cms quality strategy robert anthony deputy director, quality measurement & value-based...

CMS Quality Strategy

Robert AnthonyDeputy Director, Quality

Measurement & Value-based Incentives Group

Center for Clinical standards and Quality

September 17, 2015

Our Vision

TO OPTIMIZE HEALTH OUTCOMES BY IMPROVING CLINICAL QUALITY AND

TRANSFORMING THE HEALTH SYSTEM.

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html

Better Health forthe Population

Better Carefor Individuals

Lower CostThrough

Improvement

Our Three Aims

3

4

National Quality Strategy promotes better health, better healthcare, and

lower costs through

• Make care safer by reducing harm caused in the delivery of care

• Ensure that each person and family are engaged as partners in their care

• Promote effective communication and coordination of care• Promote effective prevention and treatment practices for

the leading causes of mortality, starting with cardiovascular disease

• Work with communities to promote wide use of best practices to enable healthy living

• Make quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models

Six Priorities

The Six Priorities Have Become the Goals for the CMS

Quality Strategy

Making care safer Strengthen person and family engagement

Promote effective communication and coordination of care

Promote effective prevention and

treatment

Work with communities to promote best

practices of healthy living

Make care affordable

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

• Develop measures meaningful to patients and providers, focused on outcomes (including patient-reported outcomes), safety, patient experience, care coordination, appropriate use, and cost

• 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 or process distal from outcome)

• Align measures with states, private payers, boards and specialty societies

Make Care Safer

Reduce inappropriate

and unnecessary care

Prevent or minimize harm in

all settings

Improve support for a culture of

safety

Objectives

Goal 1 Goal 2 Goal 3 Goal 4 Goal 5 Goal 6

Make Care Safer

Improve support for a culture of

safety


Objective Desired Outcomes Improved application of safety practices in our

programs to involve all team members, patients, and families and assure that the patient voices are heard

Organizations exhibit strong leadership that educates and empowers the workforce to recognize harm and increase reporting of errors

Increased access to understandable health information

Expanded use of evidence-based services and primary care

Disparities of care are eliminated

Make Care Safer

Reduce inappropriate

and unnecessary care


Objective Desired Outcomes

Health care organizations continually assess events in accordance with evidence-based practices

Health care cost reductions are attributed to the reduction of unnecessary, duplicative, and inappropriate care

Improved achievement of patient-centered goals of care is evident

Disparities of care are eliminated

Make Care Safer



HACs and HAIs are reduced Medication error rates are improved Falls are decreased Visibility of harm is improved in all settings Use of evidence-based services and primary

care is expanded Patient and family access to understandable

health information is increased Disparities of care are eliminated

Prevent or minimize harm in

all settings

Partnership for Patients and QIO work: Hospital Acquired Condition (HAC) Rates

Show Improvement

Ventilator-Associated Pneumonia

(VAP)

Early Elective Delivery

(EED)

Obstetric Trauma

Rate (OB)

Venous thromboembolic

complications (VTE)

Falls and Trauma

Pressure Ulcers

55.3% ↓ 52.3% ↓ 12.3% ↓ 12.0% ↓ 11.2% ↓ 11.2% ↓

•2010 – 2012 - Preliminary data show a 9% reduction in HACs across all measures

•Many areas of harm dropping dramatically (2010 to 2013 for these leading indicators)

Reduced Potential for Adverse Drug Events

44,640 Potential adverse

drug events were

prevented

Measurement Period

n= 44,640 instances of potential adverse drug events identified and prevented

d= 195,352 opportunities for adverse drug events

Total Beneficiaries = 57, 657

Reducing HAC in Hospitals - Fewer infections

85,149 fewer days with urinary catheters for beneficiaries

Strengthen Person and Family Engagement

Ensure care delivery

incorporates patient and

caregiver preferences

Improve experience of

care for patients, caregivers and

families

Promote patient self-management

Objectives




Ensure all care delivery

incorporates patient and

caregiver preferences

Objective Desired Outcomes Patients are partners at all levels of care Care and treatment reflects patients’ personal values and goals Coordination and communication occurs within and across care

teams, including patients, families, and caregivers Patient and family preferences are central in decision processes

and implementation Joint development of treatment goals and longitudinal plans of

care Information is updated and available for use by patients Achievement of patient-centered goals that focus on prevention Improved coordination and communication within and across

organizations Disparities in care are eliminated



Promote patient self-management


Improved application of self-management practices in our programs

Improved visibility of self-management Improved support for integrated care models Increased access to understandable health information Updated and available information for use by patients Improved patient confidence in managing chronic

conditions A respectful, trustworthy, transparent healthcare

culture

Promote Effective Communication and Coordination of Care

Reduce admissions and

readmissions

Embed best practices to

manage transitions to all practice settings

Enable effective health care

system navigation

Objectives




Reduce admissions and

readmissions

Objective Desired Outcomes• Patient self-management and activation efforts result in

reduced admission and readmission rates• Increased health literacy rates• Survey results demonstrate measurable reduction in

deficiencies related to discharge planning and care transitions

• Evidence based best practices that promote appropriate discharge planning and care transition are embedded in routine practice of care across the health care continuum

• Appropriate interventions prevent development of health conditions that require acute care

• Wasteful expenses from avoidable admissions and readmissions is reduced drastically

• All those who provide care in a particular community work in coordination to optimize patient care

2007 2008 2009 2010 2011 2012 201317%

18%

19%

20%

Medicare 30-Day, All-Condition Hospital Readmission RatesJanuary 2007 - May 2013

Monthly Rate

Trendline

Hospital Readmissions Continue to Decline Steeply



Embed best practices to

manage transitions to all practice settings


• Integrated, patient-centric discharge tools are used across all practice settings

• Community-based support systems integrated with health care delivery are developed and employed

• Patient activation efforts and self-management training are a standard part of care



Enable effective health care

system navigation


• Evidence-based best practices that enable patient activation and self-management are embedded in the routine practice of care

• Payer reimbursement is expanded beyond education to include chronic disease self-management education programs

• Cross-setting discharge planning tools that include patient and family goals and preferences are routinely employed

Promote Effective Prevention and Treatment

Increase appropriate

use of screening

and prevention

services

Strengthen interventions

to prevent heart attacks and strokes

Improve quality of care for patients

with multiple chronic

conditions

Improve behavioral

health access and

quality care

Improve perinatal outcomes

Objectives


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CMS Priorities for Measure Development

• Common Adverse Events– Global measure of harm?

• Appropriate Use of Resources• Patients with Multiple Chronic Conditions• Aligning measures and incentives across

providers• Actively monitor for unintended consequences• Advance science on Patient-Reported Outcome

Measures• De novo e-measure development

Work with Communities to Promote Best Practices of

Healthy Living

Partner with and support

federal, state, and local public

health improvement

efforts

Improve access within communities

to best practices of

healthy living

Promote evidence-

based community

interventions to prevent and treat chronic

disease

Increase use of community-

based social supports

Objectives


Work with Communities to Promote Best Practices of

Healthy Living


Partner with and support federal, state, and local public health improvement

efforts


• Promote interoperability of health IT systems• Improved population health outcomes • Reduced disparities in health outcomes• Reduced health care costs through better

coordination across sectors

Make Care Affordable

Develop and implement payment systems that

reward value over volume

Use cost analysis data to inform payment policies

Objectives


Delivery system and payment transformation

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PUBLICSECTOR

Future State – People-Centered

Outcomes Driven Sustainable

Coordinated Care

New Payment Systems (and many more)

Value-based purchasing ACOs, Shared Savings Episode-based payments Data Transparency

Current State – Producer-Centered Volume Driven

Unsustainable

Fragmented Care

FFS Payment Systems

PRIVATESECTOR

Medicare Per Capita Spending Growth at Historic Lows

Source: CMS Office of the Actuary2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

9.24%

5.99%

4.63%

7.64%7.16%

*27.59%

1.98%

4.91%

4.15%

1.36%

2.25%

1.13%0.35%

Medicare Per Capita Growth Medical CPI Growth

*Medicare Part D prescription drug benefit implementation, Jan 200628%

27%

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Framework for Progression of Payment to Clinicians and Organizations in Payment Reform Category 1: Fee for Service – No Link to Quality

Category 2: Fee for Service – Link to Quality

Category 3: Alternative Payment Models on Fee-for Service Architecture

Category 4: Population-Based Payment

Description Payments are based on volume of services and not linked to quality or efficiency

At least a portion of payments vary based on the quality or efficiency of health care delivery

• Some payment is linked to the effective management of a population or an episode of care

• Payments still triggered by delivery of services, but, opportunities for shared savings or 2-sided risk

• Payment is not directly triggered by service delivery so volume is not linked to payment

• Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (eg, >1 yr)

Examples

Medicare • Limited in Medicare fee-for-service

• Majority of Medicare payments now are linked to quality

• Hospital value-based purchasing

• Physician Value-Based Modifier

• Readmissions/Hospital Acquired Condition Reduction Program

• Accountable Care Organizations

• Medical Homes• Bundled Payments

• Eligible Pioneer accountable care organizations in years 3 – 5

• Some Medicare Advantage plan payments to clinicians and organizations

• Some Medicare-Medicaid (duals) plan payments to clinicians and organizations

Medicaid Varies by state • Primary Care Case Management

• Some managed care models

• Integrated care models under fee for service

• Managed fee-for-service models for Medicare-Medicaid beneficiaries

• Medicaid Health Homes• Medicaid shared savings

models• Medicaid waivers for delivery

reform incentive payments• Episodic-based payments

• Some Medicaid managed care plan payments to clinicians and organizations

• Some Medicare-Medicaid (duals) plan payments to clinicians and organizations

Rajkumar R, Conway PH, Tavenner M. The CMS—Engaging Multiple Payers in Risk-Sharing Models. JAMA. Doi:10.1001/jama.2014.3703

ACO Participation is Growing Rapidly

•ACO-Assigned Beneficiaries by County • 360+ ACOs have been established, including 123 new

Shared Savings ACOs for 2014• 5.3 million assigned beneficiaries in 47 states, plus DC and

PR

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

Focusing on Outcomes

• Focusing on the end results of care and not the technical approaches that providers use to achieve the results

• Measure 30 day mortality rates, hospital-acquired infections, etc…

• Determine if desired clinical results are achieved (low re-admissions, weight reduction, etc…)

Challenges in Measuring Performance

• Determining indicators of outcomes that reflect national priorities

• Recognizing that outcomes are usually influenced by multiple factors

• Determining thresholds for ‘good’ performance

• Recognizing that Process Measures don’t always predict outcomes

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Medicare Access and CHIP Reauthorization Act of 2015

(MACRA)

• Passed House 3/26/2015- Senate 4/14/2015• Signed into Law 4/16/2015• Repeals 1997 Sustainable Growth Rate Physician

Fee Schedule (PFS) Update• Changes Medicare PFS Payment

– Merit-Based Incentive Payment System (MIPS)– Incentives for participation in Alternate Payment Model

(APM)

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MIPS & APM Incentives

• Separate application of payment adjustments under PQRS, VM, and EHR-MU will sunset Dec. 31, 2018

• January 1, 2019 – MIPS and APM incentive payments begin

• EPs can participate in MIPS or meet requirements to be qualifying APM participant

• MIPS – Can receive positive, negative or zero payment adjustment

• APM Participant – If criteria are met, can receive 5 percent incentive payment for 6 years

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Merit-Based Incentive Payment System (MIPS)

• Jan 1, 2019- MIPS payment adjustment begins• Under MIPS the Secretary must develop a

methodology to assess EP performance and determine a composite performance score

• Features of PQRS, the Value Modifier and the EHR Meaningful Use program are included in MIPS

• The score is used to determine and apply a MIPS payment adjustment factor for 2019 onward

• Adjustment Can Be Positive, Negative, or Zero

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More on MIPS

4 Performance Categories – Quality measures (30% of Score) – Resource Use measures (30% of Score)

• Counts for not more than 10% in 2019 and 15% in 2020; additional weight of at least 20% and 15%, respectively, are added to the Quality score in those years

– Clinical Improvement Activities (15% of Score)• Sub-Categories- Includes Better Off-Hours

Access, Care Coordination• Patient Safety, Beneficiary Engagement• Others as Determined by Secretary

– Meaningful Use of EHRs (25% of Score)

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More on MIPS

• CMS will propose the initial policies for the MIPS in CY2017 PFS Rule Making - proposed rule published around June 2016

• CMS must make available timely (“such as quarterly”) confidential feedback reports to each MIPS EP starting July 1, 2017

• Beginning July 1, 2018, CMS must make available to each MIPS EP information about items and services furnished to the EP’s patients by other providers and suppliers for which payment is made under Medicare

• Information about the performance of MIPS EPs must be made available on Physician Compare

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MIPS & Measures

• Nov 1st each year, CMS to publish measure list for MIPS– Update, add, revise list for coming performance period

• MACRA explicitly states to emphasize outcome measures• CMS may use:

• Inpatient hospital measures for MIPS EPs• Outpatient hospital measures may be used for

emergency physicians, radiologists, & anesthesiologists.

• Population based measures are allowed for MIPS• In selecting MIPS measures and applying the MIPS formula,

Secretary shall give consideration to “non-patient facing” specialties

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MIPS – Resource Use

• To measure resource use, MACRA requires CMS to develop: – Care episode and patient condition groups and classification

codes;– Patient relationship categories and codes, which include:

• Primary responsibility for ongoing patient care over extended periods of time

• Lead EP during acute care episode- including coordinating items & services by other EPs

• Supporting EP during acute care episode providing continuing items, & services (but not lead)

• EP providing occasional items & services; upon request of another EP

• EP providing items & services as ordered by another EP• April 2016 – CMS to publish proposed codes online.

– Stakeholder feedback comment period (4 months)• April 2017 – Final categories & codes published.• Revisions allowed Nov. 1, 2018 then every Nov. 1st thereafter.

Expanded Practice Access

• Same day appointments for urgent needs

• After hours clinician advice

Population Management

• Monitoring health conditions & providing timely intervention

• Participation in a qualified clinical data registry

Care Coordination

• Timely communication of test results

• Timely exchange of clinical information with patients AND providers

• Use of remote monitoring

• Use of telehealth

Beneficiary Engagement

• Establishing care plans for complex patients

• Beneficiary self-management assessment & training

• Employing shared decision making

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MIPS - Clinical Practice Improvement Activities

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MIPS Composite Performance Score

– Performance assessment in four categories using weights established in the statute

– Weights may be adjusted if there are not sufficient measures and activities applicable for each type of EP, including assigning a scoring weight of 0 for a performance category.

– EHR weighting can be decreased and shifted to other categories if Secretary estimates the proportion of physicians who are meaningful EHR users is 75% or greater (statutory floor for EHR weight is 15%)

– Performance threshold will be established based on the mean or median of the composite performance scores during a prior period

– The composite performance score will range from 0 – 100– The score will assess achievement & improvement (when

data available)

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Alternative Payment Model (APM) Incentive Payments

Beginning in 2019 and for 6 years 5% incentive payment for:

– EPs or groups of EPs who participate in certain types of APMs and who meet specified payment thresholds.

– Payment is made in a lump sum on an annual basis. – EPs or groups of EPs meeting criteria to receive APM

incentive payment are excluded from the requirements of MIPS.

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APM Incentive Payment Requirements

Requirements: 1) Participate in a defined APM and meet additional

criteria of an eligible alternative payment entity.2) Meet established thresholds.

Definition of APM• A Centers for Medicare and Medicaid Innovation (CMMI) model • Medicare Shared Savings Program Accountable Care

Organizations• A CMS demonstration under section 1866C of the SSA; or

required by Federal law

Questions?

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cms quality strategy robert anthony deputy director, quality measurement & value-based...

Documents

unnecessary care goal

higherquality care

cost of quality health

care coordination

evidentdisparities of

affordable care

centered goals of care

care saferimprove support