Medicare

The Million Hearts® Cardiovascular Disease Risk Reduction Model used data-driven predictive modeling approaches to generate individualized risk scores and mitigation plans for eligible Medicare fee-for-service beneficiaries.

The data from the trial is released as a suite of seventeen linked data files. The data include detailed information about the beneficiaries, physician practices, specific providers and clinic visits. The files do not contain names, street addresses or contact information. However, they can be linked to other CMS files through the CCW beneficiary ID.

The following data files are included in the model:

• Raw Clinical File - all visit and clinical data for beneficiaries as it was uploaded to the data collection registry by the provider
• Final Clinical File - a model-curated version of the raw clinical data
• Beneficiary Demographic File - demographic data submitted by the practice
• Visit File – All data extracted to create a beneficiary visit, and includes the generated risk scores and baseline groups for each participating beneficiary
• Practice List File - information about practices enrolled in the model
• Provider List File - information about the providers (National Provider Identifiers) enrolled in the model
• Alignment Files (11) – Point-in-time beneficiary alignment and program eligibility determination analytic file. This alignment validation process occurred semi-annually throughout the duration of the model.

For more information on the Million Hearts® Cardiovascular Disease Risk Reduction Model, visit the CMS Innovation Center website.

What does this file include? (variable highlights)

• Model ID (with which the Beneficiary is associated)
• Entity ID (with which the Beneficiary is associated)
• CCW Beneficiary ID
• Beneficiary Start Date
• Beneficiary End Date
• Voluntary Alignment Indicator

The Entity ID is the only key field needed to link a Beneficiary to their Entity.

The Beneficiary file also contains the CCW Beneficiary ID that can be used to link to claims and other relevant CCW data.

A Beneficiary may have an End Date of 12/31/9999, which indicates that the Beneficiary is “currently” participating in the model.

What does this file include? (variable highlights)

• Model ID (in which the Provider participates)
• Entity ID (with which the Provider is associated)
• National Provider Identifier (NPI)
• Tax Identification Number (TIN)
• CMS Certification Number (CCN)
• Provider Start Date
• Provider End Date
• Provider Participation Type Code

The Entity ID is the only key field needed to link a Provider to their Entity.

The NPI, TIN, and/or CCN can be used to link to claims and other relevant CCW data.

A Provider may have an End Date of 12/31/9999, which indicates that the Provider is “currently” participating in the model.

What does this file include? (variable highlights)

• Model ID (in which the Entity participates)
• Model Name (in which the Entity particpates)
• Entity ID
• Entity Name
• Entity Type
• Entity Start Date
• Entity End Date

The Entity ID is unique to CMMI systems and cannot be used to link to claims data or other CCW data. The Entity ID is the key field for tying CMDS Provider and Beneficiary participation data to a specific Entity and is unique across all models.

An Entity may have an End Date of 12/31/9999, which indicates that the Entity is “currently” participating in the model.

These data files may be used as ‘finder files’ in combination with other requested Chronic Conditions Warehouse (CCW) files to isolate results to include (or not include as desired) entities, providers and or beneficiaries participating in specific models.

Each model has a set of up to three (3) files, one per participant type:

1. Entity file
2. Provider file
3. Beneficiary file

Data for each model will be updated the first month of each calendar quarter, unless the model has ended. Models which have ended are identified in the table below.

The quarterly file updates are full replacement files and contain data from the launch of each model to the current quarter. Note: Participating entities, providers and beneficiaries may frequently change due to time lags in updates by model participants to their provider lists and/or to changes in beneficiary attribution. As such, these files should not be considered fully complete or final until approximately 6-12 months after a model has ended.

Data files are available for the following models:

• ACO Realizing Equity, Access, and Community Health (REACH) Model - This model aims to improve the quality of care for people with Medicare through better care coordination, reaching and connecting health care providers and beneficiaries, including those beneficiaries who are underserved.

          Note: The ACO REACH model was previously called the Global and Professional Direct Contracting (GPDC) model.

• Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model - This model supports healthcare providers who invest in practice innovation and care redesign to better coordinate care and reduce expenditures, while improving the quality of care.
• Comprehensive Care for Joint Replacement (CJR) - This model is designed to improve care for Medicare patients undergoing hip and knee replacements (also called lower extremity joint replacements or LEJR) performed in the inpatient or outpatient setting and for total ankle replacements performed in the inpatient setting.
• Comprehensive Primary Care Plus (CPC+) Model - This national advanced primary care medical home model aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.
• Emergency Triage, Treat and Transport (ET3) Model - This model aims to improve quality and lower costs by reducing avoidable transports to hospital Emergency Departments and unnecessary hospitalizations following those transports.
• End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model - This model is intended to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with ESRD, while reducing Medicare expenditures and preserving or enhancing the quality of care furnished to beneficiaries with ESRD.
• Frontier Community Health Integration Project Demonstration (FCHIP) - This demonstration aims to develop and test new models of integrated, coordinated health care in the most sparsely-populated rural counties with the goal of improving health outcomes and reducing Medicare expenditures.
• Frontier Community Health Integration Project Demonstration - Extension (EFCHIP) - This demonstration aims to develop and test new models of integrated, coordinated health care in the most sparsely-populated rural counties with the goal of improving health outcomes and reducing Medicare expenditures.
• Graduate Nurse Education (GNE) Demonstration - Under the Graduate Nurse Education Demonstration, CMS provided reimbursements to up to five eligible hospitals for the reasonable cost of providing clinical training to advanced practice registered nursing (APRN) students added as a result of the demonstration.
• Home Health Value-Based Purchasing (HHVBP) Model - This model is designed to improve the quality and delivery of home health care services to Medicare beneficiaries. Specific goals include providing incentives for better quality care with greater efficiency, studying new potential quality and efficiency measures for appropriateness in the home health setting, and enhancing the public reporting process. 
• Independence At Home (IAH) Demonstration - Under this model, the CMS Innovation Center works with medical practices to test the effectiveness of delivering comprehensive primary care services at home and to determine if doing so improves care for Medicare beneficiaries with multiple chronic conditions. Additionally, the Demonstration rewards health care providers that provide high quality care while reducing costs.
• Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents (NFI) - This effort aimed to improve the quality of care for people residing in long-term care (LTC) facilities by reducing avoidable hospitalizations.
• Kidney Care Choices (KCC) Model - This model helps health care providers reduce the cost and improve the quality of care for patients with late-stage chronic kidney disease and ESRD and aims to delay the need for dialysis and encourage kidney transplantation.
• Maryland Total Cost of Care (MDTCOC) - CMS and the state of Maryland are partnering to test the model, which sets a per capita limit on Medicare total cost of care in Maryland. The MDTCOC Model is the first Center for Medicare and Medicaid Innovation (Innovation Center) model to hold a state fully at risk for the total cost of care for Medicare beneficiaries.
• Medicare Care Choices Model (MCCM) - This model tested a new option for Medicare beneficiaries to receive supported care services from selected hospice providers, while continuing to receive services provided by other Medicare providers, including care for their terminal condition.
• Medicare-Medicaid Financial Alignment Initiative (FAI) - This initiative is designed to provide individuals dually enrolled for Medicare and Medicaid with a better care experience and to better align the financial incentives of the Medicare and Medicaid programs.
• Oncology Care Model (OCM) - In this model, physician practices enter into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.
• Pennsylvania Rural Health Model (PARHM) - This model seeks to test whether care delivery transformation in conjunction with hospital global budgets increases rural Pennsylvanians' access to high-quality care and improves their health, while also reducing the growth of hospital expenditures across payers, including Medicare, and improving the financial viability of rural Pennsylvania hospitals to improve health outcomes of and maintain continued access to care for Pennsylvania's rural residents.
• Primary Care First (PCF) Model - This voluntary alternative five-year payment model rewards value and quality by using an innovative payment structure to support the delivery of advanced primary care.
• Prior Authorization of Non-Emergent Hyperbaric Oxygen (HBO) Therapy - CMS implemented a prior authorization model from 2015 until 2018 for non-emergent HBO therapy in Illinois, Michigan, and New Jersey that tested whether prior authorization helps reduce expenditures, while maintaining or improving quality of care.
• Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) - The model establishes a prior authorization process for repetitive, scheduled non-emergent ambulance transports to reduce the utilization of services that do not comply with Medicare policy while maintaining or improving quality of care.
• Rural Community Hospital Demonstration (RCH) - This program tests the feasibility and advisability of cost-based reimbursement for small hospitals that are too large to be Critical Access Hospitals. CMS is conducting an intensive evaluation of the demonstration, assessing the financial impact on participating hospitals, as well as the effect on health care for the populations served.
• Transforming Clinical Practice Initiative (TCPI) - The Transforming Clinical Practice Initiative (TCPI) model was uniquely designed to support clinician practices through nationwide, collaborative, and peer-based learning networks designed to help clinicians and practices to achieve large scale health care transformation, prepare practices to successfully participate in value-based payment arrangements, including Alternative Payment Models (APMs), and improve the quality of care.
• Value in Opioid Use Disorder Treatment (ViT) Demonstration Program - This is a four-year demonstration program authorized under section 1866F of the Social Security Act (Act), which was added by section 6042 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act). The purpose of the demonstration, as stated in the statute, is to “increase access of applicable beneficiaries to opioid use disorder treatment services, improve physical and mental health outcomes for such beneficiaries, and to the extent possible, reduce [Medicare program expenditures].”
• Vermont All-Payer Model (VTAPM) - This model is CMS’s test of an alternative payment model in which the most significant payers throughout the entire state – Medicare, Medicaid, and commercial health care payers – incentivize health care value and quality, with a focus on health outcomes, under the same payment structure for the majority of providers throughout the state’s care delivery system and transform health care for the entire state and its population.

The group of models for which CMDS participation files are available will expand over time to include additional models.

The model IDs for the 25 models in the CMDS file set is depicted in the table below.

CMDS Models

For further detail, please refer to the specific model website accessible through https://innovation.cms.gov/innovation-models#views=models.

What does this file include? (variable highlights)

• Readmission indicator
• Chronic condition weight

Each record represents a hospitalization for a beneficiary in the calendar year (CY). Beneficiaries with multiple hospitalizations will have multiple records in this file.

Beneficiaries can be linked to other beneficiary data via the BENE_ID and to plan information via the HEDIS_CONTRACT_ID and HEDIS_PLAN_ID variables.

What does this file include? (variable highlights)

• Colorectal cancer screening
• Comprehensive diabetes care (multiple measures)
• High risk medication usage

Each record represents the experience of a beneficiary in a specific plan for the calendar year (CY). Beneficiaries enrolled in more than one plan during the CY will have multiple records in this file.

Beneficiaries can be linked to other beneficiary data via the BENE_ID and to plan information via the HEDIS_CONTRACT_ID and HEDIS_PLAN_ID variables.

What does this file include? (variable highlights)

• Two flags for each chronic condition:
  • First occurrence date
  • End of year indicator

Special considerations

• The algorithms used to assign the flags are available from the CCW website.
• Algorithms requiring a multiple-year look back period are completed without requiring the researcher to order multiple years of data.
• Algorithms search data from Medicare Fee-For-Service (FFS) claims.
• This file is a segment that can be requested in addition to the Master Beneficiary Summary File (MBSF) base file.
• The algorithms for the 30 CCW Chronic Conditions data file use only ICD-10-CM diagnosis codes. The first full calendar year that is used to identify conditions is 2016.
• Three new conditions are added compared with the 27 CCW version.
• The changes to the algorithms compared with the 27 CCW version are noted on the individual variable pages and detailed descriptions of changes can be found in the Chronic Conditions File Enhancements white paper.

What does this file include? (variable highlights)

• ACO identifier
• Performance year
• Organization Name
• CMS organization identifiers including Tax Identification Number, CMS Certification Number (CCN)
• Provider type description

Special considerations

• This file can be linked to any other CMS file that contains the ORG_TIN, ORG_NPI or ORG_CCN
• Providers can be linked to their assigned beneficiaries by linking the ACO_ID in the provider file to the ACO_NUM in the beneficiary file
• Questions regarding the Next Generation ACO Model can be directed to NextGenerationACOModel@cms.hhs.gov