Academic Internal Medicine Week Baltimore, MD March 19, 2017 ALLIANCE FOR ACADEMIC INTERNAL MEDICINE KATE GOODRICH, M.D., MHS CHIEF MEDICAL OFFICER DIRECTOR, CENTER FOR CLINICAL STANDARDS & QUALITY
DISCLAIMERS This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.
AGENDA Career Trajectory and How to Get Involved in Alternative Career Paths Overview of CMS Quality and Cost in US Delivery System Reform and Results to Date Quality Payment Program Primary Care and Impact of Delivery System Reform
CAREER TRAJECTORY Internal Medicine Residency/Chief Medical Residency Hospitalist Clinician Educator Robert Wood Johnson Clinical Scholars Program Medical Officer at the Office of the Assistant Secretary for Planning and Evaluation (HHS) Centers for Medicare and Medicaid Services Senior Advisor to the Chief Medical Officer Director, Quality Measurement and Value-based Incentives Group Director, Center for Clinical Standards and Quality and Chief Medical Officer Staff Hospitalist, George Washington University Hospital
ALTERNATIVE CAREER PATHS Examples: Health Services Research, Public Policy, Public Health, Business of Medicine, Entrepreneur, Health IT, NGO, Foundations, Global Health Training is helpful, but not necessary Robert Wood Johnson CSP National Research Service Awards MBA, MHA, MPH, etc. Take advantage of electives and internships National Clinical Scholars Program Mentorship is critical and not just early in your career Don t be afraid to reach out to leaders in your area of interest
INTRODUCTION TO CMS Over 140 million Americans receive healthcare coverage through programs administered by CMS Medicare Health insurance for individuals age 65 and older, as well as those with disabilities Medicaid/CHIP Health insurance managed by the states for individuals with lower incomes Health Insurance Marketplaces A resource that allows individuals to sign-up for private health insurance with tax credits to offset premiums
CENTER FOR CLINICAL STANDARDS AND QUALITY Over 530 federal FTE s, approximately $1.3 billion budget Contemporary Quality Improvement: Quality Improvement Networks, PTNs, SANs, ESRD Networks Quality Measurement and Public Reporting: Hospital Quality Reporting, Dialysis Facility Compare, Post-acute care, Hospice Incentives: Hospital Value Based Purchasing, ESRD QIP, SNF VBP and Quality Payment Program Health and Safety Standards: Conditions of Participation (Hospitals, 15 other provider types) and Survey and Certification to enforce standards Coverage Decisions: National Coverage Determinations, Coverage with Evidence Development Clinician Engagement and Burden Reduction: Focus on quality reporting, HER and Documentation burdens IT and Business Operations: Strong support for all of the above Lean and Continuous Improvement: Leadership for the Agency
CLINICAL CASE STUDY 73 y.o. woman with anxiety and OA who comes in for a check up. She is a smoker, and has tried to cut back recently. She drinks wine on occasion. She takes OTC NSAIDs for her OA and an occasional Xanax for anxiety. She complains of LBP that is worse on the left for the last several weeks, that has modestly limited her ability to do housework. She is retired, a widow with 2 children who live out of state, and she lives alone. Her last mammogram was 3 years ago, and her last colonoscopy was at age 55. She brings in BP readings she has taken occasionally at CVS which range from 150-170/85-100. Physical exam shows a BP of 155/95 with pulse of 74. Joint exam is c/w changes from OA. MSK exam shows modest reduction in flexion and extension of the lumbar spine due to pain, mild TTP in the lumbo-sacral region on the left, but no weakness or sensory loss and normal reflexes. She has a slightly flat affect, smiles very little and acknowledges that she sometimes drinks wine to go to sleep.
WHY IS THE HEALTHCARE PAYMENT SYSTEM CHANGING?
*2012 Notes: GDP refers to gross domestic product Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers. Source: OECD Health Data 2015
Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010. Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; Word Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).
100% Better Same Worse 80% 82 72 37 42 13 12 PERCENT 60% 40% 68 86 75 61 81 15 15 20% 0% 35 6 28 37 16 48 9 10
CMS INVESTING IN A SYSTEM FOR BETTER CARE, SMARTER SPENDING, AND HEALTHIER PEOPLE Public and Private Sectors Evolving Future State Key characteristics Producer-centered Incentives for volume Unsustainable Fragmented care Key characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care
A VALUE-BASED SYSTEM REQUIRES FOCUSING ON HOW WE PAY PROVIDERS, DELIVER CARE, AND DISTRIBUTE INFORMATION Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system. FOCUS AREAS Pay Providers Deliver Care Distribute Information Source: Burwell SM. Setting Value-Based Payment Goals HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.
CMS HAS ADOPTED A FRAMEWORK THAT CATEGORIZES PAYMENT TO PROVIDERS Population-Based Accountability Category 1 Category 2 Category 3 Category 4 Fee for Service No Link to Quality & Value Fee for Service Link to Quality & Value APMs Built on Fee-for-Service Architecture Population- Based Payment Source: Rajkumar R, Conway PH, Tavenner M. CMS engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.
MARCH 2016 HHS announced that goal of 30% payments tied to quality through APMs achieved one year ahead of schedule! GOAL: Medicare Fee-for Service Medicare payments are tied to quality or value through alternative payment models (categories 3-4) by the end of 2016 1 Next Steps Testing of new models and expansion of existing models 2 Health Care Payment Learning and Action Network
TARGET PERCENTAGE OF PAYMENTS IN FFS LINKED TO QUALITY AND ALTERNATIVE PAYMENT MODELS BY 2016 2011 2014 2016 0% ~70% ~20% >80% 30% 85% Historical Performance Goals All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4)
PAYMENT POLICIES AND TRANSPARENCY DRIVE BETTER SAFETY AND QUALITY The Hospital-Acquired Condition (HAC) Reduction Program: Penalizes hospitals with higher rates of harm The Hospital Readmissions Reduction Program (HRRP) focuses on preventing readmissions, including preventing complications Hospital, Nursing Home, Dialysis, Physician, and Home Health Compare all include public reporting of safety and quality measures. Next: Inpatient Rehabilitation, Long Term Care Hospitals and Hospice
CMS ESTABLISHED LARGE-SCALE, ACTION- 21 ORIENTED NETWORKS TO SPREAD QUALITY IMPROVEMENT AND SAFETY ACTIVITIES ON A NATIONAL SCALE Partnership for Patients 4,000 Hospitals Transforming Clinical Practices Initiative 140,000 Clinicians Quality Innovation Networks Quality Improvement Organizations 250+ Communities 10,000+ Nursing Homes 3,800 Home Health Organizations 300 Hospices 1,700 Pharmacies End Stage Renal Disease Networks 6,000 Dialysis Facilities MACRA and Quality Payment Program - Small, Underserved, Rural Support Up to 200,000 Clinicians
NATIONAL RESULTS ON PATIENT 22 SAFETY SUBSTANTIAL PROGRESS THRU 2014, COMPARED TO 2010 BASELINE 21 percent decline in overall harm 125,000 lives saved $28B in cost savings from harms avoided 3.1M fewer harms over 5 years Think about what these means for so many patients and families Source: Agency for Healthcare Research & Quality. Saving Lives and Saving Money: Hospital-Acquired Conditions Update. Interim Data from National Efforts to Make Care Safer, 2010 2014. December 1, 2015
PERCENT REDUCTION IN HACS 2010 VS. PRELIMINARY 2015 Percent Reduction in HACs, 2010 vs. Preliminary 2015 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Adverse Drug Events Catheter-Associated Urinary Tract Infections Central Line-Associated Urinary Tract Infections Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias (Post-op) Venous Thromboembolisms All Other HACs Total 29% 33% 15% 10% 10% 16% 24% 16% 21% 76% 91%
PHYSICIAN PAYMENT REFORM MACRA AND THE QUALITY PAYMENT PROGRAM
The Sustainable Growth Rate (SGR) Established in 1997 to control the cost of Medicare payments to physicians Medicare Payment Prior to MACRA IF Overall physician costs > Target Medicare expenditures Physician payments cut across the board Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. Each year, Congress passed temporary doc fixes to avert cuts (no fix in 2015 would have meant a 21% cut in Medicare payments to clinicians)
THE The Quality QUALITY Payment Program policy PAYMENT will: PROGRAM Reform Medicare Part B payments for more than 600,000 clinicians Improve care across the entire health care delivery system Clinicians have two tracks to choose from: The Merit-based Incentive Payment System (MIPS) If you decide to participate in traditional Medicare, you may earn a performance-based payment adjustment through MIPS. OR Advanced Alternate Payment Models (APMs) If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model.
QUALITY PAYMENT PROGRAM STRATEGIC GOALS Improve beneficiary outcomes Enhance clinician experience Increase adoption of Advanced APMs Maximize participation Improve data and information sharing Ensure operational excellence in program implementation Quick Tip: For additional information on the Quality Payment Program, please visit QPP.CMS.GOV
WHAT IS THE MERIT-BASED INCENTIVE PAYMENT SYSTEM? Performance Categories Quality Cost Improvement Activities Advancing Care Information Moves Medicare Part B clinicians to a performance-based payment system Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice Reporting standards align with Advanced APMs wherever possible
ALTERNATIVE PAYMENT MODELS (APMS) A payment approach that provides added incentives to clinicians to provide high-quality and costefficient care. Can apply to a specific condition, care episode or population. May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs. Advanced APMs are a Subset of APMs APMs Advance d APMs 29
ADVANCED APMS MUST MEET CERTAIN CRITERIA To be an Advanced APM, the following three requirements must be met. The APM: Requires participants to use certified EHR technology; Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk. 30 30
COMPREHENSIVE PRIMARY CARE (CPC) IS SHOWING EARLY POSITIVE RESULTS CMS convenes Medicaid and commercial payers to support primary care practice transformation through enhanced, non-visit-based payments, data feedback, and learning systems. $11 or 1%* reduction part A and B expenditure in the first 2 years (through 9/2014) among all 7 CPC Reductions appear to be driven by initiative-wide impacts on hospitalizations, ED visits, and unplanned 30-day readmissions. 7 regions (AR, OR, NJ, CO, OK, OH/KY, NY) encompassing 31 payers, nearly 500 practices, and approximately 2.5 million multi-payer patients Duration of model test: Oct 2012 Dec 2016 * Reductions relative to a matched comparison group and do not include the care management fees (~$20 pbpm)
SPOTLIGHT: COMPREHENSIVE PRIMARY CARE, SAMA HEALTHCARE SAMA Healthcare Services is an independent four-physician family practice located in the rural southeast town of El Dorado, Arkansas. Services Made Possible by CPC Investment Care Management Each Care Team consists of a doctor, a nurse practitioner, a care coordinator, and three nurses Teams drive proactive preventive care for approximately 19,000 patients Teams use Allscripts Clinical Decision Support feature to alert the team to mission screenings and lab work Risk Stratification The practice implemented the AAFP six-level risk stratification tool Nurses mark records before the visit and physicians confirm stratification during the patient encounter Practice Administrator A lot of the things we re doing now are things we wanted to do in the past We needed the front-end investment of start-up money to develop our teams and our processes.
COMPREHENSIVE PRIMARY CARE PLUS (CPC+) CMS s largest-ever initiative to transform how primary care is delivered and paid for in America GOALS 1. Strengthen primary care through multi-payer payment reform and care delivery transformation. 2. Empower practices to provide comprehensive care that meets the needs of all patients. 3. Improve quality of care, improve patients health, and spend health care dollars more wisely. CARE TRANSFORMATION FUNCTIONS Access and continuity Care management Comprehensiveness and coordination Patient and caregiver engagement Planned care and population health PARTICIPANTS AND PARTNERS 5 year model: 2017-2021 Up to 5,000 practices in up to 20 regions Two tracks depending on practice readiness for transformation and commitment to advanced care delivery for patients with complex needs Public and private payers in CPC+ regions HIT vendors (official partners for Track 2 only) PAYMENT REDESIGN COMPONENTS Performance-based incentive payments for quality, experience, and utilization measures that drive total cost of care For Track 2, hybrid of reduced fee-for-service payments and up-front Comprehensive Primary Care Payment to offer flexibility in delivering care outside traditional office visits PBPM risk-adjusted care management fees
CLINICAL CASE STUDY 73 y.o. woman with anxiety and OA who comes in for a check up. She is a smoker, and has tried to cut back recently. She drinks wine on occasion. She takes OTC NSAIDs for her OA and an occasional Xanax for anxiety. She complains of LBP that is worse on the left for the last several weeks, that has modestly limited her ability to do housework. She is retired, a widow with 2 children who live out of state, and she lives alone. Her last mammogram was 6 months ago, and her last colonoscopy was at age 55. She brings in BP readings she has taken occasionally at CVS which range from 150-170/85-100. Physical exam shows a BP of 155/95 with pulse of 74. Joint exam is c/w changes from OA. MSK exam shows modest reduction in flexion and extension of the lumbar spine due to pain, mild TTP in the lumbo-sacral region on the left, but no weakness or sensory loss and normal reflexes. She has a slightly flat affect, smiles very little and acknowledges that she sometimes drinks wine to go to sleep.
PATIENT CARE IN THE NEW PAYMENT SYSTEM Goals for this Patient 1. Diagnosis and Control of Hypertension 2. Smoking Cessation 3. Appropriate Preventive Screening 4. Diagnosis and Treatment of LBP 5. Screen for Depression and Unhealthy Alcohol use
PATIENT CARE IN THE NEW PAYMENT SYSTEM: PAYMENT FOR HIGH QUALITY CARE OUTCOME Measure: Controlling High Blood Pressure Colon Cancer Screening Appropriate Use of MRI for Low Back Pain Smoking screening and cessation intervention Screening and follow up for Depression (if + then patientreported outcome measure on depression remission) Patient Experience Survey
PATIENT CARE IN THE NEW PAYMENT SYSTEM: PAYMENT FOR PRACTICE IMPROVEMENT AND USE OF HEALTH IT Engage the patient in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology. Enable the patient to capture blood pressure and tobacco use at home tobacco and share those outcomes with you through certified EHR technology Collection and follow up on patient experience data and development of a practice improvement plan Integrated prevention and treatment activities for patients with behavioral or mental health conditions (including unhealthy alcohol use)
Technical Assistance for Clinicians CMS has free resources and organizations on the ground to provide help to clinicians who are eligible for the Quality Payment Program:
FUTURE OF HEALTH SYSTEM Alternative Payment Models ACOs Bundled Payments Comprehensive Primary Care Physician-focused APMs Private payer and CMS collaboration critical States and Communities driving innovation and delivery system reform Increasing integration of public health and population health with health care delivery system Patient-centered, coordinated care is the norm Focus on quality and outcomes
IMPORTANCE OF PHYSICIAN AND CLINICIAN EXECUTIVE LEADERSHIP We are in a stage of fairly dramatic health system transformation Skills of past may not be what is needed for future Population health management, quality improvement, system redesign, collaborative teamwork, measurement and data feedback, and change management leadership are critical skills Physicians and other clinicians MUST help lead the change to achieve better care, smarter spending, and healthier people
WHAT CAN YOU DO? Eliminate patient harm Engage in achieving better outcomes at lower cost; Invest in the quality and safety infrastructure Focus on data and performance transparency Test new innovations in care delivery Relentlessly pursue improved patient outcomes.
CONTACT INFORMATION Kate Goodrich, M.D., MHS Director, Center for Clinical Standards and Quality Chief Medical Officer Centers for Medicare and Medicaid Services 410-786-6841 kate.goodrich@cms.hhs.gov qpp.cms.gov