Strategies Today for Higher Quality Tomorrow

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Strategies Today for Higher Quality Tomorrow

• Barbara R. Paul, MD
• Director, Quality Measurement and Health
  Assessment Group
• CMS
• November 11, 2003

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Overview of Todays Presentation

• Strategies available to CMS to improve quality
• Focus on public reporting and rewarding superior
  performance
• Current Quality Initiatives
• Next steps

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Pursuing Excellence
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CMS Approach to Quality

• Announced November 2001 by Secretary Thompson
• Empower consumers to make more informed decisions
  regarding their healthcare
• Stimulate / support providers clinicians to
  improve the quality of health care

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A focus on consumer information, complemented by
additional tactics
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Comparative Quality Information on
www.medicare.gov

• Medicare Health Plan Compare - 1999
• Dialysis Facility Compare - 2001
• Nursing Home Compare - 2002
• Home Health Compare 2003
• Hospital Compare 2004

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The Quality Initiatives - Nursing Home

• 4 prongs - consumer info, quality improvement
  technical support, partnerships, oversight.
• National launch November 2002
• Measures currently 10 outcomes measures, will
  increase/modify soon

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The Quality Initiatives - Home Health

• Same 4 prongs - consumer info, quality
  improvement technical support, partnerships,
  oversight
• Phase I (8 states) launched May 2003
• National launch November 3, 2003
• Measures 11 outcomes measures

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The Quality Initiatives - Hospital

• End-game
• excellent quality care
• To get there
• one robust and prioritized set of measures
  reported by every hospital in the country,
  accepted by all purchasers, overseers and
  accreditors
• technical assistance from our QIO program
• Collaborations, standardization, rewards,
  oversight

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The Quality Initiatives - Hospital

• A three state pilot
• A national voluntary public reporting partnership
• A standardized patient perception of care survey
  (HCAHPS)
• A Pay for performance demonstration project
• Ongoing measures work and quality improvement
  support from QIOs
• Infrastructure work

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The National Voluntary Hospital Reporting
Initiative

• A partnership
• American Hospital Association, Federation of
  American Hospitals, Assoc of American Medical
  Colleges, The Disclosure Group (consumer, union
  and private purchaser advocates), National
  Quality Forum, JCAHO, American Medical
  Association, Nat Assoc of Hosp for Children and
  Related Inst, Agency for Healthcare Research and
  Quality, AFL-CIO, AARP
• Public reporting and building of a data
  infrastructure simultaneously

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The National Voluntary Hospital Reporting
Initiative

• Phase I report starter set of 10 measures (NOW
  in progress)
• Phase II report standardized patient perception
  of care survey (HCAHPS) (late 2004 at earliest)
• Phase III more measures

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The National Voluntary Hospital Reporting
Initiative

• October
• www.cms.hhs.gov website live
• 415 hospitals reporting at least one measure
• At least 600 more in the data pipeline for
  February
• Working to resolve technical details (lots!)
• Hospitals continue to pledge and submit data

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The National Voluntary Hospital Reporting
Initiative

• February
• Using the CMS clinical data warehouse rather than
  JCAHO data.
• Should have at least 1,025 hospitals w data on at
  least one measure.
• And, 408 w data on 2 or more conditions.
• Validation, recruitment will be ongoing.

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The National Voluntary Hospital Reporting
Initiative

• Going forward
• Building out the measure set by engaging
  consumers, hospitals, professionals, JCAHO,
  others
• You will be involved
• Standardizing the measures via a
  standards-setting body, the National Quality
  Forum
• Ongoing technical support from our Quality
  Improvement Organization program
• Continue to build out the data infrastructure

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The Premier Hospital Quality Incentive
Demonstration

• A demo is a way for CMS to send a new message, to
  test new payment methods
• This demo Test how/if financial incentives drive
  superior quality inpatient care
• CMS demonstration with Premier, Inc.
• Reports the performance data on www.cms.hhs.gov

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The Premier Hospital Quality Incentive
Demonstration

• 5 clinical conditions (34 measures)
• Acute MI
• Heart Failure
• Pneumonia
• Coronary Artery Bypass Graft
• Hip and Knee Replacement

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The Premier Hospital Quality Incentive
Demonstration

• Top 50 of hospitals in each clinical area
  publicly listed on CMS website
• 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 for laggards

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One possible payment scenario
Condition X
Condition X
1st Decile
Hospital 2
2nd Decile
1st Decile
Condition X
3rd Decile
2nd Decile
4th Decile
5th Decile
3rd Decile
1st Decile
Top Performance Threshold
4th Decile
6th Decile
2nd Decile
5th Decile
7th Decile
3rd Decile
6th Decile
8th Decile
4th Decile
9th Decile
7th Decile
5th Decile
10th Decile
8th Decile
6th Decile
9th Decile
7th Decile
Payment Adjustment Threshold
10th Decile
8th Decile
9th Decile
10th Decile
Year One
Year Two
Year Three
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The Quality Initiatives - Physician Offices

• Current work via Quality Improvement
  Organizations (QIO)
• Developmental work
• DOQ
• DOQ-IT

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Current work via QIOs

• Measures
• Adult immunization (flu and pneumococcal)
  survey-based
• Mammographic screening claims-based
• Diabetes claims-based
• QIOs in each state offering improvement
  assistance
• Reminders
• Community-based education

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Doctors Office Quality (DOQ) Project (early
stages now)

• Topics Preventive care, DM, HTN, CAD, HF,
  Osteoarthritis, Depression, patient perceptions
  of care, assessment of systems of care.
• Clinical measures
• Developed in conjunction with AMA/Consortium and
  with expert panels
• Exploring ability to create composite score
• Exploring use of claims-based data, EHRs.
• Process improvements
• Care reminders, other

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DOQ-IT Objectives

• Promote adoption and use of IT in physician
  offices
• Create infrastructure for QIO to receive data
  from electronic office-based systems for use in
  confidential technical assistance and public
  reporting
• Just starting this completing some early
  contracting

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DOQ-IT What QIOs will do

• Assist physicians in decision to adopt IT
• Provide implementation assistance
• Technical issues
• Workflow redesign
• Receive electronic data from physicians and
  provide improvement assistance
• EHR specifications for clinical measures and
  systems operating reports
• Process redesign to support chronic care
  management

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DOQ-IT Demo A Potential Demonstration

• Requirements for payment
• Adopt specified IT systems to improve
  safety/quality and manage patients with chronic
  disease
• Full EHR or
• E-Rx, e-lab results management, e-registry
• Demonstrate use of such systems through
  electronic data transmitted to QIO
• Meet performance targets public reporting
• Meet cost reduction targets (in aggregate)
• Coordination with Bridges to Excellence program

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What is Quality?

• Quality is doing the right thing, at the right
  time, in the right way, for the right person,
  producing the best possible results.
• Quality care is safe, patient-centered, timely,
  effective, efficient and equitable.

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What is Quality?

• High performance on a limited set of measures is
  important, but insufficient.
• An entity that truly is providing superior
  quality care will in fact excel on published
  measures of quality.
• But in addition, it will have the structure and
  systems in place that assure quality is delivered
  every minute whether it is being measured or
  reported or not.

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CMS assessing Quality

• Some thoughts
• Performance on clinical measures
• Participation in public reporting
• Having a robust QI program
• Satisfying our conditions of participation
• Being an honest business partner
• Achieving accreditation, where available
• Having appropriate data and information
  infrastructure
• More - what else?

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Assessing Quality - some next steps

• Need measures that address
• all 6 IOM aims - safe, patient-centered, timely,
  effective, efficient and equitable
• all 20 IOM priority areas
• Need to consider how to incorporate all the info
  available to us as we assess whether quality is
  appropriate for extra payment - not just the
  clinical measures

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More Information

• http//www.medicare.gov
• Comparative databases for NH, HH, MC, Dialysis
  Facilities
• http//www.cms.hhs.gov
• Comparative database for hospitals
• Technical Users manuals
• Measure specifications
• Frequently asked questions
• Fact Sheets

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Thank you

• Barbara R. Paul MD
• 410-786-5629
• bpaul_at_cms.hhs.gov