1 Institute of Medicine Committee on Quality Measures Healthy People Leading Health Indicators December 10, 2012 Quality Measurement at the Interface of Health Care and Population Health Shari M. Ling, MD CMS Deputy Chief Medical Officer Center for Medicare & Medicaid Services
National Quality Strategy BETTER HEALTH Population & Community Health Care Coordination Efficiency & Cost Reduction BETTER CARE LOWER COSTS Clinical Care Safety Person /Caregiver Centered 2
Population Health relevant quality measure topics Cardiovascular risk identification & management BP Aspirin Cholesterol Smoking cessation & avoidance of tobacco products Obesity & physical activity High risk populations i.e. diabetes Prevention Vaccination Bone health Cancer screening Mental & Behavioral Health Depression Alcohol 3
ABCs: Getting to Goal Intervention Baseline Target Clinical target Aspirin for those at high risk 47% 65% 70% Blood pressure control 46% 65% 70% Cholesterol management 33% 65% 70% Smoking cessation 23% 65% 70% Sodium reduction ~ 3.5 g/day 20% reduction Trans fat reduction ~ 1% of calories 50% reduction 4 Unpublished estimates from Prevention Impacts Simulation Model (PRISM).
Alignment of Clinical Quality Measures Million Hearts Clinical Quality Measures Physician Quality Reporting System Meaningful Use PQRS CV Prevention Measures Group Accountable Care Organizations HRSA Uniform Data System National Quality Forum Aspirin Use PQRS #204 S1 opt, S2 core (prop) Yes Yes Yes (2012) NQF #0068 BP Screening PQRS #317 Yes Yes BP Control PQRS #236 S1 opt, S2 core (prop) Yes Yes Yes NQF #0018 Chol Control Pop PQRS #316 S2 core (prop) TBD* Chol Cont DM PQRS #2 S1 opt, S2 opt (prop) Yes Yes NQF #0064 Chol Cont IVD PQRS #241 S1 opt, S2 opt (prop) Yes Yes NQF #0075 Smoking Cessation PQRS #226 S1 core, S2 core (prop) Yes Yes Yes (2011) NQF #0028
CMS Quality Programs Hospital Quality Reporting Medicare and Medicaid EHR Incentive Program PPS-Exempt Cancer Hospitals Inpatient Psychiatric Facilities Inpatient Quality Reporting Outpatient Quality Reporting Physician Quality Reporting Medicare and Medicaid EHR Incentive Program PQRS erx quality reporting PAC and Other Settings Inpatient Rehabilitation Facility Nursing Home Compare Measures LTCH Quality Reporting ESRD QIP Hospice Quality Reporting Home Health Quality Reporting Payment Model Reporting Medicare Shared Savings Program Hospital Valuebased Purchasing Physician Feedback/Valuebased Modifier* 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. 6
Affordable Care Act Provision with Quality Focus Value based purchasing 3001 - Hospital value-based purchasing 3006 - Value-based purchasing for SNF 3014 - Quality and efficiency measurement 10301 - Develop a plan to implement VBP for ambulatory surgical centers 10326 - Pilot testing for pay-for-performance Hospital readmissions 3025 - Hospital readmissions reduction program 3026 - Community-based care transitions program Healthcare acquired conditions 2702 - Payment adjustment for health care-acquired conditions 3008 - Payment adjustment for conditions acquired in hospitals Accountable care organizations 2706 - Pediatric accountable care organization demonstration project 3022 - Medicare Shared Savings Program Dual eligibles 2602 - Providing federal coverage and payment coordination for dual eligible beneficiaries Preventative services 4103 - Annual wellness visit providing a personalized plan 4104 - Removing barriers to preventive services 4105 - Evidence-based coverage of preventive services Coordination of care 2703 - State option to provide health homes for enrollees with chronic conditions 2704 - Demonstration project to evaluate integrated care around a hospitalization Long term care 2401 - Community first choice option 2402 - Removal of barriers to providing home and community based services 2403 - Money follows the person rebalancing demo 2404 - Protection for recipients of home and community-based services against spousal impoverishment 10202 - Incentives for states to offer home community based serviced Public reporting 10303 - Development of outcome measures 10327 - Improvements to the physician quality reporting system -- also see Provision 3002 10331 - Public reporting of performance information Quality reporting initiative 2701 - Adult health quality measures 3002 - Improvements to the physician quality reporting system. 3004 - Quality Reporting for Long Term Care Hospitals (LTCH), inpatient rehabilitation hospitals, and hospice programs 3005 - Quality reporting for PPS-exempt cancer hospitals 10322 - Quality reporting for psychiatric hospitals 8
Medicare s Annual Wellness Visit (AWV) Detection of cognitive Impairment Health Risk Assessment Medical & Family History Providers & medications Biometric measurements Preventive service plan (5-10 yrs) Personalized health advice, referrals, Other elements determined appropriate by the Secretary and health education
National Alzheimers Project Act For millions of Americans, the heartbreak of watching a loved one struggle with Alzheimer's disease is a pain they know all too well. Alzheimer's disease burdens an increasing number of our Nation's elders and their families, and it is essential that we confront the challenge it poses to our public health. -- President Barack Obama National Alzheimer s Plan Goals Prevent and Effectively Treat Alzheimer's Disease by 2025. Optimize Care Quality and Efficiency. Expand Supports for People with Alzheimer's Disease and Their Families. Enhance Public Awareness and Engagement. Track Progress and Drive Improvement. 10
Overarching Goals 1. Foster health care and public health system changes 2. Maximize the use of proven self-care management and other services 3. Provide better tools and information to health care, public health, and social services workers 4. Facilitate research to fill knowledge gaps
Multiple Chronic Conditions account for a Disproportionate Share of Medicare Spending 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Number of chronic conditions 0 1 2 3 4 5 6+ 12.3 8.9 43.0 12.9 16.4 15.1 16.5 14.3 14.5 11.9 18.5 8.4 5.1 2.2 Percent of Beneficiaries Percent of Total Costs 12
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 13
How Will Change Actually Happen? There is no silver bullet We must apply many incentives We must show successful alternatives We must offer intensive supports Help providers with the painstaking work of improvement We must learn how to scale and spread successful interventions
CMS Implementation Levers Fraud & Abuse Enforcement Coverage of services Physician Feedback report Quality Resource Utilization Report Physician Value Modifier Readmissions Target surveys Payment Policy Survey & Cert. Program Integrity CMMI Demos & Research ACOs Community Based Transitions Care Program Dual Eligibles Demonstration Projects Pilots Quality ESRD QIP Hospital VBP Plans for Skilled Nursing Facility and Home Health Agencies, Ambulatory Surgical Centers VBP QIOs EQROs ESRD Networks Q.I. COP Other CMS programs HHS Programs Hospitals, Home Health Agencies, Hospices, ESRD facilities Partnership for Patients Million Hearts National Quality Strategy Data.gov HITECH Hospital Inpatient Quality Reporting Programs
16 Rapid Cycle Improvement - How can we improve more quickly? Apply proven interventions reliably across settings and measure results Test the application of new interventions and learn in rapid cycle Partner with providers, communities, and patients Move beyond a traditional government contract with delayed evaluation model Focus efforts where improvement most needed and target interventions
Hospitals Role in Population Health: Community Health Needs Assessment New requirements under ACA. To retain tax exempt status, non-profit hospitals must: Conduct a community health needs assessment at least every three years Adopt implementation strategy to meet the community health needs identified through the assessment Penalty: $50,000 tax for each year that a tax exempt hospital fails to satisfy requirement
Hospitals Role in Population Health: Community Building IRS-approved activities: Physical improvements and housing Leadership development / training for community Community health improvement advocacy Coalition building Economic development Community support Environmental improvement Workforce development
Building Community Capacity, Improving Care Transitions 19
Health Outcomes of Interest? More Persuasive Longer life, fewer deaths Fewer distressing symptoms Better function Greater participation Deferred retirement Fewer burdensome tests and treatments E.g Hospitalization, long-term care, etc Less Persuasive Longer life with declining function/participation Improved disease-specific survival without improved overall survival Surrogate test result better Image looks better Doctor feels confident How will we measure this for a population?
21 Thank you! Shari M. Ling, M.D. Deputy Chief Medical Officer Centers for Medicare & Medicaid Services 410-786-6841 shari.ling@cms.hhs.gov