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

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Presentation on theme: "The Affordable Care Act and Quality Transformation Kate Goodrich, M.D. MHS Senior Technical Advisor, CMS Office of Clinical Standards and Quality June."— Presentation transcript:

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

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

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 6

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

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 s Research in above domains T1T2T3 Basic biomedical science Clinical efficacy knowledge Clinical effectiveness knowledge 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 9 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 10

11 Quality Measurement

12 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.

13 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 Medicare and Medicaid EHR Incentive Program 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* 13 CMS has a variety of quality reporting and performance programs * 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 Greatest commonality of measure concepts across domains 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 Person- and Caregiver- centered experience and outcomes CAHPS or equivalent measures for each settings Functional outcomes Efficiency and cost reduction Spend per beneficiary measures Episode cost measures Quality to cost measures Care coordination Transition of care measures Admission and readmission measures Other measures of care coordination Clinical quality of care HHS primary care and CV quality measures Prevention measures Setting-specific measures Specialty-specific measures Population/ community health Measures that assess health of the community Measures that reduce health disparities Access to care and equitability measures Safety HCACs, including HAIs All cause harm

15 Quality can be measured and improved at multiple levels 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 Increasing individual accountability Increasing commonality among providers Community Practice setting Individual physician/EP Population-based denominator Multiple ways to define denominator, e.g., county, HRR Applicable to all providers Denominator based on practice setting, e.g., hospital, group practice 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 16

17 Value Based Purchasing

18 18 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.

19 19 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

20 20 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

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

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

23 Readmissions Program and Risk- Standardized Readmission Measures

24 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 Why Measure Readmissions? 24

25 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 25 Aims for Readmission Measures

26 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 26 Current CMS Readmission Measures

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

28 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 Risk Adjusted Readmission Rate

29 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 29 Public Reporting

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 –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 –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 34


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