Part 3 of 3 Welcome to this presentation on “Quality Measures in Cholesterol and Diabetes Management.” 1

The tables show the average plan ratings for the Part C measures related to cholesterol and diabetes management. Blood sugar and cholesterol control showed moderate improvements. Greater improvements were noted in eye exams and kidney disease monitoring of patients with diabetes. Cholesterol screening of patients with heart disease showed a moderate improvement, but cholesterol screening for patients with diabetes remained virtually the same. Reference Centers for Medicare & Medicaid Services. 2012 Part C and D plan ratings. http:// www.cms.gov/PrescriptionDrugCovGenIn/Downloads/PlanRatings_CD_2012.zip. Updated October 18, 2011. Accessed October 13, 2011. 2

This slide shows average star ratings for 3 new measures pertaining to diabetes and cholesterol management under Part D. As can be seen from the table, average star rating are relatively low, between 3 and 3.2 stars. Reference Centers for Medicare & Medicaid Services. 2012 Part C and D plan ratings. http:// www.cms.gov/PrescriptionDrugCovGenIn/Downloads/PlanRatings_CD_2012.zip. Updated October 18, 2011. Accessed October 13, 2011. 3

Let’s now shift our attention to some of the quality measures that have been developed for providers, again focusing on diabetes and cholesterol management. 4

VBP may influence the development and expansion of accountable care organizations (ACOs), considering the shared common goals of joint accountability, improvement of healthcare quality, and reduction of costs. Some key features of ACOs are: Accountability for effective management across the full continuum of care Shared savings Performance measurement, including outcomes and patient experience The graph provides suggestions on how different stakeholders can contribute to cost reduction and quality improvement within an ACO model. Primary care providers can help improve the access to care; improve prevention and early diagnosis; reduce unnecessary testing, referrals, and medications; and choose lower cost treatment options; effective primary care can reduce preventable emergency room visits and hospitalizations. Hospitals and specialty care providers can improve the efficiency of care, reduce the number of adverse and sentinel events, and reduce preventable readmissions. All providers can contribute to the improved management of complex patients and improved care coordination. Reference Capgemini Consulting. US Health Care Reform: The Emergence of Value Based Purchasing and Accountable Care Organizations. http://www.us.capgemini.com/insights-resources/ publications/us-health-care-reform-the-emergence-of-value-based-purchasing-and-accountable-care-organizations. Accessed December 2, 2011. 5

The Medicare Shared Savings Program is a component of the Affordable Care Act aimed at reforming Medicare. The program aims to provide better care for individuals, improve population-wide health, and reduce Medicare Part A and Part B spending through changes in healthcare delivery by encouraging the development of ACOs. There are 33 shared savings program measures 7 focusing on patient/caregiver experience 6 for care coordination and patient safety 8 for preventive health 12 for at-risk populations The at-risk population measures include 6 measures for diabetes care: A1C control <8%, LDL-C <100 mg/dL, blood pressure <140/90 mm Hg, tobacco nonuse, aspirin use, and poor A1C control >9%. Other measures focus on cholesterol management in patients with ischemic vascular disease or coronary heart disease. These are a complete lipid profile and LDL-C control <100 mg/dL for patients with ischemic vascular disease, and drug therapy to lower LDL-C for patients with coronary artery disease. Reference Centers for Medicare & Medicaid Services. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations. 42 CFR Part 425. Final Rule. 6

The next slides show examples of ACO pilot projects The next slides show examples of ACO pilot projects.CMS designed the Physician Group Practice Demonstration to investigate if care management initiatives could generate cost savings while improving healthcare quality. The demonstration began in April 2005, with 10 large group practices (ranging from 232 to 1291 physicians) in various regions of the country. Participating clinicians received their regular Medicare fee-for-service payments, but the groups were also eligible for an 80% share of Medicare’s savings (“performance payments”) if they collectively achieved specified quality and cost targets for their Medicare beneficiaries. To qualify for performance payments, groups had to generate savings for Medicare Parts A and B of more than 2% of their target expenditures. The 4-year results from the Medicare Group Practice Demonstration are shown here. All group practices achieved high-quality ratings, but only about half of them were profiting through shared savings. Reference Iglehart JK. Assessing an ACO prototype—Medicare’s Physician Group Practice Demonstration. N Engl J Med. 2011;364(3):198-200. 7

The Dartmouth Institute for Health Policy & Clinical Practice and The Brookings Institution are working with health systems, physicians, commercial health insurers, and state and federal government to pilot the ACO model. Five diverse provider groups have been chosen to participate in this program, and are listed on the right. Reference Capgemini Consulting. US Health Care Reform: The Emergence of Value Based Purchasing and Accountable Care Organizations. 2011. http://www.us.capgemini.com/insights-resources/by-publication/us-health-care- reform-the-emergence-of-value-based-purchasing-and-accountable-care-organizations/. Accessed December 2, 2011. 8 D

The Physician Quality Reporting System, or PQRS, has grown substantially from its inception in 2007.1,2 The PQRS measures help standardize and improve the quality of healthcare services provided to Medicare beneficiaries.1 PQRS remains a voluntary quality reporting program that offers, in 2012, an incentive payment of 0.5% of eligible Medicare Part B fee-for-service charges to professionals who satisfy reporting requirements.1-3 In order to qualify for an incentive payment, providers need to report on at least 80% of patients via a registry or electronic health record, or on at least 50% of patients via claims-based reporting.2 A penalty of 1.5% will be introduced in 2015 for those not satisfying quality reporting requirements.3 In addition, physicians can obtain an incentive for electronic prescribing, set for 2012 at 1%, and 0.5% for 2013. In 2013, CMS will introduce a penalty of 1.5% of Part B charges, and this penalty will increase to 2.0% in 2014.4 The graph shows the exponential growth in participation in the PQRS program.1 References Centers for Medicare & Medicaid Services. 2009 reporting experience report including trends (2007-2010): Physician Quality Reporting System and Electronic Prescribing (eRX) Incentive Program. https://www.cms.gov/pqrs/2009/itemdetail.asp?itemid=CMS1246584. Published April 4, 2011. Accessed October 14, 2011. Centers for Medicare & Medicaid Services. Physician Quality Reporting System: satisfactorily reporting 2011 measures−claims and registry. https://www.cms.gov/PQRS/downloads/ w2011PQRSSatisfRprtngPQRSMsresClmsRgstryTS061711f.pdf. Published June 2011. Accessed October 14, 2011. Hart Health Strategies. PPACA: a closer look-Physician Quality Reporting System (PQRS) changes. Updated January 6, 2011. Centers for Medicare & Medicaid Services. Proposed changes for calendar year 2012 physician incentive programs. http://www.snm.org/index.cfm?PageID=1110&FileID=199143. Published July 1, 2011. Accessed October 27, 2011. 9

Physicians are measured on a large number of diabetes measures, listed on this slide: A1C poor control >9.0% LDL-C control <100 mg/dL Blood pressure control <140/90 mm Hg Diabetic retinopathy: documented presence or absence of macular edema and level of severity of retinopathy; communication with physician managing ongoing diabetes care; dilated eye exam Urine screening for microalbuminuria or medical attention nephropathy Diabetic foot and ankle care, peripheral neuropathy – neurological evaluation, and ulcer prevention – evaluation of footwear and foot exam A1C control <8% Daily aspirin use Tobacco nonuse Cholesterol-related measures are also listed here: Diabetes LDL-C control <100 mg/dL (as mentioned earlier) Coronary heart disease LDL-C control <100 mg/dL, or LDL-C >100 mg/dL with documented plan of care to improve LDL-C levels Ischemic heart disease: complete lipid panel and LDL-C control <100 mg/dL Hypertension LDL-C control (at goal) and preventive care and screening: fasting LDL-C test and risk stratified LDL-C at or below recommended goal Reference Centers for Medicare & Medicaid Services. 2012 Physician Quality Reporting System (Physician Quality Reporting) measures list. https://www.cms.gov/PQRS/15_MeasuresCodes.asp. Published November 11, 2011. Accessed January 9, 2012. 10