Leveraging QPP: Foster Relationships Create Synergy August 22, 2017 Patricia A Meier MD CMO, Region VII, CMS

Acknowledgements Some slides provided by Drs. Ashby Wolfe and Rob Furno

CQISCO has dual mission: quality improvement and quality assurance Consortium for Quality Improvement and Survey and Certification Operations (CQISCO) CQISCO has dual mission: quality improvement and quality assurance Field focal point for: Survey and Certification Quality Improvement Clinical and Medical Science Issues and Policies Three components: Divisions of Survey and Certification Division of Quality Improvement Regional Chief Medical Officers

CMS OFFICES For those of you unfamiliar with CMS, we currently insure 1 out of every 3 Americans through our 4 programs: Medicare, Medicaid, CHIP and the Marketplace programs. To implement these programs, we have one central office in Baltimore and 10 regional offices that you see here. Region VII, in which I work, covers Iowa, Kansas, Missouri and Nebraska We work with about 20 million beneficiaries in this vastly diverse geographic region, with multiple languages spoken, multiple ways of providing health care and multiple cultural approaches to health. CMS responsibilities CMS is the largest purchaser of health care in the world Combined, Medicare and Medicaid pay approximately one-third of national health expenditures (approx $800B) CMS programs currently provide health care coverage to roughly 105 million beneficiaries in Medicare, Medicaid and CHIP; or roughly 1 in every 3 Americans. The Medicare program alone pays out over $1.5 billion in benefit payments per day. Through various contractors, CMS processes over 1.2 billion fee-for-service claims and answers about 75 million inquiries annually. Millions of consumers will receive health care coverage through new health insurance exchanges authorized in the Affordable Care Act.

What is the Merit-based Incentive Payment System? Performance Categories Quality Cost Improvement Activities Advancing Care Information Comprised of four performance categories. Provides MIPS eligible clinician types included in the 2017 Transition Year with the flexibility to choose the activities and measures that are most meaningful to their practice.

Transitions of Care Multiple sites for interventions and data sharing https://www.linkedin.com/pulse/how-many-things-can-go-wrong-amy-panza-pharm-d-

Screen shots of the shopping cart https://qpp.cms.gov

Quality Measures: Antibiotic Stewardship

MIPS Performance Category Improvement Activities 15% of Final Score in 2017 Attest to participation in activities that improve clinical practice Examples: Shared decision making, patient safety, coordinating care, increasing access Clinicians choose from 90+ activities under 9 subcategories: 1. Expanded Practice Access 2. Population Management 3. Care Coordination 4. Beneficiary Engagement 5. Patient Safety and Practice Assessment 6. Participation in an APM 7. Achieving Health Equity 8. Integrating Behavioral and Mental Health 9. Emergency Preparedness and Response

MIPS Improvement Activity related to Antibiotic Stewardship www.qpp.cms.gov/measures/ia

Technical Assistance for Clinicians CMS has free resources and organizations to provide help to clinicians who are participating in the Quality Payment Program: TCPI is designed to support more than 140,000 clinical practices achieve large-scale transformation by sharing, adapting and further developing their comprehensive quality improvement strategies. Funding for practice transformation networks (PTNs) is contingent upon minimum 20% of clinicians served are from rural or underserved locations. Several PTNs have committed greater than 50% of clinicians who participate stem from rural areas, including: Rural health clinics Rural community health centers Health profession shortage areas Supporting medically underserved populations To learn more, view the Technical Assistance Resource Guide: https://qpp.cms.gov/resources/education

Practice Transformation in Action This technical assistance would enable large-scale transformation of more than 140,000 clinicians‘ and their practices to deliver better care and result in better health outcomes at lower costs. Transforming Clinical Practice would employ a three-prong approach to national technical assistance.

Focus on Collaboration

“engage emergency clinicians and leverage emergency departments to improve clinical outcomes, coordination of care and to reduce costs” Improving outcomes for patients with sepsis Reducing avoidable imaging in low risk patients by implementation of ACEP’s Choosing Wisely recommendations High-cost imaging for low back pain Head CT scan after minor head injury Chest CT for pulmonary embolus Abdominal CT for renal colic Head CT for syncope Improving the value of ED evaluation for low risk chest pain by reducing avoidable testing and admissions

Why an ongoing focus on Sepsis? An increasingly common cause of mortality Between 1999 and 2014, the annual number of all reported sepsis- related deaths (primary and secondary diagnoses combined) increased 31 percent, from 139,086 in 1999  182,242 in 2014 Data reveal that the sepsis mortality rate is more than eight times higher than mortality rates among patients admitted for other conditions Most expensive condition treated in U.S. hospitals Costs associated with the treatment of sepsis alone aggregated to $20.3 billion, or approximately 5.2 percent of the total cost of all hospitalizations in the country AHRQ data reveal that the sepsis mortality rate is more than eight times higher than mortality rates among patients admitted for other conditions.

The other side of the coin: Antibiotic Stewardship Update to SEP-1 Specifications changed in v5.2  allow cases with known culture results and known sensitivities to use targeted antibiotic choice Alignment with other reimbursement policy Quality Payment Program Improvement Activity related to promoting antibiotic stewardship programs The only link to stewardship is that the spec was changed in v5.2 to allow cases with known culture results with know sensitivities to use targeted antibiotic choice. Over view here. ALSO: We also have some MIPS IAs related to promoting antibiotic stewardship programs Looking into supporting QI related to the use of antibiograms

11th SoW Current Quality Improvement Tasks Quality Innovation Network (QIN) Diabetes Care Everyone with Diabetes Counts Nursing Home Care B.1 Cardiac Health B.2 C.2 Care Coordination Reduction of Admissions/ Readmissions Antibiotic Stewardship C.3 C.3.6 Medication Safety C.3.10 Quality Reporting/ Quality Payment Program Quality Improvement Initiatives (QII) D.1 E.1 F.1 Immunizations G.1 Behavioral Health Screening H.1 Transforming Clinical Practice Initiative Note: Patient and Family Engagement is a cross-cutting requirement for all QIN tasks. 18

Connecting MIPS and Antibiotic Stewardship

Great Plains QIN – QIO Healthcare Associated Infections and Antibiotic Stewardship and QPP Participation in the Great Plains QIN Outpatient Antibiotic Stewardship initiative will not only improve patient care, but it will also increase the potential for improved participation in national and local quality payment programs: 2017 MIPS Participation Benefits (full MIPS/ABS crosswalk developed): 10 Quality Measures that relate to antibiotic stewardship which can be selected for reporting 5 Practice Improvement Activities that relate to antibiotic stewardship which can be selected for attestation By providing patient-specific education on Antibiotic Stewardship using your Certified EHR, providers are able to perform improvement activity IA_PSPA_16 electronically, which qualifies for the bonus score in the Advancing Care Information Performance Category. Blue Cross and Blue Shield of Kansas Value Based Reimbursement Program: Participating providers may receive incentives based upon their performance on HEDIS measures including antibiotic use: ·  Appropriate treatment for children with upper respiratory tract infections ·  Avoidance of Antibiotic treatment in adults with acute bronchitis

Resource Sharing http://greatplainsqin.org/initiatives/antibiotic-stewardship/

Telligen Outpatient Antibiotic Stewardship Program Partner with outpatient clinics who are interested in reducing unnecessary antibiotic usage. Improve patient outcomes and reducing microbial resistance. Monitor, reduce, and prevent misuse and/or overuse of antibiotics using a multidisciplinary team and strategic approach. Implement antibiotic stewardship teams within your facility to reduce misuse of antibiotics. Problem: Antibiotic use, particularly the overuse and misuse of these drugs, is also the greatest risk factor for developing antibiotic resistance, which compromises the effectiveness of the drug. Antibiotic resistance has been identified as a fundamental aspect of global health security. Inpatient facilities have already began to address antibiotic stewardship, and many have programs in place today. This project specifically focuses on outpatient settings such as clinics, ESRDs, EDs, and pharmacies.

Telligen is Assisting Outpatient Providers to: Implement the Centers for Disease Control and Prevention Antimicrobial Stewardship in Outpatient Settings programing materials. Core Elements of Outpatient Antibiotic Stewardship Telligen will work with outpatient providers to implement the CDC “Clinician Checklist for Core Elements of Outpatient Antibiotic Stewardship. We are looking for outpatient settings across Iowa, and welcome opportunities to visit with settings who would be interested in working on this important project. Conduct education and training related to antimicrobial stewardship in the outpatient setting, based on the CDC Core Elements. Provide technical assistance and guidance for your team to implement an antimicrobial stewardship program.

Quality Payment Program National Coverage of Technical Assistance for Small, Underserved and Rural Clinicians 11 uniquely experienced organizations to provide national coverage to eligible clinicians in small practices. Challenges in small and rural locations include: Study of VA rural hospitals identified three prominent themes (Harrod et al, 2013): Lack of human capital Difficulty in accessing new knowledge Mandate conflicts (mandates not always relevant) Need to cultivate resources: Tap into local or regional expertise Participate in collaboratives Professional networks

https://www.cdc.gov/getsmart/community/~local/modules/programs-measurement/stewardship-in-small-rural-hospitals-workbook-wa-508.pdf

Patricia A. Meier MD, CMO, Kansas City Regional Office patricia.meier@cms.hhs.gov