The Centers for Medicare and Medicaid Services (CMS) is responsible for administering Medicare and overseeing the administration by the State governments of Medicaid, as well as the State Children’s Health Insurance Program (SCHIP). CMS’s budget justification submission for Fiscal Year 2009 provides a glimpse into the Administration’s priorities for the coming year and many health policy experts would suggest that it is also a likely template for the foreseeable future, regardless of the ultimate outcome of the 2008 Presidential election. In 2006, CMS launched a new Strategic Action Plan, with the stated mission of ensuring effective, up-to-date health care coverage for its beneficiaries and promoting quality care. The underlying vision is a transformed and modernized health care system for America. Using the Strategic Action Plan as a roadmap, CMS has been working to ensure that those who provide services are paid the right amount at the right time; striving toward a high-value health care system; increasing consumer confidence by giving them more information (i.e., fostering “educated consumers”); strengthening the workforce to manage and implement its programs; and continuing to develop collaborative partnerships. CMS is the largest purchaser of health care in the United States, serving over 92 million beneficiaries, almost one in three Americans. Medicare and Medicaid combined pay approximately one-third of the nation’s health expenditures. During the coming year, their benefit costs are projected to total $703.9 billion. Within the U.S. Senate, CMS falls under the jurisdiction of the Senate Finance Committee. Some highlights from this year’s CMS budget justification submission to Congress.
Recent reports from the Government Accountability Office (GAO) and the Office of the Inspector General (OIG) highlight the need for federal oversight to ensure quality of care. The GAO placed aspects of survey and certification, particularly oversight of nursing homes and dialysis facilities, into a high risk category, indicating in their judgment a greater vulnerability to fraud, waste, abuse, and mismanagement. Maintaining survey and certification frequencies at or above the levels mandated by policy and statue is critical to ensuring Federal dollars support only quality care. Individuals in nursing homes are a particularly vulnerable population and consequently CMS places considerable importance on ensuring nursing home quality. The readership should appreciate that CMS proffers that it has two performance measures related to the quality of care in nursing homes to assess the effectiveness of these and other survey and certification activities in nursing homes. Goals to decrease the prevalence of restraints and pressure ulcers in nursing homes are viewed as being clinically significant and closely tied to the care given to beneficiaries.
Without question, our nation’s senior citizen population is steadily growing with the over 65-age population projected to increase from 35 million in 2000 to 40 million in 2010. By 2030, there are expected to be approximately 71.5 million older persons, posing entirely new challenges for long-term care efforts. This should be an exciting growth area for professional psychology and I have personally been quite pleased by the number of senior colleagues who have recently expressed interest in becoming involved in geropsychology. As behavioral scientists, psychology should be in the forefront of designing more humane measures of “quality” care; for example, cognitive stimulation modules, therapeutic virtual realities and real-time social support communities, not to mention a wide range of behavioral-based programmatic activities. Our academic colleagues, in particular, should be working closely with other healthcare disciplines (e.g., clinical pharmacy, professional nursing, and engineering) to design entirely different types of 21st century assisted living facilities.
Under the CMS Research, Demonstration, and Evaluation account: Electronic Health Records (EHR). The EHR demonstration is a five-year initiative that promotes high-quality care through the adoption and use of electronic health records. This proposal will expand the base created by the Medicare care management performance demonstration and is expected to be implemented in locations that include Better Quality Information (BQI) pilot sites or Chartered Value Exchanges (CVEs). The demonstration is to be implemented in approximately 1,200 small- to medium-sized primary care physician practices in up to 12 sites. Under the demonstration, practices will be eligible to earn incentive payments for the implementation and adoption of health information technology in their practice and for achieving specified standards on clinical performance measures for diabetes, congestive heart failure, coronary artery disease, and the provision of preventive health services. This demonstration is an important step towards meeting the President’s goal of nationwide adoption of EHRs by 2014. Physician recruitment is planned for 2008. Our Division’s membership should be concerned that the present CMS plans are apparently focusing solely upon physicians, even though ultimately non-physician practitioners will be required to comply with the standards that evolve. And, notwithstanding the recent GAO testimony that in recent years, while the supply of primary care professionals has increased, the supply of nonphysicians is increasing faster than physicians. The dollars involved are substantial. In 2004 the Administration estimated that a national health record information network would save $140 billion per year in safer and better care and in reduced duplication of medical tests. The underlying “CMS” commitment to the Secretary’s Value-Driven Health Care Initiative is supported through demonstrations conducted in multiple provider settings and research on quality and efficiency. Our research activities will inform the agency on how to develop and implement initiatives that promote value in health care and will provide policymakers with information on the impacts of performance incentives.
We, however, would rhetorically ask: Are there any indications that the all important psychosocial-cultural-economic gradient of care, which is being primarily promoted by health psychology, is being seriously considered by the Administration in its determination of “quality care”?
The Administration’s CMS legislative proposals include developing a set of universal Medicaid performance measures and linking State performance on these measurers to Federal funding for Medicaid through administrative and legislative actions. The projected five-year budget savings involved would be $310 million. On average, the Federal Government provides 57 percent of the costs of Medicaid with the States coving 43 percent. Notwithstanding the strongly held and highly emotional views within psychology regarding managed care, CMS reports: “One of the most significant developments for the Medicaid program has been the growth of managed care as an alternative service delivery method. Prior to 1982, 99 percent of Medicaid recipients received coverage through fee-for-service arrangements. Since the passage of the number of Medicaid recipients enrolled in managed care organizations has vastly increased. As of June 30, 2006 nearly 65 percent of all Medicaid beneficiaries (more than 29.8 million) in 48 States and the District of Columbia were enrolled in some type of managed care delivery system. States continue to experiment with various managed care approaches in their efforts to reduce unnecessary utilization, contain costs, improve access to services, and achieve greater continuity of care.”
In an effort to re-conceptualize the delivery of care, the CMS Money Follows The Person (MFP) Rebalancing Demonstration would provide the various States with new options to rebalance their long-term support programs, thereby allowing Medicaid programs to be more sustainable while helping individuals achieve independence. Specifically, the MFP demonstration will support State efforts to:
- Rebalance their long-term support system so that individuals will have a choice of where they live and receive services.
- Transition individuals from institutions who want to live in the community; and,
- Promote a strategic approach to implement a system that provides person centered services and a quality management strategy that ensures the provision of, and improvement of, such services in both home and community-based settings and institutions.
This particular demonstration provides for enhanced Federal medical assistance percentage (FMAP) for 12 months for qualified home and community-based services for each person transitioned from an institution to the community during the demonstration period. Eligibility for transition is dependent upon residence in a qualified institution. Again, however, we would ask the fundamental question: How many of our colleagues are aware of this program and perhaps more importantly in the long run -- Is this type of substantive change which is occurring within our nation’s healthcare environment being discussed by state associations during their annual meetings? Without such basic information and an appropriate health policy context, it will ultimately be very difficult for our practitioners to become involved in, and provide proactive leadership for, the dramatic challenges of the 21st century.
Finally, under the budget justification designation of Significant Items of Interest to Congress, pursuant to the Senate Appropriations Committee: “Telehealth Services – This Committee has supported demonstration projects that have assessed the efficacy of using interactive video technology as a means for providing intensive behavioral health services to individuals with serious emotional and behavioral challenges, such as autism and other at-risk populations. Such projects have assessed the effectiveness of the medium in providing a range of services such as behavior analysis, case management, medical services, psychiatric services, support to education and training. However, the Committee has observed that one of the most serious obstacles to the integration of telemedicine into health practices is the absence of consistent, comprehensive reimbursement policies. Medicare authorizes only partial reimbursement. Medicaid policies set at state levels vary widely and are inconsistent from State to State. The Committee believes that telehealth technology is a way to provide intensive behavioral health therapy services in a cost effective manner. Further, since the 1999 Supreme Court Olmstead decision, the Committee has been dedicating resources towards States to move individuals out of institutions into community-based settings. The Committee recognizes the potential benefits that telehealth technologies can have in supporting the independence, productivity and integration into the community of persons with developmental disabilities.
“The Committee urges CMS this year to provide it with a comprehensive survey on a State-by-State basis of telehealth services provided under Medicaid. It further requests that CMS meet with an appropriate array of telehealth specialists including those who have been involved in the demonstration projects supported by this Committee to survey and assess best practices and professional criteria standards and make recommendations to the Committee concerning national standards for telehealth reimbursement which advances and encourages this technology.
“Action taken or to be taken: A comprehensive State-by-State survey of Medicaid coverage and reimbursement for telemedicine services has not been completed by CMS for several years. However, in the coming year, CMS plans to do such a survey and also to update its current website which provides policy guidance with regard to Medicaid coverage, reimbursement and coding of telemedicine. We expect that the States’ survey will obtain information on the standards used by States to provide telemedicine under the Medicaid programs, and based on the results of the survey, we will consider the need for national guidance to State Medicaid agencies on the provision of these services.” We would emphasize that absent of a specific statutory requirement, CMS has historically been very hesitant to direct the States as to how they should implement their Medicaid programs. Since 1993, the Steering Committee on Telehealth and Healthcare Informatics has convened more than 115 publically available educational sessions and technology demonstrations for those servicing on Capitol Hill. The future is steadily approaching. Aloha,
Pat DeLeon, former APA President – Division 42 – February, 2008
