CMS Vision for Quality Measurement February 23, 2013 Kate Goodrich, MD MHS Director, Quality Measurement and Health Assessment Group Centers for Medicare and Medicaid Services DISCLAIMER: The v iews and opinions expressed in this presentation are those of the author and do not necessarily represent of f icial policy or position of HIMSS.
Conflict of Interest Disclosure Kate Goodrich, MD MHS Has no real or apparent conflicts of interest to report. 2014 HIMSS
Learning Objectives 1. Explain CMS quality and value-based purchasing strategy and principles 2. Explain current federal quality measure alignment initiatives. 3. Describe opportunities to comply with multiple federal reporting programs through single measures submissions 4. Assess opportunities for your organization to participate in on of the Innovation Models..
An Introduction to the Benefits Realized for the Value of Health IT CMS has a variety of activities that directly address the Value Steps below many of which are described in the recently published CMS Quality Strategy http://www.himss.org/valuesuite
Size and Scope of CMS Responsibilities CMS is the largest purchaser of health care in the world. Combined, Medicare and Medicaid pay approximately onethird of national health expenditures (approx $800B) CMS programs currently provide health care coverage to roughly 105 million beneficiaries in Medicare, Medicaid and CHIP (Children s Health Insurance Program); or roughly 1 in every 3 Americans Medicare program alone pays out over $1.5 billion in benefit payments per day and answers about 75 million inquiries annually Millions of consumers will receive health care coverage through new health insurance programs authorized in the Affordable Care Act
Quality Measurement and Health Assessment Group 4 divisions (ambulatory care, hospital, postacute care, Program management support) and about 85 staff Implement 12 quality and public reporting programs, and support 17 others Partner with external stakeholders to align measures across public and private sectors Lead development of the quality measures and the CMS quality strategy Provide measure support to the Innovation Center, Exchanges, Medicaid and many others
CMS Quality Strategy http://www.cms.gov/medicare/quality-initiatives-patient- Assessment- Instruments/QualityInitiativesGenInfo/CMS-Quality- Strategy.html
Our Vision TO OPTIMIZE HEALTH OUTCOMES BY LEADING CLINICAL QUALITY IMPROVEMENT AND HEALTH SYSTEM TRANSFORMATION
Strategy Logic Strategic Altitude 30,000 ft. Mission Vision What do we exist to do? What is our picture of the future? 15,000 ft. Goals Objectives & Desired Outcomes Performance Measures and Targets What are our main focus areas? What results are needed to satisfy stakeholders? What continuous improvements are needed to get results? How will we know if we are achieving desired results? Initiatives What actions could contribute to the desired results? Ground Level Activities What will support the initiatives?
Our Three Aims Better Health for the Population Better Care for Individuals Lower Cost Through Improvement 10
The Six Goals of the CMS Quality Strategy 1 Make care safer by reducing harm caused in the delivery of care 2 Strengthen person and family engagement as partners in their care 3 4 Promote effective communication and coordination of care Promote effective prevention and treatment of chronic disease 5 Work with communities to promote healthy living 6 Make care affordable INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Foundational Principles of the CMS Quality Strategy Eliminate disparities Strengthen infrastructure and data systems Enable local innovations Foster learning organizations
Four Years Later - Affordable Care Act
Early Example Results Cost growth leveling off - actuaries and multiple studies indicated partially due to delivery system changes But cost and quality still variable Moving the needle on some national metrics, e.g., Readmissions Line Infections Increasing value-based payment and accountable care models Expanding coverage with insurance marketplaces and Medicaid
Reducing Early Elective Deliveries Nationally: Improvement from Baseline Source: August 2013 HEN Submissions. Baseline and Current time periods vary by HEN.
Results: Medicare Per-Capita Spending Growth at Historic Low 6% 4% 2% 0% 2008-2009 2009-2010 2010-2011 2011-2012 Total Medicare Source: CMS Office of the Actuary, Midsession Review FY 2013 Budget
Medicare All Cause, 30 Day Hospital Readmission Rate 19.5 19.0 18.5 Percent 18.0 17.5 17.0 Jan-10 Jan-11 Jan-12 Jan-13 Rate CL UCL LCL Source: Office of Information Products and Data Analytics, CMS
CLABSI National Rates CLABSIs per 1,000 central line days 2.5 2 1.5 1 0.5 0 41 % Reduction 1.133 Quarters of participation by hospital cohorts, 2009 2012
Transformation of Health Care at the Front Line At least six components Quality measurement Aligned payment incentives Comparative effectiveness and evidence available Health information technology Quality improvement collaboratives and learning networks Training of clinicians and multi-disciplinary teams Source: P.H. Conway and Clancy C. Transformation of Health Care at the Front Line. JAMA 2009 Feb 18; 301(7): 763-5
Quality Measurement Strategy
CMS has a variety of quality reporting and performance programs, many led by CCSQ Hospital Quality Physician Quality Reporting PAC and Other Setting Quality Reporting Payment Model Reporting Population Quality Reporting EHR Incentive Program PPS-Exempt Cancer Hospitals Inpatient Psychiatric Facilities Inpatient Quality Reporting HAC payment reduction program Readmission reduction program Medicare and Medicaid EHR Incentive Program PQRS erx quality reporting Inpatient Rehabilitation Facility Nursing Home Compare Measures LTCH Quality Reporting ESRD QIP Hospice Quality Reporting Medicare Shared Savings Program Hospital Valuebased Purchasing Physician Feedback/Valuebased Modifier CMMI Payment Models Medicaid Adult Quality Reporting CHIPRA Quality Reporting Health Insurance Exchange Quality Reporting Medicare Part C Medicare Part D Outpatient Quality Reporting Ambulatory Surgical Centers Home Health Quality Reporting
Landscape of Quality Measurement Historically a siloed approach to quality measurement Different measures within each quality program Different reporting criteria for each quality program No clear measure development strategy Confusing and Burdensome to stakeholders Burdensome to CMS with stovepipe solutions to quality measurement
CMS framework for measurement maps to the six National Quality Strategy priorities Care coordination Clinical quality of care Care type (preventive, acute, post-acute, chronic) Conditions Subpopulations Patient and family activation Infrastructure and processes for care coordination Impact of care coordination Population/ community health Health Behaviors Access Physical and Social environment Health Status Measures should be patientcentered and outcome-oriented whenever possible Person- and Caregivercentered experience and outcomes Patient experience Caregiver experience Preference- and goaloriented care Safety All-cause harm HACs HAIs Unnecessary care Medication safety Efficiency and cost reduction Cost Efficiency Appropriateness Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures
CMS Vision for Quality Measurement Align measures with the National Quality Strategy and Six Measure Domains Implement measures that fill critical gaps within the 6 domains Develop measures meaningful to patients and providers, focused on outcomes (including patient-reported outcomes), safety, patient experience, care coordination, appropriate use, and cost Align measures across CMS programs whenever possible Parsimonious sets of measures; core sets of measures Removal of measures that are no longer appropriate (e.g., topped out or process distal from outcome) Align measures with states, private payers, boards and specialty societies
Lean Culture Change 5-10% Improvement Manager Commitment Priority Part of Daily Work Aligned to Strategic Objectives Recognition 30-40% Improvement 3
CMS Quality Measures Task Force Charge: Develop recommendations on CMS measure implementation with the goal of aligning and prioritizing measures across programs and avoidance of duplication or conflict among developing and implemented measures Goals: Establish and operationalize policies for program-specific and CMSwide measurement development and implementation Align and prioritize measures across programs where appropriate Coordinate development of new measures across CMS Coordinate measure implementation, development and measurement policies with external HHS agencies 26
HHS Measure Policy Council (MPC) February 2012 leadership provided initial charge to align measures for: Hypertension control Smoking cessation Depression screening Hospital acquired conditions HCAHPS Care coordination (closing the referral loop) Initial members include senior advisors from AHRQ, CMS (co-chairs), ASH, ASPE, CDC, CMS Medicare, CMS Medicaid, FDA, HRSA, IHS, NIH, OMH, SAMHSA Convened in March, the Council meets bi-weekly and reports to the Deputy Secretary for HHS 27
MPC Scope of Work Measure alignment Develop criteria on when it is appropriate /not appropriate to align measures Develop consensus on the measure aspects on which to align (concepts, specifications, data sources, etc.) Develop decision rules for measure categorization by NQS domains New measure development and implementation Implement strategic direction for future measurement priorities Coordinate measure submissions to the MAP Coordinate measure development contracts across HHS Measurement policy/management Measure domains Measure selection, removal and retirement criteria Core sets of measures Other 28
MPC Guiding Principles Focus on measures and policies that maximize QI, minimize provider burden, and allow for assessment of the health of populations Deliberately align with National Quality and Prevention Strategies (and others when relevant) Leverage lessons learned from related HHS activities Develop consensus on standard definitions for data components of measures as well as measures themselves Select EHR-based measures where possible Maintain a portfolio of easily accessed artifacts from MPC deliberations Recognize alignment may not always be appropriate but document justification when this occurs Use MAP measure selection criteria 29
Results to Date Hypertension Control NQF 0018 MU Stage 2: percentage of patients aged 18-85 years with a diagnosis of hypertension whose blood pressure improved during the measurement period Smoking Cessation NQF 0028, CHIPRA composite in development Depression Screening NQF 0418 (screening with standardized tool and f/u) NQF 0710 (12 month remission defined by PHQ-9 score) NQF 1401 (post partum screen during child wellness visit) Other topics include HIV, Obesity, Peri-natal, Patient Experience, HACs Focused on both Retrospective and Prospective Alignment 30
Core Council Members ACL: AHRQ: ASPE: CDC: CMS: FDA: HRSA: IHS: NIH: Sharon Lewis Nancy Wilson (co-chair), Mary Nix Pierre Yong, Ann Page Peter Briss, Gail Janes Kate Goodrich (co-chair), Karen Llanos, Stephen Cha Peter Lurie Kayura Felix Dick Church, Diane Leach Lisa Lang SAMHSA: Lisa Patton OASH: Deborah Hoyer ONC: Kevin Larsen, Julia Skapik 31
CMS Quality and Public Reporting Programs
Three Categories of CMS Programs Pay-for-Reporting Provider incentivized for to report information. Pay-for-Performance Provider incentivized to achieve targeted threshold or clinical performance Pay-for-Value Incentives linked to both quality and efficiency improvements.
Focusing on Outcomes Focusing on the end results of care and not the technical approaches that providers use to achieve the results Measure 30 day mortality rates, hospital-acquired infections, etc Determine if desired clinical results are achieved (low re-admissions, weight reduction, etc )
Challenges in Measuring Performance Determining indicators of outcomes that reflect national priorities Recognizing that outcomes are usually influenced by multiple factors Determining thresholds for good performance Recognizing that Process Measures don t always predict outcomes
Value Based Purchasing
Value Based Purchasing Measuring and reporting comparative performance Paying Providers differentially based on performance Designing Health Benefit Strategies and incentives to encourage individuals to select high value providers and better manage their own care.
Value-Based Purchasing Goal is to reward providers and health systems that deliver better outcomes in health and health care at lower cost to the beneficiaries and communities they serve. Five Principles - Define the end goal, not the process for achieving it - All providers incentives must be aligned - Right measure must be developed and implemented in rapid cycle - CMS must actively support quality improvement - Clinical community and patients must be actively engaged VanLare JM, Conway PH. Value-Based Purchasing National Programs to Move from Volume to Value. NEJM July 26, 2012
Vision Implement a unified, aligned set of clinical quality measures and reporting requirements to synchronize and integrate CMS quality programs which will reduce provider reporting burden and maximize improvement on patient outcomes Report Once Hospitals: Inpatient Quality Reporting Program (IQR), Hospital Value-Based Purchasing (HVBP), and the EHR incentive program for Meaningful Use. Eligible Professionals: Physician Quality reporting System (PQRS), Physician Value Modifier (PVM), EHR Incentive Program for Meaningful Use, and Medicare Shared Savings Program (ACOs)
Future Vision Technology and innovation focused on eliminating patient harm Best practices spread rapidly Payment and incentive systems reward eliminating harm and improved patient outcomes Electronic health records, monitoring, and data analytics utilized to drive improvement Learning from other industries (e.g., reliability science, LEAN, etc) applied to health care Systems redesign achieves better health, better care, and lower costs through improvement
Why do we do this work? As a practicing hospitalist physician I see the need for system changes Left a hospital medicine and academic position I loved to help foster a broader system enabling others to drive improvement Almost all of us have family members in the populations we serve The nation needs our service We have seen success; now the question is how do we scale and spread?
Contact Information Questions? Thank You! Kate Goodrich, MD MHS Director, Quality Measurement and Health Assessment Group Centers for Clinical Standards and Quality 410-786-7828 kate.goodrich@cms.hhs.gov