CMS Quality Programs, Coverage, and
Evidence
Patrick Conway, M.D., MSc
CMS Chief Medical Officer and
Director, Center for Clinical Standards and Quality
December 10, 2012
Objectives
• Summary of CMS Quality Programs
• Coverage – coverage with evidence
development
• Guidelines and Evidence implementation
Size and Scope of
CMS Responsibilities
•
CMS is the largest purchaser of health care in the world (approx $800B
per year)
•
Combined, Medicare and Medicaid pay approximately one-third of national
health expenditures.
•
CMS programs currently provide health care coverage to roughly
105 million beneficiaries in Medicare, Medicaid and CHIP (Children’s
Health Insurance Program); or roughly 1 in every 3 Americans.
•
The Medicare program alone pays out over $1.5 billion in benefit
payments per day.
•
Through various contractors, CMS processes over 1.2 billion fee-forservice claims and answers about 75 million inquiries annually.
•
Millions of consumers will receive health care coverage through new
health insurance programs authorized in the Affordable Care Act.
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Our Aims
Better Health for
the Population
Better Care
for Individuals
Lower Cost
Through
Improvement
4
Center for Clinical Standards and Quality
Levers for Safety, Quality & Value
•
Over 425 federal FTE’s, $1.3 billion and approximately 10K contractors
focused on improving quality across the nation
•
Contemporary Quality Improvement: Quality Improvement
Organizations
•
Quality Measurement and Public Reporting: Hospital Inpatient Quality
Reporting Program
•
Incentives: Hospital Value Based Purchasing, ESRD, physician value
modifier
•
Regulation: Conditions of Participation (Hospitals, 15 other provider
types) and Survey and Certification
•
Coverage Decisions: Coverage with evidence development, coverage
for Preventative Services
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Goals of CMS Quality Programs
 Improvement aimed at achieving better care and
better health
 Focus on patient-centered outcome measures
whenever possible
 Engage physicians, other clinicians, and providers in
helping shape and improve the quality programs
 Foster shared accountability in a health care system
that achieves better outcomes for patients
 Align programs to maximize improvement and
minimize burden
CMS has a variety of quality reporting and performance
programs
Hospital Quality
•Medicare and
Medicaid EHR
Incentive Program
•PPS-Exempt Cancer
Hospitals
•Inpatient Psychiatric
Facilities
•Inpatient Quality
Reporting
•HAC payment
reduction program
•Readmission
reduction program
•Outpatient Quality
Reporting
Physician Quality
Reporting
PAC and Other Setting
Quality Reporting
Payment Model
Reporting
“Population” Quality
Reporting
• Medicare and
Medicaid EHR
Incentive
Program
• Inpatient
Rehabilitation
Facility
• Medicare
Shared Savings
Program
•Medicaid Adult
• PQRS
• Nursing Home
Compare
Measures
• Hospital Valuebased
Purchasing
• CHIPRA Quality
Reporting*
• eRx quality
reporting
• LTCH Quality
Reporting
• Hospice Quality
Reporting
• Physician
Feedback/Value
-based
Modifier*
• ESRD QIP
• Home Health
Quality
Reporting
Quality
Reporting*
• Health Insurance
Exchange
Quality
Reporting*
• Medicare Part
C*
• Medicare Part
D*
•Ambulatory Surgical
Centers
* Denotes that the program did not meet the statutory inclusion criteria for pre-rulemaking, but was included to
foster alignment of program measures.
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National Quality Strategy promotes better health,
better healthcare, and lower costs
Six priorities:
• Making care safer by reducing harm caused in the delivery of
care.
• Ensuring that each person and family are engaged as partners in
their care.
• Promoting effective communication and coordination of care.
• Promoting the most effective prevention and treatment practices
for the leading causes of mortality, starting with cardiovascular
disease.
• Working with communities to promote wide use of best practices
to enable healthy living.
• Making quality care more affordable for individuals, families,
employers, and governments by developing and spreading new
health care delivery models.
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CMS framework for measurement maps to the
six National Quality Strategy priorities
Care coordination
Clinical quality of care
•HHS primary care and CV
quality measures
•Prevention measures
•Setting-specific measures
•Specialty-specific
measures
Person- and Caregivercentered experience and
outcomes
•CAHPS or equivalent
measures for each settings
•Functional outcomes
•Transition of care
measures
•Admission and
readmission measures
•Other measures of care
coordination
Safety
•Health care acquired
conditions and infections
•All cause harm
Population/ community
health
•Measures that assess
health of the community
•Measures that reduce
health disparities
•Access to care and
equitability measures
Efficiency and cost
reduction
•Spend per beneficiary
measures
•Episode cost measures
•Quality to cost measures
• Measures should
be patientcentered and
outcome-oriented
whenever possible
• Measure concepts
in each of the six
domains that are
common across
providers and
settings can form
a core set of
measures
Greatest commonality
of measure concepts
across domains
Quality can be measured and improved at multiple
levels
Increasing commonality among providers
Increasing individual accountability
Community
•Population-based denominator
•Multiple ways to define
denominator, e.g., county, HRR
•Applicable to all providers
Practice setting
•Denominator based on practice setting,
e.g., hospital, group practice
Individual physician
•Denominator bound by patients cared for
•Applies to all physicians
•Greatest component of a physician’s total
performance
•Three levels of
measurement critical to
achieving three aims of
National Quality Strategy
•Measure concepts should
“roll up” to align quality
improvement objectives at
all levels
•Patient-centric, outcomes
oriented measures preferred
at all three levels
•The “five domains” can be
measured at each of the
three levels
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
• 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)
• Major aim of measurement is improvement over time
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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.
• Hospital VBP, ESRD, and Physician Value-Modifier
• Five Principles
- Define the end goal, not the process for achieving it
- All providers’ incentives must be aligned
- Right measures 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
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Coverage Topics
• Coverage with Evidence Development (CED) Updates
– Guidance
– MEDCAC
• List of coverage topics
National Bioeconomy Blueprint
http://www.whitehouse.gov/sites/default/files/microsites/ostp/national_bioe
conomy_blueprint_april_2012.pdf
Coverage with Evidence Development
Current Status
• MEDCAC (May 16, 2012) on review of CED
- Support for CED
- Input given on how to best frame guidance and next
stage of CED
- Transcript on the coverage home page
• Published draft guidance document on November 29,
2012 http://www.cms.gov/medicare-coveragedatabase/details/medicare-coverage-documentdetails.aspx?MCDId=23
• Welcome comments
CED MEDCAC information is available on
the CMS website
PROPOSALS FOR THE
PHYSICIAN QUALITY REPORTING
SYSTEM (PQRS)
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html
http://www.cms.gov/medicare-coverage-database/details/medcacmeeting-details.aspx?MEDCACId=63&
List of Potential Coverage Topics
• CMS requested public comment on items or services
that may be misused, underused, or overused
• Public responded
• November 27th CMS posted the list online
•
http://www.cms.gov/medicare-coverage-database/details/medicare-coverage-documentdetails.aspx?MCDId=19&McdName=Potential+NCD+Topics&mcdtypename=Potential+Nationa
l+Coverage+Determination+&MCDIndexType=2&bc=AAAEAAAAAAAA&
The “3T’s” Road Map to
Transforming U.S. Health Care
Basic biomedical
science
T1
Clinical efficacy
knowledge
T2
Clinical effectiveness
knowledge
Key T1 activity to test
what care works
Key T2 activities to test
who benefits from
promising care
Clinical efficacy research
Outcomes research
Comparative effectiveness
Research
Health services research
T3
Improved health
care quality &
value &
population health
Key T3 activities to test
how to deliver high-quality
care reliably and in
all settings
Quality Measurement and
Improvement
Implementation of
Interventions and health
care system redesign
Scaling and spread of
effective interventions
Research in above domains
Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp. 2319-2321. The “3T’s Roadmap to Transform U.S. Health Care:
The ‘How’ of High-Quality Care.”
Goal
Percent
Average Percent discharged on oral antibiotics
Control Limits
07/15/11 (n=01)
05/31/11 (n=02)
05/15/11 (n=01)
Ramp 4,
Local expert
opinion
03/15/11 (n=01)
01/31/11 (n=02)
01/15/11 (n=01)
Ramp 2,
consult
criteria
12/15/10 (n=01)
11/30/10 (n=01)
60.0
10/31/10 (n=01)
80.0
10/15/10 (n=01)
Ramp 1,
test 2
09/30/10 (n=01)
40.0
09/15/10 (n=01)
90.0
07/31/10 (n=01)
07/15/10 (n=02)
06/30/10 (n=02)
05/31/10 (n=04)
04/30/10 (n=05)
03/31/10 (n=02)
02/28/10 (n=00)
01/31/10 (n=01)
12/31/09 (n=01)
11/30/09 (n=02)
10/31/09 (n=04)
09/30/09 (n=01)
08/31/09 (n=00)
07/31/09 (n=05)
Percent of children with routine osteomyelitis discharged on
oral antibiotics
Rapid Evidence Adoption
Percent of children with routine osteomyelitis discharged on oral antibiotics
100.0
Ramp 5,
Family shared
decision-making
70.0
Ramp 3 Real
time identify and
feedback
50.0
Ramp 1, test 1
Evidence
implementation
30.0
20.0
10.0
0.0
Quality and Evidence
• Quality measurement needs to based on strong evidence
• Quality data infrastructure can be built in manner for
systematic measurement and improvement
• Coverage policy can determine appropriateness based on
the evidence and be utilized to develop more evidence
when needed
• Guidelines can support transformation but likely need to be
thought of and implemented in much more dynamic
manner
• Evidence can and should be shared with patients in shared
decision-making model that meets individual patient needs
whenever possible
Contact Information
Dr. Patrick Conway, M.D., M.Sc.
CMS Chief Medical Officer and
Director, Center for Clinical Standards and Quality
410-786-6841
patrick.conway@cms.hhs.gov
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