Broad Issues in Quality Measurement: the CMS perspective

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Broad Issues in Quality Measurement: the CMS perspective

Shari M. Ling, MD Deputy Chief Medical Officer Centers for Medicare & Medicaid Services


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


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


We need delivery system and payment



Future State –

People-Centered Outcomes Driven Sustainable Coordinated Care Systems

New Payment Systems


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


– Training of clinicians and multi-disciplinary teams



CMS Authorized Programs & Activities

CMS Coverage Payment Clinical Standards Surveys Program Integrity HHS Innovation Quality Improvement Value Based Purchasing Quality Reporting

Reducing & Preventing HAIs

Reducing & Preventing Adverse Drug Events National Alzheimer’s Project Act

Partnership for Patients Million Hearts

National Quality Strategy

Physician Feedback report Quality Resource Utilization Report

Hospital Readmissions Reduction Program Health Care Associated Conditions Program


Physician value modifier

Plans for Skilled Nursing Facility and Home Health Agencies


ESRD Networks

Hospitals: inpatient psychiatric, inpatient acute, outpatient acute, Cancer

Ambulatory Surgical Centers

Physicians: Quality Reporting 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

Accountable Care Organizations Community Based Transitions Care Program

Dual eligible coordination

Care model demonstrations & projects 1115 Waivers

Hospitals, Home Health Agencies, Hospices, ESRD facilities

National & Local decisions

Mechanisms to support innovation (CED, parallel review, other)

Welcome to Medicare & Annual Wellness Visit exams

Target surveys

Quality Assurance Performance Improvement


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


The Six Goals

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

Strengthen person and family engagement as partners in their care Promote effective communication and coordination of care

Promote effective prevention and treatment of chronic disease Work with communities to promote 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


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


Hospital Quality Reporting • Medicare and Medicaid EHR Incentive Program • PPS-Exempt Cancer Hospitals • Inpatient Psychiatric Facilities • Inpatient Quality Reporting • Outpatient Quality Reporting • Ambulatory Surgical Centers Physician Quality Reporting • Medicare and Medicaid EHR Incentive Program • PQRS • eRx quality reporting


• 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.


Quality Reporting Towards

Value-Based Purchasing

2011 • ACA, HITECH • 190 individual measures • 14 Measures Groups • eRx • Individual

Reporting via Claims, Registry, or EHRs • GPRO I • GPRO II •Maintenance of Certification Program Incentive 2007 • TRHCA • 74 measures • Claims-based reporting only 2008 • MMSEA • 119 measures • 4 Measures Groups • Reporting via Claims or Registry 2009 • MIPPA • 153 individual measures • 7 Measures Groups • eRx • Reporting via Claims or Registry • EHR-testing VBP 2010 • MIPPA • 179 individual measures • 13 Measures Groups • eRx • Individual

Reporting via Claims, Registry, or EHRs • Group reporting option (GPRO)

2012 2013

•ACA, HITECH 13 participation options

• 210 individual measures 258 measures • 22 Measures Groups

• eRx

• Individual Reporting 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


Meaningful Use as a Building Block

Use technology Access information Transformation Care coordination Robust CDS (evidence based medicine & practice

goals) Patient centered,

team based care CQM data enables

outcome improvements

Case management & longitudinal view Clinical Decision Support Performance and population management Patient engagement Patient informed Improved population health Enhanced access and continuity Structured data capture


Value-Based Purchasing Program Objectives over Time

Towards Attainment of the Three-part Aim

Initial programs FY2012-2013 Near-term programs FY2014-2016 Longer-term FY2017+ •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

•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

•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


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


The CMS Innovation Center



CMS Innovations Portfolio:

Testing New Models to Improve Quality


Accountable Care Organizations (ACOs)

• Medicare Shared Savings Program (Center for


• 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)


• 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


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


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

Opportunities and Challenges of a Lifelong Health



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?


The Future of Quality Measurement for

Improvement and Accountability


Data Uniformity and Re-use Capabilities

As Is To Be


As Is: Multiple Incompatible Data Sources

Uniform Data Elements

Across Providers Standardized Nationally Vetted Nursing Homes MDS Home Health Agencies OASIS Inpatient Rehab Facilities IRF-PAI Hospitals No Standard Data Set Physicians No Standard Data Set LTCHS LTCH CARE Data Set Outpatient Settings No Standard Data Set

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


The Preferred Road to Coverage

 The incremental information

obtained by new diagnostic technology compared to alternatives

 Changes physician/clinician


 Resulting in changes in therapy

 That improve clinically meaningful

health outcomes

 A treatment strategy

using the new therapeutic technology compared to alternatives  Leads to improved clinically meaningful health outcomes




Contact Information Shari M. Ling, M.D.

CMS Deputy Chief Medical Officer 410-786-6841





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