Shantanu Agrawal, MD is a Board-certified Emergency Medicine physician and Fellow of the American Academy of Emergency Medicine. He is currently serving as Deputy Administrator for Program Integrity and Director of the Centers for Medicare & Medicaid Services’ (CMS) Center for Program Integrity. His focus is to improve health care value by lowering the cost of care through the detection and prevention of waste, abuse and fraud in the Medicare and Medicaid programs. Prior to this role, Dr. Agrawal served as Chief Medical Officer of the Center for Program Integrity, where he helped to launch new initiatives in data transparency and analytics, utilization management, assessment of novel payment models and a major public-private partnership between CMS and private payers. Prior to joining CMS, Dr. Agrawal was a management consultant at McKinsey & Company, serving senior management of hospitals, health systems, and biotech and pharmaceutical companies on projects to improve the quality and efficiency of health care delivery. Dr. Agrawal has also worked for a full-risk, capitated delivery system as the head of clinical innovation and efficiency. He has published articles in the Journal of the American Medical Association, New England Journal of Medicine and Annals of Emergency Medicine among others, and has given national presentations on health care policy and the cost of care. Dr. Agrawal completed his undergraduate education at Brown University, medical education at Cornell University Medical College, and clinical training at the Hospital of the University of Pennsylvania.
Q. Tell us a bit about the Center for Program Integrity's mission and its goals for the remainder of this year.
Broadly speaking, the mission of the Center for Program Integrity (CPI) is around payment accuracy. We make sure that we are paying for services and benefits the Centers for Medicare & Medicaid Services (CMS) intends to cover and that we are driving the kind of utilization we want to see in our programs. We have a number of priorities for this year. First, we hope to expand our footprint to include all major programs at CMS, including Medicare and Medicaid, as well as in the marketplace. It’s very important that we have rigorous systems in place to make sure all of the dollars that flow through our programs are being spent in the right way. Our second major objective is that we continue to coordinate across the Agency with other centers like the Center for Clinical Standards and Quality (CCSQ) to ensure that we are getting involved on the front-end — in the design of payment policy and in coverage determination — to ensure there are safeguards and controls for payment accuracy. Third, we are aiming to work directly with the provider community to help reduce improper payments and burden. We have implemented a lot more controls over the years around provider screening to make sure we are working with the right people, as well as in data analytics for more real-time claims analysis than ever before. This has put us in a substantively new place where we can leverage advanced algorithms and predictive analytics, as well as reduce burden and take a risk-based approach in working with the provider community. Finally, lots of things are changing in the health care industry through payment innovation and delivery system reform. We need to engage with all parts of CMS to make sure all of our approaches are being applied to the evolving parts of the broader system.
Q. How do the CPI's activities fit in with the work of the CMS CCSQ and Quality Improvement Organization (QIO) Program?
Our relationship with CCSQ has been deepening over the last few years since the creation of the Center. It’s a really important collaboration for me personally. In many respects, we work on different aspects of the same issues. CCSQ has a focus on quality and certification. It essentially is asking which providers CMS should be working with and determining if they meet our qualifications for the program and are aiming for the right objectives. We ask the same sets of questions but have different tools for answering them. We definitely see eye-to-eye and have lots of potential collaboration in the survey and enrollment space to make sure that the right, high-quality health care providers are able to see Medicare and Medicaid patients. We too get concerned about patient harm issues, which unfortunately we see all too often in our work, especially around overutilization or misapplication of services. That is definitely an area in which we collaborate with CCSQ. Within the QIO Program specifically, there is a whole new focus around the enforcement of the two-midnight rule, which is a collaboration between CCSQ and CPI. It prioritizes education on the front-end to make sure that providers are aware of and complying with the rules, and taking action where there isn’t a demonstration of compliance.
Q. As you know, June is Men’s Health Month, and this issue of QIO News is dedicated to men’s health. How would you describe the current landscape of men’s health and the work to improve it, particularly within the QIO Program?
Overall, I draw both on my experience at CMS and as a practicing clinician. So I see there is generally good news for men’s health. Life expectancy is improving, but there are caveats. There is maldistribution of health involving chronic illnesses like cardiovascular disease and diabetes. Socioeconomically-disadvantaged men — and all people in general — are at a different place with respect to disease burden and access to resources. Disease prevalence for diabetes and obesity also varies with racial, ethnic and socioeconomic status. I think we have a lot to be positive about, but it’s important for CMS, a huge health care provider in this country, to keep an eye on these important factors. We must meet everyone’s needs and advance the health of men, regardless of their socioeconomic or geographic location. Quality Innovation Network (QIN)-QIOs are doing a great job of connecting with communities at the local level to share best practices and achieve large-scale improvement around a number of clinical areas. CMS’ Everyone with Diabetes Counts program comes to mind: A diabetes self-management education program that is designed to improve health outcomes and quality of life among disparate and underserved Medicare populations, including older men. QIN-QIOs are also organizing Learning and Action Networks involving multiple stakeholders to harvest and spread ideas and best practices for other critical clinical topics involving men’s health, including cardiac health, health care-acquired infections, care coordination and nursing home care.
Q. A common misconception among men is that if you are generally “healthy,” you don’t need to worry about preventive screenings or actively maintaining your wellness. How are CMS, and its partners like providers and QIN-QIOs, poised to improve and increase preventive health, screenings and promotion of wellness to the communities served?
I plead guilty that like so many men, I too have put off getting my preventive checkups and screenings in the past. I certainly remember from my clinical practice the great lengths to which many men would go to avoid seeing their physician, and it was only when their health worsened that they would visit their primary care doctor. Communicating the importance of preventive screenings to male beneficiaries, and QIN-QIOs’ regular interaction with the clinical community to support preventive care best practices represent the right approach. Medicare covers a host of preventive services like annual screening visits and vaccinations, among many others. QIN-QIOs are working directly with providers and other key partners to drive people with Medicare benefits to take advantage of these prevention and screening programs. From improving immunization rates to increasing colorectal cancer screening rates to increasing the identification of behavioral health issues like alcohol use disorder and depression, QIN-QIOs are beginning to generate results at the community and national levels.
Q. Anything else you would like QIO News readers to know?
Overall, I want to stress the significance of preventive services for both men and women, young and old, and the importance of patients and providers having open discussions about screenings and preventive care. We do have a lot to be optimistic about. There are a lot of community-oriented payment and delivery system reforms that place a central focus on the health of populations. And CMS is working diligently with QIN-QIOs and payers in general to get to a place where we can achieve and maintain overall population health — not just treat and cure illness.