L&M and its subcontractors are assisting CMS in evaluating care and disease management programs available through Medicare Advantage plans by addressing four key aims: 1) document and characterize the universe of care and disease management programs under MA plans; 2) document and characterize the populations enrolled in these programs; 3) characterize how health plans or vendors function in the structure and implementation of C/DM programs;  and 4) document the range of effectiveness measures (e.g. structure, process, outcomes metrics)  used to monitor and provide feedback in these programs, noting any particular findings on  program effectiveness.

These aims will be assessed through a series of data collection activities and analyses including:  literature review of studies examining the effectiveness of care/disease management in a managed care setting; survey of MA plans to document which offer care/disease management programs, characteristics of these programs and the landscape of these programs under MA; key  informant interviews with C/DM experts and stakeholders for a more in-depth understanding of  the different perspectives relevant to care/disease management; and case studies with six MA plans with C/DM programs in place. 

Findings from this study will help CMS monitor trends and innovations in care and disease  management, as well as identify successful implementation of such programs, by developing a  working framework that accurately depicts the current landscape, yet is dynamic enough to  capture changes over time. While the scope of this work will not provide any definitive  evaluation of C/DM program effectiveness, it is a critical first step in documenting a base-line  distribution of program characteristics and offering up a framework for longer-term profiling  efforts, charting trends, and benchmarking the evolution of these programs in the managed care arena.

L&M is assisting CMS in evaluating of the 2006 Medicare Oncology Demonstration Program using both qualitative and quantitative methods. It is a national program that supports the use of evidence-based practice guidelines for cancer care. CMS has clear and compelling reasons to focus on encouraging appropriate and high quality of care for the beneficiaries it serves, in addition to fostering efficiencies across in all facets of cancer treatment. The purpose of the evaluation is to determine how oncologists and hematologists adapted their practice in response to the CMS payment incentive, and to understand lessons learned for future demonstration projects involving oncologists and all specialists.

The evaluation will address the first two aims in two phases. The first phase of the evaluation documented the implementation and operational experiences through site visits with physician practices participating in the demonstration and one-on-one telephone discussions with physician practices not participating in the demonstration. Currently underway is the second phase of the evaluation, which includes of a national survey of eligible physicians to collect information on implementation and attitudes of participating physicians and basic descriptive and attitudinal information among non-participating physicians. As part of the implementation of the physician survey, the project team obtained approval for data collection activities from the Office of Management and Budget (OMB). Finally, a Medicare claims analysis will provide additional perspective on those physicians choosing to participate in the demonstration, the nature and degree of their participation, and validate the extent to which their reported compliance with evidence-based clinical guidelines is consistent with claims submissions.

• How does the “pay for performance” concept work within a nursing home setting
• Demonstration impact on selected nursing home quality, cost, service delivery, and resident outcome characteristics as well as on organizational structure and financial status
• Characterizing non-participating nursing homes, on a more limited scale, to serve as a comparison

The evaluation will comprise a multi-method data collection approach that integrates demonstration-generated administrative, cost, quality and performance data with qualitative information solicited through direct interviews with nursing home staff. Data collection will follow the course of the 3-year demonstration.

As part of a broader effort to develop innovative and streamlined strategies for identifying and enrolling eligible Medicare beneficiaries into the Part D Low-Income Subsidy (LIS) program, the National Council on Aging (NCOA) has developed a partnership with AstraZeneca to launch the My Medicare Matters campaign. While the first phase of outreach and awareness raising activities focused broadly on Medicare Part D has been completed, a second phase involving grants with nine Area Agencies on Aging (AAA) was initiated to focus specifically on identifying and enrolling individuals into the LIS program. NCOA has contracted with L&M to conduct an evaluation of this phase, incorporating qualitative and quantitative approaches to evaluating the effectiveness of grantee activities in successfully enrolling eligible individuals. In addition, the L&M team will develop a “best practices” resource that draws from the experience of AAA grantees and other agencies conducting LIS outreach and enrollment, to benefit other agencies that may be initiating or refining their own LIS strategies.

The evaluation is comprised of grantee case studies and a return on investment analysis. The grantee case studies are being used to obtain contextual information relevant to the outreach, characterize the grantees, document details of the outreach activities, and review the detailed cost information submitted for the return on investment analyses. The case studies include site visits to the grantees and interviews with key staff. The return on investment analysis is being used to evaluate resource allocation, detailing performance on specific benchmarks within the context of the resources spent. Data is to be collected from each grantee on both direct (e.g., outreach and enrollment salaries and benefits, printing and postage costs associated with letters or flyers, etc.) and indirect costs (e.g., rent and overhead costs, etc.). These data will be used to arrive at a cost per beneficiary identified or cost per beneficiary enrolled metrics.

The Medicare Modernization Act of 2003 (MMA) has significantly expanded the managed care landscape of the Medicare program to include a broad array of different health plan offerings collectively referred to as Medicare Advantage (MA) plans. In the years since, there has been limited opportunity to assess the status of these offerings and understand their relative impact on the Medicare population. CMS has contracted with L&M Policy Research and its partners, Mathematica Policy Research and McGee & Evers Consulting to conduct a two-pronged study that will both document how MA plan benefits impact the Medicare population and refine MA plan marketing materials to be more consumer friendly. Specifically, this study will:

1. Document enrollment and disenrollment in MA plans
2. Describe how plan benefits and covered lives have changed over time<
3. Document the fiscal impact of these changes on the large chronically ill subset of beneficiaries and identifying which segments of the population are served by what coverage scenarios (e.g. MA plans, FFS).
4. Improve the quality and consistency of MA plan-related information provided to beneficiaries, ensuring access to materials that inform their health care decisions.

This study comprises a longitudinal quantitative analysis of Medicare data sources to examine MA plan availability, premiums, benefits and enrollment trends from a dynamic and longitudinal perspective, considering how chronically ill beneficiaries may face different benefits and cost sharing depending on their selection into MA or FFS. Analyses will be conducted on an analytic file constructed from multiple Medicare-related data sources from 2006 – 2009 including: Health Plan Management System, Medicare Beneficiary Database, Medicare Claims, Personal Plan Finder, Medicare Plan and Contract Summary reports, Prescription Drug Event data, and the Chronic Condition Warehouse.

To help redesign the marketing materials, the team will conduct a preliminary communications analysis of selected products such as the Annual Notice of Change to improve content clarity and utility. The team will then capture input from MA plan representatives and the information intermediaries through “listening sessions” and conduct usability testing with Medicare beneficiaries to further guide material refinement.

Through a subcontract with the prime contractor, Optimal Solutions Group (OSG), L&M is assisting the CMS Center for Beneficiary Choices in understanding how beneficiaries access information and what information needs remain. National efforts are underway to inform beneficiaries, and CMS has looked at the population of beneficiaries as a whole to describe awareness and usage of available communications vehicles. However, there is a need to ascertain how certain subpopulations of Medicare beneficiaries, namely the low-income, those with Medigap, and those with retiree employer drug coverage access and understand Medicare information. To address the research questions, the study team first completed an initial analysis of two secondary data sources, the Medicare Current Beneficiary Survey (MCBS) and National Medicare Education Program (NMEP) data to describe the subpopulations of interest.  The team then offered suggestions for additional analyses based on the findings.

CMS has a long-standing commitment to providing a high-level of customer service to people with Medicare. To this end, CMS contracted with The Lewin Group to assess the level of customer satisfaction with CMS telephone customer service. L&M assisted with the following tasks:

• Medicare Incentive Pilot: Measurement of Beneficiary Satisfaction, Round 3. CMS invited three Medicare contractors, CIGNA Health Care Administration, Palmetto GBA and United Government Services, LLC, to participate in a pilot project to explore measuring performance through outcomes versus process while providing incentives to contractors for good performance. The focus of this pilot project was to measure contractor performance in the area of beneficiary telephone inquiries. L&M assisted in analyzing survey data for Round 3 of the pilot and comparing beneficiary satisfaction scores among the baseline round and subsequent rounds of the survey.
• Beneficiary Satisfaction with 1-800-MEDICARE: Prescription Drug Discount Card and Preventive Services. CMS conducted a survey of Medicare beneficiaries who called 1-800-MEDICARE to obtain more information on the prescription drug discount card program and the new preventive services implemented under the Medicare Modernization Act. As part of the project team, L&M assisted in analyzing a survey of beneficiaries or their caregivers to assess their satisfaction with the 1-800-MEDICARE customer service representative performance regarding the prescription drug discount card and preventive services.

The purpose of this study is to design and implement a cost model analysis to explore how increasing colorectal cancer screening (Fecal Occult Blood Test, Flexible Sigmoidoscopy, Flex Sigmoidoscopy + FOBT, Colonoscopy, and Double Contrast Barium Enema) rates among individuals aged 50-64 (early Medicare beneficiaries) could possibly impact eventual costs to the Medicare program by early detection and treatment of colorectal cancer. A combination of epidemiological models linked to a health economic model, based on Congressional Budget Office (CBO) cost accounting and decision-analytic techniques will demonstrate how the incidence and prevalence of the morbidity associated with colorectal cancer is affected by colorectal screening and how this information can be translated into a reduction in Medicare expenditures.

The analysis followed a hypothetical cohort of men and women aged 50 to 64 years at the beginning of the study and cover a 15-year period. Screening costs for both the 50-64 year old and early Medicare beneficiary populations and expenditure savings will be calculated for the Medicare program. Specific study endpoints included changes in incidence and prevalence of colorectal cancer among Medicare beneficiaries, total direct cost of treating colorectal cancer, direct costs (saved) per change (decrease) in colorectal cancer, lifetime cost of care and quality of life at different stages of colorectal cancer, cost impact to Medicare of screening individuals aged 50-64 (and early Medicare beneficiaries to detect and remove adenomatous polyps. Under contract to The Lewin Group, L&M staff helped developed the underlying assumptions and model algorithm to frame the cost-savings calculations. A combination of Congressional Budget Office-style cost accounting and decision-tree modeling were used to develop the cost algorithm. Input from the National Colorectal Cancer Roundtable, data from the Medicare Standard Analytic File and CDC vital statistics were compiled to generate inputs into the model.

The purpose of this research was to provide an estimate of both the health effects and expected cost savings in health care for the average American who takes a daily multivitamin. The project team sought to determine if multivitamin use has an independent effect on self-reported health status, controlling for demographics, healthy behaviors, and other factors known to influence health. Other areas examined in the analysis included chronic health conditions and health risk behaviors among users and nonusers of multivitamins. The analytic approach to addressing the research question was comprised of two distinct phases. The first phase examined the role of multivitamin use on health status. The second phase incorporated the models used in Phase One to calculate savings in medical care expenditures among people who took multivitamins. As part of The Lewin Group project team, L&M staff managed the day-to-day modeling and analytic efforts and drafted the methods, findings and implications portion of the final report.

Hospital Compare is a consumer-oriented web tool that provides information on how well hospitals provide recommended care to their patients. On this website, consumers can see the recommended care that an adult should get if being treated for a heart attack, heart failure, or pneumonia or having surgery. The L&M project team is assisting CMS in incorporating additional quality measures and improving Hospital Compare web tool. A combination of qualitative methods are being used to perform the work on these subtasks. The research activities include an environmental scan to gain a better understanding of the key elements surrounding the public reporting initiative and a literature review that synthesizes information on research, trends in health care and consumer behavior, and other relevant factors. Three rounds of research and testing will be conducted with various audiences to learn more about the intended users and their information interests and needs, and for guiding the design of web tools that are easy to understand and use. Finally, the project team will form and convene a stakeholder workgroup to assist in the review of the study design and advise the project team before each round of testing and then review the findings from each testing round.

CMS has undertaken an initiative focused on promoting high quality and efficient use of imaging services.  By developing a set of measures to document the prevalence and variation in efficiency of imaging services, CMS can potentially develop program guidance and policies to ensure that high quality, appropriate, care is delivered with minimum waste. As part of this effort, CMS has contracted with L&M and its partners, National Imaging Associates and The Lewin Group to develop a preliminary set of imaging efficiency measures.

This work is exploratory, focusing on a small set of measures to assess their feasibility and utility. The study is driven by clinical evidence, tested on both commercial and Medicare claims data, and pilot tested in a sample of different provider settings to validate real-world feasibility. The project team utilized both quantitative and qualitative data collection and analytic approaches. Specific activities include: an assessment of the current literature and existing efforts in imaging efficiency; guidance from a technical expert panel throughout the project; development of G-codes to collect outcomes for negative studies measures; and pilot-testing of G-codes and final measures in provider settings and across different data platforms to ensure general utility of measures for broader use. 

Each year the Centers for Medicare & Medicaid Services (CMS) updates its payment rates for physician Medicare services as established in the Physician Fee Schedule (PFS).  When calculating these payment rates, CMS considers three factors as measured in Relative Value Units (RVU): the relative amount of work required to provide a service (wRVUs), the relative expense of maintaining a practice (PE RVUs), and relative malpractice costs (MP RVUs).

L&M Policy Research (L&M) and its partner Social & Scientific Systems (S3) are assisting CMS throughout the process of determining PE RVUs for the CY 2010 PFS.  A number of tasks directly supporting the calculation of the new PE RVUs are being conducted, including:

• Assessing the impact and appropriateness of calculating PE RVUs with practice expense per hour data from the AMA’s updated Physician Practice Information Survey
• Maintaining and updating the Direct Practice Expense Input database, as well as reviewing the AMA RUC recommendations for updating practice expenses.

Further support for the rule making process includes summarizing and responding to public comments to the proposed rule, creating public use files, drafting support documentation, and assistance in responding to public inquiries after the final rule is published.

Research and analytic support is also being provided for medical equipment and medical supply pricing updates and a proposed expansion of Medicare’s Multiple Procedure Payment Reduction policy in advance of the CY 2011 PFS.

The Medicare Payment Advisory Commission (MedPAC) engaged The Lewin Group to develop and establish a framework for measuring the handling costs incurred by hospitals to prepare, store, transport and dispose of various categories of outpatient drugs (including biologicals and radiopharmaceuticals). This study was developed in response to a mandate in the Medicare Modernization Act concerning handling costs for drugs. Under contract to The Lewin Group, L&M was involved in: (1) identifying pharmacy handling costs and determine if these costs might be of significant magnitude to merit payment adjustments; (2) developing a methodology for measuring handling costs; and (3) conducting three to five case studies of hospitals of varying types (including outpatient cancer centers) to assess the feasibility of using the framework for measuring pharmacy handling costs.

The development of the framework involved two phases: (1) drug categorization; and (2) micro-costing. L&M staff conducted structured telephone discussions with six hospitals (primarily pharmacy staff) to understand their rational for categorizing drugs along a continuum of intensity of resource utilization based on characteristics such as toxicity, special handling requirements, and route of administration.

The second phase to assess the framework was a micro-costing exercise, using cost accounting techniques that are commonly used by the hospital industry. L&M staff assisted in the development of a cost documentation spreadsheet and instructions to collect the information on direct costs. After receiving the micro-costing spreadsheet from the case study facilities, L&M staff participated in structured interviews to understand the inputs and services contained within the spreadsheet. Then, L&M staff analyzed the data (e.g., labor time or supplies) from each of the case study hospitals to obtain cost relatives for each of the drug categories and identified discrepancies among these inputs.

staff presented the findings from this study during the April 21-22, 2004 public meeting of the MedPAC Commissioners.

Under subcontract arrangement with Westat, Inc., L&M assisted the Office of the Assistant Secretary for Planning and Evaluation in defining and evaluating the landscape of health and well-being data relevant to American Indians, Alaska Natives and other Native Americans (AI/AN/NA). This study is intended to address the lack of systematic information on available data sources and on the quality and usefulness of available data. In addition, the project identified strategies to improve the quality, usefulness, and population and geographic coverage of data on AI/AN/NA health and well-being.

The objectives of the study are: 1) to identify, review, and assess existing data sets that provide information on health and well-being of the AI/AN/NA populations; 2) to compile information on the quality, usefulness, population and geographic coverage of each data set; 3) to develop a Data Catalog that includes information on all identified data sets, including characteristics of the data sets that affect usefulness for research, policy development, and management purposes; and 4) to prepare a paper on data issues, data gaps, and potential strategies that could be implemented to improve data on AI/AN/NA health and well-being, based on results of the data review and input from key stakeholders from the Federal Government, research community, and AI/AN/NA Tribes and communities.

Under contract to The Lewin Group, L&M staff examined the current standards of practice relating to Long Term Care Pharmacy (LTCP) services, including the complex delivery and financing issues associated with these services, and developing a set of options for integrating the LTCP system into the new Medicare Part D benefit. This study was conducted for the Centers for Medicare & Medicaid Services (CMS). L&M staff prepared a detailed description of current standards of practice for pharmacy services provided to patients in LTC facilities, with particular emphasis on areas which present particular challenges as they relate to Part D, and conducted key informant interviews with beneficiary advocates and LTCP stakeholders to capture a more detailed picture of how Part D implementation would impact beneficiaries and the LTCP market.

The study utilized a two-tiered, iterative, data collection approach to assess the regulatory and operational landscape of the long term care pharmacy market and roles of key stakeholders. The first component comprised an information scan of existing data sources to gain a comprehensive and detailed understanding of current LTCP practice standards in the finance and delivery of pharmacy services, the evolution of and state variation in these standards, and features of the LTCP industry market, including both product flow and money flow.

Key themes from the information scan were then used to inform the second portion of data collection, which entailed key informant telephone interviews with LTCP stakeholders. These interviews facilitated a more nuanced understanding of how regulations are implemented in practice, how market features intersect with day-to-day LTCP operations, and how Part D implementation issues might impact the LTC market and service delivery. Open-ended interview protocols, tailored to each stakeholder category, were used to guide the telephone discussions and served as the organizing framework for compiling interview responses.

Hospital charges are used for many things. Some insurers pay discounted charges. Medicare uses hospital charges as a primary data source for setting payment rates for both inpatient and outpatient services, and for determining Medicare’s costs by service line in the Medicare cost report. Hospitals report their uncompensated care burdens as charges. However, little is known about how hospitals set their charges and the extent to which charges reflect hospitals’ costs. As a contractor to The Lewin Group, L&M staff conducted a study for the Medicare Payment Advisory Commission (MedPAC) on hospital charge-setting practices.

Specifically, the study examined the process hospitals used to set charges, the goals of the charge-setting process, and the factors that influence how charges are established. The study also explored how hospitals update charges for existing services compared to how they set charges for new services. Finally, the study surveyed the relationship between costs and charges and variations in the mark up of charges over costs across services.

Structured telephone interviews, using a standard protocol, were conducted with 57 hospitals, covering 238 hospitals. Respondents included charge master managers and their supervisors in hospital finance departments. The project team contacted over 500 hospitals in the recruitment effort. Those contacted included hospitals from all regions, of various sizes, teaching status, and ownership. MedPAC staff presented the findings from this study during the September 9-10, 2004 public meeting of the MedPAC Commissioners.