From Medscape Education Family Medicine The National Quality Strategy and You: How CMS Quality Measures Affect Policy and Practice CME

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1 This article is a CME certified activity. To earn credit for this activity visit: From Medscape Education Family Medicine The National Quality Strategy and You: How CMS Quality Measures Affect Policy and Practice CME Kate Goodrich, MD, MHS; Shari M. Ling, MD CME Released: 05/13/2013; Valid for credit through 05/13/2014 CME Information This activity is intended for all physicians practicing in the United States. The goal of this activity is to describe the nature of the National Quality Strategy and its relationship to quality measurement and payment initiatives administered by the Centers for Medicare & Medicaid Services (CMS). Upon completion of this activity, participants will be able to: 1. Recognize the historical context and legislative mandate ofcms' quality measurement programs 2. Describe the origins of quality measures used by CMS and other healthcare entities 3. Illustrate the impact CMS quality measures have on clinical practices 4. Describe the intersection of quality measurement with reimbursement in various CMS programs Faculty and Disclosures As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest. Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

2 Kate Goodrich, MD, MHS Acting Director, Quality Measurement and Health Assessment Group, Center for Medicare & Medicaid Services, Baltimore, Maryland Disclosure: Kate Goodrich, MD, MHS, has disclosed no relevant financial relationships. Dr Goodrich does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States. Dr Goodrich does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States. Shari M. Ling, MD Deputy Chief Medical Officer, Centers Medicare & Medicaid Services, Baltimore, Maryland Disclosure: Shari Ling, MD, has disclosed no relevant financial relationships. Dr Ling does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States. Dr Ling does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States. Jane Lowers Group Scientific Director, Medscape, LLC Disclosure: Jane Lowers has disclosed no relevant financial relationships. Nafeez Zawahir, MD CME Clinical Director, Medscape, LLC

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5 Slide 1. Dr Goodrich: Hello, and welcome to the program. I am Dr Kate Goodrich, acting director of the Quality Measurement and Health Assessment Group within the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS) in Baltimore, Maryland. I am also a practicing hospitalist. With me today is my friend and colleague, Dr Shari Ling, deputy chief medical officer at CMS. Dr Ling: Hi, Kate, and thank you for inviting me. As a practicing geriatrician, internist, and rheumatologist, I am delighted to be here. Dr Goodrich: Thank you. I would like to welcome you to this program titled "The National Quality Strategy and You: How CMS Quality Measures Affect Policy and Practice."

6 Slide 2. As with any CME activities, there are learning objectives to go over at the beginning, so I would like to share them with you. These include recognizing the historical context and legislative mandate of the CMS quality measurement programs, describing the origins of quality measures used by CMS and other healthcare entities, illustrate the impact CMS quality measures have on clinical practices, and finally, describe the intersection of quality measurement with reimbursement in various CMS programs. I am going to turn it over to Shari now to talk a little bit about the background and history of

7 Slide 3. Dr Ling: Thank you, Kate. The history of quality measurement as it pertains to the National Quality Strategy is really evolving in real time before us. We are in an exciting period of time witnessing healthcare transformation as it progresses. In 1999, the first indication of the Foundation for the National Quality Strategy was published. That is, "To Err Is Human," as published by the Institute of Medicine (IOM). At the same time, the National Quality Forum (NQF) was established. Shortly thereafter, "Crossing the Quality Chasm" was published by the IOM. A few years thereafter, CMS Quality Roadmap was established, and at the same time, "Performance Measurement: Accelerating Improvement," was published, again by the IOM. Shortly thereafter, in 2006, Medicare established the Quality Improvement Organization Program, and in 2008, NQF established the National Priorities Partnership. All this has served as a backbone for the Quality Measurement Strategy and the National Quality Strategy that we will hear more of shortly.

8 Slide 4. We pause for a moment on 2 landmark pieces of work that led to the quality improvement process. First, the Harvard Medical Practice I, in 1991, conducted 2 large studies across 2 separate geographic sites and found and demonstrated that adverse events (ie, errors) occurred in approximately 3% to 4% of hospitalizations. Dr Goodrich: That is really high. Dr. Ling: That is exceedingly high. Over half of these adverse events resulted from medical errors that could have been prevented, so we are talking about preventable harm. Shortly thereafter, the "Quality of Healthcare in the United States" project was published in Again, this was conducted by the IOM. It was a 10-year project funded by the Commonwealth Fund and the National Research Council, and they released "To Err Is Human" in 1999, a report on the prevalence of medical errors, and soon thereafter, "Crossing the Quality Chasm," which outlined 6 aims and 10 rules for healthcare redesign. Dr Goodrich: It seems that the IOM has really played a foundational role in identifying the problem of poor quality care.

9 Slide 5. Dr Ling: Absolutely, and importantly, their products and reports are predicated on evidence, evidence that has been developed, published, and is evolving as we speak. To that point, To Err is Human: Building a Safer Health System, published in 1999, begins to define the quality problem in the United States, and astoundingly, medical harm, or errors, affect 44,500 to 98,000 patients annually. Thus, each year medical errors cost $17 billion to $29 billion. Dr Goodrich: Wow. That is impressive. Dr Ling: It certainly is, and this includes the expense of added care, the additional care necessitated by those errors, lost income, and household productivity, as well as disability. Dr Goodrich: It sounds like some of the problems that we have in this country with high cost of care might be related to poor quality care. Dr Ling: It certainly is, and I think that is where the connection is made, and also why we are here today. Dr Goodrich: Right.

10 Dr Ling: This points out the opportunity for improvement, in that flawed systems and conditions that result from these flawed processes lead people to make mistakes or to fail to prevent them. Let me say that again. Flawed systems and processes and conditions lead people to make mistakes or fail to recognize and prevent them. Slide 6. Furthermore, the IOM defines quality, and this definition has become the guide for all national quality efforts. The definition on this slide was published in Importantly, we acknowledge, and the IOM acknowledges, that medicine is not an exact science. It is possible to have the best medicine with the worst health outcomes and vice versa. Also, it is important to note that medicine is evolving to become a well-informed collaborative process involving the patient, their family, as well as clinicians. Dr Goodrich: I think that is going to be an important point for the audience to keep in mind as we talk about quality measures. It is not just about the individual provider or individual patient. It is about everybody working together as a team to improve the quality of care.

11 Slide 7. Dr. Ling: Absolutely, and importantly, with the patient and the family at the center of that team. Going on, we also have a demonstration of a national commitment to improving quality as represented by the second Institute of Medicine committee report in 2001, "Crossing the Quality Chasm: A New Health System for the 21st Century." This sets the agenda for quality for all stakeholders, including patients and families. This report asks policymakers, healthcare purchasers, regulators, health professionals of all different types, healthcare trustees and management, and patients and consumers to commit to a national statement and effort to improve quality through the improvement of the healthcare system as a whole. This commitment represents a shared agenda of 6 aims for improvement to raise the quality of care to unprecedented levels.

12 Slide 8. Moving on, this requires and acknowledges the creation of an infrastructure to support evidence-based practices. I will say that again: This commitment includes the creation of an infrastructure to support evidence-based practices. It also requires facilitation of the use of health information technology (ie, meaningful use), as well as aligning payment incentives with performance, again focusing on improving health outcomes for patients and their families. As consensus was reached around the importance of improving quality, Congress passed several landmark laws to establish a new quality reporting effort and quality reporting programs, again giving us the authority to implement quality improvement and measurement programs.

13 Slide 9. I will call your attention to just 2 that are more recent in history, that is, the American Recovery and Reinvestment Act (ARRA), which is the basis for our technological improvements and meaningful use, and of course, the Affordable Care Act (ACA) that provides us with the authority to develop and implement quality reporting programs across multiple care settings and really sets the foundation for the conversation evolving from quality measurement and reporting to the pursuit of higher value healthcare. Dr Goodrich: Right, I think the ACA really starts that transition across settings, from paying for reporting to paying for performance, which will be a sea change, I think, in how we report quality measures and how we use quality measures.

14 Slide 10. Dr Ling: The Department of Health and Human Services (DHHS) is front and center in the implementation of the National Quality Strategy (NQS). The goal of the National Quality Strategy for Quality Improvement in Health Care is promotion of quality health care that meets the needs of patients and families and communities. This quality improvement strategy will guide the actions of all who deliver health care, and the goal, importantly, includes 3 aims and 6 priorities, and I will go a little bit into detail on this. Dr Goodrich: I think it is also an important point for the audience to understand that the National Quality Strategy is not a federal quality strategy. It is not something that is imposed by the government. It is really a national quality strategy that has really seen tremendous uptake and interest by private payers, by patient and family organizations, and by providers. I think that is an important point for the audience to understand. Dr Ling: Yes, I agree with you completely, and this is intended to be the focus of a multidirectional conversation involving all stakeholders, for maximum efficiency.

15 Slide 11. I earlier mentioned the 3 aims of the NQS, and they are to achieve better care, to achieve healthier populations and communities, and of course, care that is affordable with a focus on improving quality.

16 Slide 12. The 6 priorities that we mentioned really fit into the rubric of those 3 aims: to make care safer by reducing harm that is caused through the delivery of healthcare; to ensure that each person and family is engaged as true and sincere partners in their care; to promote effective communication and coordination of care, both with patients and families and among healthcare providers and physicians and systems; to promote the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease; working with communities to promote wide use of best practices to enable healthy living; and finally, to make care more affordable for individuals, families, employers, our communities, and our nation.

17 Slide 13. Implementing the NQS also has been challenging at times. Dr Goodrich: It is a tall order. Dr Ling: It is a tall order that necessarily involves all stakeholders at the table and in the conversation. Again, it is an all-teach, all-learn method. It is intentionally designed to allow participation and collaboration, not only for federal agencies, as you pointed out, but our national partners, including patients, patient advocates, and their families. This strategy is designed to be one that evolves as the state of evidence evolves and as the national needs evolve. To summarize, the Department of Health and Human Services then monitors the progress and provides annual updates to Congress on the National Quality Strategy. At this point, I think we will be hearing more from you on quality focus, and on measurement, and how this all fits into the framework that we have laid out. Dr Goodrich: Great. Thank you, Shari. I think my job is to get down into the weeds just a little bit with you so that we can help understand what quality measurement is and how we are using it.

18 Slide 14. First, I want to start off by talking about who develops measures. Where do they come from? There are a number of organizations that develop quality measures, including us here at CMS. Some organizations you may have heard of include the Joint Commission, medical societies such as the American Medical Association, the Society of Thoracic Surgeons, etc. Healthcare associations develop measures. The CMS, as I mentioned before, also develops measures, as do some of our federal partners, such as the Agency for Healthcare Research and Quality (AHRQ). The National Committee for Quality Assurance (NCQA) is another major partner of CMS that develops measures. Certainly, private entities such as employer groups, even some payers and pharmaceutical companies, develop measures as well. This is an enterprise that cuts across a number of different types of organizations.

19 Slide 15. A really key partner for us and for others in the quality measurement enterprise, as you know, is the National Quality Forum. They are major partners with the CMS. The NQF is an independent, nonprofit organization that refines and endorses standards and measures of health quality using a national consensus-based approach. They have a number of criteria that they have put forward that are required for a measure to meet to receive its endorsement. A measure that is NQF-endorsed sort of gets the "Good Housekeeping Seal of Approval," if you will. Briefly,some of those criteria include that the measure must address an important area to measure, such as an area in which there is a quality problem and there is not a current measure that can measure that area. The measure must be scientifically acceptable. It must be usable by providers, whether physicians, hospitals, or other types of healthcare settings. The measure must be feasible to implement. For example, if it is an electronic measure, it must be practical within an electronic health record environment.

20 Slide 16. This slide is a little bit busy, but basically this just describes the entire quality measure lifecycle, starting with identifying what measures or quality topics are important to measure, so really at the concept stage. Moving into identifying what the population is to be measured, whether it is children, older patients, or patients with multiple chronic conditions. Deciding on how that measure should be reported. Should we be using administrative claims, or should we be using electronic health records? Of course, after we develop the measure, we have to test it within specific settings, so we call these pilot sites. Can those data be collected? These are some of the questions we ask. Can the data be collected? Do the results that we get from collecting that data make sense? Is the information useful to the provider who is being measured, so that they can use that information to improve the quality of care for their patients? Then we send those measures to NQF for endorsement, and then finally we implement the measures in some of our quality reporting programs that I will talk about in just a minute. Then we have a whole feedback loop back to the beginning to understand better whether or not that measure is really being used and practiced. Do providers and patients find it useful? It goes all the way back to the beginning in one big feedback loop. Dr Ling: It sounds as though there is plenty of opportunity to contribute to the measure inventory, being mindful of what already exists and what opportunity there is to improve care through measurement. Dr Goodrich: That is right, and we rely on a number of stakeholders to help with that issue, including providers such as the ones watching this program, who give us input as to what they feel is important to them and to the patients that they serve.

21 Slide 17. Let me talk a little bit now about the types of quality measures. One size does not fit all. We use a combination of types of measures within our program. I will start by talking about structural measures. These are measures that look at certain capabilities, whether it is within an electronic medical record system or within a health system itself. A concrete example might be one of the measures that we use in our meaningful use program. We call this a core objective. That is, does your electronic health record have computerized provider order entry capability, yes or no? That is an example of a structural measure. A type of measure that more providers are probably familiar with and have used themselves are process measures. These relate to very specific processes of care, such as administering an aspirin for a patient admitted to the hospital with a heart attack. An example of a measure that we use in our physician quality reporting system is whether patients who have had bypass surgery receive antiplatelet medications at discharge. These measures look at processes that have been shown in randomized clinical trials to have benefit to improve outcomes.

22 Slide 18. That brings me to, of course, outcome measures. This is an area of measurement that is rapidly evolving. The science is rapidly building and changing over time, and these types of measures are important to CMS, and I think to other stakeholders in particular patients. These relate to outcomes of care that a patient would really care about. That is how I like to think about them. For example, a measure that we use in our hospital program includes the 30-day mortality after admission to a hospital for a heart attack. Another might be a safety type measure, so for example, for patients who have bypass surgery, if they developed a deep sternal wound infection after that surgery. They can also include outcomes that are reported directly by patients or even their caregivers. We think these kinds of measures are particularly important. An example of that might be a patient who has depression, whether or not they improved on their depression score over a 12-month period; looking at those more longitudinal outcomes are really important to patients. Another key area of measurement for us that is also a science that is rapidly evolving is those types of measures that represent patient experience of care. These relate to patient satisfaction sometimes, but sometimes their actual experience with the healthcare system and with the care that they received. An example that we use at our Hospital Value-based Purchasing Program are a type of survey you all may be familiar with called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey, kind of a mouthful. This is a survey that asks a number of questions about the care patients received, whether or not they understood their discharge instructions, whether or not the nurses and doctors communicated with them, etc.

23 Slide 19. How do we use quality measures? We use them in a number of different ways. We see quality measures as a mechanism for assessing the degree to which a provider safely delivers clinical services that are appropriate for the patient at the right time. The right care, at the right place, at the right time, for the right patient. We use these measures to support quality improvement activities such as those that our quality improvement organizations help to support. We use them for information transparency, for our public reporting programs. Some of you may be familiar with our Hospital Compare website, which reports how hospitals perform on a variety of quality measures. Making that information transparent is very important to providers, purchasers, and patients. Finally, we use quality measures to align financial incentives and to reward providers that work together to deliver high-quality care.

24 Slide 20. CMS implements quality initiatives to assure quality healthcare for Medicare and Medicaid beneficiaries through accountability and public disclosure. I might add, while we, of course, focus on Medicare and Medicaid beneficiaries, we think that our programs and programs that other payers implement really can help drive the increased quality of care for all patients, not just our beneficiaries. We use quality measures in a variety of quality initiatives that include incentive programs, thus giving a higher reimbursement for reporting quality measures. That would be pay for reporting, as well as value-based purchasing programs. As we mentioned before, the ACA has accelerated the use of value-base purchasing programs. Another term for value-based purchasing, of course, is pay for performance. Measures are used to inform policy decisions around quality, again to inform the public about the level of quality provided within an institution or by a particular provider, and then to really improve the national level of healthcare quality by focusing programs that are designed to target areas that need quality improvement, to ensure that we are all aligned and driving toward the same improvements.

25 Slide 21. We have a number of quality reporting programs. Several of those affect physicians -- individuals, or groups of physicians directly. We have pay for reporting programs and we have pay for performance programs. The pay for reporting programs that most of you are probably familiar with include the Physician Quality Reporting System (PQRS), the Children s Health Insurance Program Reauthorization Act Quality Reporting -- this is the children s program, and the Medicaid Adult Quality Reporting Program.

26 Slide 22. We also, of course, have the E-Prescribing (erx) Incentive Program and we have the Medicare and Medicaid Electronic Health Record Incentive Program, known to most of you probably as Meaningful Use. We have the Medicare Shared Savings Program, which is our accountable care organization program. Finally, our pay for performance program, our value-based purchasing program, is the Physician Feedback and Value-Based Modifier Program. This is a program focused on Medicare fee-for-service payments. It is on a voluntary basis at this time for groups of 100 physicians or more. The law requires that we phase this in over the next few years, and then by 2017 it will apply to all physicians. Participating providers will receive annual feedback reports on how they do on their quality metrics as well as how they do on their cost metrics. We also have 2 other value-based purchasing programs that are worth noting. The first is the Hospital Value-Based Purchasing Program, and the second is related to dialysis facilities, the End-Stage Renal Disease Quality Incentive Program. That was actually the initial value-based purchasing program that we implemented here at CMS.

27 Slide 23. I mentioned that we report quality measures for transparency s sake as well, so we have a number of what we call our compare sites. Many of you are probably familiar with Hospital Compare. We also have a Physician Compare website. This serves as a healthcare professional directory of physicians and healthcare professionals who are enrolled in the Medicare program. It describes demographic information about physicians and other healthcare professionals, such as their name, their address, what languages they may speak, and whether or not they accept Medicare payments. It also tells us whether or not physicians satisfactorily participate in the PQRS program, as well as our erx program. It does not yet contain physician information about performance on quality measures, although we were required, under the ACA, to make a plan for reporting that information on physician performance, and that should roll out over the next few years. Dr Ling: Is it in the plan that you earlier mentioned -- HCAHPS, physician CAHPS, what patients experience of care is -- do you envision that that would eventually be included in Physician Compare as well? Dr Goodrich: I do think so, because those are measures that we know are particularly important to patients and consumers. We anticipate reporting on a number of different types of measures, including process and outcomes measures, but we know that the patient experience of care measures are really what is very important to the patients that we serve. I do anticipate we will be reporting those as well.

28 Slide 24. One of the major efforts that we have been undertaking here at CMS over, I would say, the last couple of years is to be able to align our quality measures across programs. It can be a significant burden for physicians if they have to report measures for one program within a Medicare program to a second Medicare program, to a Medicaid program, and then maybe also to a private payer program. That can really cause a lot of burden, and can also lead to a diffusion of focus on quality improvement efforts if they are not all looking at the same areas to improve. We have made some really tremendous strides in aligning our measures across programs. This means that providers will really have to report once, to meet the requirements for multiple programs such as the PQRS program, the Value Modifier, and the Meaningful Use program. We are also, through an effort with the National Quality Forum, working hard with private payers to identify measures that can be used for both public and private quality reporting initiatives, and I am glad to say that that effort is going extremely well.

29 Slide 25. What do we do with the quality measure data we receive? We do receive much data, and there is much that we do with them. For clinicians who report measures to us, we analyze the data to determine whether or not that particular provider is eligible for an incentive such as through the Meaningful Use program. We also use the data to see if they may receive a payment adjustment for not successfully reporting to that program. These data we use to provide individual feedback reports to providers summarizing their eligibility for the program, whether or not they are going to have any change to their reimbursement, as well as their performance on those quality measures and reporting rates for each individual measure. Dr Ling: So this really signals our interest and intent of encouraging physicians of all types to participate in our quality reporting programs. Dr Goodrich: Yes, we think that quality reporting is a major lever to drive improvement of care and to help physicians in being able to identify where there needs to be improvement and to be able to rapidly work on that improvement through the use of the information they get back from us. I think also that for the public this information is really important and so we use these data to identify and publicly report provider participation, ultimately their performance, as well as quality trends over time.

30 Slide 26. I think everything that we have talked about today really highlights the increased importance of quality measures within the healthcare sphere. We expect that this will continue to expand and grow in importance in CMS programs, and again, not just for physicians, but also for other providers of care, including nursing homes, dialysis facilities, etc. Participation in quality reporting is becoming routine across care settings. Again, physicians and other providers that fail to participate in quality reporting programs could face a payment reduction for not participating. Then, of course, performance on these measures is going to be publicly reported, and patients will be able to compare providers performance across measures. We already see this happening with Hospital Compare and Home Health Compare. Quality measures, to emphasize again, are being used in our value-based purchasing programs to pay for high quality care. Providers performance on these measures will be used increasingly to determine how they get paid. This drives home the point that physicians should really work together, not only among themselves, but also with other healthcare professionals and importantly, as you pointed out, with patients and their caregivers to improve the quality of care that they deliver. This cannot be done just by the individual professional alone. It really is a team effort. Let me turn it back over to you to talk a little bit about how our viewers here can have an impact on the quality measures that we use.

31 Slide 27. Dr Ling: Thank you, Kate. Really, this is about improving quality and driving toward better health outcomes for patients and their families, again, focusing and using this strategy as a mechanism to get there. It seems there is ample opportunity for providers, physicians, and other healthcare providers of different forms, different types, different experiences, to really play a part in what our national quality outcomes will look like as time goes on. It is important that each physician has an opportunity to also influence what measures are used, perhaps even how those measures are used, and participate, either as individuals or as a member of a professional or institutional organization of some form, to focus and decide on what measures are implemented and how they are used to drive improvement. I think there is also opportunity to provide comment, even as a member of the public, and certainly patients and families have that opportunity to be a part of the National Quality Strategy and to use and inform how quality measures are used with the different levers at our disposal, be it quality reporting or public reporting, informing what value looks like as time in the system evolves, and also how to improve on the quality by way of sharing success stories, best practices, and the like. Technical assistance, if you will. Dr Goodrich: I think it is important for our audience to recognize that many of the quality measures that we use in our physician programs in particular have been suggested to us by physicians. Most of the measures we use in that program received significant input from individual physicians as well as specialty societies on the types of measures and the specific measures we should use. You all have a big role to play in our program, and we take your input and your comments very seriously.

32 Slide 28. Dr Ling: I just wanted to leave you with a couple of resources, recognizing that you in the audience are incredibly busy taking care of the patients that we care so deeply about. There are resources that can make understanding and using and accessing the quality reporting and participation programs much easier. These are some of the references, including the Medicare Learning Networks, the National Clearinghouse for Quality Measures, and also National Guidelines Clearinghouse, all of which are resources that we are here to share with you.

33 Slide 29. Dr Goodrich: I would like to just maybe recap what we think some of the most important takeaway points are for the audience. Number one, if it is not clear already, we really see these types of programs as being designed to improve quality of care for patients. Use of that measure information by you is something that we believe, and we know from experience, can help to really drive that improvement. Quality also is at the center of multiple opportunities to earn incentives and to avoid payment adjustments. Finally, the data that we feed back to providers, and the data that we use internally, as well as the technology, such as the increasing use of electronic health records, support quality improvement within the practice setting. That is the whole purpose of the Meaningful Use program, to support quality improvement at the point of care.

34 Slide 30. Shari, I want to thank you so much for joining us today. Your perspective as a practicing geriatrician and rheumatologist is so important for everything that we have talked about today. Dr Ling: Thank you, Kate. It was my pleasure. Dr Goodrich: I want to thank you for participating in this activity. You may now take the CME posttest by clicking on the Earn CME Credit link. Please also take a moment to complete the program evaluation that follows. Thank you. This transcript has been edited for style and clarity. CME Information This activity is intended for all physicians practicing in the United States. This article is a CME certified activity. To earn credit for this activity visit:

35 The goal of this activity is to describe the nature of the National Quality Strategy and its relationship to quality measurement and payment initiatives administered by the Centers for Medicare & Medicaid Services (CMS). Upon completion of this activity, participants will be able to: 1. Recognize the historical context and legislative mandate ofcms' quality measurement programs 2. Describe the origins of quality measures used by CMS and other healthcare entities 3. Illustrate the impact CMS quality measures have on clinical practices 4. Describe the intersection of quality measurement with reimbursement in various CMS programs Faculty and Disclosures As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest. Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content. Kate Goodrich, MD, MHS Acting Director, Quality Measurement and Health Assessment Group, Center for Medicare & Medicaid Services, Baltimore, Maryland Disclosure: Kate Goodrich, MD, MHS, has disclosed no relevant financial relationships. Dr Goodrich does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States. Dr Goodrich does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States. Shari M. Ling, MD

36 Deputy Chief Medical Officer, Centers Medicare & Medicaid Services, Baltimore, Maryland Disclosure: Shari Ling, MD, has disclosed no relevant financial relationships. Dr Ling does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States. Dr Ling does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States. Jane Lowers Group Scientific Director, Medscape, LLC Disclosure: Jane Lowers has disclosed no relevant financial relationships. Nafeez Zawahir, MD CME Clinical Director, Medscape, LLC Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships. Instructions for Participation and Credit There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board. This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit, you must receive a minimum score of 70% on the post-test. Follow these steps to earn CME/CE credit*: 1. Read the target audience, learning objectives, and author disclosures. 2. Study the educational content online or printed out. 3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

37 You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker. *The credit that you receive is based on your user profile. Credits Available Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s) You Are Eligible For AMA PRA Category 1 Credit(s) Accreditation Statements For Physicians Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Medscape, LLC designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. Medscape, LLC staff have disclosed that they have no relevant financial relationships. Contact This Provider For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact CME@medscape.net Hardware/Software Requirements To access activities, users will need: A computer with an Internet connection. Internet Explorer 7.x or higher, Firefox 4.x or higher, Safari 2.x or higher, or any other W3C standards compliant browser. Adobe Flash Player and/or an HTML5 capable browser may be required for video or audio playback. Occasionally other additional software may be required such as PowerPoint or Adobe Acrobat Reader.

38 Abbreviations ACA = Affordable Care Act AHRQ = Agency for Healthcare Research and Quality ARRA = American Recovery and Reinvestment Act CABG = coronary artery bypass graft CAHPS = Consumer Assessment of Healthcare Providers and Systems CMS = Centers for Medicare and Medicaid Services CPOE = computerized provider order entry DHHS = Department of Health and Human Services DRA = Deficit Reduction Act EHR = electronic health record HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems IOM = Institute of Medicine MHPAEA = Mental Health Parity and Addiction Equality Act MIPPA = Medicare Improvements For Patients and Providers Act MMA = Medicare Prescription Drug, Improvement, and Modernization Act MMSEA = Medicare, Medicaid, and SCHIP Extension Act NCQA = National Committee for Quality Assurance NQF = National Quality Forum NQS = National Quality Strategy PHQ = Patient Health Questionnaire PQRS = Physician Quality Reporting System TRHCA = Tax Relief and Health Care Act Additional Resources CMS Medicare Learning Network (MLN) National Quality Measures Clearinghouse (NQMC) National Guideline Clearinghouse (NGC) AHRQ/Health Care Innovations Exchange National Quality Forum National Committee on Quality Assurance Disclaimer The educational activity presented above may involve simulated case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient is intended or should be inferred.

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