Health Research Case studies

Office of the Medicare Ombudsman Support Contract

DHHS CMS, Contract Value: $2,785,279.00

Optimal is the program support contractor for the CMS Office of the Medicare Ombudsman (OMO), supporting the OMO’s to improve Medicare for beneficiaries. Optimal developed the 2009, 2010, 2011, 2012, 2013, and 2014, 2015, and 2016 Reports to Congress (RTCs), and the RTCs are now awaiting HHS clearance. Optimal also supports the Issues Management process, the OMO’s tracking of recommendation implementation, and the development of the Competitive Acquisition Ombudsman (CAO) RTC. The contract requires management of a complex project with various overlapping and simultaneous tasks. Under this contract, Optimal provides support for beneficiaries in locations such as the Virgin Islands, Puerto Rico, Florida, Texas and American Samoa.

Learning System Data Management (LSDM)

DHHS CMS, Contract Value: $4,745,329.00

The Affordable Care Act charged CMS’ Center for Medicare & Medicaid Innovation (CMMI) with developing, testing, and implementing new health care models that improve health care delivery, provide better health status for Medicare and Medicaid beneficiaries and other individuals, and lower health care costs. Optimal developed a secure web portal (Data Management, Analysis, and Reporting System [DMARS]) for the CMMI Learning and Diffusion Group to collect and track stakeholder engagement and Government Performance and Results Act (GPRA) outcomes. DMARS is housed in a FedRAMP FISMA moderate environment on Amazon Web Services and complies with CMS’s XLC life cycle processes.

Evaluation and Oversight of Qualified Independent Contractors (QIC)

Contract Value: $5,046,662.00

U.S Department of Health and Human Services, Centers for Medicare and Medicaid Services Optimal was contracted by CMS to evaluate the accuracy, timeliness, and quality of QICs’ decisions and processes. QICs, which are part of the Medicare appeals process, provide reconsideration decisions for claims appealed by providers, beneficiaries, or suppliers after a claim has been denied by a Medicare carrier, fiscal intermediary, or Medicare Administrative Contractor. For this contract, Optimal developed detailed protocols for measuring process management and the accuracy of coverage and medical decisions in the previous contract (HHSM-500-2007-00028C). The protocols included the measures under review along with the data elements to support the measures. These protocols were further refined under the current contract prior to conducting the onsite audits to improve usability during the audits. Based on CMS guidance, Optimal also created a quality measure rating system to provide standardized and unbiased reporting for each QIC.

HHS Evaluation of the Graduate Nurse Education Demonstration (GNE), Phase I

Department of Health and Human Services, Centers for Medicare & Medicaid Services

Contract Value: $999,241.00

The GNE demonstration, aims to increase the supply of advanced practice registered nurses (APRNs) in the U.S. health care delivery system. This demonstration also contributes to the creation of partnerships between hospitals, schools of nursing, and community-based care settings. Optimal and its subcontractor, AIR, designed and implemented a program evaluation to inform the demonstration’s RTC.

Website Monitoring of Part D Benefits

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid (CMS)

Contract Value: $1,022,588

CMS has broad oversight of Medicare prescription drug plans that contract directly with CMS to provide Part D drug coverage to Medicare beneficiaries. To complete the assessment, Optimal and CMS developed an interactive, web-based tool to assess the availability of 20 specific elements required by the MMGs. The project management team tracked the progress of the reviewers on each website in real time through an online interactive database that captured and stored assessment data. The database was linked to the dashboard that presented the overall progress of the data collection. This dashboard also calculated and displayed the overall percent agreement among the primary and secondary reviewers, the overall and pair-wise Kappa coefficients, as well as average completion times. These data were presented for each reviewer, assessed plan, and the assessed requirement. This allowed for the comprehensive data quality control in real time and helped identify possible data discrepancies.

Part C and Part D Reporting Requirements Data Validation project

Center for Medicare and Medicaid Services

Contract Value: $811,395

Optimal is assessing the standards and criteria used for validating Medicare Part C and Part D reporting requirements and providing revised and improved standards to support and increase the accuracy of data validation. In its current performance year, Optimal has streamlined the documents and tools used by plans, Sponsoring Organizations (SOs), and the data validation contractor’s hired by the plans, focused on aligning the various documents used at different stages of the data validation process, and minimizing inconsistencies across these different artifacts. Optimal is further assessing the standards to evaluate for sufficiency and efficacy, and is developing new and/or revised standards that would allow CMS to effectively monitor the performance of plans and SOs against reporting requirements.


Evaluation Study Design for the Senior Medicare Patrol Program

U.S. Department of Health and Human Services (HHS)

Optimal Solutions Group, LLC (Optimal) supported the Department of Health & Human Services’ Administration on Aging (AoA) by developing a program evaluation design for the Senior Medicare Patrol (SMP) program. Optimal worked collaboratively with the AoA and other SMP stakeholders to design a program evaluation to provide meaningful insight into the successes and challenges of the program and offer actionable suggestions for program improvement.

To help stakeholders understand the SMP program structure, Optimal Solutions Group, LLC (Optimal) developed the program logic model. Logic models provide a framework for program evaluation design, including process and impact evaluation. The SMP logic model consists of the program assumptions and problems that the program is designed to address, resources, program activities (e.g., volunteer training, outreach events, group education sessions, and counseling), program outputs, and outcomes. The logic model posits that activities lead to program outputs that contribute to program outcomes, such as an increase in the number of beneficiaries who protect their Medicare and Social Security numbers, seek assistance with billing, and report detectable FWA. These outcomes ultimately lead to the program impact, such as a reduction in detectable FWA and savings to Medicare and Medicaid that can be attributed to the SMP program.