1. CMS Quality Strategy Robert Anthony
Deputy Director, Quality Measurement & Value-based Incentives Group
Center for Clinical standards and Quality
September 17, 2015

2. Our Vision
to optimize health outcomes by improving clinical quality and transforming the health system.

3. Our Three Aims Better Health for the Population Lower Cost Through
Better Care
for Individuals
Lower Cost
Through
Improvement
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.

4. National Quality Strategy promotes better health, better healthcare, and lower costs through
Make care safer by reducing harm caused in the delivery of care
Ensure that each person and family are engaged as partners in their care
Promote effective communication and coordination of care
Promote effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease
Work with communities to promote wide use of best practices to enable healthy living
Make quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models
Six Priorities 4

5. The Six Priorities Have Become the Goals for the CMS Quality Strategy
Making care safer
Strengthen person and family engagement
Promote effective communication and coordination of care
Promote effective prevention and treatment
Work with communities to promote best practices of healthy living
Make care affordable

6. 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
Develop measures meaningful to patients and providers, focused on outcomes (including patient-reported outcomes), safety, patient experience, care coordination, appropriate use, and cost
Align measures across CMS programs whenever possible
Parsimonious sets of measures; core sets of measures
Removal of measures that are no longer appropriate (e.g., topped out or process distal from outcome)
Align measures with states, private payers, boards and specialty societies

7. Make Care Safer Objectives Reduce inappropriate and unnecessary care
Prevent or minimize harm in all settings
Improve support for a culture of safety
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

8. Improve support for a culture of safety
Make Care Safer
Objective
Desired Outcomes
Improve support for a culture of safety
Improved application of safety practices in our programs to involve all team members, patients, and families and assure that the patient voices are heard
Organizations exhibit strong leadership that educates and empowers the workforce to recognize harm and increase reporting of errors
Increased access to understandable health information
Expanded use of evidence-based services and primary care
Disparities of care are eliminated
Expand use of patient experience surveys across all settings and programs and assign higher weight in VBP programs
Incorporate the measure of use of AHRQ culture of safety tools into IQR then HVBP and reward improvement
Incorporate measures of harm/safe practices into all quality and VBP programs
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

9. Reduce inappropriate and unnecessary care
Make Care Safer
Objective
Desired Outcomes
Reduce inappropriate and unnecessary care
Health care organizations continually assess events in accordance with evidence-based practices
Health care cost reductions are attributed to the reduction of unnecessary, duplicative, and inappropriate care
Improved achievement of patient-centered goals of care is evident
Disparities of care are eliminated
Publicly report Appropriate Use measures
Work with OC and others to create a 5 star domain on Appropriate Use on Compare/Marketplace sites
Through E&O (ODFs, Measure forums, Grand Rounds, NPCs, etc.), work with stakeholders such as NQF and others to ensure that Appropriate Use is seen as a safety issue, not just a cost issue
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

10. Prevent or minimize harm in all settings
Make Care Safer
Objective
Desired Outcomes
Prevent or minimize harm in all settings
HACs and HAIs are reduced
Medication error rates are improved
Falls are decreased
Visibility of harm is improved in all settings
Use of evidence-based services and primary care is expanded
Patient and family access to understandable health information is increased
Disparities of care are eliminated
Use patient-centered quality measures related to harm in all models
Develop new collaborative models of care that incentivize team based practice and use evidence based medicine to reduce harm
Enable multi-disciplinary teamwork through sharing of best practices (LANs), coordination and collaboration
Incentivize multi-disciplinary teamwork in all models to coordinate care and reduce waste
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

11. Partnership for Patients and QIO work: Hospital Acquired Condition (HAC) Rates Show Improvement
2010 – Preliminary data show a 9% reduction in HACs across all measures
Many areas of harm dropping dramatically (2010 to 2013 for these leading indicators)
Ventilator-Associated Pneumonia (VAP)
Early Elective Delivery (EED)
Obstetric Trauma Rate (OB)
Venous thromboembolic complications (VTE)
Falls and Trauma
Pressure Ulcers
55.3% ↓
52.3% ↓
12.3% ↓
12.0% ↓
11.2% ↓

12. Reduced Potential for Adverse Drug Events
Measurement Period
n= 44,640 instances of potential adverse drug events identified and prevented
d= 195,352 opportunities for adverse drug events
Total Beneficiaries = 57, 657
44,640
Potential adverse drug events
were
prevented

13. 85,149 fewer days with urinary catheters for beneficiaries
Reducing HAC in Hospitals - Fewer infections
85,149 fewer days with urinary catheters for beneficiaries

14. Strengthen Person and Family Engagement
Objectives
Ensure care delivery incorporates patient and caregiver preferences
Improve experience of care for patients, caregivers and families
Promote patient self-management
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

15. Strengthen Person and Family Engagement
Objective
Desired Outcomes
Patients are partners at all levels of care
Care and treatment reflects patients’ personal values and goals
Coordination and communication occurs within and across care teams, including patients, families, and caregivers 
Patient and family preferences are central in decision processes and implementation
Joint development of treatment goals and longitudinal plans of care
Information is updated and available for use by patients
Achievement of patient-centered goals that focus on prevention
Improved coordination and communication within and across organizations
Disparities in care are eliminated
Ensure all care delivery incorporates patient and caregiver preferences
Collaborate with states through new delivery systems and payment models to include ways to measure how patients experience care
Develop patient experience surveys for ages and settings where none exist (e.g., Home and Community-Based Services experience survey and Pediatric HCAHPS)
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

16. Strengthen Person and Family Engagement
Objective
Desired Outcomes
Promote patient self-management
Improved application of self-management practices in our programs
Improved visibility of self-management
Improved support for integrated care models
Increased access to understandable health information
Updated and available information for use by patients
Improved patient confidence in managing chronic conditions
A respectful, trustworthy, transparent healthcare culture
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

17. Promote Effective Communication and Coordination of Care
Objectives
Reduce admissions and readmissions
Embed best practices to manage transitions to all practice settings
Enable effective health care system navigation
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

18. Promote Effective Communication and Coordination of Care
Objective
Desired Outcomes
Patient self-management and activation efforts result in reduced admission and readmission rates
Increased health literacy rates
Survey results demonstrate measurable reduction in deficiencies related to discharge planning and care transitions
Evidence based best practices that promote appropriate discharge planning and care transition are embedded in routine practice of care across the health care continuum
Appropriate interventions prevent development of health conditions that require acute care
Wasteful expenses from avoidable admissions and readmissions is reduced drastically
All those who provide care in a particular community work in coordination to optimize patient care
Reduce admissions and readmissions
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

19. Hospital Readmissions Continue to Decline Steeply

20. Promote Effective Communication and Coordination of Care
Objective
Desired Outcomes
Embed best practices to manage transitions to all practice settings
Integrated, patient-centric discharge tools are used across all practice settings
Community-based support systems integrated with health care delivery are developed and employed
Patient activation efforts and self-management training are a standard part of care
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

21. Promote Effective Communication and Coordination of Care
Objective
Desired Outcomes
Enable effective health care system navigation
Evidence-based best practices that enable patient activation and self-management are embedded in the routine practice of care
Payer reimbursement is expanded beyond education to include chronic disease self-management education programs
Cross-setting discharge planning tools that include patient and family goals and preferences are routinely employed
Through focus groups and targeted communications to new duals, ensure that Medicare-Medicaid enrollees are better able to navigate their health care system
Promote innovative models of integrated care across Medicare and Medicaid to streamline care
Reduce misalignments across Medicare and Medicaid for Medicare-Medicaid enrollees
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

22. Promote Effective Prevention and Treatment
Objectives
Increase appropriate use of screening and prevention services
Strengthen interventions to prevent heart attacks and strokes
Improve quality of care for patients with multiple chronic conditions
Improve behavioral health access and quality care
Improve perinatal outcomes
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

23. CMS Priorities for Measure Development
Common Adverse Events
Global measure of harm?
Appropriate Use of Resources
Patients with Multiple Chronic Conditions
Aligning measures and incentives across providers
Actively monitor for unintended consequences
Advance science on Patient-Reported Outcome Measures
De novo e-measure development

24. Work with Communities to Promote Best Practices of Healthy Living
Objectives
Partner with and support federal, state, and local public health improvement efforts
Improve access within communities to best practices of healthy living
Promote evidence-based community interventions to prevent and treat chronic disease
Increase use of community-based social supports
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

25. Work with Communities to Promote Best Practices of Healthy Living
Objective
Desired Outcomes
Partner with and support federal, state, and local public health improvement efforts
Promote interoperability of health IT systems
Improved population health outcomes
Reduced disparities in health outcomes
Reduced health care costs through better coordination across sectors
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

26. Make Care Affordable
Objectives
Develop and implement payment systems that reward value over volume
Use cost analysis data to inform payment policies
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

27. Delivery system and payment transformation
Current State –
Producer-Centered
Volume Driven
Unsustainable
Fragmented Care
FFS Payment Systems
Future State – People-Centered
Outcomes Driven
Sustainable
Coordinated Care
New Payment Systems (and many more)
Value-based purchasing
ACOs, Shared Savings
Episode-based payments
Data Transparency
PRIVATE
SECTOR
PUBLIC
SECTOR

28. Medicare Per Capita Spending Growth at Historic Lows
*Medicare Part D prescription drug benefit implementation, Jan 2006
27%
28%
Source: CMS Office of the Actuary

29. Framework for Progression of Payment to Clinicians and Organizations in Payment Reform
Category 1: Fee for Service – No Link to Quality
Category 2: Fee for Service – Link to Quality
Category 3: Alternative Payment Models on Fee-for Service Architecture
Category 4: Population-Based Payment
Description
Payments are based on volume of services and not linked to quality or efficiency
At least a portion of payments vary based on the quality or efficiency of health care delivery
Some payment is linked to the effective management of a population or an episode of care
Payments still triggered by delivery of services, but, opportunities for shared savings or 2-sided risk
Payment is not directly triggered by service delivery so volume is not linked to payment
Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (eg, >1 yr)
Examples
Medicare
Limited in Medicare fee-for-service
Majority of Medicare payments now are linked to quality
Hospital value-based purchasing
Physician Value-Based Modifier
Readmissions/Hospital Acquired Condition Reduction Program
Accountable Care Organizations
Medical Homes
Bundled Payments
Eligible Pioneer accountable care organizations in years 3 – 5
Some Medicare Advantage plan payments to clinicians and organizations
Some Medicare-Medicaid (duals) plan payments to clinicians and organizations
Medicaid
Varies by state
Primary Care Case Management
Some managed care models
Integrated care models under fee for service
Managed fee-for-service models for Medicare-Medicaid beneficiaries
Medicaid Health Homes
Medicaid shared savings models
Medicaid waivers for delivery reform incentive payments
Episodic-based payments
Some Medicaid managed care plan payments to clinicians and organizations
This slide describes the framework for transition from pure FFS to population based payments and alternative payment structure
Relevant for CMS and private payers
Within CMS programs, category 1 is now significantly in the minority – most programs are in category 2
Our goal is to move an increasingly large share of total payments to all providers from FFS to models that explicitly reward value – quality and efficiency
Will be a steep learning curve – ultimately you want to align the CQMs across public and private payers as well as the payment systems, but will need time for payers (incl. CMS) to experiment with different models to best understand “what works” in which circumstances/environments.
Rajkumar R, Conway PH, Tavenner M. The CMS—Engaging Multiple Payers in Risk-Sharing Models. JAMA. Doi: /jama

30. ACO Participation is Growing Rapidly
ACO-Assigned Beneficiaries by County
360+ ACOs have been established, including 123 new Shared Savings ACOs for 2014
5.3 million assigned beneficiaries in 47 states, plus DC and PR

31. Value-Based Purchasing7
Value-Based Purchasing
Goal is to reward providers and health systems that deliver better outcomes in health and health care at lower cost to the beneficiaries and communities they serve.
Five Principles
Define the end goal, not the process for achieving it
All providers’ incentives must be aligned
Right measure must be developed and implemented in rapid cycle
CMS must actively support quality improvement
Clinical community and patients must be actively engaged
VanLare JM, Conway PH. Value-Based Purchasing – National Programs to Move from Volume to Value. NEJM July 26, 2012 31

32. Focusing on Outcomes
Focusing on the end results of care and not the technical approaches that providers use to achieve the results
Measure 30 day mortality rates, hospital-acquired infections, etc…
Determine if desired clinical results are achieved (low re-admissions, weight reduction, etc…)

33. Challenges in Measuring Performance
Determining indicators of outcomes that reflect national priorities
Recognizing that outcomes are usually influenced by multiple factors
Determining thresholds for ‘good’ performance
Recognizing that Process Measures don’t always predict outcomes

34. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Passed House 3/26/2015- Senate 4/14/2015
Signed into Law 4/16/2015
Repeals 1997 Sustainable Growth Rate Physician Fee Schedule (PFS) Update
Changes Medicare PFS Payment
Merit-Based Incentive Payment System (MIPS)
Incentives for participation in Alternate Payment Model (APM)
Jon Stewart- “only took 17 years”

35. MIPS & APM Incentives
Separate application of payment adjustments under PQRS, VM, and EHR-MU will sunset Dec. 31, 2018
January 1, 2019 – MIPS and APM incentive payments begin
EPs can participate in MIPS or meet requirements to be qualifying APM participant
MIPS – Can receive positive, negative or zero payment adjustment
APM Participant – If criteria are met, can receive 5 percent incentive payment for 6 years

36. Merit-Based Incentive Payment System (MIPS)
Jan 1, MIPS payment adjustment begins
Under MIPS the Secretary must develop a methodology to assess EP performance and determine a composite performance score
Features of PQRS, the Value Modifier and the EHR Meaningful Use program are included in MIPS
The score is used to determine and apply a MIPS payment adjustment factor for 2019 onward
Adjustment Can Be Positive, Negative, or Zero

37. More on MIPS 4 Performance Categories Quality measures (30% of Score)
Resource Use measures (30% of Score)
Counts for not more than 10% in 2019 and 15% in 2020; additional weight of at least 20% and 15%, respectively, are added to the Quality score in those years
Clinical Improvement Activities (15% of Score)
Sub-Categories- Includes Better Off-Hours Access, Care Coordination
Patient Safety, Beneficiary Engagement
Others as Determined by Secretary
Meaningful Use of EHRs (25% of Score)
On EHR- current MU statute is all or nothing. No sliding scale.
Legal comment: Quality Domain amounts could be higher than 20% and 15%, depending on the percentage applied under section 1848(q)(5)(E)(i)(II)(bb). We believe the language "not more" in that section gives the Secretary discretion to specify percentages for Resource Use of less than 10% and 15% for 2019 and 2020, respectively. Thus, using 2019 as an example, if Resource Use is 8%, then Quality would be increased by 30%-8%=22%.

38. More on MIPS
CMS will propose the initial policies for the MIPS in CY2017 PFS Rule Making - proposed rule published around June 2016
CMS must make available timely (“such as quarterly”) confidential feedback reports to each MIPS EP starting July 1, 2017
Beginning July 1, 2018, CMS must make available to each MIPS EP information about items and services furnished to the EP’s patients by other providers and suppliers for which payment is made under Medicare
Information about the performance of MIPS EPs must be made available on Physician Compare

39. MIPS & Measures
Nov 1st each year, CMS to publish measure list for MIPS
Update, add, revise list for coming performance period
MACRA explicitly states to emphasize outcome measures
CMS may use:
Inpatient hospital measures for MIPS EPs
Outpatient hospital measures may be used for emergency physicians, radiologists, & anesthesiologists.
Population based measures are allowed for MIPS
In selecting MIPS measures and applying the MIPS formula, Secretary shall give consideration to “non-patient facing” specialties

40. MIPS – Resource Use
To measure resource use, MACRA requires CMS to develop:
Care episode and patient condition groups and classification codes;
Patient relationship categories and codes, which include:
Primary responsibility for ongoing patient care over extended periods of time
Lead EP during acute care episode- including coordinating items & services by other EPs
Supporting EP during acute care episode providing continuing items, & services (but not lead)
EP providing occasional items & services; upon request of another EP
EP providing items & services as ordered by another EP
April 2016 – CMS to publish proposed codes online.
Stakeholder feedback comment period (4 months)
April 2017 – Final categories & codes published.
Revisions allowed Nov. 1, 2018 then every Nov. 1st thereafter.

41. MIPS - Clinical Practice Improvement Activities
Expanded Practice Access
Same day appointments for urgent needs
After hours clinician advice
Population Management
Monitoring health conditions & providing timely intervention
Participation in a qualified clinical data registry
Care Coordination
Timely communication of test results
Timely exchange of clinical information with patients AND providers
Use of remote monitoring
Use of telehealth
Beneficiary Engagement
Establishing care plans for complex patients
Beneficiary self-management assessment & training
Employing shared decision making
Measures

42. MIPS Composite Performance Score
Performance assessment in four categories using weights established in the statute
Weights may be adjusted if there are not sufficient measures and activities applicable for each type of EP, including assigning a scoring weight of 0 for a performance category.
EHR weighting can be decreased and shifted to other categories if Secretary estimates the proportion of physicians who are meaningful EHR users is 75% or greater (statutory floor for EHR weight is 15%)
Performance threshold will be established based on the mean or median of the composite performance scores during a prior period
The composite performance score will range from 0 – 100
The score will assess achievement & improvement (when data available)
Hospital report the same measures
EPs don’t so not clear if how many EPs will be eligible for “improvement”

43. Alternative Payment Model (APM) Incentive Payments
Beginning in 2019 and for 6 years 5% incentive payment for:
EPs or groups of EPs who participate in certain types of APMs and who meet specified payment thresholds.
Payment is made in a lump sum on an annual basis.
EPs or groups of EPs meeting criteria to receive APM incentive payment are excluded from the requirements of MIPS.

44. APM Incentive Payment Requirements
Participate in a defined APM and meet additional criteria of an eligible alternative payment entity.
Meet established thresholds.
Definition of APM
A Centers for Medicare and Medicaid Innovation (CMMI) model
Medicare Shared Savings Program Accountable Care Organizations
A CMS demonstration under section 1866C of the SSA; or required by Federal law

46. Questions?