Transcript CMS & Healthcare Stakeholders: Opportunities for Collaboration

CMS & Healthcare Stakeholders:
Opportunities for Collaboration
Barry M. Straube, M.D.
Chief Medical Officer
Centers for Medicare & Medicaid Services, Region IX
LA Collaborative Meeting
December 3, 2004
Federal Stakeholders in the U.S.
Healthcare System
• Department of Health &
Human Services
• Veterans Affairs
• Department of Defense
• Department of Labor
• Federal Bureau of
Prisons
• United States Coast
Guard
• Office Personnel
Management
• Federal Trade
Commission
• Office of Management &
Budget
• Department of
Commerce
• National Highway
Transportation & Safety
Administration
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Department of Health & Human Services:
Agencies
• Secretary of HHS
• Administration for
Children and Families
• Administration on Aging
• Agency for Healthcare
Research & Quality
• Agency for Toxic
Substances & Disease
Registry
• Centers for Disease
Control
• Centers for Medicare &
Medicaid Services
(CMS)
• Food & Drug
Administration
• Health Resources &
Services Administration
• Indian Health Service
• National Institute of Health
• Program Support Center
• Substance Abuse &
Mental Health Services
Administration
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Centers for Medicare & Medicaid
Services (CMS)
• Health benefits for over 76 million
Americans
– Medicare
– Medicaid
– State Children's Health Insurance Program
(SCHIP)
• Spends over $450 billion annually for
health care services in CMS programs
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Centers for Medicare & Medicaid
Services (CMS)
• Healthcare Benefits Administration
– Establish payment methodology for providers
– Conduct research on financing, treatment &
management
– Assure that contractors & state agencies run
CMS programs correctly
– Identify fraud & abuse, take appropriate action
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Centers for Medicare & Medicaid
Services (CMS)
• Beneficiary-Focused Activities
– Benefits and health education
– Advocacy: Appeals, Grievances, patient rights
– Assuring access and continuity of care
– Preventive services
– Healthcare data for choice
– Promoting partnerships of patients and
providers to provide patient-centered care
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Centers for Medicare & Medicaid
Services (CMS)
• Quality-Focused Activities
– Laboratory Testing (CLIA)
– Survey & Certification of Health Care Facilities
(Hospitals, LTC, SNF, HHA, etc.)
– End-Stage Renal Disease Networks
– Organ Procurement Organizations
– Quality Improvement Organizations
– Quality Improvement Systems in Managed
Care (QISMC)
– Multiple Demonstration Projects
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CMS 2005 Priorities
• Implementation of the Medicare
Modernization Act
• Quality, quality, quality…….
• Ongoing reimbursement reform
– Pay-for-Performance (P4P)
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Health Information Technology promotion
Prevention
Contractor reform
A host of other issues…….
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CMS Quality Initiatives
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Nursing Homes
Home Health
Hospitals
Doctor Offices
End Stage Renal Disease Facilities
More initiatives to come…..
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Medicare Modernization Act:
Disease Management Projects
• Medicare Health Care Quality
Demonstration Programs (Section 646)
– 5 year project expanding current physician
group practice demonstration
• Consumer Directed Chronic Outpatient
Services (Section 648a)
– 3 demonstration projects aimed at improving
the quality of care for Medicare patients with
chronic conditions
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Medicare Modernization Act:
Disease Management Projects
• Care Management Performance Demonstration
(Section 649)
– 3 year P4P pilot
– Adoption and use of health information
technology
• Voluntary Chronic Care Improvement Program
under traditional fee-for-service (Section 721)
– 3 year contracts with chronic care improvement
organizations for randomized clinical trials
– Guide beneficiaries with chronic disease to
disease management programs
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Medicare Modernization Act:
Chronic Disease Sections
• Chronically Ill Medicare Beneficiary
Research, Data, Demonstration Strategy
(Section 723)
– Within 6 months of enactment, Secretary must
develop a plan to improve quality of care and
reduce cost to chronically ill Medicare
beneficiaries
– Integrate existing datasets, identify new data
needs and methodology to address them, plan
for new data warehouse, develop research
agenda
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CMS Region IX Quality Forum
• CMS RO IX
• QIOs
• Associations
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Physician
Hospital
Health Plan
Medical group
SNF, hospice, etc.
• Employer groups
• Pay-for-Performance
initiatives
• NFP health foundations
• Individual
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Health Plans
Medical Groups
Hospital chains
SNFs, other providers
• Private-sector health
companies
• Academic institutions
• Growing list of others
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CMS Region IX Quality Forum
Quality Forum Mission
• We strive to make healthcare better, safer, and
more cost-effective for residents within the region.
Quality Forum Vision
• Pursue high-quality, safe, accessible and
affordable health services for residents in the
region
• Enhance collaboration and communication among
all stakeholders
• Detect problems & engage in problem solving
• Seek out the best healthcare practices to drive
innovation and quality in all aspects of healthcare14
CMS Region IX Quality Forum
Quality Forum Goals
• Select projects that affect broad group of
healthcare providers
• Address evolving health system needs to
prepare healthcare for the future
– Public health
– Evolving information infrastructure needs
• Develop 2-3 project plans by May 2005
• Focus on and promote California as the
initial pilot location
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Quality Forum Initial Project List
1. Collect and Share Physician Performance
Data
2. Create Personalized Beneficiary Health
Information Communication
3. Alleviate Emergency Department
Overcrowding
4. Develop Public Physician and Physician
Practice Information Website
5. Expand Use of e-ICUs
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Quality Forum Initial Project List
6. Expand Use of Telemedicine – Target
Rural Populations
7. Promote Fistula First Initiative
8. Support California Adult Immunization
Coalition
9. Focus on End-of-Life / Palliative Care
10. Assist Physicians Entering into EHR
Capabilities
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Quality Forum Project Selection
• Physician Level Performance Measurement
– Data Use for Beneficiary Healthcare
Improvement
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Emergency Department Overcrowding
Workgroups established
Synopsis of progress to date
Additional function of identifying problems
that CMS and stakeholders need to address
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Physician Level Performance
Measurement
• Choose measures and validate
– Database issues: Medicare FFS is essential
• Phase I: Voluntary & confidential physician
quality improvement
• Phase II: Credentialing, proprietary QI,
other proprietary uses
• Phase III: Public reporting, P4P, etc.
• Complementary beneficiary education
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E.D. Overcrowding
• One in three U.S. hospital E.D.s are
routinely on diversion
• 34% of hospitals in U.S. report operating
over capacity
– 28% report at capacity
• For large, urban hospitals 61% operating
over capacity
– 30% operating at capacity
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E.D. Overcrowding
• E.D. visits have increased from 90 million
in 1992 to 110 million in 2002
– 23% increase
• Over same timeframe number of hospital
E.D.s have decreased by 15%
– 10% decrease in California
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E.D. Overcrowding
• CMA 2001 Study
– E.D.s under-reimbursed by all payers,
particularly Medi-Cal
– Ranks of uninsured continue to grow
– Medi-Cal patients accounted for 40% of all
E.D. visits in 1998-1999
• 53% for CA E.D.s with largest E.D. losses
– 80% of E.D. visits of Medi-Cal & uninsured did
not require an E.D. setting
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E.D. Overcrowding
• Factors leading to overcrowding
– More patients
– Fewer E.D.s
– Inappropriate use of E.D.s by patients
– Decreased access to physician offices and
other sites
– EMTALA restrictions
– Downsized E.D. and hospital staffs and facilities
– Throughput problems
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– Fewer discharge setting options
E.D. Overcrowding Goals
• Obtain more data
• Reduce frequent users and inappropriate
use of E.D.s
– Frequent user grants and initiatives
– FQHC, CHC, RHC options
– Specialized centers: Alcohol, substance abuse,
wound care, etc.
• Address barriers to receiving care outside
E.D.s
– PCP and managed care focus
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E.D. Overcrowding Goals
• Identify & address EMTALA, regulatory &
accreditation components
• Identify and address “throughput”
problems
• Tackle discharge barriers
• Address quality measurement and
payment issues
– P4P overlap
– CMS E.D. quality metric development
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Select Other Region IX
Priorities
• Access to and continuity of care
• Fraud & Abuse (Program Integrity) Increase
• Ethnic & Racial Health Disparities, cultural
competence, health literacy
• Rural health issues
• Health Information Technology Initiatives
• Pay-for-Performance (P4P) initiative
collaboration
• Employer retirement coverage subsidies
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Contact Information
Barry M. Straube, M.D.
Chief Medical Officer
Centers for Medicare & Medicaid Services
Region IX
75 Hawthorne Street, Suite 408
San Francisco, CA 94105
Email: [email protected]
Phone: (415) 744-3503
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