Broad Issues in Quality Measurement: the CMS perspective

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1 Broad Issues in Quality Measurement: the CMS perspective Shari M. Ling, MD Deputy Chief Medical Officer Centers for Medicare & Medicaid Services Workshop on Quality Measurement Developing Evidence-Based Standards for Psychosocial Interventions for Mental Disorders May 19, 2014, Washington, DC

2 Centers for Medicare & Medicaid Services (CMS) Size and Scope of Responsibilities CMS is the largest purchaser of health care in the world (approx $900B per year) Combined, Medicare and Medicaid pay approximately one-third of national health expenditures. CMS programs currently provide health care coverage to roughly 105 million beneficiaries in Medicare, Medicaid and CHIP (Children s Health Insurance Program); or roughly 1 in every 3 Americans. The Medicare program alone pays out over $1.5 billion in benefit payments per day. CMS answers about 75 million inquiries annually. Millions of consumers will receive health care coverage through new health insurance programs authorized in the Affordable Care Act.

3 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 3

4 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):

5 CMS Authorized Programs & Activities Physician Feedback report Quality Resource Utilization Report Hospital Readmissions Reduction Program Health Care Associated Conditions Program Hospitals, Home Health Agencies, Hospices, ESRD facilities Target surveys uality Assurance Performance Improvement Fraud & Abuse Enforcement Clinical Standards Surveys Program Integrity Payment National & Local decisions Mechanisms to support innovation (CED, parallel review, other) Welcome to Medicare & Annual Wellness Visit exams Coverage CMS Quality Value Based Purchasing Quality Improvement Hospitals: inpatient psychiatric, inpatient acute, outpatient acute, Cancer Ambulatory Surgical Centers Physicians: Quality System, Meaningful use HITEC, Post-acute care entities: Home Health Agencies, Long-term Care Acute Hospitals, In-patient rehabilitation facilities, Hospice, Nursing homes short (SNF) and long-stay Medicaid Hospital VBP ESRD QIP Physician value modifier Plans for Skilled Nursing Facility and Home Health Agencies QIOs ESRD Networks Reducing & Preventing HAIs Reducing & Preventing Adverse Drug Events National Alzheimer s Project Act Partnership for Patients Million Hearts National Quality Strategy Data.gov HHS Innovation Accountable Care Organizations Community Based Transitions Care Program Dual eligible coordination Care model demonstrations & projects 1115 Waivers

6 National Quality Strategy promotes better health, healthcare, and lower cost The Affordable Care Act (ACA) requires the Secretary of the Department of Health and Human Services (HHS) to establish a national strategy that will improve: The delivery of health care services Patient health outcomes Population health 6

7 The Six Goals 1 Make care safer by reducing harm caused in the delivery of care 2 Strengthen person and family engagement as partners in their care 3 4 Promote effective communication and coordination of care Promote effective prevention and treatment of chronic disease 5 Work with communities to promote healthy living 6 Make care affordable

8 CMS Vision for Quality Measurement Align measures with the National Quality Strategy and Six Measure Domains Implement measures that fill critical gaps within the 6 domains Align measures across CMS programs whenever possible Parsimonious sets of measures; core sets of measures Removal of measures that are no longer appropriate (e.g., topped out) Align measures with external stakeholders, including private payers and boards and specialty societies Major aim of measurement is improvement over time 8

9 CMS Quality Programs Hospital Quality Physician Quality PAC and Other Setting Quality Payment Model Population Quality Medicare and Medicaid EHR Incentive Program PPS-Exempt Cancer Hospitals Inpatient Psychiatric Facilities Medicare and Medicaid EHR Incentive Program PQRS erx quality reporting Inpatient Rehabilitation Facility Nursing Home Compare Measures LTCH Quality Medicare Shared Savings Program Hospital Valuebased Purchasing Physician Feedback/Valuebased Modifier* Medicaid Adult Quality CHIPRA Quality Health Insurance Exchange Quality Inpatient Quality Outpatient Quality Ambulatory Surgical Centers ESRD QIP Hospice Quality Home Health Quality Medicare Part C Medicare Part D 9

10 Inpatient Psychiatric Facility Quality Program IPFQR is a pay-for-reporting program which just began last year The reporting program applies to all psychiatric hospitals and psychiatric units that are paid under Medicare s IPF Prospective Payment System (PPS) Designed to provide patients with quality of care information to help them make informed decisions about healthcare options Intended to improve the quality of inpatient care provided to beneficiaries by ensuring that providers are aware of and reporting on practices related to quality care Failure to report according to CMS requirements will result in a 2% reduction in the annual rate update.

11 Quality Towards Value-Based Purchasing VBP 2007 TRHCA 74 measures Claimsbased reporting only 2008 MMSEA 119 measures 4 Measures Groups via Claims or Registry 2009 MIPPA 153 individual measures 7 Measures Groups erx via Claims or Registry EHR-testing 2010 MIPPA 179 individual measures 13 Measures Groups 2011 ACA, HITECH 190 individual measures 14 Measures Groups erx erx Individual Individual via Claims, via Claims, Registry, or EHRs Registry, or EHRs GPRO I Group reporting option (GPRO) GPRO II Maintenance of Certification Program Incentive ACA, HITECH 13 participation options 210 individual measures 258 measures 22 Measures Groups erx Individual via Claims, Registry, or EHRs Single GPRO for groups with at least 25 eligible professionals Incentive payments for PQRS, GPRO, and erx reporting Payment Adjustments for non-successful erx reporters Maintenance of Certification Program Incentive

12 Meaningful Use as a Building Block Transformation Enhanced access and continuity Access information Performance and population management CQM data enables outcome improvements Improved population health Case management & longitudinal view Care coordination Patient centered, team based care Use technology Patient informed Structured data capture Patient engagement Clinical Decision Support Robust CDS (evidence based medicine & practice goals) Stage 1 MU Stage 2 MU Stage 3 MU Future

13 Value-Based Purchasing Program Objectives over Time Towards Attainment of the Three-part Aim Initial programs FY Limited to hospitals (HVBP) and dialysis facilities (QIP) Existing measures providers recognize and understand Focus on provider awareness, participation, and engagement SNF and HH VBP Plans Near-term programs FY 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

14 The CMS Innovation Center Identify, Test, Evaluate, Scale The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals under such titles. - The Affordable Care Act 14

15 CMS Innovations Portfolio: Testing New Models to Improve Quality Accountable Care Organizations (ACOs) Medicare Shared Savings Program (Center for Medicare) Pioneer ACO Model Advance Payment ACO Model Comprehensive ERSD Care Initiative 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 Capacity to Spread Innovation Partnership for Patients Community-Based Care Transitions Million Hearts Health Care Innovation Awards 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 15 15

16 Health Care Innovation Awards (HCIA) Goal: The Health Care Innovation Awards are funding up to $1 billion in awards to organizations that are implementing the most compelling new ideas to deliver better health, improved care and lower costs. HCIA Round 1 Out of 107 Round one HCIA awards: 33 focus on behavioral/mental health services 13 focus on substance abuse services 33 include integrated physical, behavioral/mental health and social services. The evaluation of HCIA Round one awards begun in August of 2013 Interim results are provided on a quarterly and annual basis The evaluation ends in 2017 HCIA Round 2 was announced in May of 2013 Awards will be announced in Spring/Summer 2014 Additional behavioral health projects could be funded in the second round

17 Opportunities and Challenges of a Lifelong Health System Goal of system to optimize health outcomes and lower costs over much longer time horizons Payers, including Medicare and Medicaid, increasingly responsible for care for longer periods of time Health trajectories modifiable and compounded over time Importance of early years of life Source: Halfon N, Conway PH. The Opportunities and Challenges of a Lifelong Health System. NEJM 2013 Apr 25; 368, 17:

18 The Future of Quality Measurement for Improvement and Accountability Meaningful quality measures increasingly need to transition away from setting-specific, narrow snapshots Reorient and align measures around patient-centered outcomes that span across settings Measures based on patient-centered episodes of care Capture measurement at 3 main levels (i.e., individual clinician, group/facility, population/community) Why do we measure? Improvement Source: Conway PH, Mostashari F, Clancy C. The Future of Quality Measurement for Improvement and Accountability. JAMA 2013 June 5; Vol 309, No

19 Data Uniformity and Re-use Capabilities As Is Transition To Be Nursing Homes MDS LTCHS LTCH CARE Data Set As Is: Multiple Incompatible Data Sources Inpatient Rehab Facilities IRF-PAI Home Health Agencies OASIS Hospitals No Standard Data Set Physicians No Standard Data Set Outpatient Settings No Standard Data Set GOAL: Uniform Data Elements Across Providers Standardized Nationally Vetted To be: increased uniformity: Critical Outputs To Be: Uniform Assessment Data Elements Enable Use/re-use of Data Exchange Patient-Centered Health Info Promote High Quality Care Support Care Transitions Reduce Burden Expand QM Automation Support Survey & Certification Process Generate CMS Payment 19

20 The Preferred Road to Coverage Provide adequate evidence that Diagnostics The incremental information obtained by new diagnostic technology compared to alternatives Changes physician/clinician recommendations Resulting in changes in therapy That improve clinically meaningful health outcomes Therapeutics A treatment strategy using the new therapeutic technology compared to alternatives Leads to improved clinically meaningful health outcomes

21 Contact Information Shari M. Ling, M.D. CMS Deputy Chief Medical Officer

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