CMS-10356 emergency Justification

Justification for Emergency PRA Clearance

Evaluation of Practice Models for Dual Eligibles and Medicare Beneficiaries with Serious Chronic Conditions

Medicare beneficiaries who are also receiving benefits under the Medicaid program (i.e., dual eligibles) are among the most vulnerable Medicare beneficiaries.

• 60% of dual eligibles have multiple chronic conditions compared with half of non-dual beneficiaries.

• 20% of dual eligibles have more than one mental or cognitive condition compared with 5% of non-dual beneficiaries.

• Approximately 40% of duals have both a physical and mental disease compare with 17% of non-duals.

• Medicare beneficiaries with multiple mental or cognitive conditions are more likely to be at risk for hospitalization. 50% of beneficiaries with multiple mental or chronic conditions are hospitalized in a year.

Section 2602 of the Affordable Care Act (ACA) established the Federal Coordinated Health Care Office (FCHCO) to more effectively integrate benefits under Medicare and Medicaid and to improve coordination between the federal government and states for dual eligibles. Among the goals of FCHCO mandated by ACA are:

• Simplifying the processes for dual eligible individuals to access the items and services they are entitled to under the Medicare and Medicaid programs.

• Improving the quality of health care and long-term services for dual eligible individuals.

• Eliminating regulatory conflicts between rules under the Medicare and Medicaid programs.

• Improving care continuity and ensuring safe and effective care transitions for dual eligible individuals.

• Improving the quality of performance of providers of services and suppliers under the Medicare and Medicaid programs.

Under Section 2602(e) of ACA, the Secretary is required to submit an annual report to the Congress, as part of the budget transmittal, with recommendations for legislation to improve care coordination and benefits for duals. Recommendations for the report to be submitted in 2012 along with the FY 2013 budget will be finalized in the fall of 2011. This requires that policies be developed during the summer of 2011. To be fully informed and to meet the expectations of the Congress in mandating a report, policy development requires extensive research and data analysis.

To support the development of recommendations for the report mandated by section 2602(e) of ACA, CMS’s Office of Policy contracted L&M Policy Research, LLC, beginning Sept. 27, 2010. Under this contract, patterns of care and best practice models for dual eligibles, including those participating in the Program for All-Inclusive Care for the Elderly (PACE), and for other Medicare beneficiaries with complex health needs will be explored. The project will comprise qualitative information gathering through open-ended discussions with providers, local health care leaders, patient advocates, quality improvement specialists, and professionals involved in implementing care coordination initiatives. These discussions will be held in-person during site visits to 16 hospital referral regions (HRRs) that reflect a mix of dual-eligible enrollment levels, severe chronic illness prevalence rates, and diversity in geography, urban/rural balance, and socio-economic considerations. Topic areas that will be addressed during these discussions will include:

• History, goals, and objectives of care models/interventions for duals and the seriously chronically ill in the HRR;

• Community-, provider-, patient-level factors associated with quality, costs, and outcomes;

• Barriers/opportunities to participation in models/interventions that improve care; and

• Role of health information technology and personal health records in interventions.

The research team has been tasked to complete all of the data-collection activities by the end of April 2011 so that findings can be submitted to CMS by mid-June 2011. The aggressive schedule for this research is needed in order to inform policy development during the summer of 2011 in preparation for the report to Congress. Given the deadline for the report to Congress mandated by ACA, CMS does not have sufficient time to follow the normal PRA notice and comment periods. We are requesting an emergency review and approval for the information collection request so that the team may begin field work in late January 2011.