Moving the Dial on Quality - PDF Free Download

Moving the Dial on Quality Washington State Medical Oncology Society November 1, 2013 Nancy L. Fisher, MD, MPH CMO, Region X Centers for Medicare and Medicaid Serving Alaska, Idaho, Oregon, Washington

How do we ensure quality care? Improvement as a Strategy Customer-Mindedness Outcomes Focus Statistical Thinking Continual Improvement (PDSA) Leadership

ACA Provisions: Quality and Efficiency of Care Emphasize Prevention and Promote Primary Care Expand quality measurement including outcomes and efficiency Expand settings covered by quality reporting and public reporting programs Value Based Purchasing Base payment in part on quality Address specific quality issues Readmissions Health disparities Health Care Associated Conditions Introduce New Care Models ACO program Multiple Demonstrations and pilots (CMMI) Bundled payment Medical Home

We need delivery system and payment transformation Current State Producer-Centered Volume Driven Unsustainable PRIVATE SECTOR Future State People-Centered Outcomes Driven Sustainable Fragmented Care Systems PUBLIC SECTOR Coordinated Care Systems FFS Payment Systems New Payment Systems Value-based purchasing ACOs Shared Savings Episode-based payments Care Management Fees Data Transparency 4

Size and Scope of CMS Responsibilities CMS is the largest purchaser of health care in the world. Combined, Medicare and Medicaid pay approximately one-third of national health expenditures (approx $900B) CMS programs currently provide health care coverage to roughly 105 million beneficiaries in Medicare, Medicaid and CHIP; or roughly 1 in every 3 Americans. The Medicare program alone pays out over $1.5 billion in benefit payments per day. Through various contractors, CMS processes over 1.2 billion feefor-service claims and answers about 75 million inquiries annually. Millions of consumers will receive health care coverage through new health insurance exchanges authorized in the Affordable Care Act. 5

The 3T s Road Map to Transforming U.S. Health Care Basic biomedical science Clinical efficacy knowledge Clinical effectiveness knowledge T1 T2 T3 Improved health care quality & value & population health Key T1 activity to test what care works Clinical efficacy research Key T2 activities to test who benefits from promising care Outcomes research Comparative effectiveness Research Health services research Key T3 activities to test how to deliver high-quality care reliably and in all settings Quality Measurement and Improvement Implementation of Interventions and health care system redesign Scaling and spread of effective interventions Research in above domains Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp. 2319-2321. The 3T s Roadmap to Transform U.S. Health Care: The How of High-Quality Care.

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 7

Six Priorities have become the Goals for the CMS Quality Strategy Making care safer by reducing harm caused in the delivery of care Ensuring that each person and family are engaged as partners in their care Promoting effective communication and coordination of care Promoting the most effective prevention and treatment practices Working with communities to promote healthy living Making quality care by developing and spreading new health care delivery models

CMS has a variety of quality reporting and performance programs Hospital Quality Medicare and Medicaid EHR Incentive Program PPS-Exempt Cancer Hospitals Inpatient Psychiatric Facilities Inpatient Quality Reporting HAC payment reduction program Readmission reduction program Outpatient Quality Reporting Physician Quality Reporting Medicare and Medicaid EHR Incentive Program PQRS erx quality reporting PAC and Other Setting Quality Reporting Inpatient Rehabilitation Facility Nursing Home Compare Measures LTCH Quality Reporting Hospice Quality Reporting Home Health Quality Reporting Payment Model Reporting Medicare Shared Savings Program Hospital Valuebased Purchasing Physician Feedback/Valuebased Modifier* ESRD QIP Population Quality Reporting Medicaid Adult Quality Reporting* CHIPRA Quality Reporting* Health Insurance Exchange Quality Reporting* Medicare Part C* Medicare Part D* Ambulatory Surgical Centers * Denotes that the program did not meet the statutory inclusion criteria for pre-rulemaking, but was included to foster alignment of program measures. 9

CMS framework for measurement maps to the six national priorities Greatest commonality Clinical quality of care HHS primary care and CV quality measures Prevention measures Setting-specific measures Specialty-specific measures Person- and Caregivercentered experience and engagment CAHPS or equivalent measures for each settings Shared decision-making Care coordination Transition of care measures Admission and readmission measures Other measures of care coordination Safety Healthcare Acquired Infections Healthcare acquired conditions Harm Population/ community health Measures that assess health of the community Measures that reduce health disparities Access to care and equitability measures Efficiency and cost reduction Spend per beneficiary measures Episode cost measures Quality to cost measures of measure concepts across domains Measures should be patientcentered and outcomeoriented whenever possible Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures

Quality can be measured and improved at multiple levels Community Increasing individual accountability Increasing commonality among providers Population-based denominator Multiple ways to define denominator, e.g., county, HRR Applicable to all providers Practice setting Denominator based on practice setting, e.g., hospital, group practice Individual physician/ep Denominator bound by patients cared for Applies to all physicians/eps Three levels of measurement critical to achieving three aims of National Quality Strategy Measure concepts should roll up to align quality improvement objectives at all levels Patient-centric, outcomes oriented measures preferred at all three levels The six domains can be measured at each of the three levels

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. Hospital value-based purchasing program shifts approximately $1 billion based on performance 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 13

FY2014 HVBP domains Weighted value of each domain Outcomes domain (25%) Patient experience domain (30%) Clinical process of care domain (45%) 14

FY2013 HVBP measures 12 Clinical Process of Care Measures Weighted Value of Each Domain 8 Patient Experience of Care Dimensions 15 15

Physician Reporting Programs Principle of report once and receive credit for all programs: Physician Quality Reporting System, Physician Value- Based Modifier, EHR Incentive Meaningful Use, and ACO if applicable Focus on registry reporting and EHR based reporting, both of which can be all payer Group reporting growth, including for ACOs Physician value modifier starts in 2013 (groups of 100 or more), proposed down to groups of 10 or more for 2014 and by 2017 adjusting all Medicare payments to physicians based on quality and cost 16

PQRS and VM Programs are Linked VM implementation in 2015 is based on PQRS participation in 2013 Groups of physicians with > 100 eligible professionals PQRS Participation Groups that register for PQRS GPRO (via web interface, registry or CMS- calculated admin claims ) and meet the minimum reporting requirement Non-PQRS Participation Groups that do not register for PQRS GPRO and do not meet the minimum reporting requirement. Elect quality-tiering calculation Upward, downward, or no adjustment based on performance 0.0% (no adjustment) -1% (downward adjustment) 17 17

Quality Tiering Methodology Quality-tiering uses domains to combine each quality measure into a quality composite and each cost measure into a cost composite by using equally weighted standardized scores for each measure. Clinical care Patient experience Population/ Community Health Patient safety Care Coordination Quality of Care Composite Score VALUE MODIFIER AMOUNT Efficiency Total overall costs Cost Composite Score Total costs for beneficiaries with specific conditions 18 18

Quality-Tiering Approach for 2015 Each group receives two composite scores (quality of care; cost of care), based on the group s standardized performance (e.g., how far away from the national mean). This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers. Low cost Average cost High cost High quality +2.0x* +1.0x* +0.0% Average quality +1.0x* +0.0% -0.5% Low quality +0.0% -0.5% -1.0% * *Eligible for an additional +1.0x if : Reporting quality measures via the web based interface or registries AND Average beneficiary risk score in the top 25% of all beneficiary risk scores 19 19

Which Group Practices and Individual EPs Do Not Have to Register in the PV-PQRS System? Group practices that participate in the Medicare Shared Savings Program Group practices that only provide care to Medicare beneficiaries who are enrolled in a Medicare Advantage plan Group practices that only practice in a Rural Health Clinic Group practices that only practice in a Federally Qualified Health Center Group practices that only practice in a Critical Access Hospital (using method II billing) Individual EPs who want to participate in the PQRS in 2013 using a participating registry, claims, or electronic health records (EHRs) 20

2015 Link Between the VM (Groups 100+) and PQRS Reporting. Group Self- Nomination Action Group Reporting Action EP Reporting Action VM PQRS Self-nominates for PQRS GPRO Self-nominates for PQRS GPRO Self-nominates for PQRS GPRO Self-nominates PQRS for Admin. Claims Self-nominates PQRS for Admin. Claims Meets criteria for PQRS incentive N/A 0.0%* 0.5% Submits at least one PQRS measure N/A 0.0% 0.0% Does not submit PQRS measures N/A -1.0% -1.5% Does not submit PQRS measures Does not submit PQRS measures Meets criteria for PQRS incentive 0.0%* 0.5% Does not meet criteria for PQRS incentive 0.0%* 0.0% * If the group elects quality-tiering, the VM could be positive, zero, or negative based on performance. 21

2015 Link Between VM and PQRS for Groups (100+) that do not Self-Nominate for PQRS Reporting. Individual EP Reporting Action VM PQRS Meets PQRS reporting requirements -1.0% 0.5% Submits at least one PQRS measure -1.0% 0.0% Elects Admin Claims option -1.0% 0.0% Does nothing -1.0% -1.5% 22

National Bloodstream Infection Rate CLABSIs per 1,000 central line days 2.5 2 1.5 1 0.5 0 41 % Reduction 1.133 Baseline Q1 Q2 Q3 Q4 Q5 Q6 Over 1,000 ICUs achieved an average 41% decline in CLABSI over 6 quarters (18 months), from 1.915 to 1.133 CLABSI per 1,000 central line days. Quarters of participation by hospital cohorts, 2009 2012

Wide Variation in Spending Across the Country: CT Scans CT Scans Per Capita Spending* (2011) National Average = $76 Honolulu, HI $49 per capita Fort Myers, FL $117 per capita Ratio to the national average *includes institutional and professional spending

Wide Variation in Spending Across the Country Heart Failure and Shock with Complications MS-DRG 291 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 NJ - Ridgewood FL - Hudson PA - Lancaster NC - Raleigh KY - Owensboro All Other Outpatient Physician Readmissions Post-Acute Inpatient Ratio to Nat l Avg 1.49 1.15 1.00 0.85 0.71 Source: CMS Office of Information Products and Data Analysis, Medicare Claims Analysis - 2010

CMS Hospital Readmission Measures 30-day timeframe from date of discharge of index admission All-cause readmission excludes planned readmissions Risk Adjusted for patient case mix 28

Medicare All Cause, 30 Day Hospital Readmission Rate 19.5 19.0 Percent 18.5 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

CMS Innovations Portfolio: Testing New Models to Improve Accountable Care Organizations (ACOs) Medicare Shared Savings Program (Center for Medicare) Pioneer ACO Model Advance Payment ACO Model Comprehensive ERSD Care Initiative Quality Capacity to Spread Innovation Partnership for Patients Community-Based Care Transitions Million Hearts Health Care Innovation Awards Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Bundled Payment for Care Improvement Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care State Innovation Models Initiative Initiatives Focused on the Medicaid Population Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicare-Medicaid Enrollees Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents 31 31

Innovation is happening broadly across the country 32 32

4 million Medicare beneficiaries having care coordinated by 220 SSP and 32 Pioneers ACOs (Geographic Distribution of ACO Population) 33

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

Innovation Center 2013 Looking Forward We re Focused On Implementation of Models Monitoring & Optimization of Results Evaluation and Scaling Integrating Innovation across CMS Portfolio analysis and launch new models to round out portfolio 35

?Questions? Contact Information: Nancy L. Fisher, MD, MPH CMO, CMS, Region X 206-615-2390 nancy.fisher@cms.hhs.gov 36