1. Medicare Beneficiary Quality Improvement Project (MBQIP) Update July 2016
Yvonne Chow
MBQIP Coordinator, Hospital-State Division Federal Office of Rural Health Policy (FORHP)
Health Resources and Services Administration (HRSA)

2. Overview Policy Updates Trends in Quality Reporting
MBQIP 2016 Recap and Next Steps

3. Policy Update
Centers for Medicare and Medicaid Services (CMS) Proposed Rule: Changes for critical access hospitals (CAHs) include standards for:
Maintaining a data-driven quality assessment and performance improvement (QAPI) program.
Mentions MBQIP as a national quality measurement and reporting program
Written non-discrimination policies;
Regularly evaluating the care provided by practitioners at the CAH;
Maintaining active infection prevention, infection control, and antibiotic stewardship programs.
Due date for public comments: August 15, 2016
National Quality Forum Rural Project report (2015)
$100 million contract over 5 years to support rural provider participation in new Quality Payment Program (MACRA/MIPS) 3

4. Trends in Quality Reporting
Quality Reporting and the ‘Move to Value’
CMS retiring “topped out” measures
Shift towards outcome vs. process metrics
Electronic Clinical Quality Measures (eCQMs)
Star Measure Composites
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Overall Hospital Quality Star Ratings
One quarter of all US hospitals are CAHs
JAMA Article(s) from 2011 calling out CAHs for poor quality
PPS hospitals paid based on quality performance – expectation that third party payers will follow the lead of CMS and expect value demonstration from CAHs even if Medicare reimbursement for CAHs doesn’t change.

5. Centers for Medicare & Medicaid Services (CMS) Payment Goals
Percent of Medicare Payment Goals
Alternative Payment Models (APMs) – 50%
Shared savings program (ACOs)
Patient-centered medical homes (PCMH)
Bundled payments
Remaining fee-for-service payment linked to quality/value – 90%

6. Move to Value: Rural Context
Value-Based Purchasing (VBP) programs have typically launched with ‘reporting’ efforts:
MBQIP measures aligns with CMS IQR (Inpatient Quality Reporting) and OQR (Outpatient Quality Reporting) programs
For CMS Hospital VBP, measures required to be part of CMS IQR for a least a year before included in VBP.
Infrastructure built on traditional Fee for Service (FFS)/Prospective Payment System (PPS) payment structure
Continued roll-out by CMS across health care sectors:
Hospitals, ESRD, Home Health, Long Term Care, Physicians…
MACRA/MIPS: Quality Payment Program (QPP)
CAH Value-Based Purchasing Demonstration included in the Affordable Care Act (ACA), but not yet implemented

7. Definition -“topped out”
“Measure performance among hospitals is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made.”
Federal Register /Vol. 81, No. 81 /Wednesday, April 27, 2016 / IPPS Proposed Rules/page 25175
Topped out measures: 1) should show statistically indistinguishable performance at the 75th and 90th percentiles; and 2) should also have a truncated coefficient of variation ≤0.10.

8. Shift away from Process Measures
“We note that we have proposed above to remove the Clinical Care—Process subdomain from the Hospital VBP Program beginning with the FY 2018 program year.”
Federal Register /Vol. 80, No. 83 /Thursday, April 30, 2015 / IPPS Proposed Rules 24503
DOMAIN WEIGHTS FOR THE FY 2017 PROGRAM YEAR FOR HOSPITALS RECEIVING A SCORE ON ALL DOMAINS
Domain Weight
Safety percent.
Clinical Care percent.
• Clinical Care—Outcomes • 25 percent.
• Clinical Care—Process • 5 percent.
Efficiency and Cost Reduction percent.
Patient and Caregiver-Centered Experience of Care/Care Coordination percent.
PROPOSED DOMAIN WEIGHTS FOR THE FY 2018 PROGRAM YEAR FOR HOSPITALS RECEIVING A SCORE ON ALL DOMAINS
Safety percent.
Clinical Care percent.

9. Shift Towards Outcome and Cost Measures
Hospital VBP now includes four categories:
Safety (Health Care-Associated Infections, Complications)
Clinical Care (Readmissions, Mortality)
Patient and Caregiver-Centered Experience of Care/Care Coordination (HCAHPS)
Efficacy and Cost Reduction (MSPB)
Efficacy and Cost metrics added in 2015 –
Health Affairs Study:
Adding A Spending Metric To Medicare’s Value-Based Purchasing Program Rewarded Low-Quality Hospitals
With domains equally weighted, some hospitals that score well on the efficacy/cost reduction task got bonuses even though they had ‘low-quality’

10. eCQMs
“We believe that in the near future, collection and reporting of data elements through EHRs will greatly simplify and streamline reporting for various CMS quality reporting programs, and that hospitals will be able to switch primarily to EHR-based data reporting for many measures that are currently manually chart abstracted and submitted to CMS for the Hospital IQR Program.”
Federal Register / Vol. 81, No. 81 / Wednesday, April 27, 2016 / IPPS Proposed Rules/page 25174
2016 – IQR: At least one quarter of data for at least four self-selected eCQMs
2017 – IQR: Full year of data for 15 eCQMs (no selection), aligned with Medicare EHR Incentive metrics and timeline
2018 – (CAHs) Must submit all eCQMs attestation no longer acceptable

11. CMS Star Hospital Programs
HCAHPS Star Rating
Launched April 2015
Minimum of 100 surveys over most recent 4 quarters to have rating calculated
For Q Q1 2015, of the 940 CAHs (71%) that submitted HCAHPS data, more than half did not have 100 completed surveys (51.9%)
Variety of Star programs across settings
Goal is to make quality metrics more transparent and understandable for patients

12. Overall Hospital Quality Star Ratings
CMS ‘overall’ hospital quality star rating, planned to be rolled out in April 2016.
Under Congressional pressure, CMS delayed
Now anticipated July 2016
Under current methodology, more than 20% of hospitals do not have enough data to have a star rating calculated
Majority without rating likely CAH and small rural
Likely language: “Not available” with note that indicates “number of cases/patients too few to report a star rating

13. MBQIP Recap of this year
98.8% of CAHs have signed memorandums of understanding (MOUs) to participate in MBQIP
96% of CAHs reported data in at least one quarter in at least one domain in the past year
As of March 2016: 1,105 CAHs registered with National Healthcare Safety Network (NHSN)
45% increase in CAHs reporting OP-27 in 2016

14. What FORHP is doing with your data
Determine MBQIP participation criteria
Inform policy decisions and progress towards MBQIP success
Ensure MBQIP measures remain robust and rural-relevant
Flex Monitoring Team (FMT) analysis
Data trends over time
Comparison analysis between Hospital Compare and MBQIP data
Inform technical assistance gaps and overlaps to ensure Flex Coordinator and CAH needs are met

15. MBQIP Direction
Align MBQIP measures to ensure robustness with other national quality reporting improvement programs
Ensure progress towards Federal Office of Rural Health Policy (FORHP) goals
Strengthening rural health care infrastructure;
Building an evidence base for programs that improve rural community health
Updated MBQIP Data Reports

16. RQITA Updates Current MBQIP Tools and Resources:
MBQIP Monthly, Reporting Reminders, Fact Sheets, CAH Improvement Guide & Toolkit, MBQIP Reporting Guide, EDTC Tools
MBQIP Virtual Knowledge Group
Next Call September 15th
Upcoming:
Abstraction Training Materials
Basic QI Training Resources
HCAHPS Best Practices
Additional Flex Training/Support
eCQM Pilot

17. RQITA MBQIP Team Robyn Carlson Marilyn Grafstrom
Laura Grangaard Johnson
Jodi Winters
Karla Weng

18. RQITA & TASC Coordination
Resources posted to TASC website: MBQIP TA Questions should be sent to:

19. Contact Information
Yvonne Chow
MBQIP Coordinator, Hospital-State Division
Federal Office of Rural Health Policy (FORHP) Health Resources and Services Administration (HRSA)
Phone:
Web: hrsa.gov/ruralhealth/
Twitter: twitter.com/HRSAgov
Facebook: facebook.com/HHS.HRSA

20. Contact Information
Karla Weng, Senior Program Manager Stratis Health or