CMS says care pilot not meeting budget neutrality requirement

The Centers for Medicare and Medicaid Services (CMS) has announced it will end Phase I of Medicare Health Support (MHS) program upon completion of the three-year pilot, meant to provide beneficiaries additional care-management services. Expansion to Phase II of any pilot is contingent upon improving the clinical quality of care, improving beneficiary satisfaction and achieving targets for savings.

There are currently 68,000 participants in the MHS program. Prior to beginning in MHS, these beneficiaries received all of their Medicare benefits through the traditional fee-for-service program. Under the MHS program, CMS pays the Medicare Health Support Organizations (MHSOs) an additional care management fee to provide care management services. Five MHSOs remain active and are scheduled to complete their pilot operations between July and December 2008.

“We have notified the MHSOs in operation that they should continue to provide care management services to their program participants and assist them in transitioning and making the necessary connections needed to help them better manage their healthcare needs,” a CMS official tells Managed Healthcare Executive. “This program does not impact the beneficiaries fee for service Medicare benefits. The statute mandates an independent evaluation of Phase I, and CMS is adhering to the requirements in the statute as planned. However, our experience to date, suggests that Phase I of the program is not meeting the statutory conditions for expansion into Phase II. Once the independent evaluation is completed and if the conditions of improved beneficiary satisfaction, improved clinical quality outcomes and budget neutrality are met, then we will determine next steps for Medicare Health Support. We have learned a lot from this program and expect to apply what we have learned to future efforts to improve care and save resources for the Medicare Trust Fund.”

“Tens of thousands of chronically ill Medicare beneficiaries face a distressing gap in access to valuable support services for managing their conditions,” says Tracey Moorhead, president and chief executive officer, DMAA: The Care Continuum Alliance. “These beneficiaries, as well as their providers and family caregivers, enthusiastically welcomed these services, as evidenced by participation rates, satisfaction measures and a demonstrated willingness to take important steps toward better health.

“Ending Phase I of Medicare Health Support without ensuring continuity of these services as regulators consider movement toward Phase II will strand the many chronically ill fee-for-service beneficiaries who most need coordinated care,” Moorhead continues. “These beneficiaries, among Medicare’s most costly, require and deserve high-quality, targeted care tailored to the extraordinary demands of their conditions.”

DMAA says that it is urging federal regulators to move on an accelerated track toward Phase II and ensure continued provision and expansion of needed chronic care services, as well as an “expeditious, thorough review of the documented shortcomings of the pilot’s design and execution, including participant selection and randomization,” according to Moorhead.

“The CMS position that Phase I failed to meet statutory requirements is not supported by last year’s interim report, which found insufficient evidence for any firm conclusion about the pilot’s performance and noted significant disparities between the control and intervention groups and other critical flaws,” Moorhead adds.

Says Disease Management Purchasing Consortium International Inc. President Al Lewis, MHE editorial advisor: “It ain’t over until the plausibility indicators sing. CMS can’t just do an actuarial analysis. They need to confirm it with a plausibility analysis of event rates,” he says. “If the vendors are right, their study groups will show a more favorable trend in actual disease-specific events than the control population. If those two go in different directions, much more analysis is needed before any conclusion is reached.”