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Transparency in the QIO 9th Scope of Work: Beyond Hospital Compare Nancy Jane C. Friedley, MD Medical Director Delmarva Foundation May 9, 2008 Delmarva Foundation Introductions Delmarva Foundation Overview Objectives: 1) Understand the basic outline of the QIO 9th SOW 2) Understand the various CMS comparison tools for transparency 3) Understand the PQRI reporting system, how it works and why it is important to have physicians involved Delmarva Foundation Transparency in the QIO 9th Scope of Work: Outline Introduction to Delmarva and the QIO Evolution of Quality Improvement and Cost Containment at the Centers for Medicare and Medicaid Services (CMS) 1965-1986 1986-1999 1999-2008 The Quality Improvement Organizations’ 9th Scope of Work 2008-2011 Impetus for Change Goals Process Translating Process to Outcomes Measures Evaluation Transparency: Online Information about Quality and Cost PQRI: Encouraging Physicians to Embrace Transparency Delmarva ‘Call to get a level…’ Delmarva Foundation Delmarva’s Impact Across the United States External Quality Review Medicare Quality Improvement Organization Maryland Patient Safety Center Medicare Quality Improvement Organization External Quality Review (Washington, DC) Statewide Quality Assurance Program for Developmentally Disabled External Quality Review for Medicaid Program Safeguard Contract Western Integrity States Medicare+Choice Quality Assurance/ Performance Improvement Project Delmarva Foundation Organizational Structure of Delmarva Quality Health Strategies, Inc. Christian Jensen President and CEO Delmarva Foundation for Medical Care Delmarva Foundation of the District of Columbia HealthWatch Health Integrity Quality Health Foundation Delmarva Foundation Quality Improvement Organizations in Maryland and the District of Columbia Delmarva Foundation for Medical Care, Inc. (DFMC) is the CMS-contracted Quality Improvement Organization (QIO) for Maryland Delmarva Foundation of the District of Columbia (DFDC) is the CMS-contracted QIO for DC Delmarva Foundation What is a QIO? The Centers for Medicare and Medicaid Services contracts with one organization in every state, the District of Columbia, Puerto Rico, and the Virgin Islands to promote safer and more effective care in hospitals, physician practices, nursing homes, home health agencies, health plans, pharmacies, and prescription drug plans. QIOs provide a range of services for the protection of the nation’s 42 million Medicare beneficiaries Delmarva Foundation What Does the QIO Do? The primary goal of the QIO is to accelerate the diffusion of evidence-based medicine from the bookshelf to the bedside. As a community resource, the QIO serve as a national infrastructure that helps doctors, hospitals, home health agencies and nursing homes utilize best practices to improve care. CMS Delmarva Foundation Delmarva Foundation What Does the QIO Do? Improves health care quality through interventions whose impact on outcomes can be measured Provides technical support, mentoring, education and training Works with providers to help them reach specific clinical goals Helps providers collect and publicly report data on performance measures to prompt improvement Delmarva Foundation How Has the QIO Improved Quality? Increase use of life-saving drugs for MI patients Make surgery safer by reducing infection rates Improve nursing home care by ensuring limited use of restraints Support home health care to help patients stay out of the hospital Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1965-1986 Delmarva Foundation Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1965: Medicare legislation Seniors and the disabled 1966: HCFA (now CMS) sets standards for hospitals that wish to be reimbursed for Medicare beneficiaries’ care Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1971: EMCROs (Experimental Medical Care Review Organizations) Voluntary physician groups Grant funded Individual cases for Utilization Review 1972-1982: PSROs (Professional Standards Review Organizations) Medical Necessity Professional Standards Effectiveness and ‘Economics’ of Care Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1982: PROs (Peer Review Organizations) Utilization and Quality Control Beyond local norms More federal oversight Funding from Medicare Trust Fund 1983: PPS (Prospective Payment System) introduced (Maryland is waived) Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1984-1986 1st SOW Era of PRO vs. Providers continues PROs are focused on “inspecting and detecting” and sanctioning providers 1st SOW emphasizes financial sanctions on physicians for inappropriate admissions Prospective Payment System (PPS) using DRGs raises concerns about early discharges and readmissions Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1986-1999 Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1986-1993 2nd and 3rd SOW Medicare Managed Care Organizations Concerns arise that Medicare MCOs subject providers to financial incentives to under use services 1986 OBRA: PROs to extend review to other settings Delmarva Foundation Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1986-1990 PRO Problems with Providers Punitive with no positive incentives Adversarial Redundancy with other programs Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1990 Institute of Medicine Report on PRO Program Potentially valuable infrastructure Improve and build on PROs New priorities Emphasize quality review and assurance over UR and cost control More attention to average practice patterns than outliers Include additional healthcare settings Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1990 IOM Recommendations to QIOs Undergo ‘self-assessment’ Demonstrate impact on quality of care for Medicare beneficiaries Include critical provider input Develop criteria for evaluation that is objective and well-vetted Have access to a Technical Advisory Panel * Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS Late 1980’s-early 1990s Continuous Quality Improvement: According to the principles of continuous quality improvement, there is no minimum acceptable level; processes can always be improved. 1991: The Institute for Healthcare Improvement (IHI) is founded. Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1992 Jencks and Wilensky Recommended a dramatic course change from retrospective review that identified a few poor performers to prospective improvement in quality of care for all providers Health Care Quality Improvement Initiative Focus on practice patterns and care outcomes at the institutional and national levels Develop practice guidelines Initiate Cooperative Cardiovascular Project for AMI Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1993-1996 PRO 4th SOW PROs Evolve National quality improvement projects on Heart Failure and Diabetes Emphasis shifts to collaboration between governments, providers, and consumers Data collection methods improve Delmarva Foundation Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1996-1999 PRO 5th SOW National Health Care Quality Improvement Projects (HCQIP) HCFA-directed for statewide impact Local needs assessments Measurable indicators Beneficiary protection and complaints Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS Communications Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1999-2008 Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 1999-2002 PRO 6th SOW National HCQIP Specific disease topics AMI, CHF, Pneumonia, Stroke, DM, Breast Cancer Local projects Expand beyond acute care New projects for managed care Beneficiary Protection (payment error) Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 2002-2005 7th SOW: ‘PRO’ becomes ‘QIO’ Specific topics with standardized indications for each setting NH, HH, Hospital (AMI, HF, Pneumonia, Surgical infections), Physician office (DM, Cancer, Immunization) Projects for underserved and rural populations Projects for Medicare managed care Information and Communication Hospital-generated performance data QIO Data Warehouse Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 2005-2008 QIO 8th SOW Developing capacity for and achieving excellence Tasks still divided by setting of care Physician office expanded to include underserved, Part D, and HIT Beneficiary Protection continues Delmarva Foundation Quality Improvement and Cost Containment at CMS? Delmarva Foundation Evolution of Quality Improvement and Cost Containment at CMS 2008-2011 QIO 9th SOW Based on all that went before and more… Delmarva Foundation Impetus for Change Delmarva Foundation Impetus for Change Improving the Medicare Quality Improvement Organization Program, 2006 Institute of Medicine (IOM) report to Congress Focus more on quality improvement and performance measurement Prioritize program resources so that QIO can help providers who demonstrate the most need, or who face significant challenges delivering quality care Strengthen organizational structure and governance of the QIO Strengthen management of the QIO program by CMS Strengthen the evaluation system for the QIO program Delmarva Foundation Impetus for Change Nursing Home Report Nursing Homes: Federal Actions Needed to Improve Targeting and Evaluation of Quality Improvement Organizations, 2007 Government Accountability Office (GAO) report Increase the number of low-performing nursing homes that QIO assists intensively Direct QIO to focus intensive assistance on those quality-of-care areas in which nursing homes most need improvement Collect more complete and detailed data on the methods QIO are using to assist nursing homes and the impact that these methods have on quality of care Identify a broader spectrum of publicly reported quality measures to evaluate changes in nursing home quality. Delmarva Foundation Result: Transparency December 2007: CMS publishes its first ever nationwide list of poor-performing nursing homes. Poor-performers display what CMS calls a "yo-yo" compliance history of providing consistently poor care, while instituting just enough improvement to pass their next survey. These 128 out of 16,000 nationwide nursing homes are subject to double inspections by state health officials and risk losing their eligibility to receive Medicare or Medicaid reimbursements. Delmarva Foundation QIO 9th SOW: Overview Delmarva Foundation QIO 9th SOW: Overview Traditional perspectives of care from the hospital, nursing home, home health, physician office are removed. Quality Improvement in the QIO 9th SOW revolves around the patient not the health care setting or provider. Quality Improvement must occur across the continuum of care. Delmarva Foundation QIO 9th SOW: Overview Levels 4 Themes, 10 Components, to 59 Measures, and beyond Topic-oriented, not setting oriented Cross-cutting themes (HIT, disparities, and VDHC) Outcomes oriented Patient-centered 245,000 more patients screened for CKD 40,000 fewer pressure ulcers 20,000 more adult immunizations provided Delmarva Foundation QIO 9th SOW: Overview National Sub-national Special Projects QIO 9th SOW: Goals 6 Aims 10 Rules 4 Priorities 4 Design Principles 3 Objectives Delmarva Foundation QIO 9th SOW: Goals CMS’ Six Aims for Redesign of Healthcare Services Safe Timely Effective Efficient Equitable Patient-centered Delmarva Foundation Delmarva Foundation QIO 9th SOW: Goals CMS’ Ten Rules for Redesign of ClinicianPatient Interactions Care based on continuous healing relationships Care customized according to patient needs and values Patient as the source of control Knowledge is shared and information flows freely Evidenced-based decision making Safety is a system property Transparency (we’ll come back to this…) Needs are anticipated Waste is continuously decreased Cooperation among clinicians is a priority Delmarva Foundation QIO 9th SOW: Goals 4 Priorities To improve the health care system through the application of the HHS/CMS priorities of person-centered care, reducing disparities, preventing disease, and preventing re-hospitalization. Delmarva Foundation QIO 9th SOW: Goals 4 Design Principles More effective management Measurement accountability Relevance to CMS and DHHS Value-Driven Health Care (VDHC) Disparities Reduction Health Information Technology (HIT) Careful evaluation with attribution Delmarva Foundation QIO 9th SOW: Goals 3 Objectives At heart, the goals are to help providers accomplish the following objectives: Prevent illness Decrease harm to patients Reduce waste in healthcare Delmarva Foundation QIO 9th SOW: Process 3 Business Principles 4 Criteria for Interventions 4+ Overarching Themes -> 200-300 Detailed Measures Delmarva Foundation QIO 9th SOW: Process 3 Business principles Focus resources Allocate the most resources to the most capable organizations (introduce competition and reward good contractor behavior) Measure important parameters continuously during contract management Delmarva Foundation QIO 9th SOW: Process Use interventions that meet the following criteria: Employ a well designed, valid, and reproducible measurement system Require standardization, built on 8th SOW base Allow the QIO to link interventions to outcomes Can be continuously monitored by CMS Central Office and Regional Offices Delmarva Foundation QIO 9th SOW: Process Emphasize evidence-based and cost-effective care Intervene to prevent and/or slow disease progression Focus on early testing, effective, and timely interventions QIO 9th SOW: Translating Process to Outcomes ‘Themes’ Delmarva Foundation QIO 9th SOW: Translating Process to Outcomes 4 Themes (+ Evaluation) 10 Components 44 Final Measures 59 Total Measures 15 18-month and 44 28-month (Final) Measures 200 to 300 Detailed Measures Schedule of Deliverables Delmarva Foundation QIO 9th SOW: Translating Process to Outcomes 10 Components Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation QIO 9th SOW: Measures 10 Components Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation QIO 9th SOW: Measures Prevention Prevention efforts will emphasize evidence based and cost-effective care proven to prevent and/or slow the progression of disease. Adult immunizations – flu, PN Cancer screening – mammography, colorectal cancer Chronic kidney disease Focused disparities – diabetes Delmarva Foundation QIO 9th SOW: Measures Prevention Prevention (10 measures) Core (4) Mammography screening CRC screening Influenza vaccination Pneumococcal pneumonia vaccination Focused disparities: Diabetes (3) A1C rates Lipid examination rates Eye exam rates Delmarva Foundation QIO 9th SOW: Measures Prevention CKD (3) Screening for nephropathy ACE/ARB therapy to prevent progression AV fistula rate (new dialysis patients) Delmarva Foundation QIO 9th SOW: Measures 10 Components Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation QIO 9th SOW: Measures Prevention: Core Goal is to use Electronic Health Records (EHRs) to report and improve the following Colorectal Cancer (CRC) Screening * Mammography Screening Influenza Vaccination Pneumococcal Vaccination Target will be clinical offices with EHR capability Delmarva Foundation QIO 9th SOW: Measures 10 Components Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation QIO 9th SOW: Measures Prevention: Focused Disparities Emphasize preventive care for underserved population with diabetes Based on evidence collected in research trials and a special study in the 8th SOW—“Every Diabetic Counts” Will be awarded to a QIO based on population and need Delmarva Foundation QIO 9th SOW: Measures Disparities Data Find affected individuals Providers Sensitize providers (continued work from the 8th SOW) Interventions Use proven interventions, develop effective partnerships, and help CMS programs be responsive to need Messaging Get the message out Delmarva Foundation QIO 9th SOW: Measures Disparities Cross-cutting across the themes Data collection on all measures for race, ethnicity, and zip code Analytic report on disparities: findings and impact of intervention on outcomes Delmarva Foundation QIO 9th SOW: Measures Prevention: Focused Disparities Sub-national 33 states/territories (DC & MD) identified by CMS Goal: Improve diabetes measures (HbA1c, eye exam, lipid, BP) through community-based Diabetes SelfManagement Education (DSME) Outcomes measured by CMS FFS claims (utility) and Physician Quality Reporting Initiative (PQRI) clinical data (we’ll come back to this, too…) Delmarva Foundation QIO 9th SOW: Measures Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation QIO 9th SOW: Measures Prevention: CKD Sub-national Optional competitive task Will be awarded to a subset of QIOs Delmarva Foundation QIO 9th SOW: Measures Prevention: Chronic Kidney Disease Detect the incidence and decrease the progression of CKD Provide implementation of clinical tools Educate beneficiaries on risk factors Disseminate tools and resources to providers and beneficiaries Work to make a lasting impact on prevention and management of CKD Work collaboratively with organizations Reduce rate of progression to CKD Delmarva Foundation QIO 9th SOW: Measures Prevention: CKD Timely recognition of microscopic proteinuria in diabetics to reduce rate of kidney failure Slow progression of kidney disease in persons with diabetes Angiotensin Converting Enzyme (ACE) inhibitor Angiotensin Receptor Blocking (ARB) agent Arteriovenous fistula (AVF) placement and maturation, where medically appropriate, for individuals starting hemodialysis Delmarva Foundation QIO 9th SOW: Measures 10 Components Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation QIO 9th SOW: Measures Patient Safety Freeing patients from the risk of harm, injury, or loss resulting from their interaction with the health care delivery system Components of Patient Safety Pressure Ulcers—Nursing Homes and Hospitals Physical Restraints—Nursing Homes SCIP—Hospitals MRSA—Hospitals Drug Safety—Physician Offices, Nursing Homes, Home Health Nursing Homes in need of assistance with quality improvement (QI) efforts Delmarva Foundation QIO 9th SOW: Measures Patient Safety Patient safety (14 measures) PrU 1 (high risk, NH) PrU 2 (hospital, acquired) Physical restraints (NH) SCIP Infection 1,2,3,4,6,7 SCIP VTE 1,2 SCIP Cardiology 2 MRSA 1 (infection rate) MRSA 2 (transmission rate) Delmarva Foundation QIO 9th SOW: Measures Patient Safety Prescription Drug Safety Drug-drug interactions Potentially inappropriate medication Delmarva Foundation Delmarva Foundation QIO 9th SOW: Outcomes 10 Components Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation Delmarva Foundation QIO 9th SOW: Measures Care Transitions Aim of QIO work under Care Transitions Theme Improve Medicare beneficiary transitions from hospitals to other care settings through a comprehensive community effort Three general strategies of intervention Hospital/community system wide Interventions that target specific diseases or conditions Interventions that target specific reasons for readmission Delmarva Foundation QIO 9th SOW: Measures Care Transitions Patient Pathways will reduce the unnecessary rehospitalizations of Medicare beneficiaries through: Recruitment of hospitals, physicians, home health agencies, skilled nursing facilities, dialysis facilities. Collaboration among QIOs, community health systems, and professional groups Delmarva Foundation QIO 9th SOW: Measures Care Transitions Care Transitions (10 measures) 4 types of re-hospitalization rates 2 patient assessments of hospital discharge performance using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 1 physician visit post discharge (within 30 days) before re-admission 2 measures with Continuity Assessment Record and Evaluation (CARE) instrument 1 measure of adoption of interventions Delmarva Foundation QIO 9th SOW: Outcomes 10 Components Prevention (3) Core Focused disparities Chronic Kidney Disease (CKD) Patient Safety (5) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Care Transitions (1) Beneficiary Protection (1) Delmarva Foundation Delmarva Foundation QIO 9th SOW: Measures Beneficiary Protection Case review includes Utilization review, Quality of care, including beneficiary complaints, Beneficiary appeals of certain provider notices, and Review of potential anti-dumping cases. Link to quality improvement through data analysis and improvement assistance Delmarva Foundation QIO 9th SOW: Measures Beneficiary Protection Beneficiary Protection Increasing linkage of case review to quality of care Increasing awareness of complaint process among beneficiaries Emphasis on improved efficiency in the case review process Delmarva Foundation QIO 9th SOW: Measures Beneficiary Protection Beneficiary Protection (4 measures) Timely completion of case reviews Beneficiary satisfaction with complaint process Completion of satisfaction survey Percent of QIA completion Delmarva Foundation QIO 9th SOW: Measures Beneficiary Protection Statutorily Mandated Case Review Activities Are the items and/or services reasonable and medically necessary Do the quality of services meet professionally recognized standards of care Are services being provided in the appropriate and most economical setting Delmarva Foundation QIO 9th SOW: Measures Beneficiary Protection Mandatory Review Activities Utilization review Quality of care review Review of beneficiary appeals of certain provider notices [Benefits Improvement and Protection Act of 2000 (BIPA)] Review of potential Emergency Medical Treatment & Labor Act (EMTALA) cases Delmarva Foundation QIO 9th SOW: Measures Beneficiary Protection Case Review Activities Quality Improvement Activities (QIAs) Alternative Dispute Resolution (ADR) sanction activities Collaboration with CMS Transparency through reporting quality data Delmarva Foundation QIO 9th SOW: Translating Process to Outcomes 4 (+1) Themes Prevention Patient Safety Care Transitions/Patient Pathways Beneficiary Protection (Evaluation) Delmarva Foundation QIO 9th SOW: Measures Evaluation Contract Evaluation Measures/deliverables completed and submitted Mid-point evaluation (18 months) Program Evaluation Independent, outside evaluation contractor Independent report on the QIO program is a final deliverable (2011) Attribution of success to QIO interventions Delmarva Foundation QIO 9th SOW: Measures Evaluation “Attribution” carefully considered Well-defined measure set with continuous, highquality data CMS chooses participants with specified criteria Use of “matched control groups,” when possible More ability to control for confounding variables Use of standardized interventions, disseminated with help of support contractors, linked to measures Careful management of partnerships Delmarva Foundation QIO 9th SOW: Summary Goals and Objectives Interventions are linked to measures Independent outside evaluation contractor will be engaged from the beginning Final independent program evaluation report at end of contract New management strategies will be applied to continuous contract oversight, encouraging high performance throughout the contract period New contract responsive to all external stakeholders Delmarva Foundation QIO 9th SOW: Summary 9th Statement of Work incorporates a measurement system (final and interim) and support system structure Evaluation strategy has been worked out in advance with quantitative targets and some control groups Higher degree of competition has been introduced (subnational deployment) Monitoring now has greater transparency and involves both DHHS and Office of Management and Budget (OMB) regularly through contract Delmarva Foundation QIO 9th SOW: Summary Cross Cutting Themes Reducing Health Care Disparities Promoting use of Health Information Technology ExpandingValue-Driven Health Care Delmarva Foundation QIO 9th SOW: Summary Cross Cutting Themes Potential benefits of broad use of HIT Improve health care quality Prevent medical errors Reduce health care costs Increase administrative efficiencies Decrease paperwork Expand access to affordable care Improve tracking of chronic disease management http://www.hhs.gov/healthit/ Delmarva Foundation Measuring Success in 9th SOW Collaboration and Coordination Utilizing existing organizations/populations Not reinventing a process Employing known successful interventions Creating lasting change Empasizing health information technology Integration across settings of care Delmarva Foundation What’s in it for Beneficiaries? 245,000 more patients screened for CKD 39,616 fewer pressure ulcers in nursing homes 3,687 fewer pressure ulcers in hospitals 23,610 fewer physical restraints in nursing homes 7,875 fewer antibiotic-resistant infections 14,252 lives saved from postoperative complications in hospitals Delmarva Foundation Transparency Delmarva Foundation Transparency: Online Information about Quality and Cost Executive Order August 22, 2006: Aggregated health care quality and price information to be available to beneficiaries, enrollees, and providers in a readily usable manner. Interoperable health IT products be used, and quality and price data be aggregated and shared. Federal participants (Medicare beneficiaries) are motivated to become involved consumers with the power of choice and a reason to advocate a value-driven health care system. Delmarva Foundation Transparency: Sharing Information Reduce the burden of duplicate data collection and reporting Allow hospitals to share quality-of-care data with patients Allow for more effective partnership with the QIO Encourage every member of your staff to be involved in quality improvement Transparent ‘Easily understood; clear’ Delmarva Foundation Delmarva Foundation Transparency Demands critical information about: 1. Quality 2. Patient Satisfaction 3. Pricing Leavitt 2008 Abouthealthtransparency.org Delmarva Foundation News Release FOR IMMEDIATE RELEASE Friday, March 28, 2008 Contact: CMS Office of Public Affairs (202) 690-6145 New Web Site Helps Patients Shop for Hospital Care Based On Quality and Price CMS Web Site Features Updated and More Robust Information to Help Consumers with Their Health Care Choices Delmarva Foundation Delmarva Foundation Transparency: Online Information about Quality and Cost What is presently available online: Home Health Compare Nursing Home Compare Hospital Compare What’s coming? Physician Compare Delmarva Foundation Transparency: Online Information about Quality and Cost Home Health Compare Three measures related to improvement in getting around Four measures related to meeting the patient's activities of daily living Two measures about how home health care ends Three measures related to patient medical emergencies Delmarva Foundation Transparency: Online Information about Quality and Cost Nursing Home Compare Quality Measures Nursing Home Inspection Health Fire Safety Nurse Staffing CNA Staffing Medicare Coverage Delmarva Foundation Delmarva Foundation Transparency: Online Information about Quality and Cost Hospital Compare Hospital Process of Care Measures: See how often a hospital gives recommended treatments for certain conditions or procedures. Eight measures related to heart attack care Four measures related to heart failure care Seven measures related to pneumonia care Five measures related to surgical infection prevention Hospital Outcome of Care Measures: See the results of care or treatment for certain conditions or procedures. Survey of Patients' Hospital Experiences: See what hospital patients say about the care they received during a recent hospital stay. Medicare Payment and Volume: See how much Medicare paid hospitals on average for certain conditions or procedures. You can see the number of Medicare patients treated for certain conditions. Delmarva Foundation Transparency: Online Information about Quality and Cost Consumer Can consumers use the tools presently available to make informed decisions about their health care? Delmarva Foundation Transparency: Online Information about Quality and Cost Consumer Can consumers use the tools presently available on line to make informed health care decisions? Yes and No Delmarva Foundation Transparency: Online Information about Quality and Cost Consumer YES Geographic location Specific procedure volume Patient satisfaction Begin provider discussion Basic quality information about treatment for MI, HF, Pneumonia, Surgical Infection Rate Potential for regular updating and ‘real time’ information Delmarva Foundation Transparency: Online Information about Quality and Cost Consumer NO Process of care measures limited Data is several months out of date Website is complicated Requires computer access Font is tiny Only outcome measure is 30 day mortality Hospitals can control access to unflattering data Measure validity can change Delmarva Foundation Transparency: Online Information about Quality and Cost Hospital Compare During the Preview Period, hospitals have the option to suppress the public reporting of some of the information contained in the reports. Information contained in the Preview Reports will be published on the Hospital Compare website in July 2008. Delmarva Foundation Transparency: Online Information about Quality and Cost Volume-outcome relationship for coronary artery bypass grafting in an era of decreasing volume. Ricciardi R, Virnig BA, Ogilvie JW Jr, Dahlberg PS, Selker HP, Baxter NN. Since 1997, CABG volume has declined in the setting of a decrease in in-hospital mortality. A lower mortality rate in the setting of reduced CABG volume is a counterintuitive finding, suggesting that procedure volume is an insufficient predictor of outcome on which to base regionalization strategies. Delmarva Foundation Transparency: Online Information about Quality and Cost ‘Physician Compare’ Physicians need to become familiar with the methodology that will ‘compare’ them. This information will eventually be used to determine physician reimbursement. The measures used in the Physician Quality Reporting Initiative (PQRI) are evidence-based and well-vetted. Delmarva Foundation Delmarva Foundation Delmarva Foundation Transparency: Online Information about Quality and Cost Delmarva Foundation Transparency: Online Information about Quality and Cost PQRI 74 measures Consensus developed and endorsed Apply to over 95% physician Part B services Applicability depends on services rendered, not designated specialty Measures posted on website www.cms.hhs.gov/PQRI Delmarva Foundation Transparency: Online Information about Quality and Cost 2007 Preliminary Data: ~16% participation - submitted at least 1 qualitydata code Slightly over half of participants likely to qualify for bonus Delmarva Foundation Transparency: Online Information about Quality and Cost PQRI Multiple sources for information AMA and specialty provider organizations have developed user friendly forms Can report with claims data (additional codes) Can report using registries May choose measures they wish to report Must choose at least 3 measures to be eligible for incentive Must report on at least 80% of the patients who qualified for the measure Delmarva Foundation Transparency: Online Information about Quality and Cost PQRI Example: Dr. Friedley chooses three diabetes measures HgbA1C, lipids, and BP control) Dr. F has 100 patients that have Medicare claims that define them as diabetic Dr. F must report on the 3 measures for at least 80 of her 100 patients for CY08 If she does this successfully, she will earn 1.5% of her total allowable Medicare charges for 2008 Delmarva Foundation Transparency: Online Information about Quality and Cost PQRI For 2008, Dr. F will be rewarded for REPORTING these measures. Eventually, she will be paid for the RESULTS of the measures, ie the number of patients whose LDL cholesterol is < 100. Delmarva Foundation Transparency: Online Information about Quality and Cost PQRI The QIO 9th SOW will be using PQRI results to measure outcome success. Example: Prevention-Focused Disparities Diabetes measures HbgA1c < 9.0; LDL < 100; BP < 140/90 Delmarva Foundation Transparency: Online Information about Quality and Cost Outreach and Education– Engagement through communication Website at: https://www.cms.hhs.gov/PQRI Medicare Carrier/Medicare Administrative Contractor (MAC) inquiry management Speakers’ Bureau– Education for participants and their office staff Tools to support successful reporting Delmarva Foundation Transparency: Online Information about Quality and Cost What Percentage of General Practitioners in Europe Use Computers? Delmarva Foundation Delmarva Foundation Transparency: Online Information about Quality and Cost What percent of primary care physicians in US use computers in their practices (beyond billing)? ~20% We have our work cut out for us…. Delmarva Foundation Transparency: Online Information about Quality and Cost Delmarva Foundation Where are we going? Delmarva Foundation Moving from Quality to Value Better Care Lower Cost HHS Delmarva Foundation Moving from Quality to Value Economics Efficiency Cost Pricing Accountability Payment Reform Delmarva Foundation Value-Driven Health Care “The QIO program is a cornerstone in our efforts to improve the quality and efficiency of care delivered to Medicare beneficiaries,” said CMS Administrator Mark B. McClellan, M.D., Ph.D. “QIOs have had a positive impact on the quality of health care in America, and with enhanced oversight and accountability, and new initiatives to improve transparency and care, they will do more to support better care and lower costs. Delmarva Foundation Value Driven Health Care Four Cornerstones Interoperable HIT Measure and publish quality information Measure and publish price information Promote quality and efficiency of care (e.g., Value-Based Purchasing) http://www.hhs.gov/valuedriven/ Delmarva Foundation Questions? [email protected]
