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Medicare Data Scenario

Examine the CMS Chronic Conditions Triads: Prevalence and Medicare Spending
spreadsheet located in your Learning Resources. Familiarize yourself with CMS data
regarding chronic conditions and Medicare spending (CMS.gov), beginning with the first
tab in the spreadsheet, titled Overview, that summarizes the data sources, study
population chronic conditions, and socio-demographic variables involved in the data.
Note that the remainder of this data set presents five years of data on various triads of
chronic conditions that represent material co-morbidities studied by CMS.

With the CMS development of ACO’s (accountable care organizations) there is an
emphasis on managing certain chronic conditions to minimize hospital readmissions.
The pro-active medical management of heart failure, specifically CHF (congestive heart
failure), is a focus in trying to prevent unnecessary hospital admissions. In the medical
management of this condition and associated comorbidities such as diabetes chronic
kidney disease and hyperlipidemia, patients must manage both their fluid intake and
maintain a rigorous regime of medication such as beta-blockers. A lack of medication
compliance and or fluid management in these patients often results in repeated
emergency room visits and or hospital readmissions to stabilize physiologic parameters.

In this scenario assume you are an administrator of an integrated delivery network who
is working with CMS on developing an ACO. Using these historical, five year data on
CMS patients with comorbidities related to Heart Failure and per capita spending, you
are asked to work with an IT analyst to lead the design of the functional requirements
for the data warehouse. This business intelligence application will upload information
from your organization to CMS as a part of the ACO. Senior leaders want to understand
which HIT systems and which data within those HIT systems will be required to
contribute relevant information to CMS regarding comorbidities on heart failure patients.
They also want to understand the availability of those data and the level of quality of
those data in the organization, as they will be key to the financial parameters set within
the ACO agreement.