Presentation Objectives

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1 Quality Improvement and Value-Based Purchasing (VBP) How your QI program can prepare you for transformation Paul Mulhausen, MD, AGSF, FACP Medical Director Telligen Quality Improvement Network Quality Improvement Organization This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-D1-9/ Presentation Objectives You will understand the healthcare trends that transform the value of your QI program You will restate the value proposition of your QI program in light of these trends You will lead your QI program and develop medical director buy in 2 1

2 Some Big Picture Trends in Post Acute and Long Term Care Post Acute Care and Long Term Care Resident Health Hospital Readmissions Payment redesign (Value Based Purchasing) 3 Caring for Two Distinct Populations Short Term Post Acute 14% of residents at any single time Average length of stay: 27 Days Number of people served annually: 189 Long Term 86% of residents at any single time Average Length of stay: > 365 Days Number of people served annually:

3 Residents are less healthy Trends in Resident ADL Dependence Trends in RUG Score Case Mix Index 5 Hospital Readmissions National Concern One in 5 Hospitalized Medicare Patients go to a Skilled Nursing Facility after hospitalization OIG Report: About 25% of Medicare SNF residents are readmitted to the hospital. US Spent $14.3 billion for these hospitalizations. Higher rates of readmission correlate with homes having three or fewer stars in the CMS Five-Star Quality Rating System. 6 3

4 Payment Redesign Shift from volume based payment (fee-for-service) to value-based-payment (accountable care) Incentives aligned to better care and outcomes Incentives tied to quality Managed Care 74% of US Medicaid Members now enrolled in a Managed Care Plan 25% of US Medicare Beneficiaries in MA Medicaid Managed Long Term Care Services and Supports Iowa Medicaid Modernization 7 Payment Redesign: Medicaid Managed Long Term Care Expansion 8 4

5 HHS Press Release January 26, 2015 Better, Smarter, Healthier: In an historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value Percent of FFS Medicare Tied to Quality 85% 90% Percent of FFS Medicare Tied to Alternate Models 20% 30% 50% 9 CMS Quality Strategy: Make Care Affordable Paying providers based on the quality and efficiency of care delivered Developing and promulgating clinical guidelines and quality standards Improving data systems by establishing health information exchanges for administrative simplification Making healthcare costs and quality more transparent to consumers and providers, enabling them to make better choices and decisions. 10 5

6 Payment Taxonomy and Alternative Payment Models Fee for Service No Link to Quality Payments based on volume and not linked to quality or efficiency Limited in Medicare fee-forservice Majority of Medicare payments are now linked to quality 11 Fee for Service Link to Quality A portion of payments vary based on the quality or efficiency of care delivery Hospital Value Based Purchasing Physician Value Based Modifier Readmissions/Ho spital Acquired Conditions Alternative payment built on fee-for service Some payment is linked to the effective management of a population or an episode of care ACOs Medical Homes Bundled Payment CPCI Comprehensive ESRD Population Based Payment Payment is not directly triggered by service delivery. Eligible Pioneer ACO in years 3-5 Quality Program and CMS Proposed Rules for IMPACT Act SNF Quality Reporting Program Skin Integrity Falls Function SNF Value Based Purchasing Program Hospital Readmissions QAPI Develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care and quality of life. 6

7 The Role of the Nursing Facility Quality Program Contracting and payment will involve quality metrics (Quality Outcomes/Cost = Value ) Transparency Tools like the CMS Star-Rating scales (Nursing Home Compare) will now have financial impact The complexity of the care will require proactive, systematic approaches The nursing facility will be the unit of reporting 13 Two Stories Shared Informally State Medicaid Managed Long Term Care Contract Requirements Three Star or better (Overall Rating) on CMS Star Rating Accept Medicare and Medicaid clients, 24/7/365 Engaged in quality improvement projects Actively using the INTERACT program Actively participating in a QIO Program Improvement Collaborative Dually Eligible Managed Care Proactive management of LTCSS after hospitalization to reduce total length of institutional care. 14 7

8 Leadership You are being called on to lead your homes through these transitions. You need not forget your purpose to care for the vulnerable. If you lead successfully, your team (including your physicians) will follow. Make quality performance a key area of accountability. 15 The Medical Director Can Be A Transforming Leader for Quality Care Ninety-seven percent of medical directors report that participation in the nursing home's QI program is important to their leadership role. DHHS OIG 2003 OEI

9 Medical Directors Want to be a Force For Quality Percent of Medical Directors reporting they should perform the function. Function Percent of Medical Directors Encourage Quality of Care 97% Review and Analyze Quality Indicators 92% Quality Improvement Planning & Implementation Intervene with attending physicians about quality 93% 97% Review consultant pharmacists drug reviews 93% 17 DHHS OIG 2003 OEI Nurture the Inner Champion Educate your Medical Director about: QAPI The Advancing Excellence Tools INTERACT The National Partnership to Improve Dementia Care in Nursing Homes Support (yes financially) your medical director s participation in: 18 AMDA AGS Medical education focused on LTC quality. 9

10 Build the Quality Improvement Infrastructure Expect your Medical Director to participate in meetings of your QAPI Steering Committee most expect to be involved. Incorporate education materials into your QAPI Steering Committee Meetings. Quality Improvement, especially related to LTC, is not standard medical school material. Engage your Medical Director in the design, implementation, and follow-up of your Quality Improvement Initiatives most medical doctors enjoy trending data. 19 What are the resources? Your industry advocates Leading Age! Your Medicare QIN-QIO Telligen Your colleagues, co-workers, and competitors A Learning and Action Network Advancing Excellence! CMS QAPI Framework and Tools Certification/QAPI/qapitools.html CMS Learning Network 20 10

11 Summary Value-Based and Population-Based payment implementation will incorporate service measures of quality into compensation and contracting. Now is the time to transform your quality assurance program into a QAPI program. Build Buy In from your Medical Director. Systematically Use your QI consultants, your Medicare QIN-QIO, and the many resources available to support the transformation of your QI Program. 21 Questions? 22 11