for Medicare & Medicaid Services CMS _d032122e-9f23-11df-9a83-7f707a64ea2a The Centers for Medicare & Medicaid Services (CMS) is an agency within the Department of Health and Human Services (HHS). Created in 1977, CMS brought together the two largest Federal health care programs, Medicare and Medicaid under a unified leadership. In 1997, the State Children’s Health Insurance Program (SCHIP) was established to address the health care needs of uninsured children. With a current budget of over $650 billion and serving approximately 90 million beneficiaries, CMS has become the largest purchaser of health care in the United States. Mark B. McClellan, MD, PhD Administrator To achieve a transformed and modernized health care system. _d032183c-9f23-11df-9a83-7f707a64ea2a To ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries. _d0321cc4-9f23-11df-9a83-7f707a64ea2a Care and Self-Reliance Care for the truly needy, foster self-reliance. Neighborhoods and Standards National standards, neighborhood solutions. Collaboration Collaboration, not polarization. Political Transcendence Solutions transcend political boundaries. Markets Markets before mandates. Privacy Protect privacy. Science and Process Science for facts, process for priorities. Results Reward results, not programs. Change Change a heart, change a nation. Life Value life. Workforce Skilled, Committed, and Highly-Motivated Workforce _d0321e9a-9f23-11df-9a83-7f707a64ea2a 1 Attracting, developing, and retaining high-performing managers and employees are key for CMS to accomplish its many critical programs and the initiatives identified in this Plan. As a primary partner in shaping the future of America’s health care, our goal is to make CMS the “employer of choice” for seasoned professionals and emerging leaders in the health care arena. CMS will maintain a highly-skilled, diverse workforce that is equipped to transform America’s health care system. We will strive to provide state-of-the-art administrative technology and processes to enable employees to complete our important work with the least possible amount of administrative burden. CMS’ vision for human capital management calls for a strategically-aligned workforce that supports the CMS and HHS mission, responds effectively in emergencies, positions bench strength to assume leadership positions, and becomes a most efficient organization, with the “right” people in the “right” position at the “right” time. An implicit component of this strategy requires CMS to hire and retain a workforce that reflects the diversity of the populations that we serve. Doing so allows us to understand the needs of the populations we serve and effectively address them. CMS is committed to applying these principles for human capital management to ensure a workforce that is resilient, competent, diverse, flexible, and motivated to accomplish our mission. People and Expertise CMS will have the right people with the right expertise in the right positions to help deliver the Strategic Action Plan to accomplish the agency’s mission. _d0321fee-9f23-11df-9a83-7f707a64ea2a 1.1 46892fdf-ba22-453f-8466-edd419b7377f 08c3c44c-9f89-48ab-b811-6fa7c5109dac Workforce CMS senior management will assure its workforce is resilient, competent, diverse, flexible, and motivated to accomplish the mission. _d03222c8-9f23-11df-9a83-7f707a64ea2a 1.2 CMS Senior Management 0133173b-0917-4d7b-a50b-5a599a8f3de4 c2d5a69f-f56e-4c58-91eb-9a34ed744302 Human Capital and Succession CMS will complete and implement the Human Capital Management plan and the CMS Succession process and plan. _d0322494-9f23-11df-9a83-7f707a64ea2a 1.3 Human Capital Management Plan - CMS faces a series of unprecedented internal business and external environmental challenges, which have major implications for the workforce and accomplishing the Agency’s mission. These challenges include rapid and significant changes in health care delivery and related technology, CMS’ emerging strategic role as an active health care market presence, and CMS’ aging workforce and the increased competition for skilled workers. CMS’ FY 2005 - 2008 Human Capital Management Plan (HCMP) establishes a framework for developing an organizational structure that is citizen-centered, results-oriented and market-based. Our approach is strategic, dynamic, and aligned with the agency’s current and future business needs. The HCM process will: (1) integrate recruitment policies and systems to allow us to identify and quickly hire highly-competent employees; (2) retain high-performing employees through innovative incentive structures; (3) reward CMS employees by linking performance awards to specific program performance goals; and (4) develop and refine organizational structures that are efficient and effective. By FY 2008, 45 percent of CMS’ managers and 28 percent of CMS’ current workforce will be eligible to retire. This will create skill gaps in virtually all occupations within CMS. CMS must use various techniques to effectively manage human capital. For example, implementing employee development programs that cover all levels of the CMS workforce, significantly improving the agency’s hiring practices, fully exercising recruitment and retention flexibilities and e-Gov solutions, and using competitive sourcing as a mechanism for closing skill gaps are some of the comprehensive strategies that are already under way and will continue beyond FY 2009. Accordingly, we will support the HCMP by: • Implementing the Extreme Hiring Makeover Project (EHM) throughout CMS. EHM provides a new approach to effective recruitment and hiring. It also helps us get the right people with the right skills in the right jobs at the right time. To do this, CMS will use the following strategies: o have strategic conversations with hiring managers to clearly define the competencies needed for each vacancy posting; o use competency assessments to recruit employees; o re-design our vacancy announcements to attract the best talent; o use a “Manager’s Toolkit” to train managers on hiring; and o hold our managers and human resource professionals accountable for being stewards of CMS’ valuable resources. • Increasing the use of recruitment and retention flexibilities currently available, such as direct hire authority, recruitment and retention bonuses, superior qualifications appointment authority, and relocation bonuses; • Using the Federal Career Intern, Emerging Leaders, Presidential Management Fellows Program, and the Senior Executive Service Career Development Programs to supplement the pool of quality talent who can move into leadership positions as they become available; • Increasing workforce diversity, especially in mission-critical occupations, by using a variety of special appointment authorities and recruitment options, holding managers accountable for achieving results, enhancing ongoing relationships with minority organizations, and developing, implementing, and evaluating strategies for diversifying the workforce; • Integrating our competitive sourcing activities into CMS’ overall human capital management strategies (i.e. moving staff from support-type positions to mission-critical functions consistent with our competitive sourcing program); • Eliminating competency gaps in our most critical occupations by identifying proficiency gaps and proficiency levels for each Mission Critical Occupation (MCO), implementing core competency models for all MCOs, and developing and implementing plans for closing the gaps in all MCOs by the end of FY 2007; • Implementing new Performance Management Appraisal Program (PMAP) that provides meaningful measurement of individual performance and provides information for making informed decisions about awards and recognition, training, reassignment/re-deployment potential, functional assignments, and retention; • Providing enhanced employee development programs and training options linked to individual employee development plans; and • Growing leaders by delivering or identifying leadership development programs that enable employees and managers to demonstrate CMS’ five core leadership competencies of Managing Change, Leading People, Managing Resources, Producing Results, and Building Partnerships and Coalitions. CMS Succession Plan - In the fall, 2005, CMS initiated an agency-wide succession planning system to help us identify both the talent pool in our employees and key roles that are potentially at risk due to attrition. In FY 2005, CMS conducted an inventory of its management and senior technical ranks. That study revealed the potential for a significant increase in attrition in key leadership positions over the next five to 10 years. The primary cause for the projected increase is the approaching retirement eligibility of 45 percent of CMS’ incumbent staff in grades GS-14 and above. To accomplish our mission, CMS needs leadership with extensive program knowledge, high-level technical/professional expertise, and effective management and leadership skills. Among its first benefits, the Succession Management System will provide the long-range overview necessary to help management determine the most effective way to plan for the succession in the next decade. CMS is moving forward to implement this process. • By the end of FY 2006, the CMS Succession Plan will encompass more than 1100 leadership roles and incumbent staff ranging from the SES management ranks through senior technical experts in every major occupational category. • In FY 2007 CMS will create a flexible and automated Succession Management System, which will be the driver for our recruitment and retention, employee development, management development, and diversity recruitment plans. 1bfbb3fa-44c8-4886-b2cd-75c10c98b96f 17abb0fd-166e-4704-a646-2981449c3f1e Enterprise Portfolio Management To make sure that the daily work of CMS reflects the goals in this plan, CMS will establish Enterprise Portfolio Management. _d0322624-9f23-11df-9a83-7f707a64ea2a 1.4 Senior Leadership This system will inventory all CMS projects and assign resources. Doing this helps senior leadership prioritize employee workload. Automation to Support Employee Work - CMS is automating a variety of internal administrative processes in order to support managers and staff who are accountable for effectively developing and executing CMS’ many complex initiatives. In 2007-2008, Enterprise Portfolio Management (EPM) will serve as the bridge between the Strategic Action Plan and day-to-day CMS work. The Priority Project Tracker (PPT) System, a performance-based EPM system, will effectively manage the work performed at CMS. The system tracks and reports information on projects to support the CMS Organizational Assessment and crosswalks projects with the “HHS Top 20,” the Secretary’s 500 day plan, and the President’s Management Agenda. Furthermore, the projects that are managed in PPT support our Strategic Action Plan, SES performance plans, and on-going day-to-day operations. We will continue to develop and mature our EPM System by: • Establishing an inventory of all CMS projects; • Developing an enterprise portfolio structure that consists of business functions and lines of business; and • Assigning resources (FTEs, budget) and other relevant information to the projects/portfolios, which will enable senior leadership to make informed decisions in prioritizing workload from an agency-wide perspective. 3267a3b6-ce9d-451d-b46c-3222ceecf7e3 48d48cd0-8372-4b24-ab00-0669fd4c8ffb Payments Accurate and Predictable Payments _d03229b2-9f23-11df-9a83-7f707a64ea2a 2 CMS must make sure that the more than $650 billion we make in payments each year is accurate and timely. By developing and executing effective oversight and aggressive provider education and outreach, CMS can achieve strong financial performance for its programs and operations. Oversight will include expanded modernized program integrity for Medicare and Medicaid and preventing improper payments. The modernization programs will better facilitate CMS’ preparedness and response in emergencies and planning for a pandemic. Finally, CMS’ strategies for cost and quality transparency and “value incentives” for consumers have the potential to help reduce costs, which would improve both long-term sustainability and solvency for our programs. In addition to strengthening the Medicare Integrity Program to encompass the new prescription drug benefit and Medicare Advantage plans, CMS is also improving Medicaid integrity through the new Medicaid Integrity Program. Several modernization initiatives currently under way will support efforts to strengthen CMS’ financial management and program integrity. Implementing IT (HIGLAS), ICD-10, upgraded electronic claims processing, and reforming the Prospective Payment Systems will strengthen financial management of the Medicare Program. Also, part of the New Orleans Health System initiative will support accurate and predictable payments. These systems and structural changes will allow more effective financial oversight and reporting of the programs, and will result in lower error rates and improper payments. Two ways that we are supporting accurate and predictable Medicare payments are expanding the Performance Assessment of Medicare Advantage plans to include Part D plans and managing Medicare Secondary Payer (MSP) recoveries. We’re also focused on Medicaid payments by processing and overseeing Federal Medicaid grants and demonstrations, which reimburse states a percentage of their expenditures in providing health care for individuals whose income and resources fall below specified levels. Accurate and Predictable Payment initiatives through 2009 include: Measuring and Reducing Payment Errors through Improper Payments Information Act (IPIA) Compliance CMS is working diligently to measure and reduce improper payments in our programs and to comply with the Improper Payments Information Act of 2002 (IPIA). Since FY 2003, CMS has reported a Medicare fee-for-service error rate as part of our Comprehensive Error Rate Testing (CERT) program and Hospital Payment Monitoring Program. Over the past several years, CMS proactively tested the methods to estimate improper payments in Medicaid and the State Children’s Health Insurance Program (SCHIP) through Payment Accuracy Measurement (PAM) and Payment Error Rate Measurement pilots. These pilot projects led to the development of a national program called Payment Error Rate Measurement (PERM) to measure improper payments in Medicaid and SCHIP. CMS is working to achieve compliance with the IPIA and reduce improper payments by: • Reducing the Medicare fee-for-service claims payment error rate to 4.7 percent by the end of FY 2008; • Continuing to support a comprehensive provider education and outreach program so that providers know the rules and can bill appropriately; • Reporting error rates for Medicaid and SCHIP for FY 2007 in the FY 2008 Performance and Accountability Report (PAR); and • Completing the Risk Assessments for Medicare Advantage and Part D and finalizing our measurement strategies and reporting schedule. Expanding a Data-Driven Approach to the Medicare Integrity Program (Medicare MIP) The Medicare Integrity Program (MIP) established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provided CMS with dedicated funding to identify and combat improper payments and fraud and abuse. CMS uses MIP funds to support program integrity contractor performance of the following activities: audits of cost reports, medical review of claims, identification of potential fraud cases, and education to inform providers about appropriate billing procedures. As required by statute, MIP funding rose from $440 million in FY1997 to a steady rate of $720 million since FY2003. In addition, the Deficit Reduction Act of 2005 (DRA) provided additional funding for this activity in FY2006. We continually review our Medicare program integrity activities to make sure we’re using our resources effectively and performing well. Based on our experience gained from the Medicare MIP, CMS has moved ahead with efforts to expand and strengthen our work to protect the Medicare Trust Funds; increase our oversight capacity; and focus more on identifying, responding and resolving problems. CMS recently expanded our program integrity oversight to include the new Medicare prescription drug benefit (Part D) and the Medicare Advantage plans. We contracted with Medicare Drug Integrity Contractors (MEDICS) to support CMS’ anti-fraud and abuse efforts associated with Part D. CMS is also expanding the use of electronic data to more efficiently detect improper payments and program vulnerabilities. CMS will continue the expansion of the Medicare Integrity Program by: • Implementing the Medicare Drug Integrity Contractor (MEDICS) contracting strategy to find trends that may indicate fraud and abuse, investigate potential fraudulent activities, conduct fraud complaint investigations and refer cases to the appropriate law enforcement agency as needed; • Developing and validating new and existing methods to detect and prevent abusive use of services, as well as possible fraud and abuse schemes; • Leveraging CMS data systems and repositories to implement the One Program Integrity (One PI) System Integrator and modernizing our data analysis capability for program integrity efforts. Medicaid and Medicare Part D data are the initial focuses of the One PI System Integrator. • Continuing the evolution of the Program Safeguard Contractors (PSCs) toward a more outcome-oriented and performance-based approach in identifying and combating fraud and abuse; • Expanding the Medicare/Medicaid (“Medi-Medi”) data match programs beyond the current 10 states with the funding outlined in the Deficit Reduction Act. These projects use fraud and abuse mining tools to query across data from both programs to detect fraudulent patterns that may not be evident when billings for either program are viewed in isolation; • Redesigning CMS audit processes and desk review programs by using payment and savings data analysis to focus audit activities. Our efforts will be targeted to areas of higher risk; and • Continuing to consolidate the activities at the Coordination of Benefits Contractor (COBC) and our use of Voluntary Data Sharing Agreements (VDSAs) with employers and insurers to enhance the way we manage beneficiaries’ insurance coverage information. Implementing the Medicaid Integrity Program (Medicaid MIP) The Medicaid Integrity Program (MIP), created through the Deficit Reduction Act (DRA) of 2005, dramatically increases both CMS’ obligations and resources to combat fraud and abuse. Five million dollars has been appropriated in FY2006, with an additional $50 million in each of FY07 and 08, and $75 million annually in FY09 and each year thereafter. The DRA mandated CMS to hire 100 new employees, whose duties will consist solely of protecting the integrity of the Medicaid program. By 2009, CMS will fully implement the Medicaid Integrity Program by: • Creating a comprehensive integrity plan, in consultation with internal and external partners; • Procuring and overseeing Medicaid Integrity Contractors (MICs) who will conduct reviews, audits, and education; • Developing field operations to provide State program integrity oversight reviews and support in the form of technical assistance and fraud and abuse training; and • Developing fraud research and detection activities to provide statistical and data support, identifying emerging fraud trends and conducting special studies as appropriate. Enhancing CMS’ Financial Management Systems--HIGLAS CMS is replacing its legacy Medicare accounting systems, maintained by both CMS and its current Medicare FFS contractors, with the new HIGLAS – a State-of-the art electronic, integrated financial accounting system. Full implementation of HIGLAS by 2011 will allow CMS to track Medicare payments. It will also allow us to accurately pay claims for over 43 million Medicare beneficiaries (the FY07 count), and will strengthen the overall financial management of CMS’ financial operations. CMS has already implemented HIGLAS in six of our Medicare contractors, with positive results. CMS is currently transitioning from the legacy claims processors (FIs and carriers) to the new Medicare Administrative Contractors (MACs), who will use HIGLAS as they take over the claims processing responsibilities from the FIs and carriers. The immediate results are that claims have been processed more accurately and improper payments have been reduced. HIGLAS processes have resulted in an additional $9 million of interest earned in the Medicare trust funds. HIGLAS is also a component of the Department-wide Unified Financial Management System (UFMS) initiative. HIGLAS continues its coordination efforts with HHS to ensure that internal CMS administrative accounting/financial data can be interfaced with UFMS. Unifying the systems improves the Department’s data consolidation and financial reporting capabilities. When fully implemented by 2011, HIGLAS will: • Strengthen how we manage our accounts receivable and allow us to collect outstanding debts faster and more effectively; • Enhance CMS’ oversight of contractor financial operations, including data entry, transaction processing, and reporting; • Produce automated financial statements and other required reports quickly, leading to fewer errors in financial reporting and a reduction in manual labor; • Eliminate redundant accounting processes; • Interface with the Recovery Management and Accounting System (ReMAS), which reconciles claims and payments to providers and beneficiaries when Medicare is the secondary payer, further ensuring that claims are paid appropriately; • Be used by all Medicare Administrative Contractors; • Assess Part C (managed care) and Part D (prescription drug) system requirements; and • Save millions of benefit dollars each year for the Medicare program. Updating Outmoded Coding Systems—ICD-10 ICD-10 is the modernized update to ICD-9, the current code set for recording diagnoses and inpatient hospital procedures. ICD-10 provides a more robust, more granular, more modern and more accurate code set. ICD-10 will improve the quality of information reported on claims. This information will provide for more accurate payments and will improve quality monitoring, payment, coverage, risk adjustment, research, and statistical reporting. Requiring the industry to move from ICD-9 to ICD-10 needs input from both Congress and the Department. Because the codes impact so many parts of CMS, the implementation process is expected to be a 4-5 year effort, starting well before the implementation date and lasting several years after. This will be a significant, agency-wide effort, impacting virtually every part of CMS and all of our partners. Implementing Private Sector Recovery Techniques As part of the effort to strengthen and improve our financial management performance, and protect the Medicare Trust Funds, we considered and adopted proven private sector approaches in our program operations. For example, using innovative financial management strategies allows CMS the opportunity to integrate more efficient and effective processes into our operations and demonstrate the potential value of these approaches to other programs within HHS. Our current Medicare recovery initiatives include the use of new contracting authority provided by the Medicare Modernization Act and the consolidation of functions and workloads to maximize financial performance and ensure accurate payments. The Medicare Modernization Act provided for a three-year demonstration project to allow CMS the ability to use recovery audit contractors (RACs) to identify underpayments and overpayments in Medicare claims, and to reimburse the contractor a percentage of the recoveries. The law also requires CMS to evaluate this project and report on savings to the Medicare program and recommendations for extending or expanding the project. Our current experience under the demonstration has resulted in a significant increase in Medicare overpayments collected without using increasing current program funding. CMS is actively pursuing improvements in Medicare Secondary Payer (MSP) operations. To do this, CMS now has one MSP recovery contract that consists of MSP post-payment recovery work and Group Health Plan (GHP) MSP debts. Consolidating this work will improve our administration and operations, improve consistency of processes, and enhance customer service. Over the next few years, CMS will: • Complete the three-year Recovery Audit Contractor (RAC) demonstration, in three states (CA, NY, FL), to identify and recover Medicare overpayments, use the findings to further reduce improper payments and pay the RACs on a contingency basis; • Submit the report to Congress on the impact of the RAC demonstration and recommendations for extending or expanding the approach; • Award the Medicare Secondary Payer Recovery Contract (MSPRC) and begin implementation of the consolidation by October 2006; and • Oversee the MSPRC operations to ensure efficiencies in the post-payment aspects of the MSP program improve recoveries and enhance customer service. Implementing the National Provider Identifier (NPI) As we continue to upgrade our systems to ensure accurate payments, high quality health care, and to reduce improper payments, CMS is implementing the HIPAA requirement for health care providers to adopt a standard unique health identifier. The NPI was adopted in 2004 as the standard unique health identifier for all health care providers. In May 2005, CMS announced the availability of the new identifier for use in the standard electronic health care transactions. One year later, CMS announced the availability of electronic file interchange (EFI), also referred to as "bulk enumeration," functionally. The EFI enumeration process allows organizations to apply for NPIs for a large number of individuals or organizations by submitting an electronic file rather than submitting a paper application or web-based application for each individual or organization. Because a file can contain thousands, even tens of thousands, of providers' applications, the administrative burden on both the provider community and CMS is greatly reduced when this process is used. By implementing the NPI requirements as noted below, we can facilitate more accurate payments, strengthen quality assurance, and reduce improper payments. • May 23, 2007: All HIPAA-covered entities such as providers completing electronic transactions, health care clearinghouses, and large health plans, must implement NPI. • May 23, 2008: All small health plans must implement NPI. Ensuring Effective Grants Management We use the Grants Administration, Tracking and Evaluation System (GATES) to efficiently manage administrative grants. The system streamlines the work processes within the agency. It also gives the grantee community improved services, full disclosure of all grant opportunities within the Federal government, and streamlines the application process. We are currently transitioning the processing, paying, and accounting of the Medicaid grants into the Healthcare Intergraded General Ledger Accounting System (HIGLAS). Once completed, the HIGLAS system will enhance CMS’ capability to oversee and monitor Medicaid grants by providing timelier and more comprehensive data. Transitioning to Medicare Administrative Contracting In Section 911 of the MMA, the Congress mandates that the Secretary of Health and Human Services replace the current Fee-for-Service (FFS) contracting authority under Title XVIII of the Social Security Act (the Act) with the new Medicare Administrative Contractor (MAC) authority. Referred to as Medicare contracting reform, it will improve Medicare’s administrative services to beneficiaries and health care providers and will bring standard contracting principles, such as competition and performance incentives, to Medicare. Using competitive procedures, Medicare has begun to replace its current claims payment contractors, fiscal intermediaries (FIs) and carriers with new contract entities called MACs. The MMA requires that CMS compete and transition all work to MACs by October 2011. CMS expects to complete the transition by 2009, thereby realizing additional Trust Fund savings sooner. CMS is meeting the needs of its growing beneficiary population through this initiative by: • Improving customer service by establishing a single point-of-contact so Medicare beneficiaries and providers can get information. The MACs will serve as the point of contact for all Medicare providers and physicians in their respective jurisdictions, while beneficiary claims questions go to a Beneficiary Contact Center; • Continuing operation of efficient provider call centers that respond to over 55M calls annually; • Competing and awarding 23 MACs during the initial implementation phase (2005-2011); • Making advances toward the delivery of comprehensive, patient-centered care; and • Emphasizing the MAC role in provider education and outreach. Although Medicare contracting reform requires a significant up-front investment, this initiative will also generate significant Trust Fund and administrative savings over time. Assuming that our proposed transition schedule is maintained, the Office of the Actuary estimates that the savings resulting from Medicare contracting reform will start in FY 2008 and will accumulate rapidly to nearly $1.5 billion through FY 2011. Beyond FY 2011, CMS projects that administrative savings, in the form of contractor cost reductions from the competitive contracting environment, could exceed $180 million annually. The transition to the MACs will occur in three cycles as follows: • The Start-Up Cycle: Will transition a small discrete workload (approximately 8.8 percent of the national workload). This cycle will allow CMS to analyze lessons learned from the acquisition and transition process prior to implementing the bulk of the transfer. This cycle is already under way. • Cycle One: Will complete and transition half of the balance of the workload. Lasts one year. Will subject more than 40 percent of the national workload to competition and transition at a single time. • Cycle Two: Will complete and transition the balance of the workload. Lasts one year. Will subject more than 40 percent of the national workload to competition and transition at a single time. Improving Electronic Claims Processing This initiative supports the Secretary’s priority of increased use of Health Information Technology. CMS is initiating a number of projects to support more accurate and efficient electronic claims processing. It has three major parts as described below: Electronic Data Interchange (EDI) is the automated transfer of data in a specific format following specific data content rules between a health care provider and CMS or between CMS and another health care plan. The EDI transactions allow a provider to submit transactions faster and be paid for claims faster. Doing this generally costs less than paper or manual transactions. This option has already been implemented for Medicare FFS providers and contractors. By the end of 2007, CMS expects the following results from these efforts: • Electronic Media Claim rates will increase to 98% for intermediaries and 90% for carriers. • Electronic Remittance Advice rates will increase to 55% for intermediaries and 35% for carriers. • Electronic claims status volume will increase by 5% from FY 2006 level. • Standard Paper Remittance Advice volume will be reduced by 30% as compared to FY 2005 baseline volume for both intermediaries and carriers. CMS will develop the initial goal for eligibility query based on data collected in FY 2006 by the end of 2007. Electronic Claims Filing (ECF) is required to be used for all Medicare claims except those from small providers and several other rare instances. Medicare provides free software to providers to enable them to use ECF. Claims may be submitted electronically to a Medicare carrier, durable medical equipment regional carrier (DMERC), or a fiscal intermediary (FI) from a provider’s office using a computer with software that meets electronic filing requirements as established by the HIPAA claim standard and by meeting CMS requirements. The Standard Front End (SFE) Project is a critical component of the modernization initiative to increase electronic claims processing. This system will be fully implemented by 2009, and it will support Medicare Administrative Contractors (MACs) operations. Establishing a SFE can reduce the problems associated with the current Medicare claim submission process by implementing common specifications for the front-end claim editing and by standardizing and simplifying the process. Reforming Payment Systems—Inpatient Prospective Payment System (IPPS), Ambulatory Surgical Centers (ASC), and Outpatient Prospective Payment System (OPPS) The Medicare Payment Advisory Commission (MedPAC) and further agency analysis resulted in recommendations to change the Inpatient Prospective Payment System (IPPS). CMS’ analysis suggests that the current, charge-based weights and the current diagnosis related groups (DRG) classifications result in notable distortions between payments and the relative costs of care. The revisions will improve the accuracy of payments, leading to better incentives for hospital quality More specifically, these changes are expected to reduce incentives for hospitals to “cherry pick” or treat only the most profitable patients. To improve the accuracy of payments to Ambulatory Surgical Centers (ASCs) and in accordance with section 626 of the MMA, CMS proposed and will finalize a new payment system for ASCs, effective January 1, 2008. The proposal expands the list of covered surgical procedures, while increasing the number of payment groups for ASC procedures in order to improve accuracy. The proposed system is based on the relative weights used in the outpatient hospital prospective payment system. The system will also contain safeguards to prevent overpayment for procedures currently provided predominantly in physician offices. To improve the accuracy of the hospital outpatient prospective payment system (OPPS) and to create better incentives for hospitals to improve quality and efficiency, CMS proposed to base the 2007 OPPS payment rates on 2005 claims data and the most current available cost report data. CMS continues to explore means of addressing hospital and other stakeholder concerns about payment for clinic and emergency department visits, procedures that require expensive devices, and use of multiple procedure claims to set payment weights. CMS will take action to address these concerns by: • Publishing the proposed rule with comment explaining the changes we will make for CY 2007 payment under OPPS; • Conducting biannual meetings of the Ambulatory Payment Classification (APC) Panel. APC is a Federal advisory committee chartered by the Secretary of HHS, composed of hospital industry representatives who advise CMS on many aspects of the OPPS from the hospital perspective; and • Enhancing OPPS claims to ensure that the charges for all items and services are included in the claims so that the payment rates will fully reflect the total cost of the services and the claims data can be used to efficiently monitor quality of care. Improving the Accuracy of Payment and Quality Measurement To improve the accuracy of quality measurements and the comparability of results across Post Acute Care (PAC) facility types and to improve the accuracy of payment for post acute care, CMS is developing a Post Acute Care Payment Reform Demonstration based on a Congressional mandate (Deficit Reduction Act Section 5008). CMS’ analysis suggests that the separate payment systems, patient assessment forms, and requirements lead to problems with care continuity, the inability to compare quality results across settings and inappropriate incentives for transfer and care provision. CMS will take action to address these concerns by: • Developing a patient assessment tool to be used in acute care hospitals and in PAC settings including Long-Term Care Hospitals (LTCHs), Independent Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs); • Developing a cost collection tool to access resource use in the four PAC settings; and, • Designing a large-scale implementation of the new patient assessment tool and cost collection tool with the intent to reform payment across the four sites based on the information collected. Part C and Part D Payment Validation CMS has implemented a new beneficiary level monthly payment validation process prior to payment authorization in order to confirm that the MARx calculated payments for the Medicare Advantage (MA), Part D and demonstration plans are accurate. This validation process is used to identify any potential payment issues and to track their resolution. Generally, the types of payment issues identified will originate as systems processing issues. The focus of the beneficiary payment validation is on independently replicating the monthly payment calculations to check the validity of the MARx payment calculations starting with beneficiary level payments and then rolling these payments up to the plan and national levels. In addition, the input data sources for these payment calculations are also analyzed to validate the accurate transfer of data across different CMS data systems to the MARx system. By the end of 2008, CMS will refine the process of validating payments made to Medicare Advantage organizations, Prescriptions Drug Plans and other organizations paid through the Medicare Advantage Prescription Drug System (MARx). We will continue to confirm that MARx calculated payments are accurate using the new beneficiary level monthly payment validation process, and will add a routine validation analysis to evaluate retrospective monthly payment adjustments. In addition, we will further automate procedures to more rapidly generate validation reports for the monthly payment decisions. As part of this payment validation initiative, CMS will continue to document in detail the complete payment transaction process and identify existing and needed controls. Documentation will include cycle memos and standard operating procedures. New controls will be defined in detail and initiated as part of the routine payment validation process. Ensuring Provision of Services During Emergencies and Disasters CMS must assure that Medicare and Medicaid providers and CMS employees are paid, even in the event of an emergency or disaster. The CMS Continuity of Operations Plan (COOP) addresses policies and procedures that enable CMS and its contractors to continue these services. The COOP, which is updated annually, encompasses evacuation, assessment, decision-making, and relocation of designated personnel to conduct the following essential functions at an alternate site: • Managed care organizations payments; • Medicare Fee-for-Service special payments by fiscal intermediaries, carriers, and/or MACs; • Medicaid/State Children’s Insurance Plan budget and expenditure reporting; • Critical payments and authorizations; • Payroll; and • Travel authorization. All essential functions except travel authorization are fiscal in nature and can be delayed for at least 48 hours. The actual priority of one essential function over another depends upon when a disruptive event occurs in the CMS payment schedule. CMS staff has been designated to assist in determining which essential functions have priority during a disruptive event, and all the plans have failsafe backups. Oversight, Education, and Outreach CMS will effectively oversee its providers and aggressively deliver provider education and outreach. _d0322c14-9f23-11df-9a83-7f707a64ea2a 2.1 Providers Doing so will help us achieve strong financial performance for our programs and operations. Oversight will include expanded, modernized program integrity for Medicare and Medicaid and ways to prevent overpayments and improper payments. 3d7d5956-d77c-4994-9dcc-166c537855d5 22934f6a-cc25-41cd-a7e1-4eb3632ac643 Emergencies and Pandemics These modernization objectives will better facilitate CMS preparedness in emergencies and pandemic planning. _d0322f34-9f23-11df-9a83-7f707a64ea2a 2.2 fc179b4e-458e-4c4a-a4c8-e4730dce1383 8119fdca-6405-4a00-b65a-0feca0ba2c34 Transparency and Value Incentives By developing strategies for transparency and value incentives for consumers and providers, CMS may improve the long-range sustainability of CMS programs and reduce costs and improve long-range solvency for Medicare. _d03233c6-9f23-11df-9a83-7f707a64ea2a 2.3 66ae3956-6d56-4281-83c8-c548713362d6 d741b73f-75a3-43d9-a138-580116f06cfa Modernization Initiatives Additional modernization initiatives include implementing a Health Care Integrated General Ledger Accounting System and a National Provider Identifier; transitioning the legacy system of Intermediaries and Carriers to the Medicare Administrative Contractor system; increasing electronic claims processing using upgraded Information Technology systems; and reforming the Prospective Payment Systems. _d0323786-9f23-11df-9a83-7f707a64ea2a 2.4 5b351669-4c58-48a4-8c48-9b552cf0edfb fe83a857-71b2-43ed-b27c-6ecd9cf24f3d Payment Validation CMS will refine the process of validating payments made to Medicare Advantage organizations, Prescriptions Drug Plans and other organizations paid through the Medicare Advantage Prescription Drug System (MARx). _d0323ae2-9f23-11df-9a83-7f707a64ea2a 2.5 b0d6cde0-eb1c-4f70-abb3-8c2a1e81017c 5ffe5a3e-225e-4b92-b5d0-3504199ece05 Value High-Value Health Care _d0323f9c-9f23-11df-9a83-7f707a64ea2a 3 CMS supports the transformation of the nation’s current health care system to one in which patients and doctors can make informed decisions about the most effective medical care, based on timely access to the latest evidence, in a way that delivers the highest value care. This transformed system includes SMART health care, secure electronic records, electronic prescribing, health transparency based on immediate, accurate, and comparative quality and cost information, new Medicare Advantage plan designs and innovative prescription plan approaches, disease management programs, disease prevention, and value-based payment. CMS processes an estimated 1.2 billion Medicare fee-for-service claims, handles millions of inquiries and appeals, and conducts thousands of health care facility inspections and complaint investigations. To support high-value health care, we plan to inform and support Medicare Prescription Drug plans, Medicare Advantage plans, and employer-sponsored retiree health care coverage so that beneficiaries have maximum choice of benefit options at affordable prices. We work closely with industry groups and providers, facilitate enrollment of millions of dual-and low-income subsidy eligibles, and develop policies that facilitate health plans meeting beneficiary needs while controlling costs. We collaborate with states, regions, and providers, including projects to implement survey procedures and interpretive guidelines related to organ transplants and restraint use. We also continue to work with states and provide support on 1115 demonstrations, 1915(b) waivers, train survey and certification surveyors, implement Medicaid quality initiatives, and develop and implement policies to better integrate Medicare and Medicaid. CMS’ High-value Health Care initiatives through 2009 include: Information Technology Modernization The current IT modernization initiatives will have a major impact on both infrastructure and applications and will result in systems that are scalable, flexible, and responsive to policy changes, supportive of queries, and maintained on platforms that facilitate easy system-to-system communication. Modernized systems will produce consistency in the use of Medicare data and predictability in systems changes, and will increase the reliability of information used by the program’s stakeholders. This will lead to improved quality of care and a better level of service for beneficiaries and providers. We are evaluating a number of options and have already undertaken several modernization initiatives. CMS’ information technology modernization efforts include: • Consolidating the number of data centers to increase our control of data center operations and better secure protected health information; • Integrating functions, processes and data to improve service to beneficiaries and providers; • Implementing improvements in service levels to beneficiaries and providers through the creation of web-based services and increased access to quality data; • Integrating help desks and call centers to enable greater control over data security and privacy, sharing of information, and service continuity across data centers; • Enhancing the data that CMS uses to administer its programs; • Optimizing the use of the Internet while protecting the privacy of beneficiary information, which will reduce the administrative burden on providers, help to ensure more accurate payments, and improve agency-to-provider communication; • Implementing industry and Consolidated Health Informatics (CHI) standards in CMS systems; • Encouraging adoption of health IT to enhance safety and reduce the burden of reporting quality measures; and • Implementing the Clinger-Cohen Act which requires that every Federal agency develop an Enterprise Architecture (EA), a representation of the business and technical processes used by the agency to accomplish its mission. EA provides a clear and comprehensive picture of what the current business and technology environment looks like today, the desired capability and structure of the enterprise for the future, and a transition plan to act as a roadmap from its current to its target environment. EA is a critical element in ensuring that the current and future business and technical architectures for the Agency support the HHS mission, Strategic Action Plans, and performance and outcome objectives. CMS will continue to optimize the interdependencies and interrelationships among its internal business operations and the underlying IT infrastructure and applications that support these operations. Medicare Prescription Drug Program CMS’ new prescription drug benefit provides seniors and people with disabilities comprehensive prescription drug coverage, the most significant improvement to senior health care in 40 years. Millions of seniors and people with disabilities are already using this benefit to save money, stay healthy, and gain peace of mind. Over 38 million Medicare beneficiaries have some type of prescription drug coverage. Since launching this benefit, we have improved our data system (particularly helping the dual eligible population), strengthened our 1-800-MEDICARE call centers, instructed plans on ways to better serve both beneficiaries and work with pharmacists, and dedicated greater CMS resources to addressing enrollee concerns. CMS’ plans for the Medicare Prescription Drug Program include: • Making sure beneficiaries can get prescriptions at a reduced cost, by building on the foundation for a strong program management structure and competitive environment; • Providing Medicare beneficiaries with good prescription drug plan choices that provide quality services that contribute to beneficiaries’ overall health and quality of life; and • Continuing to work with partners, including states, plans, pharmacists, and advocates to ensure the continued success of the program. Long-Term Solvency To potentially improve long-term solvency for CMS’ programs, and to improve their sustainability over time, we have developed strategies for price and quality transparency and “value incentives” for consumers and providers. To continue our progress toward addressing long-term Medicare solvency while providing better care and sustainable coverage, we need to accelerate adopting Health Information Technology, focus more on prevention, and create more transparency. These steps will improve Medicare for current and future generations. When we launched the prescription drug benefit earlier this year, CMS found that competition provides greater value with lower cost. In this competitive approach, private drug insurance companies are very actively competing with each other to provide the lowest premiums, best coverage, and best services on behalf of Medicare beneficiaries. Their efforts have helped hold program costs and beneficiary premiums below expectations. Moreover, beneficiaries and their caregivers, with support from Medicare and many local partners around the country, are using information on prices and coverage to choose the most appropriate benefit coverage and at the lowest annual cost. Competition with good information on quality and price has the potential to lead to cost savings in many other aspects of Medicare. CMS is beginning to implement competitive reforms in durable medical equipment, Part B drug pricing, and other areas. The President has proposed budget reforms that will reduce Medicare spending growth and save more than $36 billion over the next 5 years (FY 2007 – FY 2011), improving Trust Fund solvency and reducing the general revenue needs of Medicare. The President’s FY 2007 budget also proposes additional reforms and initiatives to improve Medicare’s financial condition by preventing costly complications and getting the right care to each patient, instead of paying for more medical services. These proposals include: • Pilot-testing quality and efficiency measures to pay more for better results rather than for more services; • Implementing competitive bidding approaches to the delivery of care; • Continuing to expand access to Medicare Advantage plans, which save beneficiaries around $80 a month and can help reduce overall health care costs by coordinating care and prevention; • Promoting the adoption of interoperable Health Information Technology; • Making Health Savings Accounts available in Medicare in 2007 • Implementing modest reductions in market basket rates of growth, including a proposed 0.4 percent reduction in the growth rate of Medicare payments (if Congress doesn’t pass a specific alternative proposal to achieve needed improvements in sustainability); and • Gradually increasing the share of program costs paid by the highest-income beneficiaries. Medicaid Reform Roadmap The Medicaid Modernization initiative is to develop and implement sustainable Medicaid programs that provide coverage for millions of people who are not covered now. People in differing economic situations will be helped through flexible benefits and incentives tailored to meet their needs. The Deficit Reduction Act of 2005 moves the program in this direction by mandating reform and giving CMS the flexibilities needed to accomplish the goals. CMS will help all states use the new benefit flexibility options to realize Medicaid innovation and efficiencies. As we do this, we will also create programs tailored to meet the needs of diverse populations through Medicaid State Plan Amendments. CMS will increase flexibility options to states by identifying a means by which States may begin the process of incorporating Health Opportunity Accounts into the Medicaid programs. People with disabilities will have access to care in their homes and communities. With Long-Term Care Reform, states will have the flexibility to give people access to health care without waivers. Self-direction will be available in long-term and acute care settings. We will increase access to community-based long-term care. The integrity of Medicaid will be assured, while also guarding against financial abuse. The Deficit Reduction Act of 2005 affords States the voluntary opportunity to reform their long-term care delivery system in a variety of ways through grant programs and multiple state plan options. CMS efforts to reform Medicaid include: • Providing clear policy direction and encouraging all states to use new benefit flexibility options (including Health Opportunity Accounts) to realize Medicaid innovation and efficiencies while creating programs tailored to meet the needs of diverse populations through Medicaid State Plan Amendments; • Administering grant programs included in the Deficit Reduction Act of 2005 which were designed to promote innovation and expand benefits and coverage. Grants include the Transformation Grants, High Risk Pool Grants, and grants for the establishment of alternate non-emergency services providers; • Providing states with flexibility through the approval of their application for 1115 Demonstrations and 1915(b) Waivers with parameters that could include reducing uninsured, promotion of personal responsibility, budget neutrality and program outcomes evaluation; • Developing mechanisms to provide support to states in rebalancing long-term care systems and increasing the number of individuals transitioned from institutions to communities; • Developing measures to determine the effectiveness of rebalancing efforts; • Implementing the Medicaid Quality Improvement Strategy to support states in their efforts to promote safe, effective, efficient, timely, equitable and patient-centered care; • Providing guidance to State Medicaid Agencies on how to become a long-term “Partnership State;” • Increasing the number of people who have the option to self-directed services through the new self-directed personal care state plan option, the new Home and Community Based Services (HCBS) State plan option, and HCBS waivers; and • Creating a person-centered vision for the future of the LTC, to serve as a blueprint for the long-range effort to reform the system over the next decade. State Child Health Insurance Program (SCHIP) Reauthorization The State Child Health Insurance Program was authorized through Title XXI of the Social Security Act and is jointly financed by the Federal and State governments and administered by the states. Within broad Federal guidelines, each state designs its program, eligibility groups, benefit packages, payment levels for coverage, and administrative and operating procedures. This important program has expanded health care coverage to millions of children; however, the program is currently only authorized through fiscal year 2007. To ensure continued coverage of eligible children through the SCHIP program CMS will: • Work with Congress to provide information necessary for reauthorization of the program. • Maintain program operations and implement any new provisions of the program when reauthorization is obtained. The New Orleans Health System CMS is developing a redesign project with the goal of producing an appropriate, comprehensive, system-wide Medicaid waiver and Medicare demonstration proposal to accomplish the Secretary’s vision for the Greater New Orleans area. We are actively developing direct relationships with beneficiaries through personalized tools and with the cooperation of a well-developed grassroots network of partners. Specifically, CMS activities related to this initiative include: • Supporting and helping the Louisiana Health Care Redesign Collaborative as it develops a practical blueprint for an evidence-based, quality-driven health care system for Greater New Orleans; • Encouraging the Collaborative to expeditiously prepare an appropriate, comprehensive, system-wide Medicaid Waiver and Medicare Demonstration proposal for the Greater New Orleans area that will guide the rebuilding of its health care system; • Leveraging the power, resources and authority of other HHS operating divisions and other Federal agencies to redesign the health system as efficiently and effectively as possible; and • Monitoring expenditure of funds allocated through the DRA for the rebuilding process. Prevention and Quality Care We are at a turning point. Medicare is providing new up-to-date preventive benefits and prescription drug coverage to prevent disease complications for beneficiaries with chronic illness. To take full advantage of this support and the improved benefits, we need to take steps to encourage, support, and reward the effective use of these benefits to provide high-quality care. CMS efforts to increase prevention services and quality of care include: • Increasing the use of Medicare preventive screenings such as the “Welcome to Medicare Physical,” diabetes screenings and counseling; • Reducing disparities in effective preventive services by measuring current national trends and statistics; • Producing annual Quality and Disparities reports to increase the use of preventive services by racial and ethnic minorities; • Evaluating future needs of the population and the levels of evidence required to incorporate personalized health risk assessment, screening, and disease prevention intervention; • Examining new economic models for the diagnostics industry that stimulate commercial development of cost-effective health screening and monitoring approaches; • Evaluating evidence-based protocol management of health systems, ensuring that they include standardized safety and disease response and outcome measures; • Supporting innovative knowledge engineering and developing new clinical decision support and service delivery models for personalized health choices to prepare for the adoption of advanced technologies in the marketplace based on consumer-family history and genetic-based risk assessment; • Continuing support for the value-based purchasing system for hospital pay-for-reporting and the physician voluntary reporting program, which will include preventive services measures; • Continuing to offer and promote a broad array of free provider educational products geared to enhance the providers understanding of preventive benefits; • Developing new Medicare Advantage plan types, such as dual eligible and chronic care special needs plans, to improve overall cost and quality outcomes for high risk populations and increase integration and coordination with state Medicaid Programs for dually eligible Medicare beneficiaries; and • Supporting drug plan sponsors in their efforts to improve care coordination and to develop innovative approaches to improving the quality of care for our beneficiaries. Pay-for-Performance CMS’ strategic objective is to shift to a quality-oriented, patient-centered payment system. Because payment for care should be based on a patient’s needs rather than on the type of facility that provides the care, we are developing a single assessment instrument for hospitals, nursing homes and home health agencies. CMS is also working to implement a pay-for-performance system (P4P), which rewards providers on the basis of quality (patient outcomes) and efficiency (less waste). Rewarding higher quality and better efficiency benefits both Medicare beneficiaries and the Medicare program. We have joined the growing consensus that the best way to help health care providers deliver high-quality, efficient care is to provide positive financial incentives. MedPAC and bipartisan members of Congress have urged Medicare to provide financial incentives for both higher-quality and efficient care. And leading provider groups representing physicians, hospitals, nursing homes, dialysis centers, and others have also endorsed the movement toward quality-based payments that improve patient care. As in our other initiatives, we’ll be looking to health care providers to help lead this effort. We are implementing and evaluating these payment reforms now. Efforts related to Pay-for-Performance include: • Collaborating with Premier, Inc., a group of non-profit hospitals, to operate a demonstration to improve their quality of care by tracking and reporting quality data for 34 measures at each of about 270 participating hospitals; • Using the lessons learned from the Premier demonstration to shape our future hospital pay-for-performance initiatives and help us develop a hospital pay-for-performance plan as mandated by the Deficit Reduction Act section 5001 (b); • Operating the Physician Group Practice demonstration, implemented in April 2005, to provide rewards to large, multi-specialty group practices for improving the quality of care and reducing the cost increases for their patients; • Working to bring better continuity of care and support for chronically ill beneficiaries in our traditional Medicare plan, by creating financial incentives for care coordination through our Medicare Health Support (MHS) initiative and other disease management initiatives; • Paying organizations to help chronically ill Medicare beneficiaries get better support, treatment and continuity of care within Medicare Advantage health plans, including HMOs, PPOs, and fee-for-service plans that offer additional benefits; • Working with states on Medicaid waiver and demonstration programs that provide financial support for improvements in quality, beneficiary outcomes, and costs; • Conducting the Medicare Demonstration Project to Permit Gainsharing Arrangements (DRA Section 5007) and other demonstrations under our authority to promote collaboration between hospitals and physicians to improve care. The hospital provides for gainsharing payments to the physicians that are based on the savings incurred directly as a result of collaborative efforts between the hospital and the physician. • As part of the development of the Medicare Hospital Pay-for-Performance Plan, CMS is evaluating innovative uses to expand competitive bidding for episodes of care and exploring ways Medicare could incorporate this approach in the hospital value-based purchasing program. Competitive bidding programs would provide positive financial quality incentives to winning providers and suppliers based on a combination of quality and efficiency measures. • Advancing the progress that has been made in the early stages of implementing pay-for-performance in the following settings: hospital, physician, home health, skilled nursing and renal dialysis facilities. Early initiatives include the hospital pay-for-reporting program and physician voluntary reporting program. Quality and Cost Measurement in Medicare Fee-for-Service Systems CMS has many important opportunities to help health professionals, patients, and all of the stakeholders in our health care systems turn promising new ideas into action. What our agency does about quality in Medicare and Medicaid has great impact on the future of health care. By supporting the transformation of our health care system to prevention-oriented coverage, Medicare has tremendous opportunities to help our health care system deliver higher-quality care in both the acute and post-acute care settings. We want our health care system to deliver: • The right care, for the right patient, at the right time; • High-quality care that is safe, effective, efficient, patient-centered, timely, and equitable; • Care that is personalized, prevention-oriented, and patient-centered, based on evidence about the benefits and costs for each particular patient; and • Care that is based on 21st Century biomedical science, science that is marked by new approaches in the lab such as genomics, nanotechnology, and next-generation information technology. These new sciences are only just beginning to have an impact on patient care, but they hold tremendous potential. CMS will encourage cross-licensing agreements among inventors of fundamental technologies such as genomic and proteomics patents as well as research tools to streamline integration of components into health care deliverables. Our Integrated Data Strategy Our Integrated Data Strategy (IDS) is the centerpiece of the new CMS data environment. It is the foundation for sharing data at all levels within CMS, HHS, other Government entities, and external business partners. CMS has established a series of goals that are fundamental to achieving its vision of providing a centralized, scalable, enterprise-wide repository for the Agency’s health care data. The high-level goals for the IDS are to: • Transition from a claims-centric orientation to a multi-view orientation that includes Beneficiaries, Providers, Health Plans, Claims, Drugs, and other views as needed; • Provide uniform privacy and security controls; • Provide database scalability to meet current and expanding volumes of CMS data; • Transition from a stove-piped approach to a highly integrated data environment for the enterprise; • Integrate data from such other sources as the Food & Drug Administration (FDA), Department of Veterans Affairs (VA), and Department of Defense; and • Let users analyze the data in place rather than rely on data extracts. The IDS implementation will incrementally incorporate new datasets within four phases: Phase 1 - Medicare Drug and Beneficiary Data; Phase II - Medicare Part A & B Claims Data; Phase III - State Medicaid Data; Phase IV - Historical Data. Informed Provider Community CMS must work closely with the provider community to make sure that they support high quality services to beneficiaries. This relationship requires that CMS fulfill its responsibility to offer the provider community timely and accurate information, prompt response to inquiries and comprehensive education outreach about CMS programmatic initiatives such as new payment systems, NPI, prevention, and reducing overpayments. To continuously enhance the ability to keep providers informed, we will: • Expand and improve the technology that supports communication to providers and increases the availability of electronic and web based transactions. • Continue to pursue all opportunities to engage in a two-way dialogue with providers. By listening, CMS programs are improved and operational burden minimized. • Continue a comprehensive provider education program using the Provider Center, Medicare Learning Network educational products including “MLN Matters,” expanded provider listservs, FI/carrier/MAC outreach, and Regional Office outreach activities. This level of service to the provider community encourages providers to partner with CMS and help reach the beneficiary whenever there is important information that individual beneficiaries need to know. Transformation CMS must support the transformation of the health care system to one in which patients and doctors can make informed decisions together about the most effective medical care, based on timely access to the latest evidence, and in a way that delivers the highest value care. _d0324348-9f23-11df-9a83-7f707a64ea2a 3.1 a28876d4-af02-40af-b602-3ef8f06b24cd 063ad65f-9cc9-42ae-b2c0-cd4c464c2390 System This transformed system will include SMART health care (Science-driven opportunity for Management of personal health through Affordable, Reliable, and Targeted care); secure electronic records; e-prescribing; transparency based on immediate, accurate and comparative quality and cost information; new Medicare Advantage plan designs and innovative prescription plan approaches, disease management programs, disease prevention; and value-based payment. As part of this transformed system, CMS will stay committed to protecting the security and privacy of our beneficiaries’ health care data. _d03247a8-9f23-11df-9a83-7f707a64ea2a 3.2 a5987581-0e26-42ec-9864-9c2317c8c110 23911e51-3063-41f6-a923-322248bdf145 Transformation Initiatives To achieve this transformation, we will expand quality and cost measurement in Medicare fee-for-service systems; emphasize prevention and better support for quality care; implement pay-for-performance to promote better quality and more efficient care; enhance long-term solvency; encourage Medicaid reform; help redesign the New Orleans Health System; establish an integrated data repository; and modernize IT capabilities. _d0324d84-9f23-11df-9a83-7f707a64ea2a 3.3 9642513d-cc42-43ce-b4e0-1b6b959777b6 ad5f2624-8886-4c13-9f8e-cd3d2fea11fc Medicare Advantage Developing new Medicare Advantage plan types, such as dual eligible and chronic care special needs plans, to improve overall cost and quality outcomes for high risk populations and increase integration and coordination with state Medicaid Programs for dually eligible Medicare beneficiaries. _d032528e-9f23-11df-9a83-7f707a64ea2a 3.4 644014a8-2247-4327-9f3f-3679615900f1 7bc6e67e-b964-4c5a-86b9-50dce2b5fab8 Drug Plans Supporting drug plan sponsors in their efforts to improve care coordination and to develop innovative approaches to improving the quality of care for our beneficiaries. _d0325702-9f23-11df-9a83-7f707a64ea2a 3.5 5f6ee5bf-1212-4adc-81ff-cbf7281a03f8 6292eb44-44b1-4f78-afc5-299319ffdf5c Consumers Confident, Informed Consumers _d0325cfc-9f23-11df-9a83-7f707a64ea2a 4 CMS will develop personal relationships with beneficiaries through the use of increasingly personalized tools and with the cooperation of a well-developed grassroots network of partners. The goal is to ensure that our beneficiaries become confident, well-informed consumers that make maximum use of the program. Doing this will result in a successful system of personalized health care – the right care at the right time. Consumers will participate in SMART health care and have immediate access to affordable Medicare prescription drugs, comparative information on quality and cost, flexible Medicaid benefits and incentives, and access to care in homes and communities for the disabled population. The New Orleans Health System will become prevention-centered, neighborhood-located and electronically-connected. CMS’ ongoing projects include efforts to maintain and expand our use of technology, including beneficiary e-Services via and upgraded call centers. Our efforts also include maintaining a multi-pronged approach for various outreach and awareness campaigns at the national, regional, and local levels regarding beneficiary rights, benefits, and health care options. We support the activities of the Ombudsman in helping beneficiaries make better health care choices in addition to providing technical assistance and training to stakeholders involved in educating beneficiaries about Medicare. Through expanded use of the self-directed personal care state plan option, the new Home and Community Based Services (HCBS) State plan option, and HCBS waivers, we are increasing the number of people who have the option to self-directed Medicaid services. We are also developing and disseminating patient-focused promotional materials designed to communicate the Agency’s various health care initiatives to promote good health and disease prevention. CMS’ initiatives through 2009 include: Personal Health Records (PHR) CMS continues to work to give our beneficiaries more control and use of their own electronic health information, with their permission and control and with full security protections. We have launched the Medicare Beneficiary Portal at, an online tool that will enable beneficiaries to get access to all their Medicare information, such as Fee-for-Service (FFS) claims, deductibles, eligibility, enrollment and other personal data. Implementing PHRs also means enhancing our security systems. We are the largest maintainer of health-related information in the world. CMS is committed to protecting the security and privacy of our sensitive beneficiary health care data. How we protect and manage that information is not only a critical service for our customers, but it sets a standard for the larger health care system. CMS will continue promoting the use of personal health records by: • Conducting a PHR feasibility study; • Actively supporting the PHR activities of the Office of the National Coordinator (ONC) and the American Health Information Community (AHIC); • Developing a process for the secure transmission of Medicare information to populate the PHRs for beneficiaries who have chosen to use them; • Participating in Secretary’s Advisory committee for EHR, AHIC; and • Working with industry groups on developing standards for PHRs that will support the Medicare and Medicaid populations. Electronic Prescribing The ability to create electronic prescriptions (e-Rx) has obvious implications for quality improvement and cost savings. Medication errors due to handwriting or similar errors caused by a paper-based process can be significantly reduced by prescribing through a computer or hand-held device and electronically transmitting that prescription to a pharmacy. The Medicare Modernization Act requires us to implement e-prescribing no later than 2009. This e-prescribing requirement is also a stepping stone in moving the Secretary’s Health Information Technology initiative forward. We have already significantly accelerated the e-prescribing schedule by publishing a set of standards for communicating basic e-prescribing transactions and awarded contracts to conduct five pilot programs that will test additional standards, interoperability and workflow. We will continue in this direction by: • Developing plans to inform and educate health professionals, and to partner with key players in the health care industry to encourage adoption of e-prescribing; • Evaluating the pilots and report to Congress the results in 2007; and • Promulgating final uniform standards in 2008 Beneficiary Contact Centers A key outcome of reforming the fee-for-service environment, responding to a projected 40 million calls a year, and improving customer service in Medicare is the implementation of the Beneficiary Contact Center. By focusing our operations on larger call center contractors we are able to improve operational efficiency, reduce operating costs and improve service to callers (more consistent and accurate). This strategy allows us to respond quickly and efficiently to general inquiries that will be handled by the Internet, national IVR and 1-800-MEDICARE customer service representatives while routing more complex telephone inquiries to contractors providing the best value and the most qualified agents. Additionally, we are able to develop and implement centralized standards and approaches to core call center functions, i.e., quality assurance, training development, and content development, so that beneficiaries get understandable, usable, and accurate information every time. Specifically, the CMS strategy includes: • Maintaining the network Interactive Voice Response (IVR) system that will provide beneficiaries 24X7 access to information; • Making 1-800 MEDICARE’s standard desktop, the Next Generation Desktop (NGD), the standard desktop for all call centers so that all the virtual call centers have access to all data systems necessary to answer Medicare inquiries; and • Establishing one national information warehouse. Money to follow the person (MFP) in State Medicaid program The 2005 Deficit Reduction Act authorizes the Secretary to award grants to States to eliminate barriers or mechanisms that prevent or restrict the flexible use of Medicaid funds. The grants were created to enable Medicaid-eligible individuals to receive support for appropriate and necessary long-term care services in the setting of their choice. Specifically, CMS will be: • Offering $1.75 billion in competitive grants to the states for a period of 5 years, starting in January 2007; • Giving an MFP-enhanced Federal Medical Assistance Percentage rate for a period of one year for each person that the State transitions from an institution to the community; and • Educating states about the benefits and availability of the MFP program. Up-to-date Medicaid benefit choices and personal consumer responsibility about health care choices Medicaid has tremendous potential to give beneficiaries more choice, especially with the implementation of the DRA. DRA gives states many more options of delivering benefits. CMS will encourage all states to use these new benefit flexibility options to realize Medicaid innovation and efficiencies. To this end, we will be: • Providing clear policy direction to help all states to use new benefit flexibility options; • Reviewing and approving benefit flexibility State Plan Amendments expeditiously; and • Increasing flexibility options to States by identifying ways states may begin the process of incorporating Health Opportunity Accounts into the Medicaid programs. Medicare Health Support Pilot Program Section 721 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 authorized the development and testing of voluntary chronic care improvement programs, called Medicare Health Support programs, to improve the quality of care and life for people living with multiple chronic illnesses. Implementation of the Medicare Health Support program is the first large-scale initiative of this type for selected chronically ill populations in traditional fee-for-service Medicare. This new Medicare initiative is designed to help reduce health risks, improve quality of life, and provide savings to the beneficiaries and to Medicare. As of Spring 2006, more than 120,000 Medicare beneficiaries had agreed to participate in these programs. Now that these pilots are underway, we will continue to evaluate the progress of these pilots, and will be • Submitting an interim report to Congress on progress to date in 2007; and • Submitting a second report to Congress on pilot findings in 2009. Pandemic Flu HHS is engaged in a broad array of activities to prepare for an influenza pandemic, and CMS plays a supportive role in this effort. Building off of the successful development and implementation of our Continuity of Operations Plan, we have developed a plan in the event of an influenza pandemic that supports the HHS plan. We have established relationships with Federal, State, and local officials, and tribal partners and are able to work with them to develop surge capacity for deploying of medical resources during an outbreak. To further our preparedness, CMS efforts include: • Developing policy-specific: (a) standards for emergency preparedness for providers and agents, (b) standards for quality and service delivery performance, and (c) policies and procedures for adjusting standards to match emergency situations (e.g., waivers or deferrals under section 1135 authority); • Enhancing Business Continuity Plan (BCP) policies that address critical employees, time and compensation issues, continuity of business functions, work at home; • Continue building and maintaining employee call rosters and critical employees; • Continuing to train critical employees on duties and responsibilities and cross-train staff on essential functions; • Strengthening shelter-in-place (SIP) plans and train critical employees on shelter-in-place/quarantine possibilities; and, • Conducting tests and exercises to assess, validate, or identify a subsequent corrective action for specific aspects of plans, policies, procedures, systems and facilities used in response to an emergency situation. Transparency: Availability of accurate and comparative information for beneficiaries During the drug benefit implementation, we saw beneficiaries input their specific drug information to get detailed reports on which drug plan would provide the greatest value. We are well-positioned to update our award-winning comparative tools. During the next few years, we will be: • Working to use up-to-date IT systems to help beneficiaries and the organizations that support them to get the personalized assistance they need to take advantage of Medicare’s new coverage and new information on quality and costs; • Continuing to improve and expand the content of Hospital Compare, Home Health Compare, Nursing Home Compare, and Dialysis Facility Compare; • Developing transparency collaborations to ensure beneficiaries get the best quality care for the best price by developing ways to let a beneficiary know their medical options, the quality and expertise of doctors and hospitals in their area, and what their medical care will cost them before they need a specific type of care. • Encouraging our beneficiaries to become more confident and informed participants in choosing their health care; and, • Publishing reimbursements rates for common procedures and treatments. Transparency: Quality information on disease prevention and management CMS is working to support and collaborate on the development of useful quality measures in virtually all areas of care. Much of this activity is taking place through broad partnerships focused on measuring quality and then achieving measurable improvements in quality. CMS is one of many stakeholder participants in these collaborations. The measures being developed, applied, and improved through these collaborations include: • Expanding the hospital quality measures to include outcomes such as patient satisfaction and surgical complications. These measures are developed through the joint efforts of CMS, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Agency for Healthcare Research & Quality (AHRQ), and members of the Hospital Quality Alliance (HQA), and endorsed by the National Quality Forum. • Developing measures of ambulatory care quality and efficiency; • Continue enhancing nursing home quality with the Nursing Home Quality Initiative, taking further steps to improve additional important outcomes and efficiency, such as to reduce pressure ulcers and avoid hospital admissions with preventable complications; • Providing information on health plan performance (including prescription drug plans); • Collaborating in other areas of quality measurement, including home health care, dialysis care, and performance measures specifically related to Medicaid and SCHIP populations; • Improving cancer care, which involves measurement in an effort to understand what care is actually being provided and whether it is meeting our beneficiaries’ needs for comfort and support; and • Continuing to support and rely on the National Quality Forum (NQF). Medicare Advantage In 2006, all Medicare beneficiaries have access to at least one type of private Medicare Advantage plan. The increase in access (up from 77 percent in 2004) stems largely from the creation of new Medicare regional PPOs and the expansion of private Medicare fee-for-service plans. With Medicare Advantage, beneficiaries can save about $80 a month compared to the traditional plan with or without a Medigap plan they purchase on their own. To continue to ensure Medicare Advantage is universally available, and ensuring beneficiary choices, CMS will: • Continue to encourage new regional PPOs so that the availability of regional PPOs extends beyond the 2006 level of 70 percent; • Continue to educate health plan organizations and encourage plans to participate; • Continue to streamline and automate the application and bidding process to reduce the burden for plan participation; and • Use the stabilization fund (under the authority of the Secretary), to provide incentives to Regional PPOs to remain in areas with below-national-average MA market penetration or enter MA regions with low or no participation by reducing administrative obstacles to using the fund data systems capacity for Baby Boomers. Data systems capacity for Baby Boomers The baby boomers are a different population than our current beneficiaries. They are more willing to put their health data in an electronic format; they are more Internet savvy. Baby Boomers will use our tools to assist their parents (current beneficiaries), and ultimately to address their own needs. Unless we are modernizing our systems, we won’t be able to sustain our programs. Accordingly, over the next few years, we will: • Maintain a robust, stable, and modernized enterprise-wide IT environment; • Implement the Medicare and Medicaid IT Architecture; • Strengthen the data infrastructure; • Implement an Integrated Data Repository • Continue maturation of the CMS Enterprise Architecture; and • Continue to implement the enterprise data centers. Beneficiary outreach and education on coverage, services, and privacy CMS is committed to protecting the security and privacy of our sensitive beneficiary health care data. As we continue to implement the Health Information Technology strategy, CMS must continue to ensure the public that we are safeguarding individual privacy and ensure they understand not only the program coverage and services, but also their privacy rights and protections. To that end, we will: • Continue to use the media to alert beneficiaries of activities that may infringe these rights; • Continue to use and expand our many information vehicles (, 1-800-MEDICARE, publications/fact sheets) and partners to educate beneficiaries on coverage, services, and the privacy and security of their personal information; and • Integrate the CMS Office of External Affairs with supporting program goals by 2009. Personalized Health Care To create a successful personalized health care system, we will make sure that everyone with Medicare makes the most of their Medicare benefits. _d03261f2-9f23-11df-9a83-7f707a64ea2a 4.1 23136b7e-04e7-43e3-89d5-b389195830e3 01901909-c405-41b3-ba0f-899947223323 Tools and Network We will use our personalized tools and our well-developed grassroots network of partners to develop direct relationships with beneficiaries. _d0326742-9f23-11df-9a83-7f707a64ea2a 4.2 fe452f17-6a9c-4fd9-9dc4-af8c296e0cba 7c2000fd-8584-4669-9d7a-6ffc60d75f39 SMART Health Care Consumers will participate in SMART health care and have immediate access to affordable Medicare prescription drugs, transparency based on comparative quality and cost information, flexible Medicaid benefits and incentives, and access to care in homes and communities for the disabled population. _d0326e04-9f23-11df-9a83-7f707a64ea2a 4.3 247b6dfa-6a71-4c55-a18f-cbf9bf2de2d1 37f1c0d6-b7cc-4bad-8e3d-73991c48a89e Quality and Price CMS will get beneficiaries the best quality care for the best price by developing ways to let them know their medical options before they need treatment, the quality and expertise of doctors and hospitals in their area, and how much their medical care will cost them. _d03273cc-9f23-11df-9a83-7f707a64ea2a 4.4 02e895ba-113a-4534-98c6-3def58f8bb90 75eed135-9b11-43e9-bf82-3b52a87b5981 Partnerships Collaborative Partnerships _d0327976-9f23-11df-9a83-7f707a64ea2a 5 CMS recognizes that its success is dependent on collaborative relationships with a variety of organizations, individuals, and institutions, such as the U.S. Congress, states, physicians, hospitals, other provider types, professional societies, health plans, employers, State Health Insurance Assistance Programs (SHIPs), community grassroots, and other organizations, building upon our recent collaborative experiences and partnerships in successfully implementing Medicare Part D. A partnership with CMS consists of organizations coming together around issues that affect a common population. By working together, partners extend the reach and impact of programs aimed to improve the health and wellness of seniors, children, families, and people with disabilities, and indirectly impact caregivers and employers. A partnership with CMS allows the partners to leverage their resources and expertise, and to share access to CMS’ training and educational materials, research, and a connection to the Regional Offices. The CMS definition of partnership is expanded to allow for meaningful two-way exchange and true collaboration for all CMS programs and special initiatives. Internal Customer Service To ensure success with external partnerships, CMS must recognize that the practice of partnership begins internally, starting with mutually-supportive working relationships between all components. CMS employees must make a conscious effort to support one another in our work, incorporating cross-component communication and integration. To support this, CMS will: • Integrate the CMS Office of External Affairs into a primary role with respect to the program goals, ensuring appropriate roles for partnership, media, and intergovernmental affairs; • Develop cross-component work teams as appropriate; • Continue Regional Offices’ role as “on-the-ground” resources in planning and implementing agency outreach initiatives; and • Continue the commitment to provide training for relationship management and work teams. External Partners To achieve real improvements in quality, we need to work together in partnership with other stakeholders from throughout our health care system. We have opportunities for system-wide quality improvement today because of the broad interest, commitment, and momentum to create and sustain a better environment for high-quality, personalized care for every patient every time. This is not a CMS-led effort – it comes from all parts of our health care system. Our system has the advantages of flexibility and responsiveness to new ideas and to individual patient needs. We aren’t as constrained by “one-size-fits-all” rules that are increasingly bad fits in modern health care. This is important, with all the promising new approaches for delivering health care. But the pluralism of our system also means no one entity can close the quality gap by itself. And because CMS is such an important part of the health care system, the agency must participate actively as full partners in these collaborative efforts. Our external partnerships include both new or enhanced collaborations with other government agencies and unprecedented collaborations with many health advocacy, research, and provider organizations. Our government partners include agencies such as the Administration on Aging (AoA), Health Resources & Services Administration (HRSA), Substance Abuse and Mental Health Services Administration (SAMHSA), Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), U.S. Department of Agriculture (USDA), Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), the Veterans Administration (VA), Social Security Administration (SSA), Railroad Retirement Board (RRB), Office of Personnel Management (OPM), and the Department of Defense (DoD). To move the quality agenda forward, we are also engaging in numerous partnerships with non-governmental organizations where specific opportunities for short-term improvements in quality exist. Examples of the central role of strong partnerships in the CMS Quality Roadmap include: • Partnering with public- and private-sector groups in the Institute for Health Care; • Partnering with the Institute for Healthcare Improvement’s (IHI) “Campaign to Save 100,000 Lives”, involving dozens of partners and about 2000 enrolled hospitals focused on reducing the hospital mortality rate; • Partnering with the Surgical Care Improvement Partnership, a public-private group led by the American College of Surgeons that is working together to reduce surgical complications; • Partnering with the Fistula First National Renal Coalition, in which a dozen partners are promoting the best evidence-based approach to vascular access for hemodialysis patients; • Partnering with the Alliance for Cardiac Care Excellence alongside more than 30 organizations supporting four specific, major improvements in cardiac care; • Partnering with the quality alliances, including the Hospital Quality Alliance (HQA), Ambulatory Quality Alliance (AQA), Pharmacy Quality Alliance (PQA), and National Quality Forum (NQF) to implement performance measures; • Partnering with medical societies, like the American Medical Association (AMA) and medical specialty societies, to support quality initiatives; • Partnering with the National Initiative for Children’s Healthcare Quality to improve the outcomes of low-birth weight infants; • Partnering with the Centers for Health Care Strategies on Medicaid quality improvement initiatives related to the business case for quality, disparities and value based purchasing; • Partnering with the Institute for Quality Laboratory Management (IQLM); and • Participating in the Department’s efforts for interoperability of IT systems, which include collaboration with America’s Health Information Community (AHIC), the Health Information Technology Standards Panel (HITSP), the Federal Health Architecture (FHA), Consolidated Health Informatics (CHI), and others. We are also engaging in focused “breakthrough” projects to achieve large improvements in specific areas where large quality gaps have been demonstrated and stakeholders have identified specific steps to improve performance. For example, to substantially increase influenza immunization in nursing homes requires not only participation of and coordination across CMS components and the Long-term Care Task Force (to develop policy, improve payment, track participation, provide education, share quality information, and provide technical assistance), but also coordinating with nursing homes, vaccine providers, states, and others. In addition, we aim to establish collaborative partnerships with other insurers in the U.S. health care system. Our beneficiaries’ health and health behaviors are affected by a lifetime of experience well before they enter our programs. Working with employers and other social insurance organizations to exchange and implement ideas on how to provide a sustained and coordinated focus on quality benefits the whole U.S. population – not just our individual programs. In continuing these initiatives, and developing others, CMS will implement proven partnership techniques, such as: • Using a collaborative approach, CMS will continue to develop health and grassroots networks for Medicare and Medicaid through an integrated cross-component effort within CMS and HHS; • Targeting key partners and stakeholders early in the development process of new initiatives to build buy-in and support, to capture the maximum input from partners, and to use nontraditional partners to “get our message out” timely and consistently; • Managing partner relationships on a regular, ongoing basis through visits, phone calls, and emails, employing two-way communication techniques; • Continuing the Regional Offices’ role as primary resources in planning and implementing agency outreach initiatives, and for working collaboratively with local and grassroots partners and coalitions to develop effective campaigns for informing, educating, and assisting beneficiaries with health care options; • Maintaining and enhancing relationships with State and local professional societies and providers, as well as with the National societies and associations; • Expanding our communication activities to allow us to have well established interactions with outside groups; • Establishing ties with quality alliances and local communities to support getting better health care; and • Expanding our collaborative relationships with additional organizations in health care technology, SMART health care, prevention, and health transparency to support the transformation of health care. Health Plans and Prescription Drug Plan Sponsors To continuously improve beneficiary choices and awareness of Medicare managed care products and prescription drug coverage we will work with our private sector health plan and prescription drug plan partners, various industry and trade groups and beneficiary organizations. We will work in collaboration with our private sector counterparts to design, develop and deliver integrated, high quality health care and prescription drug products that meet the needs of our customers, the Medicare beneficiaries, and meet the demands of the competitive marketplace. We will work with beneficiary groups to understand their perspectives on our products. To support this CMS will: • Encourage Medicare Advantage plans and Part D sponsors to identify approaches to achieving high quality, cost effective health care; • Identify policy opportunities that encourage the offering of health plans and prescription drug plans that combine effective care management techniques and prescription drug coverage for the beneficiary; • Work with plan organizations and Part D sponsors, and industry groups to identify product designs that meet the needs of the beneficiaries and the marketplace; • Collaborate with beneficiary and consumer groups to identify product designs that tailor to the needs of Medicare beneficiaries and subgroups; • Improve information interchange among health plans and prescription drug plans that combine coordination of benefits for our beneficiaries; • Leverage our partnerships with Medicare Advantage plans, Part D sponsors, and industry groups to expand our opportunities for delivering innovative health care delivery products to Medicare beneficiaries; and • In coordination with our partners, develop accurate and understandable performance metrics and quality information to assist beneficiaries in making informed decisions on their health care and prescription drug coverage needs. Intergovernmental Affairs State and local partnerships are critical to carrying out the mission of CMS. Our State and local partners communicate information to our beneficiaries about CMS’ activities and programs and help us carry out agency policies. CMS is more than a liaison to the states. We will continue to garner partner participation, coordinated by the CMS partnership team. We not only want our State and local partners to receive our information, but to join us in improving health care for our beneficiaries. We will continue our partnership development with State and local governments by: • Designing and executing the Agency’s communication plan, coordinating notification of pending actions with partner groups, and serving as liaison between the states and the agency to broker relations with the states over pending changes in Medicaid, both MMA and DRA related; • Fostering our relationships with the Governors, State legislators, and increasing our interactions with State and local elected officials, as well as the many State and local government associations such as the National Governors Associations, Council of State Governments, National Association of State Medicaid Directors, and the National Council of State Legislators; and • Continuing to develop these partnerships at the local level and expanding the outreach to include a more comprehensive group of State and local partners by including county governments, State health insurance commissioners, State and local intergovernmental groups, and community health centers operated by local governments. Legislative/Congressional Affairs CMS works with the U.S. Congress to promote beneficiary interests by effectively presenting the Agency’s position to Congress and by making the Agency aware of congressional positions on issues relevant to the Agency. In addition, we advance the Administration’s policy goals and objectives by: • Communicating CMS positions to Congress clearly and effectively; • Communicating Congress’ position to CMS; • Providing prompt and meaningful responses to congressional inquiries; • Providing accurate and informed technical assistance during the development of legislation; and • Collaborating with other CMS components and administration partners to advance departmental legislative priorities. State Health Insurance Assistance Program (SHIPs) The State Health Insurance Assistance Program, or SHIP, is a state-administered CMS grant program, funded jointly with federal, state, and local community funds, that offers local, personalized counseling and assistance to people with Medicare and their families. States are allowed latitude in how their programs are structured and services provided. However, programs must offer services to all eligible persons requesting assistance, develop an intra-State agency referral system, and communicate timely and accurate health insurance information. The SHIP network is strong, established, and experienced in providing service to the Medicare beneficiaries. SHIP programs have traditionally provided outreach and training to local organizations that serve beneficiaries; therefore, they can serve as key partners for strategic planning and implementation at national, state and local levels. CMS will further integrate the SHIP network into collaborative activities by: • Including representatives of the network in CMS’ strategic planning processes on both a national and regional level; • Integrating the SHIPs into CMS’ national partners’ strategic planning processes and the regional and local planning processes early in the process, as part of that collaborative effort; • Setting mutual expectations of the SHIPs’ and CMS’ roles in state and local planning, and implementing the resulting operational plans; • Involving SHIPs in planning and assessing the accountability measures for expected outcomes of mutually-implemented operations; and • Expanding the open door process for the SHIPs to promote feedback to CMS and supply program improvement. Success in engaging the SHIP Network in CMS’ collaborative planning and implementation processes will result in effective outcomes for all HHS priorities. • Health Information Technology will be understood and championed by those who provide direct beneficiary services and community training. • The Medicare Drug Benefit will be promoted and enrollment assistance provided by SHIPs and their partners. • Medicare Modernization will have benefited by input from a network that on a daily basis deals with the barriers and issues of the existing systems. • The New Orleans Health System will have local support and input to issues to be tackled. • The value of preventive benefits to the communities SHIPs serve can be communicated in a manner that will resonate both with their partners and the beneficiaries they serve. • Rapid response planning for Pandemic Preparedness can have state and local systems input and readiness for implementation at a local level, in part, through the SHIPs and their community partners. • Community-level buy–in and understanding of health care for the individual can be achieved by local collaborations that focus on disease prevalence in their communities. • Effective strategies to reach and serve people with disabilities in their communities will be implemented. Providers Collaborative partnerships that all work toward getting the beneficiary quality care information. _d03280c4-9f23-11df-9a83-7f707a64ea2a 5.1 Health Care Providers Personalized, modern health care is a complex network of various providers surrounding the person who needs care. To make this work, we need collaborative partnerships that all work toward getting the beneficiary quality care information. af3549e6-5246-4d12-ad23-b762cf8b3441 3d402a69-464a-43d4-8d6e-e099b4f5f46c Organizations The success of CMS depends on collaborative relationships with a variety of organizations, individuals and institutions. _d032874a-9f23-11df-9a83-7f707a64ea2a 5.2 5e59fa0a-4b20-4c09-b191-9fe9ad549ab6 295c2146-f0f1-4f36-900b-1cdd1713ae72 External Affairs and Communications CMS will restructure and expand its external affairs and communications activities to allow us to have well-established interactions with outside groups. _d0328d76-9f23-11df-9a83-7f707a64ea2a 5.3 54387fdd-7afa-411a-810d-4e2ee13736f0 e5fe8b04-a2ec-463a-98f5-f3de57d8eefa Regional Offices CMS Regional Offices will continue as primary resources in planning and implementing agency outreach initiatives, and in conducting environmental scanning to identify impacts on our customers. _d0329514-9f23-11df-9a83-7f707a64ea2a 5.4 698051e5-c93f-4c91-9650-624feebb280f 2fbf02f3-e2a4-4cbc-83a1-19bde09bef23 Networks We will also continue to develop health and grassroots networks for Medicare and Medicaid, and establish ties with quality alliances and local communities to support getting better health care. _d0329bae-9f23-11df-9a83-7f707a64ea2a 5.5 In addition, we will seek ways to work with other large health insurers in the U.S. system, both government and private-sector, to share ideas to improve the quality and delivery of health care and health care information. 9e265a81-bf98-4179-9f7c-0ce452d689e4 365a919b-be01-4274-9b1c-04715cb107ca Collaboration With effective collaboration, CMS will create and sustain a better environment for high-quality, personalized care for every person, every time. _d032a252-9f23-11df-9a83-7f707a64ea2a 5.6 fe373042-e197-4dc4-ab14-340debb0f90d ed0ee278-b5d6-4a82-b61f-c851464b91c5 Relationships CMS will continue to pursue relationships with provider groups at the national and local level and use these relationships to reach the individual provider with important program and initiative information. _d032aa18-9f23-11df-9a83-7f707a64ea2a 5.7 ca26c611-6345-46df-be4b-7fe3bd4aac39 d2345e23-59b2-4e14-9202-28305efa1a94 Awarness and Choices Improve beneficiary choices and awareness of Medicare managed care products and prescription drug coverage by working with our private sector health plan and prescription drug plan partners, various industry and trade groups and beneficiary organizations. _d032b01c-9f23-11df-9a83-7f707a64ea2a 5.8 d69dc966-af8a-48f4-8328-b11e1750eb1b 35144643-aaad-4743-831e-0cc41b4cd807 2006-10-16 2009-09-30 2010-08-03 Owen Ambur Submit error.