Transcript Consumer testing of revised 30

Texas Partnership for Patients
Conference
Patrick Conway, M.D., MSc
CMS Chief Medical Officer and
Director, Center for Clinical Standards and Quality
April 30, 2013
Objectives
• Share CMS work on Quality and Value
• How can we improve quality, safety and the
delivery of high value health care for
beneficiaries
• Provide overview of CMS approach to
quality measurement and health system
improvement
• Review current quality reporting programs
• Where do we go from here?
Size and Scope of
CMS Responsibilities
•
CMS is the largest purchaser of health care in the world (approx $800B
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.
Center for Clinical Standards and Quality
Vision
• To optimize health outcomes by leading
clinical quality improvement and health
system transformation
Center for Clinical Standards and Quality
Levers for Safety, Quality & Value
•
Over 425 federal FTE’s, $1.5 billion in budget, and approximately 10K
contractors focused on improving quality across the nation
•
Contemporary Quality Improvement: Quality Improvement
Organizations
•
Quality Measurement and Public Reporting: Hospital Inpatient Quality
Reporting Program
•
Incentives: Hospital Value Based Purchasing, ESRD, physician value
modifier, new payment models
•
Regulation: Conditions of Participation (Hospitals, 15 other provider
types) and Survey and Certification
•
Coverage Decisions: Coverage with evidence development, coverage for
Preventative Services
5
Objectives
• Share CMS work on Quality and Value
• How can we improve quality, safety and the
delivery of high value health care for
beneficiaries
• Provide overview of CMS approach to
quality measurement and health system
improvement
• Review current quality reporting programs
• Where do we go from here?
How do we make quality better?
How do we make quality
better?
•
•
•
•
•
•
Improvement as a Strategy
Customer-Mindedness
Outcomes Focus
Statistical Thinking
Continual Improvement (PDSA)
Leadership
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
The “3T’s” Road Map to
Transforming U.S. Health Care
Basic biomedical
science
T1
Clinical efficacy
knowledge
Key T1 activity to test
what care works
Clinical efficacy research
T2
Clinical effectiveness
knowledge
Key T2 activities to test
who benefits from
promising care
Outcomes research
Comparative effectiveness
Research
Health services research
T3
Improved health
care quality &
value &
population health
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
1/
2
3/ 00
1/ 6
2 n
5/ 00 =27
1/ 6
2 n
7/ 00 =29
1/ 6
2 n
9/ 00 =39
1 6
11 /20 n=1
/1 06 3
/2 n
1/ 00 =46
1/ 6
2 n
3/ 00 =23
1/ 7
2 n
5/ 00 =15
1/ 7
2 n
7/ 00 =13
1/ 7
2 n
9/ 00 =31
1/ 7
11 20 n=1
/1 07 3
/2 n
1/ 00 =63
1/ 7
2 n
3/ 00 =47
1/ 8
2 n
5/ 00 =31
1/ 8
2 n
7/ 00 =28
1/ 8
2 n
9/ 00 =32
1/ 8
11 20 n=4
/1 08 2
/2 n
1/ 00 =95
1/ 8
2 n
3/ 00 =68
1/ 9
2 n
5/ 00 =47
1/ 9
2 n
7/ 00 =37
1/ 9
2 n
9/ 00 =39
1 9
11 /20 n=2
/1 09 5
/2 n
1/ 00 =74
1/ 9
2 n
3/ 01 =54
1/ 0
2 n
5/ 01 =33
1/ 0
2 n
7/ 01 =42
1/ 0
2 n
9/ 01 =47
1/ 0
11 20 n=2
/1 10 4
/2 n
01 =9
0 5
n=
66
1/
Percent
Percent of Asthma Admissions that had Readmission or ED Visit within 30 Days
Hamilton Co. Medicaid Patients age 2 through 17 years old
50
45
40
35
30
25
20
11.1%
Last update: 01-11-11 by H. Atherton
Medication
Intervention
began
15
10
5
6.2%
0
Index Admission Month / n = number of index admissions
Readmitted 30 days
Median
Goal = 7.0%
Data source: Data Warehouse, Consolidated Database, EPIC
Goal
Percent
Average Percent discharged on oral antibiotics
Control Limits
07/15/11 (n=01)
05/31/11 (n=02)
05/15/11 (n=01)
Ramp 4,
Local expert
opinion
03/15/11 (n=01)
01/31/11 (n=02)
01/15/11 (n=01)
Ramp 2,
consult
criteria
12/15/10 (n=01)
11/30/10 (n=01)
60.0
10/31/10 (n=01)
80.0
10/15/10 (n=01)
Ramp 1,
test 2
09/30/10 (n=01)
40.0
09/15/10 (n=01)
90.0
07/31/10 (n=01)
07/15/10 (n=02)
06/30/10 (n=02)
05/31/10 (n=04)
04/30/10 (n=05)
03/31/10 (n=02)
02/28/10 (n=00)
01/31/10 (n=01)
12/31/09 (n=01)
11/30/09 (n=02)
10/31/09 (n=04)
09/30/09 (n=01)
08/31/09 (n=00)
07/31/09 (n=05)
Percent of children with routine osteomyelitis discharged on
oral antibiotics
Rapid Evidence Adoption
Percent of children with routine osteomyelitis discharged on oral antibiotics
100.0
Ramp 5,
Family shared
decision-making
70.0
Ramp 3 Real
time identify and
feedback
50.0
Ramp 1, test 1
Evidence
implementation
30.0
20.0
10.0
0.0
Partnership for Patients
• 40% Reduction in Hospital Acquired Conditions
– 1.8 Million Fewer Injuries
– 60,000 Lives Saved
• 20% Reduction in 30-Day Readmissions
– 1.6 Million Patients Recover Without Readmission
• Potential to save $35 billion in 3 years
• Working with 80% of hospitals in U.S.
Objectives
• Share CMS work on Quality and Value
• How can we improve quality, safety and the
delivery of high value health care for
beneficiaries
• Provide overview of CMS approach to
quality measurement and health system
improvement
• Review current quality reporting programs
• Where do we go from here?
Our National Quality Strategy Aims
Better Health
for the
Population
Better Care
for
Individuals
Lower Cost
Through
Improvement
National Quality Strategy
1)
Making care safer by reducing harm caused in the delivery of care
2)
Ensuring that each person and family are engaged as partners in their care
3)
Promoting effective communication and coordination of care
4)
Promoting the most effective prevention and treatment practices for the leading
causes of mortality, starting with cardiovascular disease
5)
Working with communities to promote wide use of best practices to enable
healthy living
6)
Making quality care more affordable for individuals, families, employers, and
governments by developing and spreading new health care delivery models
CMS has a variety of quality reporting and performance
programs, many led by CCSQ
Hospital Quality
Physician Quality
Reporting
•Medicare and
Medicaid EHR
Incentive Program
•Medicare and
Medicaid EHR
Incentive Program
•PPS-Exempt Cancer
Hospitals
•PQRS
•Inpatient Psychiatric
Facilities
•Inpatient Quality
Reporting
•HAC payment
reduction program
•Readmission reduction
program
•eRx quality reporting
PAC and Other Setting
Quality Reporting
Payment Model
Reporting
“Population” Quality
Reporting
•Inpatient
Rehabilitation Facility
•Medicare Shared
Savings Program
•Medicaid Adult
Quality Reporting*
•Nursing Home
Compare Measures
•Hospital Value-based
Purchasing
•CHIPRA Quality
Reporting*
•LTCH Quality
Reporting
•Physician
Feedback/Value-based
Modifier*
•Health Insurance
Exchange Quality
Reporting*
•ESRD QIP
•Hospice Quality
Reporting
•Medicare Part C*
•Medicare Part D*
•Home Health Quality
Reporting
•Outpatient Quality
Reporting
•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.
CCSQ framework for measurement maps to the six
national priorities
Greatest
commonality of
measure concepts
across domains
Care coordination
Clinical quality of care
•Transition of care
measures
•Admission and
readmission measures
•Other measures of care
coordination
•HHS primary care and CV
quality measures
•Prevention measures
•Setting-specific measures
•Specialty-specific measures
Person- and Caregivercentered experience and
outcomes
•CAHPS or equivalent
measures for each settings
•Functional outcomes
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
Safety
•HCACs
•Spend per beneficiary
measures
•Episode cost measures
•Quality to cost measures
– 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
Increasing commonality among providers
Increasing individual accountability
Community
•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
•Denominator bound by patients cared for
•Applies to all physicians
•Greatest component of a physician’s total
performance
•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 “five domains” can
be measured at each of
the three levels
Objectives
• Share CMS work on Quality and Value
• How can we improve quality, safety and the
delivery of high value health care for
beneficiaries
• Provide overview of CMS approach to
quality measurement and health system
improvement
• Review current quality reporting programs
• Where do we go from here?
Measure Alignment to Drive Improvement
• Aligned measures with option of single
reporting for hospital programs: IQR, HVBP,
and EHR Incentive
• Aligned measures with option of single
reporting for physician programs: PQRS,
physician VBM, ACO, and EHR Incentive
• Decentralizing feedback loop closer to
clinicians via registries, EHRs, and
intermediaries
• Goal is to align measurement and payment
incentives with value instead of volume
PQRS: What are CMS’ Goals with PQRS?
• Goals considered while establishing proposals for PQRS
– Align PQRS with other Medicare quality reporting programs,
such as the EHR Incentive Program, Medicare Shared Savings
Program, and Value-based Modifier
– Increase participation to greater than 50%
– Ease eligible professionals into reporting for the PQRS
payment adjustment by providing alternative means to avoid
the 2015 payment adjustment
– Stress the importance of PQRS becoming a program that
collects meaningful data that facilitates the overall
improvement in quality of care
PQRS Goals: What are CMS’ Goals with
PQRS? To what extent have we achieved
these goals? (cont.)
• PQRS and the EHR Incentive Program
– Extension of the PQRS-Medicare EHR Incentive
Pilot to 2013
– Alignment of PQRS with MU in 2014
• Satisfactory reporting criteria for the 2014 PQRS
Incentive via the EHR-based reporting mechanism
align with criteria for meeting the CQM component of
meaningful use under the EHR Incentive Program
PQRS Goals: ACOs and GPRO
• PQRS Group Practice Reporting Option (GPRO) and the
Medicare Shared Savings Program
– GPRO measures – PQRS and MSSP aligned
– Accountable Care Organizations (ACOs) in the Medicare
Shared Savings Program participate in PQRS using the PQRS
group practice reporting option (GPRO)
– Adoption of the Medicare Shared Savings Program method of
assignment and sampling
– Continue to work on lowering burden of GPRO reporting
PQRS Goals: Alignment with Physician
Value-based Modifier
• PQRS and the Value-based Payment Modifier
– PQRS and Value-based Payment modifier aligned
– Group practices consisting of 100+ eligible
professionals, beginning in 2013 will be subject to
the Value-based Payment Modifier
• But have choice of whether to elect tiering
– Law requires expansion of program to all physicians
by 2017 payment adjustment
Summary of Changes to PQRS
Reporting Periods
• 2015 PQRS payment adjustment
– 6-month and 12-month reporting periods that coincide with the
2013 PQRS incentive reporting periods
• 2016 PQRS payment adjustment
– 6-month and 12-month reporting periods that coincide with the
2014 PQRS incentive reporting periods
•
2017 and subsequent PQRS payment adjustments
– 12-month reporting periods only
Incentive and Payment Adjustment Amounts
– 2013: 0.5% Incentive
– 2014: 0.5% Incentive
– 2015: 1.5% Payment Adjustment (will be applied in 2015 based on
reporting in 2013)
– 2016: 2.0% Payment Adjustment (will be applied in 2016 based on
reporting in 2014)
PQRS: Mechanisms for Reporting




Claims (G codes)
Registries
Group reporting (GPRO) web interface
Electronic health records (direct or thru data submission
vendor)
 Administrative claims (to avoid negative payment
adjustment and for VBM if group chooses)
PQRS Measures Example
• HHS Million Hearts Measures
– Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low
Density Lipoprotein (LDL-C) Control: Percentage of patients aged 18
years and older with Ischemic Vascular Disease (IVD) who received at least
one lipid profile within 12 months and whose most recent LDL-C level was in
control (less than 100 mg/dL)
– Preventive Care and Screening: Cholesterol – Fasting Low
Density Lipoprotein (LDL) Test Performed AND Risk-Stratified
Fasting LDL: Percentage of patients aged 20 through 79 years whose risk
factors* have been assessed and a fasting LDL test has been performed
– Preventive Care and Screening: Screening for High Blood
Pressure and Follow-Up Documented: Percentage of patients aged
18 years and older seen during the reporting period who were screened for
high blood pressure (BP) AND a recommended follow-up plan is documented
based on the current blood pressure reading as indicated
Ongoing Work Related to Aligning CMS Programs
with other Measure Reporting Efforts
• Registries (many led by physician specialty societies) are the
fastest growing portion of PQRS
– Multi-payer data
– robust set of measures
– success rates via registries are very high
• PQRS is attempting to put forward measures suggested by
any Board or specialty society for a given program to NQF
Measures Application Partnership
• PQRS incentive related to MOC
• Increased bidirectional communication and engagement
between CMS and Boards and specialty societies
• Significant work to align measures across public and private
payers
Clinical Registry Reporting
• Enacted in fiscal cliff legislation
• Allows the secretary to establish
criteria for registries to be able to
meet quality reporting requirements
for CMS programs
• CMS released an RFI requesting
comments on the implementation
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.
• 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
Objectives
• Share CMS work on Quality and Value
• How can we improve quality, safety and the
delivery of high value health care for
beneficiaries
• Provide overview of CMS approach to
quality measurement and health system
improvement
• Review current quality reporting programs
• Where do we go from here?
Measure Development
• CMS values these efforts
• CMS measure development funding is sparse
• To fill measure gaps for physicians of various specialties, we
will need specialties developing and testing measures
• Outcome-oriented measures whenever possible
• Next generation measures from EHRs and registries
Future of Physician Payment
• Physician and non-physician groups have put out plans
with some common principles
– Current payment system and SGR not working
– Move to pay for value instead of volume
– Transition system over time
– Provide flexibility due to realization that physician
practices and communities will be at different stages
of readiness
– Need to test innovative models
– Engage physicians and other clinicians in the change
process
Using Measures to Accomplish our Vision for the
Future
• Measures Drive Improvement
–Real-time
–Local ownership with benchmarking
–Linked to decision support and patient dashboards
• Measures Drive Value-Based Purchasing
–Reliable
–Accurate
–Outcomes-based
• Measures Inform Consumers
–Meaningful
–Transparent
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 programs whenever appropriate
• Focus on patient centered outcome measures
• Parsimonious sets of measures; core sets of measures
• Removal of measures that are no longer appropriate (e.g., topped out)
• Report once and receive credit for multiple programs
• Focus on EHR and Registry quality reporting
• Align measures with external stakeholders, including private payers and
boards and specialty societies
• Major aim of measurement is improvement over time
Why do we do this work?
• As a practicing physician – I see the need for system
changes
• Left a hospital medicine and quality improvement
position I loved to help foster a broader system enabling
others to drive improvement
• Almost all of us have family members in the populations
we serve
• The nation needs our service
• We have seen success; now the question is how do we
scale and spread?
What can you do?
• Eliminate patient harm
• Focus on the three part aim for the patient population you serve
• Engage in accountable care and other alternative contracts that
move away from fee-for-service to model based on achieving
better outcomes at lower cost
• Invest in the quality infrastructure necessary to improve
• Test models to better coordinate care for beneficiaries with
multiple chronic conditions
Call to Collective Action
• Historic moment in health care
• YOU can be THE determining factor on whether
our system transforms to achieve better results
• Must focus on all 3 parts of aims: Better Care,
Better Health, and Lower Costs
• We need YOU; We cannot accomplish the three
part aim from Baltimore/DC
• Think of the patient(s) and families that inspire
you to keep striving to do better
Think about these questions…
• What is the future of quality measurement
and improvement?
• How will we get there?
• How can CMS improve?
• How can we collaborate to accelerate the
pace of improvement?
Contact Information
Dr. Patrick Conway, M.D., M.Sc.
CMS Chief Medical Officer and
Director, Center for Clinical Standards and Quality
410-786-6841
[email protected]