For over 20 years, members of the Arbor Research Collaborative for Health team have been supporting CMS (Centers for Medicare and Medicaid Services) through analytical work and clinical input to help health professionals, patients, and stakeholders in our healthcare system close quality gaps by turning promising new ideas into action. An area of concern to CMS and the broader renal community is the large gaps between the CMS goals of high-quality care for every patient every time and what our healthcare system delivers. The assurance of high-quality medical care that is personalized, prevention-oriented, and patient-centered relies on evidence about the benefits and costs for each particular patient.

Arbor Research evolved in response to the needs identified by CMS and the community for initiatives such as quality measures of performance and outcomes, and quality incentive payment plans. These initiatives fall under the Health Policy and Practice Projects (HP3), whose mission is to produce healthcare research that can inform policy and reduce gaps in quality care. Our current Disease Management Demonstration contracts with CMS, for which Arbor Research is the prime contractor, are described below.

Period of Performance: 2004-2010

Purpose:

The Evaluation of the ESRD Disease Management Demonstration is designed to study the effectiveness of disease management for patients enrolled in Medicare Advantage Plans. The disease management program offered by each plan delivers integrated and coordinated health services. Each plan receives payment from Medicare under a capitated system. Arbor Research is assessing each plan’s clinical and financial impact to determine whether integrated disease management programs can minimize treatment complications and improve clinical outcomes, while reducing costs to CMS.

Arbor Research’s Role:

In 2006 CMS contracted with Arbor Research to study the effects of disease management approaches on Medicare beneficiaries with ESRD. ESRD is the only disease covered by Medicare, regardless of a patient’s age. This has a pronounced financial impact on Medicare. According to the United States Renal Data System 2007 Annual Data Report, as of December 31, 2005 in the United States, there were 406,812 Medicare patients with ESRD, making up approximately 1% of all Medicare beneficiaries. However, in 2005, 6.4% of all Medicare costs ($21 billion out of $331.4 billion) were specifically for treatment of the ESRD patient population.

As an evaluator, Arbor Research examines disease management programs offered through a capitated payment system by private healthcare plans. The capitated payment system used by CMS reimburses healthcare plans based on a per-member per-year amount to cover all disease management services the healthcare plan provides to beneficiaries. The participating demonstration sites include three Medicare Advantage Plans that offer disease management programs within an integrated health system.

Arbor Research Investigators and Collaborators:

The Arbor Research team consists of Principal Investigator Dr. Sylvia Ramirez, and Co-Investigators Dr. Friedrich Port and Dr. Bruce Robinson. Dr. Ramirez provides primary clinical and epidemiological expertise for the clinical outcome measures. Drs. Port and Robinson also contribute clinical and epidemiological expertise. This team of investigators designed the study, and lead analyses and preparation of analytical reports to CMS. They collaborate with researchers from the National Opinion Research Center and the Lewin Group.

History and Details:

The Disease Management Demonstration evaluation builds on the summary findings of CMS’s Managed Care Demonstration, completed in 2002, in which Arbor Research was a subcontractor to the Lewin Group. This prior CMS Demonstration evaluated the impact of managed care on the enrollment experience of patients; clinical outcomes and indicators; and financial impact on CMS and on the Managed Care sites. The results of this earlier demonstration showed that Medicare patients who enrolled in the Managed Care plans experienced improved quality of life and overall satisfaction with their Managed Care programs.

The current Disease Management Demonstration is designed to evaluate outcomes for Medicare patients who have the opportunity to join integrated care management systems through enrollment in a Medicare Advantage Plan. The demonstration focuses on seven elements, each being evaluated for all participating Medicare Advantage demonstration sites:

• Disease management program structure
• Plan-specific interventions, including use of oral nutritional supplementation, home weight monitoring programs, inclusion of a pharmacist in the healthcare team, among others
• Patient outcomes including hospitalization, mortality, and transplantation
• Financial impact of the disease management program, including costs to CMS and costs to the health plans in relation to patient benefits and clinical outcomes
• Patient satisfaction
• Quality of life
• Provider acceptance

Interim analyses of the seven components of disease management were completed and submitted to CMS. The final analysis will conclude in 2009 and be included in the final project report to CMS in late 2009.

Quality Incentive Payment (QIP), Task I and Task II

Period of Performance: 2004-2011

Purpose:

QIP Task I – Implementation Support for the Quality Incentive Payment of the ESRD Disease Management Demonstration

QIP Task II – Implementation and Support for an Advisory Board for the ESRD Bundled Case-Mix Adjusted Demonstration, Mandated by Section 623(e) of the Medicare Modernization Act

Arbor Research’s Role:

Task I: Arbor Research provides regular, timely and comprehensive technical expertise to CMS in calculating target clinical measures for the quality incentive payment calculations. The final measures were developed iteratively based on the team’s experience in monitoring, predicting and identifying outcomes for dialysis in the United States and in 11 other countries through the DOPPS (Dialysis Outcomes and Practice Patterns Study). CMS’s experiences through the Core Indicators Project, the existing National Kidney Foundation’s Kidney Disease Outcomes Quality Indicators guidelines, published scientific literature, and feedback from the three large dialysis organizations also contributed to the development of the target measures.

Task II: This is a demonstration in which dialysis facilities are paid prospectively for a broader bundle of outpatient ESRD services than are currently reimbursed through the composite rate. Arbor Research oversees the project, which is conducted at University of Michigan’s Kidney Epidemiology and Cost Center (UM-KECC). Work involved the development of the bundled case-mix adjusted payment methodology. In the remaining period of performance for this contract, the work will focus on database maintenance and related analyses.

Arbor Research Investigators and Collaborators:

The Arbor Research-led team, with multidisciplinary experts from UM- KECC, brings extensive professional and organizational capability to bear on this project. Under the leadership of Drs. Port and Ramirez, and Drs. Robert Wolfe and Richard Hirth, the project involves cost analyses using both primary and secondary data sources, formulating the methodology and analysis plan for the incentive payment and bundled case-mix adjusted payments, and analyzing ESRD data.

History and Details:

Arbor Research, in collaboration with UM-KECC, administers for CMS the project, “Implementation Support for the Quality Incentive Payment of the ESRD Disease Management Demonstration, Implementation and Support for an Advisory Board for the ESRD Bundled Case-Mix Adjusted Demonstration.” The project involves collaboration on two important ESRD demonstrations that aim to improve the quality of care for dialysis patients: QIP Task I, calculating the quality incentive payment for the ESRD Disease Management Demonstration Evaluation (for which Arbor Research is the primary contractor); and QIP Task II, implementing and supporting an advisory board for the ESRD Bundled Case-Mix Adjusted Demonstration. QIP Task II includes research on payment methodology, clinical factors, and other issues as they pertain to a bundled case-mix adjusted payment system for ESRD (subcontracted by Arbor Research to UM-KECC).

For QIP Task I, Arbor Research continuously monitors national and international dialysis practice patterns and takes into account broad systemic changes in providing dialysis care that may predictably impact on the target clinical measures. This is particularly important to CMS’s work, such as their recent reviewing and revision of several clinical performance measures (based on the ESRD Measures Support contract, also awarded to Arbor Research). Researchers work closely with CMS and review input from the participating healthcare plans to address the impact of these changes on the current core set of target clinical measures for the QIP demonstration.

For QIP Task II, Arbor Research is obtaining and processing final 2007 Medicare claims, including data validation checks, creation of variables needed for modeling (e.g., comorbidity measures), creation of analytic data files, and integration with prior years' data; 2006 Medicare Cost Reports, including data validation checks, creation of variables needed for modeling, creation of analytic data files, and integration with prior years' data; and updates of other CMS data such as new Medical Evidence Forms (CMS Form 2728), including data validation checks, creation of variables needed for modeling, creation of analytic data files, and integration with prior years' data.

For information about the various ESRD Disease Management Evaluation projects for CMS, please contact: