Transcript Document 7112271

Medicare’s Healthcare Quality
Incentive Strategies
Sheila H. Roman, MD, MPH
Trent Haywood, MD, JD
CMS
September 27, 2005
Overview of Today’s Presentation
• CMS focus on public reporting and pay
for performance demonstrations
• MB Update in MMA
• Hospital Quality Incentive
Demonstration with Premier, Inc.
Calls for Medicare to Provide
Payment for Quality
• IOM report 2002
• Health Affairs article, former HCFA
administrators, 2003
• MedPAC report 2004
• Private sector efforts
• Bridges to Excellence
• Leapfrog Group
Medicare Demonstrations
• A demo is a way for CMS to send a new
message, to test new payment methods
• Medicare demonstrations linking payment
to quality
• Premier hospital quality incentive demo
• Care management performance demo
• Physician group practice demo
Hospital Quality Alliance (HQA):
Improving Care Through
Information
End-game:
• excellent quality care
To get there:
• one robust, nationally standardized and prioritized
set of measures reported by every hospital in the
country, accepted by all purchasers, overseers and
accreditors;
• Collaborations, standardization, oversight,
incentives
Differential Marketbasket
payment update, sec. 501
• “each subsection (d) hospital shall submit to the
Secretary quality data (for a set of 10 indicators
established by the Secretary as of November 1,
2003) that relate to the quality of care furnished by
the hospital in inpatient settings in a form and
manner, and at a time, specified by the Secretary.”
• If such hospital does not submit data…”the
applicable (payment) percentage increase … shall
be reduced by O.4 percentage points”
Hospital Public Reporting
4043
4192
1952
1407
434
August, 2003
February,
2004
May, 2004
October, 2004
Number of Reporting Hospitals
March, 2005
HQA: Current Status
• “Starter set” of 10 measures (bolstered by
MMA market basket payment update
incentive to PPS hospitals)
• Over 4,000 hospitals reported in
November, 2004
• More clinical measures (10 to 17 to 20
through September 2005)
CMS/Premier Hospital Quality
Incentive Demonstration Project
• The first national project to measure
hospital performance and offer additional
Medicare payment for top quality care
• “Pay for quality”
• Can economic incentives effectively
improve quality of care?
HQID Hospital Participation
• Voluntary
• Eligibility: Hospitals in Premier Perspective
system as of March 31, 2003
• 278 hospitals participating
• Demonstration Project: Pilot test of concept
• May be expanded in the future
CMS/Premier HQI – Over 270 National
participating hospitals
HQID: Expanded Set of
Measures
• Use of 34 measures
• Expands 10 measure “Starter Measure Set”
in HQA
• Drawn largely from NQF endorsed hospital
performance measure sets
• Uses both process and outcome measures
• Includes 2 AHRQ PSIs
HQI demonstration project
• A three-year effort linking payment with
quality measures (launched October, 2003)
• Top performers identified in five clinical
areas
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Acute Myocardial Infarction Indicators within AMI,
CABG, HF, and CAP
Congestive Heart Failure
represent all patients (all
payers). Hip and knee
Coronary Artery Bypass Graft replacement indicators
apply only to Medicare
Hip and Knee Replacement
patients.
Community Acquired Pneumonia
HQID Hospital Scoring
• Hospitals scored on quality measures related
to each condition
• Individual measures “rolled-up” into overall
composite score for each condition
• Composed of two components:
• Composite Process Rate
• Risk-Adjusted Outcomes Index
• Categorized into deciles by condition to
determine top performers
The Hospital Quality Incentive
Demonstration
• Bonuses for top 2 deciles for each condition
• Top decile given 2% bonus of their
Medicare DRG payments for that
condition
• Second decile given a 1% bonus
• Possible penalty in third year if below
baseline threshold
HQID: Year 3 Quality Score
Must Exceed Baseline
• Demonstration baseline
• Clinical thresholds set at year one threshold
scores
• Lower 9th and 10th deciles
• If performance in year 3 does not exceed baseline,
hospital will receive payment penalty
• 1% lower DRG payment for conditions below
9th decile baseline level
• 2% lower DRG payment for conditions below
10th decile baseline level
Anticipated payment scenario
Condition X
1st Decile
1st Decile
Top
Performance
Threshold
1st Decile
2nd Decile
Condition X
Condition X
Payment
Incentive
2nd Decile
Payment
Incentive
4th Decile
5th Decile
3rd Decile
4th Decile
5th Decile
3rd Decile
6th Decile
4th Decile
7th Decile
5th Decile
3rd Decile
2nd Decile
8th Decile
6th Decile
9th Decile
7th Decile
10th Decile
8th Decile
Payment
Incentive
Hospital
9th Decile
6th Decile
10th Decile
7th Decile
Payment
Adjustment
Threshold
8th Decile
Hospital
Payment Adjustment
- Year 3
9th Decile
10th Decile
Year One
Year Two
Year Three
CMS/Premier HQI Project
Already showing improvement
Composite Quality Score: Quarterly Median Improvement by Focus Area
Premier / CMS Hospital Quality Initiative Participants
October 1, 2003 - Septem ber 30, 2004
Prelim inary Results
100.0%
95.0%
Composite Quality Score
90.0%
92.6%*
90.5%*
90.0%*
89.9%
85.7%
84.9%
85.0%
80.0%*
80.0%
76.2%*
4Q-03
75.0%
1Q-04
70.0%
70.0%
2Q-04
3Q-04
64.1%
65.0%
60.0%
55.0%
50.0%
AMI
CABG
Pneumonia
Heart Falure
Clinical Focus Area
* Im provem ent in Com posite Quality scores betw een 4Q-03 and 3Q-04 are significant at the p < = .001 level
* Based on a paired sam ple t-test of the m ean scores for the sam e tim e periods
Hip and Knee
CMS/Premier HQI Project
Reduction in Variation
AMI Composite Quallity Score Distribution
Positive trend in both
upper and lower scores
of range
• Reduction in variance
(narrowing of range)
• Median moving
upward
Composite Quality Score
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Time Periods:4Q03 - 2Q04
120
100
80
60
4Q03
1Q04
2Q04
Challenges to Incentives for Quality
Performance
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Selection of measures/off label use of measures
Dynamic measurement environment
Measures maintenance
Hospital Burden
Unintended consequences
Time lags
Validation/Scoring methodology
Need for proof of effectiveness
Next Frontiers
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Measurement of other dimensions of quality
Scoring methodologies
Benchmarking
Incentives/Payment for quality
Health Information Technology
Improve health care systems
Thank you!
Sheila H. Roman, MD, MPH
410-786-6004
[email protected]