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Performance Measurement & Reporting:
Future Directions Janet Corrigan, PhD, MBA President and CEO National Quality Forum
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National Quality Forum Mission
Improve the quality of American healthcare by setting national priorities and goals for performance improvement Endorse national consensus standards for measuring and publicly reporting on performance Promote the attainment of national goals through education and outreach programs 2
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This Presentation at a Glance
Key Components of Health Reform Aimed at Improving Quality and Affordability of Health Care National Quality Enterprise: Key Functions Role of the National Quality Forum
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Health Reform Legislation
Patient Protection & Affordability of Care Act (ACA) of 2010 Rapid expansion of public reporting Alignment of payment with value Development of accountable care organizations American Recovery and Reinvestment Act (ARRA) of 2009 $32 billion to rapidly “wire” American healthcare
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ACA Transparency Provisions
Broad Plan for Public Reporting Requires a clear federal plan to make performance information widely available. Hospitals and Ambulatory Surgery Centers Expands Hospital Compare; includes information on the Value Based Purchasing (VBP) program; report on health care acquired admissions, hospital readmissions, and hospital charge data. Physicians Requires development of Physician Compare website by January 2011. Annually, physician ownership or investments in hospitals and manufacturers (by September 2013) will be published. Nursing Homes, Skilled Nursing Facilities, LTC Facilities New information will be added to Nursing Home Compare by March Nursing home ownership by March 2012.
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Public Reporting In 2009 more than half of Americans used the Internet to look up health information Source: CDC. National Center for Health Statistics Data from the Centers for Disease Control and Prevention’s National Center for Health Statistics
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ACA Payment Reforms Physician Payment Hospital Payment
Provides 5-year, 10% bonus for primary care and general surgeons in health professional shortage areas beginning in 2011 based on reporting of quality measures. Medicaid primary care rates will be 100% of adjusted Medicare rates for 2013 and 2014. Secretary establishes a payment modifier that provides for differential payment to physicians based on quality of care compared to cost. Must be budget neutral and program starts in 2013. Hospital Payment Reduces payments for “excess” readmissions in selected conditions starting in FY 2013. Establishes a hospital VBP program to start in FY 2013. Reduces payment for hospitals in top quartile of national health care acquired conditions rate by 1% starting in 2015. Expansion of Value-based Purchasing VBP pilots for long-term care; rehabilitation facilities; PPS-except cancer hospitals; and hospice to be implemented by 2016.
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ACA Payment Reforms (cont’d.)
CMS Innovation Center Establishes an Innovation Center with the capacity to implement innovations program-wide that require review and assessment by the Office of the Actuary. Center must be established by 2011. Piloting of New Programs Authorizes a multitude of payment redesign programs to be rapidly tested and, as proven, expanded. Bundled Payments, Shared Decision-Making, etc.
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ARRA & ACA Delivery System Reform
Build technological infrastructure necessary to improve quality and reduce costs $30B in Medicare and Medicaid incentive payments linked to “meaningful use” of EHRS Promote integration of personal health care and population health Community health teams Encourage development of clinically integrated health systems Medical Homes/ Health Care Homes Accountable Care Organizations
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Accountable Care Organizations
Patient-focused orientation Follows the natural trajectory of care over time Directed at value Quality, costs, and patient preferences Emphasizes care coordination Care transitions and hand-offs Promotes shared accountability Individual, team, system Addresses shared decision making Attention to patient preferences Supports fundamental payment reform Bundled payment for the episode of care
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Quality Enterprise Functions: Contributions of NQF
Establish National Priorities National Priorities Partnership Top 20 conditions Identify Measure Gaps Agenda for Measure Development and Endorsement Measure Development Endorse Measures, Practices, and SREs Over 600 measures covering all settings, including Safe Practices and SREs Build Data Platforms Health Information Technology Expert Panel Publicly Report Results Guidance for performance reporting on safety MAPs & Dashboard Align Payment and Other Incentives Analysis of measurement implications of various payment reform models Improve Performance Webinars Measures database Evaluate Measure use evaluation
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Why Set National Priorities?
Current state of performance measurement is a cacophony of well-meaning but uncoordinated signals National priorities help align strategies and efforts of multiple groups around common goals for improvement Drive fundamental change in the delivery system New link to ACA: Secretary to establish and implement a national strategy to improve care delivery, health outcomes and population health
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National Priorities Partnership
32 multi-stakeholder organizations: Consumers Purchasers/Employers Health Professionals/Providers Health Plans Accreditation/Certification Groups Quality Alliances Suppliers/Industry Community/Regional Collaboratives Public Sector: CMS, AHRQ, CDC, NIH, NGA Co-Chairs: Donald Berwick Institute for Healthcare Improvement Margaret O'Kane National Committee for Quality Assurance
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Criteria for Selecting the Priorities
Reduce Disease Burden Eliminate Harm High Impact Areas Remove Waste Eradicate Disparities © National Priorities Partnership 14 14
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National Priorities Population health Safety Care Coordination
- Key preventive services - Healthy lifestyle behaviors Safety Hospital-level mortality rates Serious adverse events Healthcare-Acquired Infections Care Coordination Medication reconciliation Preventable hospital readmissions Preventable emergency department visits Patient/family engagement Informed decision-making Patient experience of care Patient self-management Palliative Care: Relief of physical symptoms Help with psychological, social and spiritual needs Communication regarding treatment options, prognosis Access to palliative care services Overuse 9 major areas 15
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Potential Areas of Overuse
Inappropriate medication use Unnecessary laboratory testing Unwarranted diagnostic procedures Unnecessary maternity care interventions Unnecessary consultations Potentially harmful preventive services (USPSTF “D” list) Preventable hospitalization and ED visits Inappropriate non-palliative care at end-of-life 16
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Drivers of Change Performance Measurement Public Reporting Payment
COLLABORATIVE, ACTION-ORIENTED STRATEGIES Infrastructure (Information Technology & Workforce Applied Research Accreditation & Certification 17
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Quality Enterprise Functions: Contributions of NQF
Establish National Priorities National Priorities Partnership Top 20 conditions Identify Measure Gaps Agenda for Measure Development and Endorsement Measure Development Endorse Measures, Practices, and SREs Over 600 measures covering all settings, including Safe Practices and SREs Build Data Platforms Health Information Technology Expert Panel Publicly Report Results Guidance for performance reporting on safety MAPs & Dashboard Align Payment and Other Incentives Analysis of measurement implications of various payment reform models Improve Performance Webinars Measures database Evaluate Measure use evaluation
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ACA: Measure Development
AHRQ and CMS to conduct triennial assessment to identify measures gaps Consider gaps identified by NQF, pediatric program, and Medicaid Priority to health outcomes, functional status, coordination of care, shared decision-making, MU, safety, patient experience, efficiency and disparities $75M for measure development (not yet appropriated)
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Measure Development & Endorsement Agenda Child and Family Health
National Priorities Leading Medicare Conditions Child and Family Health HIT Meaningful Use Community Needs Population Health
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Prioritized Medicare Conditions
Major depression CHF IHD Diabetes Stroke/TIA Alzheimer’s dx Breast CA COPD AMI Colorectal CA Hip/pelvic fracture Chronic renal dx Prostate CA Rheumatoid & osteoarthritis Atrial fibrillation Lung CA Cataract Osteoporosis Glaucoma Endometrial CA
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Quality Enterprise Functions: Contributions of NQF
Establish National Priorities National Priorities Partnership Top 20 conditions Identify Measure Gaps Agenda for Measure Development and Endorsement Measure Development Endorse Measures, Practices, and SREs Over 600 measures covering all settings, including Safe Practices and SREs Build Data Platforms Health Information Technology Expert Panel Publicly Report Results Guidance for performance reporting on safety MAPs & Dashboard Align Payment and Other Incentives Analysis of measurement implications of various payment reform models Improve Performance Webinars Measures database Evaluate Measure use evaluation
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NTTAA NTTAA National Technology and Transfer Advancement of Act of 1995 (NTTAA) Defines the five key attributes of a “voluntary consensus standards-setting body” (i.e., openness, balance of interest, due process, consensus, and an appeals process) Obligates federal government to adopt voluntary consensus standards (when the government is adopting standards) Encourages federal government to participate in setting voluntary consensus standards 23
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Measurement & Improvement Paths
24 NQF, 2002 24
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NQF Consensus Development Process
Consensus Development Process Steps Call for nominations for steering committee and technical panels Call for measures Measure evaluation Member and public comment NQF member voting Consensus Standards Approval Committee (CSAC) Board of Directors endorsement Appeals 25
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NQF Evaluation Criteria
Importance to measure and report What is the level of evidence for the measures? Is there an opportunity for improvement? Relation to a priority area or high impact area of care? Scientific acceptability of the measurement properties What is the reliability and validity of the measure? Usability Can the intended audiences understand and use the results for decision-making? Feasibility Can the measure be implemented without undue burden, capture with electronic data/EHRs?
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Types of Quality Measures
Process Outcome Structure/management Access Efficiency/cost Use of services (used as proxy for outcome, cost) Patient experience of care Composite (two or more measures combined into a single score) 27 27 27
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Quality Measurement in Evolution
Drive toward higher performance Shift toward composite measures Measure disparities in all we do Harmonize measures across sites and providers Promote shared accountability & measurement across patient-focused episodes of care: Outcome measures Appropriateness measures Cost/resource use measures coupled with quality measures, including overuse 28
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Patient-Focused Episodes of Care Model
Population at Risk Evaluation & Initial Management Rehabilitation & Follow-up Care Clinical episode begins Appropriate Times Throughout Episode Determination of key patient attributes for risk adjustment Assessment of informed patient preferences and the degree of alignment of care processes with these preferences Assessment of symptom, functional, and emotional status PHASE 1 PHASE 2 PHASE 3 End of Episode Risk-adjusted health outcomes (i.e. mortality & functional status) Risk-adjusted total cost of care Time 29
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Episodes Model Measurement Domains
Patient-level outcomes (better health) Morbidity and mortality Avoidance of complications (e.g., HAIs) Functional status Health-related quality of life Patient experience of care Processes of care (better care) Technical Care coordination and transitions Alignment with patients’ preferences; shared decision-making Cost and resource use (overuse, waste, misuse) Total cost of care across the episode Indirect costs 30
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Patient-Focused Episodes of Care Model
Patient-focused orientation Follows the natural trajectory of care over time Directed at value Quality, costs, and patient preferences Emphasizes care coordination Care transitions and hand-offs Promotes shared accountability Individual, team, system Addresses shared decision making Attention to patient preferences Supports fundamental payment reform Bundled payment for the episode of care 31
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Integrated Performance Measurement Framework
Patient & Family Engagement Population at Risk Evaluation & Initial Management Follow-up Care Clinical Episode Begins PHASE 1 PHASE 2 PHASE 3 End of Episode ~ Risk-Adjusted Health Outcomes and Total Cost of Care Time Care Coordination Population Health Overuse Palliative Care Safety
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Not everything that counts can be counted, and not everything that can be counted counts.
Albert Einstein
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Quality Enterprise Functions: Contributions of NQF
Establish National Priorities National Priorities Partnership Top 20 conditions Identify Measure Gaps Agenda for Measure Development and Endorsement Measure Development Endorse Measures, Practices, and SREs Over 600 measures covering all settings, including Safe Practices and SREs Build Data Platforms Health Information Technology Expert Panel Publicly Report Results Guidance for performance reporting on safety MAPs & Dashboard Align Payment and Other Incentives Analysis of measurement implications of various payment reform models Improve Performance Webinars Measures database Evaluate Measure use evaluation
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Comprehensive Data Needed to Generate Performance Information
Data Integration Patients Laboratories Pharmacies Care Evaluation Improvement Quality Medical Claims EHRs Moved this slide up – it sets up next slide Performance Pay for Consumer Activation Data Aggregation Hospitals/ Institutions Registries RWJF Aligning Forces for Quality 35
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Linkage of HIT and Measurement
Capture the right data Calculate the performance measure Provide real-time information to the clinician with decision support Publicly report for secondary uses: accountability, payment, public health, and comparative effectiveness Data Sources Data Sources Performance Measures EHRs and HIT tools E-Infra structure 36
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Interfacing Measurement and Health IT
Performance measurement 600 + Measures Dozens of stewards Health IT Advisory Committee Translate (QDS) Harmonize measure standards and HIT standards Health IT Vendors Standard Development Orgs 37
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Shared Data Elements: “Sweet Spot”
Clinical Guidelines Quality Measures Decision Support
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QDS Data Element 39
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QDS Data Flow 40
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Shared Supply Chain QM specification repository QM
Guideline diabetes aspirin hemoglobin lumpectomy smoker EKG QDS data element repository QM CDS CDS rule repository QM specification repository map EHR quality report 41
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Quality Enterprise Functions: Contributions of NQF
Establish National Priorities National Priorities Partnership Top 20 conditions Identify Measure Gaps Agenda for Measure Development and Endorsement Measure Development Endorse Measures, Practices, and SREs Over 600 measures covering all settings, including Safe Practices and SREs Build Data Platforms Health Information Technology Expert Panel Publicly Report Results Guidance for performance reporting on safety MAPs & Dashboard Align Payment and Other Incentives Analysis of measurement implications of various payment reform models Improve Performance Webinars Measures database Evaluate Measure use evaluation
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Applications of Performance Information
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Performance-based payment incentives as a driver of change
NQF and RAND Project: Measurement Implications of Payment Reform Models Performance-based payment incentives as a driver of change Pay for performance Episode-based payment Population-based payment Payment for event or condition Payment for care of a population Payment for service Augmented fee-for- service (e.g., P4P) Bundled payment (single provider) Bundled payment (multiple providers) Fee-for-service Partial capitation Full capitation Increasing aggregation of services into a unit of payment
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Payment Reform Models
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Measurement analysis for selected payment reform models
NQF and RAND Project: Measurement Implications of Payment Reform Models Measurement analysis for selected payment reform models Assessment of measure needs Proposed measure sets Analysis of methodological issues raised by application of measures Attribution Risk adjustment Benchmarking Data source Small numbers
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Quality Enterprise Functions: Contributions of NQF
Establish National Priorities National Priorities Partnership Top 20 conditions Identify Measure Gaps Agenda for Measure Development and Endorsement Measure Development Endorse Measures, Practices, and SREs Over 600 measures covering all settings, including Safe Practices and SREs Build Data Platforms Health Information Technology Expert Panel Publicly Report Results Guidance for performance reporting on safety MAPs & Dashboard Align Payment and Other Incentives Analysis of measurement implications of various payment reform models Improve Performance Webinars Measures database Evaluate Measure use evaluation
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Searchable Database of Endorsed Measures
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Measure Use Evaluation Getting Underway
To assess the use of performance measures for driving system change: Public reporting Payment incentives Accreditation and certification Quality improvement To inform measure development, endorsement, and implementation Independent contractor
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Take Home Messages Entering a period of extraordinary challenges and opportunities Two critical drivers–- public reporting and payment alignment Early investment in HIT is critical Delivery system reform is essential to succeed Integration of personal and population health to address behavioral change Clinical integration to manage patient-focused episodes and maximize value
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Thank You
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