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Back To Vidyya Good News For CHF Patients, Physicians And Insurance Companies:

HCFA To Offer Extra Payments For Care of Congestive Heart Failure

The Health Care Financing Administration announced guidelines today for Medicare+Choice organizations to receive extra risk adjustment payment for outpatient care of enrollees with congestive heart failure (CHF) beginning in 2002.

Currently, adjustments to payment based on an enrollee's health status rely solely on inpatient encounter data. The new guidelines will ensure that Medicare+Choice organizations are paid more for the costs of providing high quality outpatient care as well.

The guidelines also contain rules for the 2001 National Quality Assessment and Performance Improvement Project, required of all Medicare+Choice organizations. Each year HCFA requires Medicare+Choice organizations to focus efforts on improving care in one HCFA-designated area. The goal of the 2001 project is to reduce the number of deaths and improve the overall quality of life for patients with congestive heart failure.

"The new guidelines will help Medicare+Choice organizations better serve their patients who have been diagnosed with congestive heart failure," said Robert A. Berenson, M.D., HCFA Director of the Center For Health Plans and Providers. "We are pleased to be able to have partnered with Medicare+Choice organizations to help identify what contributes to the successful care of CHF patients, and to reward participating Medicare+Choice organizations for their investment in quality management of this prevalent, chronic disease."

Congestive heart failure is the leading cause of hospitalization among people covered by Medicare. Three million Americans are currently diagnosed with congestive heart failure. More than 80 percent (2,400,000) are over 65 and are Medicare enrollees. While it cannot be cured, congestive heart failure can be managed effectively in an outpatient setting.

As of November 2000, more than 6.2 million of the nearly 39 million Medicare beneficiaries have chosen to enroll in a Medicare+Choice organization.

Medicare+Choice organizations may qualify for extra payments if they meet these clinical quality indicators: at least 75 percent of certain CHF enrollees have received evaluation of left ventricular function; and at least 80 percent of those enrollees with left ventricular systolic dysfunction have been appropriately prescribed an ACE Inhibitor. The clinical quality indicators are contained in full in an operational policy letter (OPL2000.129) and can be found on HCFA's Web site: or in today's Vidyya.

Qualifying Medicare+Choice organizations that meet or exceed these quality indicators will receive extra payments in calendar years 2002 and 2003. The extra payments are an interim step before a more comprehensive risk adjustment model is implemented in 2004.

Last May HCFA indicated its intention to make extra payments to Medicare+Choice organizations for successful outpatient care of congestive heart failure. HCFA has been working closely with them and with clinical experts to identify and refine the clinical quality indicators to be reported and to define the level of success to be demonstrated to qualify for extra payment.

HCFA began collecting physician encounter data from Medicare+Choice organizations last October and will begin to collect hospital outpatient encounter data in April 2001. These data will be incorporated into the comprehensive risk adjustment model that will eventually make these special payments unnecessary.

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Editor: Susan K. Boyer, RN
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