1. Medicare’s Healthcare Quality Incentive Strategies Sheila H. Roman, MD, MPH Trent Haywood, MD, JD CMS September 27, 2005

2. Overview of Today’s Presentation CMS focus on public reporting and pay for performance demonstrationsCMS focus on public reporting and pay for performance demonstrations MB Update in MMAMB Update in MMA Hospital Quality Incentive Demonstration with Premier, Inc. Hospital Quality Incentive Demonstration with Premier, Inc.

3. Calls for Medicare to Provide Payment for Quality IOM report 2002IOM report 2002 Health Affairs article, former HCFA administrators, 2003Health Affairs article, former HCFA administrators, 2003 MedPAC report 2004MedPAC report 2004 Private sector effortsPrivate sector efforts Bridges to ExcellenceBridges to Excellence Leapfrog GroupLeapfrog Group

4. Medicare Demonstrations A demo is a way for CMS to send a new message, to test new payment methodsA demo is a way for CMS to send a new message, to test new payment methods Medicare demonstrations linking payment to qualityMedicare demonstrations linking payment to quality Premier hospital quality incentive demoPremier hospital quality incentive demo Care management performance demoCare management performance demo Physician group practice demoPhysician group practice demo

5. Hospital Quality Alliance (HQA): Improving Care Through InformationEnd-game: excellent quality careexcellent quality care To get there: one robust, nationally standardized and prioritized set of measures reported by every hospital in the country, accepted by all purchasers, overseers and accreditors;one robust, nationally standardized and prioritized set of measures reported by every hospital in the country, accepted by all purchasers, overseers and accreditors; Collaborations, standardization, oversight, incentivesCollaborations, standardization, oversight, incentives

6. Differential Marketbasket payment update, sec. 501 “each subsection (d) hospital shall submit to the Secretary quality data (for a set of 10 indicators established by the Secretary as of November 1, 2003) that relate to the quality of care furnished by the hospital in inpatient settings in a form and manner, and at a time, specified by the Secretary.”“each subsection (d) hospital shall submit to the Secretary quality data (for a set of 10 indicators established by the Secretary as of November 1, 2003) that relate to the quality of care furnished by the hospital in inpatient settings in a form and manner, and at a time, specified by the Secretary.” If such hospital does not submit data…”the applicable (payment) percentage increase … shall be reduced by O.4 percentage points”If such hospital does not submit data…”the applicable (payment) percentage increase … shall be reduced by O.4 percentage points”

7. Hospital Public Reporting

8. HQA: Current Status “Starter set” of 10 measures (bolstered by MMA market basket payment update incentive to PPS hospitals)“Starter set” of 10 measures (bolstered by MMA market basket payment update incentive to PPS hospitals) Over 4,000 hospitals reported in November, 2004Over 4,000 hospitals reported in November, 2004 More clinical measures (10 to 17 to 20 through September 2005)More clinical measures (10 to 17 to 20 through September 2005)

9. The first national project to measure hospital performance and offer additional Medicare payment for top quality careThe first national project to measure hospital performance and offer additional Medicare payment for top quality care “Pay for quality”“Pay for quality” Can economic incentives effectively improve quality of care?Can economic incentives effectively improve quality of care? CMS/Premier Hospital Quality Incentive Demonstration Project

10. HQID Hospital Participation VoluntaryVoluntary Eligibility: Hospitals in Premier Perspective system as of March 31, 2003Eligibility: Hospitals in Premier Perspective system as of March 31, 2003 278 hospitals participating278 hospitals participating Demonstration Project: Pilot test of conceptDemonstration Project: Pilot test of concept May be expanded in the futureMay be expanded in the future

11. CMS/Premier HQI – Over 270 National participating hospitals

12. HQID: Expanded Set of Measures Use of 34 measuresUse of 34 measures Expands 10 measure “Starter Measure Set” in HQAExpands 10 measure “Starter Measure Set” in HQA Drawn largely from NQF endorsed hospital performance measure setsDrawn largely from NQF endorsed hospital performance measure sets Uses both process and outcome measuresUses both process and outcome measures Includes 2 AHRQ PSIsIncludes 2 AHRQ PSIs

13. A three-year effort linking payment with quality measures (launched October, 2003)A three-year effort linking payment with quality measures (launched October, 2003) Top performers identified in five clinical areasTop performers identified in five clinical areas Acute Myocardial InfarctionAcute Myocardial Infarction Congestive Heart FailureCongestive Heart Failure Coronary Artery Bypass GraftCoronary Artery Bypass Graft Hip and Knee ReplacementHip and Knee Replacement Community Acquired PneumoniaCommunity Acquired Pneumonia Indicators within AMI, CABG, HF, and CAP represent all patients (all payers). Hip and knee replacement indicators apply only to Medicare patients. HQI demonstration project

14. HQID Hospital Scoring Hospitals scored on quality measures related to each conditionHospitals scored on quality measures related to each condition Individual measures “rolled-up” into overall composite score for each conditionIndividual measures “rolled-up” into overall composite score for each condition Composed of two components:Composed of two components: Composite Process RateComposite Process Rate Risk-Adjusted Outcomes IndexRisk-Adjusted Outcomes Index Categorized into deciles by condition to determine top performersCategorized into deciles by condition to determine top performers

15. The Hospital Quality Incentive Demonstration Bonuses for top 2 deciles for each conditionBonuses for top 2 deciles for each condition Top decile given 2% bonus of their Medicare DRG payments for that conditionTop decile given 2% bonus of their Medicare DRG payments for that condition Second decile given a 1% bonusSecond decile given a 1% bonus Possible penalty in third year if below baseline thresholdPossible penalty in third year if below baseline threshold

16. HQID: Year 3 Quality Score Must Exceed Baseline Demonstration baselineDemonstration baseline Clinical thresholds set at year one threshold scoresClinical thresholds set at year one threshold scores Lower 9 th and 10 th decilesLower 9 th and 10 th deciles If performance in year 3 does not exceed baseline, hospital will receive payment penaltyIf performance in year 3 does not exceed baseline, hospital will receive payment penalty 1% lower DRG payment for conditions below 9 th decile baseline level1% lower DRG payment for conditions below 9 th decile baseline level 2% lower DRG payment for conditions below 10 th decile baseline level2% lower DRG payment for conditions below 10 th decile baseline level

17. Anticipated payment scenario 1st Decile Hospital Year One Year Two Year Three Top Performance Threshold Payment Adjustment Threshold 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 1st Decile 2nd Decile 3rd Decile 4th Decile 5th Decile 6th Decile 7th Decile 8th Decile 9th Decile 10th Decile Condition X Payment Incentive Payment Adjustment - Year 3

18. CMS/Premier HQI Project Already showing improvement

19. CMS/Premier HQI Project Reduction in Variation Positive trend in both upper and lower scores of range Positive trend in both upper and lower scores of range Reduction in variance (narrowing of range) Reduction in variance (narrowing of range) Median moving upward Median moving upward

20. Challenges to Incentives for Quality Performance Selection of measures/off label use of measuresSelection of measures/off label use of measures Dynamic measurement environmentDynamic measurement environment Measures maintenanceMeasures maintenance Hospital BurdenHospital Burden Unintended consequencesUnintended consequences Time lagsTime lags Validation/Scoring methodologyValidation/Scoring methodology Need for proof of effectivenessNeed for proof of effectiveness

21. Next Frontiers Measurement of other dimensions of qualityMeasurement of other dimensions of quality Scoring methodologiesScoring methodologies BenchmarkingBenchmarking Incentives/Payment for qualityIncentives/Payment for quality Health Information TechnologyHealth Information Technology Improve health care systemsImprove health care systems

22. Thank you! Sheila H. Roman, MD, MPH 410-786-6004sheila.roman@cms.hhs.gov