CMS in the 21 st Century ICE 2013 ANNUAL CONFERENCE David Saÿen, MBA Regional Administrator Centers for Medicare & Medicaid Services San Francisco November 15, 2013
The strategy is to concurrently pursue three aims
Success requires delivery system and payment transformation Volume Driven Outcomes Driven Payment systems support fragmentation Fragmented payment systems (IPPS, OPPS, RBRVS) Fee-for-service payment model Lack of transparency Private Sector + Public Sector + Innovation Center Payment systems support collaboration Value-based purchasing ACOs Episode-based payments Patient-centered Medical Homes Data transparency
Value-Based Purchasing Program Objectives over Time Towards Attainment of the Three-Part Aim Initial programs FY2012-2013 Limited to hospitals (HVBP) and dialysis facilities (QIP) Existing measures providers recognize and understand Focus on provider awareness, participation, and engagement Proposed and near-term programs FY2014-2016 Expand to include physicians New measures to address HHS priorities Increasing emphasis on patient experience, cost, and clinical outcomes Increasing provider engagement to drive quality improvements, e.g., learning and action networks Longer-term FY2017+ VBP measures and incentives aligned across multiple settings of care and at various levels of aggregation (individual physician, facility, health system) Measures are patient-centered and outcome oriented Measure set addresses all 6 national priorities well Rapid cycle measure development and implementation Continued support of QI and engagement of clinical community and patients Greater share of payment linked to quality Vision for VBP
FY2013 HVBP Program Summary Two domains: Clinical Process of Care (12 measures) Patient Experience of Care (8 HCAHPS dimensions) Hospitals are given points for Achievement and Improvement for each measure or dimension, with the greater set of points used 70% of Total Performance Score based on Clinical Process of Care measures 30% of Total Performance Score based on Patient Experience of Care dimensions Payment adjustments in process
13 Clinical Process of Care Measures 1. AMI-7a Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival 2. AMI-8 Primary PCI Received within 90 Minutes of Hospital Arrival 3. HF-1 Discharge Instructions 4. PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital 5. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient 6. SCIP-Inf-1 Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision 7. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients 8. SCIP-Inf-3 Prophylactic Antibiotics Discontinued within 24 Hours After Surgery 9. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 a.m. Postoperative Serum Glucose 10. SCIP Inf 9 Postoperative Urinary Catheter Removal on Postoperative Day 1 or 2. 11. SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period 12. SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 13. SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Domain Weights 8 Patient Experience of Care Dimensions 1. Nurse Communication 2. Doctor Communication 3. Hospital Staff Responsiveness 4. Pain Management 5. Medicine Communication 6. Hospital Cleanliness and Quietness 7. Discharge Information 8. Overall Hospital Rating 3 Mortality Measures 1. MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day mortality rate 2. MORT-30-HF Heart Failure (HF) 30-day mortality rate 3. MORT-30-PN Pneumonia (PN) 30-day mortality rate Represents a new measure for the FY 2014 Program not in the FY 2013 Program.
FY 2015 Finalized Domains and Measures/Dimensions 12 Clinical Process of Care Measures Domain Weights 8 Patient Experience of Care Dimensions 1. AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 2. AMI-8 Primary PCI Received Within 90 Minutes of Hospital Arrival 3. HF-1 Discharge Instructions 4. PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital 5. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient 6. SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 7. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients 8. SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery 9. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose 10. SCIP Inf 9 Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2. 11. SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period 12. SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Efficiency, 20% Outcome, 30% Clinical Process of Care, 20% Patient Experience of Care, 30% 1. Nurse Communication 2. Doctor Communication 3. Hospital Staff Responsiveness 4. Pain Management 5. Medicine Communication 6. Hospital Cleanliness & Quietness 7. Discharge Information 8. Overall Hospital Rating 5 Outcome Measures 1. MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day mortality rate 2. MORT-30-HF Heart Failure (HF) 30-day mortality rate 3. MORT-30-PN Pneumonia (PN) 30-day mortality rate 4. PSI-90 Patient safety for selected indicators (composite) 5. CLABSI Central Line-Associated Blood Stream Infection 1 Efficiency Measure 1. MSPB-1 Medicare Spending per Beneficiary measure Represents a new measure for the FY 2015 program not in the FY 2014 program.
Physician Quality Reporting System (PQRS) and Value Modifier PQRS incentive: ends in 2014 PQRS payment adjustment: starts in 2013; overlaps with the incentive for 2 years Value Modifier: first reporting year is 2013; affects payment in 2015 Must include all providers by payment year 2017 (measurement year 2015)
Value-Based Payment Modifier Value Modifier Scoring: Combine each quality measure into a quality composite and each cost measure into a cost composite using the following domains: Clinical care Patient experience Patient safety Care coordination Quality of Care Composite Score VALUE MODIFIER AMOUNT Efficiency Total overall costs Total costs for beneficiaries with specific conditions Cost Composite Score
Reducing Hospital Readmissions (ACA Sec. 3025) Readmissions penalties for applicable hospitals starting FY 13 The FY 2012 IPPS/LTCH PPS Final Rule sets forth: Conditions and readmissions to which program will apply for the first program year Readmission measures/methodology and calculation of readmission rates (e.g., CMS will use 30-day AMI, HF, and PN measures based on 3 years of data: July 1, 08 - June 30, 11) Public reporting of readmission data Next year s (FY13) proposed rule will include specific information regarding payment adjustment For more information, see: https://www.cms.gov/acuteinpatientpps/fr2012/list.asp
From: Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries JAMA. 2013;309(4):381-391. doi:10.1001/jama.2012.216607 Figure Legend: Means (solid lines) and upper and lower control limits (dashed lines) set by the experience of 2006-2008. Vertical dotted line indicates start of quality improvement in the intervention communities. Date of download: 2/1/2013 Copyright 2012 American Medical Association. All rights reserved.
Accountable Care Organizations 259 ACOs 221 Medicare Shared Savings Program ACOs 35 also participating in the Advance Payment Model 32 Pioneer ACOs 6 Physician Group Practices Over 4 million beneficiaries receiving care from ACO providers
Results: ACO Participation is Growing Rapidly All ACOs Assigned Beneficiaries by County (4.0 million total) Source: http://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/downloads/all-starts-mssp-aco.pdf
Pioneer ACOs Succeed in Improving Care, Lowering Costs Key results for performance year 1: 40% Pioneer ACOs produced shared savings with CMS, generating a gross savings of $87.6 million in 2012 and a net savings of $33 million to Medicare. Costs for Pioneer ACO beneficiaries grew by only 0.3%. This is below historical Medicare growth rates and well below the 0.8% growth rate for similar beneficiaries. As a group, Pioneer ACOs generated gross savings of $87.6 million, or 1.2 percent savings on a total benchmark of $7.59 billion for over 669,000 beneficiaries. 13 Pioneer ACOs earned shared savings totaling $76.09 million. 18 Pioneer ACOs generated savings while 14 generated losses. 2 Pioneer ACOS owe preliminary shared losses totaling nearly $4.0 million. Pioneer ACOs successfully reported quality measures and performed better than the Medicare feefor-service population on a variety of measures, such as blood pressure and cholesterol control measures
Bundled Payments: 4 Models Model 1 Model 2 Model 3 Model 4 Episode All acute patients, all DRGs Selected DRGs + post-acute period Post acute only for selected DRGs Selected DRGs Services included in the bundle All part A DRGbased payments Part A and B services during the initial inpatient stay, post-acute period and readmissions Part A and B services during the post-acute period and readmissions All Part A and B services (hospital, physician) and readmissions Payment Retrospective Retrospective Retrospective Prospective Participants 3 representing 32 health care facilities 55 representing 195 health care organizations 14 representing 165 health care organizations 37 representing 75 health care facilities 15
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Contact Information David W. Saÿen Regional Administrator San Francisco Regional Office Centers for Medicare & Medicaid Services 415-744-3501 David.Sayen@cms.hhs.gov