1. Strategies Today for Higher Quality Tomorrow Barbara R. Paul, MD Director, Quality Measurement and Health Assessment Group CMS November 11, 2003

2. Overview of Today’s Presentation Strategies available to CMS to improve quality Focus on public reporting and rewarding superior performance Current Quality Initiatives Next steps

3. Pursuing Excellence

4. 4 WHAT WE CAN DO TO IMPROVE QUALITY IDENTIFY IMPROVEMENT OPPORTUNITIES AND SELECT APPROPRIATE IMPROVEMENT INTERVENTIONS ADOPT OR DEVELOP MEASURES COLLECT & ANALYZE DATA SELECT PRIORITY AREAS MANAGE PROCESS IN PARTNERSHIP WITH STAKEHOLDERS ESTABLISH & ENFORCE STANDARDS STRUCTURE COVERAGE AND PAYMENTS TO IMPROVE CARE SUPPORT STANDARD METHODS GIVE CONSUMERS INFOR- MATION AND ASSISTANCE TO MAKE CHOICES PROMOTE OR CREATE COLLABORA- TIONS AND PARTNER- SHIPS GIVE PLANS, DOCTORS & PROVIDERS TECHNICAL ASSISTANCE REWARD DESIRED PERFORM- ANCE

5. 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

6. A focus on consumer information, complemented by additional tactics ESTABLISH & ENFORCE STANDARDS REWARD DESIRED PERFORM- ANCE SUPPORT STANDARD METHODS GIVE CONSUMERS INFOR- MATION AND ASSISTANCE TO MAKE CHOICES PROMOTE OR CREATE COLLABORA- TIONS AND PARTNER- SHIPS GIVE PLANS, DOCTORS & PROVIDERS TECHNICAL ASSISTANCE STRUCTURE COVERAGE AND PAYMENTS TO IMPROVE CARE

7. Comparative Quality Information on www.medicare.gov www.medicare.gov Medicare Health Plan Compare - 1999 Dialysis Facility Compare - 2001 Nursing Home Compare - 2002 Home Health Compare – 2003 Hospital Compare – 2004

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. The National Voluntary Hospital Reporting Initiative October: –www.cms.hhs.gov –www.cms.hhs.gov website livewww.cms.hhs.gov –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

15. 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.

16. 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

17. 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. www.cms.hhs.gov www.cms.hhs.govReports the performance data on www.cms.hhs.gov www.cms.hhs.gov

18. The Premier Hospital Quality Incentive Demonstration 5 clinical conditions (34 measures) –Acute MI –Heart Failure –Pneumonia –Coronary Artery Bypass Graft –Hip and Knee Replacement

19. 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

20. One possible payment scenario 1st Decile Hospital 2 Condition X Top Performance Threshold Payment Adjustment Threshold 2nd Decile 3rd Decile 4th Decile 5th Decile 6th Decile 7th Decile 8th Decile 9th Decile 10th Decile Year One Year TwoYear Three 1st Decile 2nd Decile 3rd Decile 4th Decile 5th Decile 6th Decile 7th Decile 8th Decile 9th Decile 10th Decile 1st Decile 2nd Decile 3rd Decile 4th Decile 5th Decile 6th Decile 7th Decile 8th Decile 9th Decile 10th Decile

21. The Quality Initiatives - Physician Offices Current work via Quality Improvement Organizations (QIO) Developmental work –DOQ –DOQ-IT

22. 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

23. Doctor’s 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

24. 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

25. 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

26. 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

27. 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.

28. 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.

29. 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?

30. 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

31. More Information http://www.medicare.gov –Comparative databases for NH, HH, M+C, Dialysis Facilities http://www.cms.hhs.gov »Comparative database for hospitals »Technical User’s manuals »Measure specifications »Frequently asked questions »Fact Sheets

32. Thank you Barbara R. Paul MD 410-786-5629 bpaul@cms.hhs.gov