1. The Affordable Care Act and Quality Transformation
Kate Goodrich, M.D. MHS
Senior Technical Advisor, CMS
Office of Clinical Standards and Quality
June 21, 2012

2. Objectives Overview of CMS and OCSQ
Discuss ACA provisions and national initiatives that are relevant to your work and that you can participate in
Hear your questions/concerns and discuss how we can partner to improve care

3. Size and Scope of CMS Responsibilities
4/11/2017
Size and Scope of 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.

4. The “Three-Part Aim” Better Health for the Population Better Care
for Individuals
Lower Cost
Through
Improvement

5. OCSQ Vision
To optimize health outcomes by leading clinical quality improvement and health system transformation

6. OCSQ Organization
Front Office leadership: Dr. Patrick Conway, Wes Perich, Dr. Shari Ling, Dr. Kate Goodrich, and Danielle Andrews
Coverage & Analysis Group (CAG), Dr. Louis Jacques
Clinical Standards Group (CSG), John Thomas
Survey and Certification Group (SCG), Thomas Hamilton
Quality Improvement Group (QIG), Jean Moody-Williams
Quality Measurement & Health Assessment Group (QMHAG), Dr. Michael Rapp
Information Systems Group (ISG), Debbra Hattery
Business Office Support Group (BOS), Rachael Weinstein

7. Office of Clinical Standards and Quality Levers for Safety, Quality & Value
Contemporary Quality Improvement: Quality Improvement Organizations
Transparency, Public Reporting & Data Sharing: Hospital Inpatient Quality Reporting Program
Incentives: Hospital Value Based Purchasing
Regulation: Conditions of Participation (Hospitals, 15 other provider types), Survey and Cert.
National & Local Coverage Decisions: Evidence-based coverage, coverage for Preventative Services
Demonstrations, Pilots, Research, Grants, Innovation: Diabetes Self Management in Mississippi 7 7

8. The “3T’s” Road Map to Transforming U.S. Health Care
Key T1 activity to test
what care works
Clinical efficacy research
Key T2 activities to test
who benefits from
promising care
Outcomes research
Comparative effectiveness
Research
Health services research
Key T3 activities to test
how to deliver high-quality
care reliably and in
all settings
Quality Measurement and
Improvement
Implementation of
Interventions and health
care system redesign
Scaling and spread of
effective interventions
Research in above domains T1 T2 T3
Basic biomedical
science
Clinical efficacy
knowledge
Clinical effectiveness
Improved health
care quality &
value &
population health
Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp The “3T’s Roadmap to Transform U.S. Health Care: The ‘How’ of High-Quality Care.”

9. 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 networks
Training of clinicians and multi-disciplinary teams
Source: P.H. Conway and Clancy C. Transformation of Health Care at the Front Line. JAMA 2009 Feb 18; 301(7): 763-5

10. Rapid Cycle Improvement - How can we improve more quickly?
Apply proven interventions reliably across settings and measure results
Test the application of new interventions and learn in rapid cycle
Partner with providers, communities, and patients
Move beyond a “traditional” government contract with delayed evaluation model
Focus efforts where improvement most needed and target interventions

11. Quality Measurement

12. National Quality Strategy promotes better health, healthcare, and lower cost
Three-part aim:
Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.
Healthy People and Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
Six priorities:
Making care safer by reducing harm caused in the delivery of care.
Ensuring that each person and family are engaged as partners in their care.
Promoting effective communication and coordination of care.
Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
Working with communities to promote wide use of best practices to enable healthy living.
Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. 12

13. CMS has a variety of quality reporting and performance programs
Hospital Quality
Medicare and Medicaid EHR Incentive Program
PPS-Exempt Cancer Hospitals
Inpatient Psychiatric Facilities
Inpatient Quality Reporting
HAC payment reduction program
Readmission reduction program
Outpatient Quality Reporting
Ambulatory Surgical Centers
Physician Quality Reporting
PQRS
eRx quality reporting
PAC and Other Setting Quality Reporting
Inpatient Rehabilitation Facility
Nursing Home Compare Measures
LTCH Quality Reporting
Hospice Quality Reporting
Home Health Quality Reporting
Payment Model Reporting
Medicare Shared Savings Program
Hospital Value-based Purchasing
Physician Feedback/Value-based Modifier*
ESRD QIP
“Population” Quality Reporting
Medicaid Adult Quality Reporting*
CHIPRA Quality Reporting*
Health Insurance Exchange Quality Reporting*
Medicare Part C*
Medicare Part D*
* Denotes that the program did not meet the statutory inclusion criteria for pre-rulemaking, but was included to foster alignment of program measures.

14. CMS framework for measurement maps to the six national priorities
Care coordination
Transition of care measures
Admission and readmission measures
Other measures of care coordination
Clinical quality of care
Population/ community health
HHS primary care and CV quality measures
Prevention measures
Setting-specific measures
Specialty-specific measures
Measures should be patient-centered and outcome-oriented whenever possible
Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures
Measures that assess health of the community
Measures that reduce health disparities
Access to care and equitability measures
Person- and Caregiver- centered experience and outcomes
Efficiency and cost reduction
Safety
Spend per beneficiary measures
Episode cost measures
Quality to cost measures
CAHPS or equivalent measures for each settings
Functional outcomes
HCACs, including HAIs
All cause harm
Greatest commonality of measure concepts across domains 14

15. Quality can be measured and improved at multiple levels
Community
Population-based denominator
Multiple ways to define denominator, e.g., county, HRR
Applicable to all providers
Three levels of measurement critical to achieving three aims of National Quality Strategy
Measure concepts should “roll up” to align quality improvement objectives at all levels
Patient-centric, outcomes oriented measures preferred at all three levels
The six domains can be measured at each of the three levels
Practice setting
Increasing individual accountability
Denominator based on practice setting, e.g., hospital, group practice
Increasing commonality among providers
Individual physician/EP
Denominator bound by patients cared for
Applies to all physicians/EPs

16. 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
Align measures across programs where appropriate
Focus on patient centered measures (patient outcomes and patient experience)
Parsimonious sets of measures; core sets of measures and measure concepts
Removal of measures that are no longer appropriate

17. Value Based Purchasing

18. Purpose statement for Value-Based Purchasing7
Purpose statement for Value-Based Purchasing
Value-based purchasing is a tool that allows CMS to link the National Quality Strategy with fee-for-service payments at a national scale. It is an important driver in revamping how services are paid for, moving increasingly toward rewarding providers and health systems that deliver better outcomes in health and health care at lower cost to the beneficiaries and communities they serve. 18

19. Introduction to the Hospital Value-Based Purchasing Program7
Introduction to the Hospital Value-Based Purchasing Program
Initially required in the Affordable Care Act and further defined in Section 1886(o) of the Social Security Act
Quality incentive program built on the Hospital Inpatient Quality Reporting (IQR) measure reporting infrastructure
Funded by an initial 1% withhold from participating hospitals’ Diagnosis-Related Group (DRG) payments 19

20. FY2013 HVBP Program Summary7
FY2013 HVBP Program Summary
Two domains: Clinical Process of Care (12 measures) and Patient Experience of Care (8 HCAHPS dimensions)
Hospitals are given points for Achievement and Improvement for each measure or dimension, with the greater set of points used
70% of Total Performance Score based on Clinical Process of Care measures
30% of Total Performance Score based on Patient Experience of Care dimensions 20

21. 8 Patient Experience of Care Dimensions Weighted Value of Each Domain7
FY2013 HVBP measures
12 Clinical Process of Care Measures
8 Patient Experience of Care Dimensions
Weighted Value of Each Domain 21 21

22. FY2014 HVBP domains Outcomes domain Patient experience domain (25%)7
FY2014 HVBP domains
Outcomes domain
(25%)
Patient experience domain
(30%)
Clinical process of care domain
(45%) 22

23. Readmissions Program and Risk-Standardized Readmission Measures

24. Why Measure Readmissions?
As you know,
Readmissions are disruptive and undesirable events for patients
Readmissions are common (one out of 5 Medicare admissions)
Readmissions are costly ($17 billion annually for Medicare)
Foster common goals across health system (hospitals, post-acute care providers, physicians, patients) to reduce the risk of readmission and coordinate care

25. Aims for Readmission Measures
Promote broadest possible efforts to lower readmission rates
Assume all patients are at risk of readmission and their risk can be lowered
Opportunity to focus efforts on patients most at risk of readmission
CMS is trying to target funding support to hospitals and communities with greatest need for improvement
Goal is not zero readmissions, but to lower readmission rates overall

26. Current CMS Readmission Measures
Publicly-reported (NQF endorsed)—Since July 2009
Acute myocardial infarction
Heart failure
Pneumonia
Development completed
Percutaneous coronary intervention (registry)
Stroke
Hip/knee replacement
Vascular procedures
Chronic obstructive pulmonary disease
Hospital-wide readmission
In development
Coronary artery bypass graft

27. CMS Hospital Readmission Measures
30-day timeframe from date of discharge of index admission
All-cause readmission
excludes planned readmissions
Risk Adjusted for patient case mix

28. Risk Adjusted Readmission Rate
Relative measure of hospital performance
Allows comparison of a particular hospital’s performance given its case-mix to an average hospital’s performance with same case-mix
Analogous “observed” to “expected” ratio

29. Public Reporting Measures reported yearly with 3 years of data
Reported on Hospital Compare as “better than the U.S. national rate” or “worse than the U.S. national rate”, “no different than the U.S. national rate” or “the difference is uncertain
Do not classify performance for hospitals that have fewer than 25 cases in 3 year period

30. Payment Adjustment Based on readmissions for AMI, HF and Pneumonia
In FY2015, 4 conditions can be added
Applies to hospital’s base DRG payments for all Medicare discharges beginning October 1, 2012
FY 2013 no more than 1% reduction
FY 2014 no more than 2% reduction
FY 2015 no more than 3% reduction
Calculation methodology not yet finalized in rule-making

31. Recap We covered We did not cover Quality Transformation Principles
National Quality Strategy
Quality Measurement Programs
Readmissions Reduction Program
Value Based Purchasing
We did not cover
Patient Centered Outcomes Research
ACOs
Bundled Payments
Meaningful use of EHRs
Much more!

32. What can Nurses do?
Partner with your hospital/practice administration and quality improvement team – we’re all in this together!
Understand your care setting’s performance data – share data within and outside your environment
Nurse leadership
Lead multidisciplinary teams to pilot and test QI projects
Understand the evidence
Teach others around you
Access the resources at your disposal – QIOs, HENs, etc.
Create a collaborative forum with community partners, other providers, patients and families

33. Contact Information Dr. Kate Goodrich, MD MHS Senior Technical Advisor Office of Clinical Standards and Quality

34. Questions or Comments Questions for you Questions or comments for me
How can I and CMS serve you better?
What are some ways that we can collaborate?
How can CMS and OCSQ improve?
What should we collectively do to achieve better outcomes?
What should I know that I might not?
Questions or comments for me