CMS Quality Program Overview

CMS Quality Program Overview AMGA/Press Ganey Survey Collaboration September 13, 2012

Presenter Information Incorporated in 1985, Press Ganey was one of the first companies to provide patient satisfaction measurement services to the health care industry, and the first to provide comparative benchmarking to clients. Today, Press Ganey partners with more than 10,000 health care organizations from across the continuum of care hospitals, medical practices, home health agencies and other providers including more than 108,000 physicians at over 10,700 practice sites and 50% of all U.S. hospitals. Nell Buhlman Vice President, Knowledge Management and Product Strategy Jodie Cunningham, Director, Public Reporting Lisa Cone-Swartz, Vice President of New Market Strategies with Press Ganey, works closely with the AMGA in an effort to align the complementary assets of PG and the AMGA to better serve the AMGA s member 2 organizations.

Agenda CMS Quality Program Overview Timeline Illustration Hospital Quality Programs as examples CMS Quality Programs for Group Practices Timeline Illustration (VBP, PQRS and ACO) Clinician and Group CAHPS (CGCAHPS) Patient Experience Quality Metric in CMS ACO programs Strategy for Quality Improvement in Patient Experience Tactical Examples for high priority areas 3

Driver of the CMS Quality Performance Programs Lower costs Higher quality Reduced utilization Better care coordination Patient engagement Volume & Costs Value & Quality 2011 Press Ganey Associates, Inc. 4

CMS-sponsored Quality Performance Programs 2010 2011 2012 2013 2014 2015 2016 2017 Inpatient Quality Reporting Requirement (IQR, formerly RHQDAPU) 2% of APU Value-based Purchasing (VBP) 1-2% Readmission Reduction Program 1-3% Hospital Acquired Conditions (Nonpayment) HAC Reduction Program 1% Meaningful Use of EHR Meaningful Use 1% CMS ACO (MSSP and Pioneer) Phys. Quality Reporting System PQRS PQRS 1.5-2% Physician Fee Schedule VBP Voluntary Incentive Penalty 5 Not Final

Hospital Exposure under Payment Reform Dollars subject to Medicare P4P programs at a 146-bed hospital in Florida Using MedPar 2010 data 2011 Press Ganey Associates, Inc. 6

Hospital Exposure under Payment Reform Dollars subject to Medicare P4P programs at a 550-bed hospital in Kansas Using MedPar 2010 data 2011 Press Ganey Associates, Inc. 7

How are hospitals responding?

Communication with Doctors: Change in performance since baseline 2010 Press Ganey Associates, Inc. 9

Communication with Nurses: Change in performance since baseline 2010 Press Ganey Associates, Inc. 10

VBP National Baseline Performance FFY13 30 55 11

VBP Change since Baseline FFY13 44 66 12

Predicted Distribution of Overall VBP Scores 56 76 13

CMS Sponsored Quality Programs - Group Practice MSSP Launched Pioneer ACO Launched Earliest potential collection of for CGCAHPS PQRS Data Collection for Public Reporting Physician Compare Public Reporting of PQRS data collected in 2013 Earliest potential public reporting for CGCAHPS 2011 2012 2013 2014 2015 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q Physician Compare Launched PQRS Data Collection for Public Reporting Physician Compare Public Reporting of PQRS Data collected in 2012 Payment Modification for those Impacted by Physician VBP 14

Clinician and Group CAHPS (CGCAHPS) Standardized tool to access patient perception of care provided by physicians and medical groups Survey Versions: Retrospective (Last 12 Months) Visit Specific Patient Centered Medical Home (PCMH) CMS ACO Four areas of focus: 1. Access to Care: Getting appointments, care and information when needed 2. Physician Communication: How well the provider communicates with patients 3. Office Staff: Helpful, courteous, and respectful office staff 4. Global Rating: Patients global rating of the provider 15

Visit Specific CGCAHPS Evaluative Questions Global Rating Questions Hybrid: Access questions are last 12 months Continuous surveying, triggered by the most recent visit Utilize for improvement and continuous monitoring of performance Adopted in preparation for public reporting 16

NCQA PCMH CGCAHPS Optional recognition in Patient Experience Measurement created to complement the PCMH Certification First data submission opportunity is April 2012 Must use Patient Centered Medical Home CAHPS survey Must use an NCQA certified vendor Distinction awarded one month following data submission; for a 12 month period Distinction retained by collecting and submitting PCMH CAHPS annually CGCAHPS Retrospective Survey Supplemental Questions measuring Patient Centeredness 17 PCMH CAHPS

CMS ACO CGCAHPS ACO Patient Experience Measurements: CMS MSSP and Pioneer ACO rules specify the Retrospective CGCAHPS plus questions related to specialists, shared decision making, and health education CMS has selected RAND Corporation to administer the ACO version of the survey in 2012 and 2013 (both years for MSSP; only 2012 for Pioneer) RAND conducted a field test with the Physician Group Practice Transition Demonstration participants in Q2 2012 90+ questions, broader than final rule specified It is very likely that the content and form of the Survey will change in response to the results of the field test CMS intends to finalize methodology and modes for ACO CAHPS later in 2012 Vendor approval process in 2013 18

Medicare Program Quality Metrics 19

Patient Caregiver Experience 4 pts possible CGCAHPS: Getting Timely Care, Appointments and Information CGCAHPS: How Well Your Doctors Communicate 2 Points CGCAHPS: Patients Rating of Doctor CGCAHPS: Access to Specialists CGCAHPS: Health Promotion and Education CGCAHPS: Shared Decision Making 2 Points HPCAHPS: Patient-Reported Health Status (P4R x 3 years) 2011 Press Ganey Associates, Inc. 20

Scoring Method ACO Performance Level Quality Points 90+ percentile 2.00 80+ percentile 1.85 70+ percentile 1.70 60+ percentile 1.55 50+ percentile 1.40 40+ percentile 1.25 30+ percentile 1.10 < 30 percentile No points Points Domain Score 3.7 92.5% 2011 Press Ganey Associates, Inc. 21

Strategy for Quality Improvement in Patient Experience Coordination of care across clinicians and settings has been shown to result in greater efficiency and better clinical outcomes. Common, too, is frequent inability of patients to make their needs understood, to be treated with respect and compassion, to learn what to expect about their health condition and treatment, and to have caregivers and institutions they can trust. The American Medical Group Association and Press Ganey have partnered to develop a new Coordinated Care survey. 22

Strategy for Quality Improvement in Patient Experience Concepts Measured CMS ACO CGCAHPS Instrument (one/year) Coordinated Care Instrument Visit CGCAHPS Instrument Office Staff X X Access to Appointments & Information X Supplemented without redundancy X Physician Communication X X Overall Rating of Physician X X Access to Specialists X Health Promotion & Education X Supplemented without redundancy Overall Health Status X Supplemented without redundancy Shared Decision Making X Supplemented without redundancy Team-oriented care Coordination of Care Coordination of Care -- across settings Patient Self Care Patient Engagement Patients' Choice in Healthcare Confidence and Loyalty 23 X X X X X X X

An illustration of how to implement today SURVEY FREQUENCY: ANNUAL TIMING 1Q 2Q 3Q 4Q Visit-specific CGCAHPS (continuous, post-visit) PCMH (1x per year for NCQA Apr. or Sept. submission) ACO-CAHPS (1x per year) Coordinated Care (annual, semi-annual or quarterly) Coordinated Care (annual, semi-annual or quarterly) Visit Specific CG CAHPS- Continuous (over course of year), post visit 24

Why start CGCAHPS assessment today? Early Adopters Outperform as HCAHPS Illustrated 25

Rate of voluntary adoption among PG clients Since 2010, Press Ganey clients have been using the CGCAHPS visit specific survey to prepare for compliance and identify areas needing improvement. Seeking ways to understand, monitor, and act to improve CGCAHPS results before public reporting and regulatory requirements Benchmarking against other first-movers/top performers 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Press Ganey CGCAHPS Early Adopter Database Nearing 20,000 providers and 3,500 sites 7,455 8,659 11,279 12,056 10,607 9,615 14,223 5,066 6,211 107 146 267 454 625 849 1,175 1,402 1,628 1,796 1,965 2,136 2,246 2,426 2,815 3,140 3,457 2,565 1,842 356 542 962 16,089 sites providers 26

More Data = Greater Utility Analyzed results from over 26,000 Medical Practice surveys examining relationship between sample size and performance. Mean Overall Score and Quartile of MD Survey Volume Conclusion: There is a relationship between the number of returned Medical Practice surveys and overall scores. Physicians in the highest quartile of returned # of surveys have significantly higher overall scores than those in the next highest quartile, and so on down to the lowest quartile. The more surveys returned per physician, the more insight and often results in higher overall scores 27

Priority Index 28

Improvement Getting Timely Care Have someone review messages received at the start of every day and forward the message(s) to the appropriate person with the expectation that the patient should receive a response within X hours, even if it is merely a progress update. Provide a time frame on any automated outgoing messages of when the caller can expect to receive a response. This step can help reduce the number of repeat calls from the same patient. Complete a study over a specified time frame to track the common reasons for patient calls after hours. Develop plans to accommodate these needs when possible. For example, direct patients to your web site where information such as directions to the office, pre-appointment paperwork and accepted insurance providers can be found. Many practices use after-hour answering services for emergencies. The on-call nurse is contacted by the answering service and responds to the patient s call, filtering to a physician when necessary. The on-call nurse should follow up with the answering service after speaking to the patient. However, if no follow-up is provided, the answering service should then call back the patient to inquire if he or she were contacted. If not, the answering service should continue to try to contact the on-call nurse or another staff member in the practice. 29

Improvement Provider Communication The average amount of time that a physician allows a patient to speak before interrupting with a question or observation is only approximately 20 seconds. Patients do not feel this is an adequate amount of time to fully explain their story. Actively listening to the patient allowing them their full voice actually doesn t take any additional time (in fact, it may actually take less time, in the long run). One part of displaying concern for the patient s worries is by tapping into the deeper, underlying reasons for the patient s visit. Studies show that patients often do not immediately share a "real" or more troubling reason for the visit until late in the physician-patient encounter. A few ways of accessing this perspective is through open-ended questions, such as: "What were you most hoping to accomplish today? "Is there anything in particular you were hoping I would do today?" "How were you hoping I could help you with your concern?" "Before we go any further, is there anything else that s on your mind? Allow the patient to determine how much participation they wish to have in the treatment process. Some patients may prefer for the physician to simply provide direction, while others want to be more involved in the process. Ask the patient about their preferences and try to tailor your approach to each patients need. Find out what role your patients want to play in the decision-making process. Only involve the patient to the extent that he or she feels most comfortable. 30

Improvement Care Coordination The American College of Physician recommends care coordination agreements (CCAs) written documents that outline expectations and responsibilities between two providers to facilitate coordination of patient care. Preliminary evidence indicates that CCAs can improve communication between clinicians, timeliness of specialty referrals, and planning of hospital discharge. Examples of care written coordination agreements: Leadership must be committed to (and provide resources for) the work necessary for shifting from the patient alone trying to navigate the health system to the medical team working together to manage through confusing systems. Home health agencies must respond to new admissions within two hours. Front desk staff must incorporate the patients primary care provider s name in every discussion. For example, Mrs. Schwartz, I understand that Dr. Quinn referred you to our office for Asking the patient an open-ended question about their perspective on the specialty care can add valuable insight to the primary care provider s plan of treatment. The patient is a valuable source of information that cannot be captured in the notes shared among professionals. During a primary care provider visit, proactively ask the patient if they d like a copy of the notes or results from the specialty provider for their own records; provide the copy at the end of their visit. 31

Which survey will be used for PQRS? The proposed rule for the Physician Quality Reporting Program (PQRS) for calendar year 2013 will add CGCAHPS Proposed: CMS will collect data for practices participating in PQRS GPRO For 2013, CMS will use a contractor to conduct the survey Survey Strategy: CMS only indicates CGCAHPS Data collected through PQRS and ACO program will be comparable PG believes they are leaning toward a retrospective version of the survey asking about the last 6 or 12 months Medical Groups Getting Timely Care, Appointments, and Information How Well Your Doctors Communicate Patients Rating of Doctor Access to Specialists Health Promotion and Education 32 ACOs Getting Timely Care, Appointments, and Information How Well Your Doctors Communicate Patients Rating of Doctor Access to Specialists Health Promotion and Education Shared Decision Making

Indications from CMS PG visit with CMS leadership on 8/24/12 CMS participants represented these domains: Center for Clinical Standards and Quality Quality Measurement and Health Assessment Group PQRS measures Physician Compare and measures for physician programs CGCAHPS development and implementation CAHPS and Health Plan Star Rating Measures ACO measures, physician outcomes measures Measurement harmonization, alignment, and coordination Comparison of CGCAHPS instruments Interest in number of physicians voluntarily surveying; cost per physician Intent to harmonize the Patient Experience of Care measures Intent to harmonize other measures and reporting mechanisms 33

Questions? Lisa Cone-Swartz lisa@pressganey.com Ryan O Connor roconnor@amga.org 34