The Affordable Care Act and Quality
Transformation
Kate Goodrich, M.D. MHS
Senior Technical Advisor, CMS
Office of Clinical Standards and Quality
June 21, 2012
Objectives
• Overview of CMS and OCSQ
• Discuss ACA provisions and national
initiatives that are relevant to your work
and that you can participate in
• Hear your questions/concerns and
discuss how we can partner to improve
care
Size and Scope of
CMS Responsibilities
• CMS is the largest purchaser of health care in the world.
• Combined, Medicare and Medicaid pay approximately one-third of
national health expenditures (approx $800B)
• CMS programs currently provide health care coverage to roughly
105 million beneficiaries in Medicare, Medicaid and CHIP; 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 feefor-service claims and answers about 75 million inquiries annually.
• Millions of consumers will receive health care coverage through
new health insurance exchanges authorized in the Affordable Care
Act.
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The “Three-Part Aim”
Better Health for
the Population
Better Care
for Individuals
Lower Cost
Through
Improvement
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OCSQ Vision
• To optimize health outcomes by leading
clinical quality improvement and health
system transformation
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OCSQ Organization
• Front Office leadership: Dr. Patrick Conway, Wes Perich, Dr.
Shari Ling, Dr. Kate Goodrich, and Danielle Andrews
• Coverage & Analysis Group (CAG), Dr. Louis Jacques
• Clinical Standards Group (CSG), John Thomas
• Survey and Certification Group (SCG), Thomas Hamilton
• Quality Improvement Group (QIG), Jean Moody-Williams
• Quality Measurement & Health Assessment Group
(QMHAG), Dr. Michael Rapp
• Information Systems Group (ISG), Debbra Hattery
• Business Office Support Group (BOS), Rachael Weinstein
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Office of Clinical Standards and Quality
Levers for Safety, Quality & Value
• Contemporary Quality Improvement: Quality Improvement
Organizations
• Transparency, Public Reporting & Data Sharing: Hospital
Inpatient Quality Reporting Program
• Incentives: Hospital Value Based Purchasing
• Regulation: Conditions of Participation (Hospitals, 15 other
provider types), Survey and Cert.
• National & Local Coverage Decisions: Evidence-based
coverage, coverage for Preventative Services
• Demonstrations, Pilots, Research, Grants, Innovation: Diabetes
Self Management in Mississippi
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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.”
Transformation of Health Care at
the Front Line
• At least six components
– Quality measurement
– Aligned payment incentives
– Comparative effectiveness and evidence available
– Health information technology
– Quality improvement collaboratives and learning
networks
– Training of clinicians and multi-disciplinary teams
Source: P.H. Conway and Clancy C. Transformation of Health Care
at the Front Line. JAMA 2009 Feb 18; 301(7): 763-5
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Rapid Cycle Improvement How can we improve more quickly?
• Apply proven interventions reliably across settings
and measure results
• Test the application of new interventions and learn
in rapid cycle
• Partner with providers, communities, and patients
• Move beyond a “traditional” government contract
with delayed evaluation model
• Focus efforts where improvement most needed and
target interventions
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Quality Measurement
National Quality Strategy promotes better
health, healthcare, and lower cost
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.
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 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
• Medicare and
Medicaid EHR
Incentive
Program
• PQRS
• eRx quality
reporting
• Inpatient
Rehabilitation
Facility
Payment Model
Reporting
• Medicare
Shared Savings
Program
• Nursing Home
Compare
Measures
• Hospital Valuebased
Purchasing
PAC and Other Setting
Quality Reporting
• LTCH Quality
Reporting
• Hospice Quality
Reporting
• Home Health
Quality
Reporting
• Physician
Feedback/Valuebased Modifier*
“Population” Quality
Reporting
•Medicaid Adult
Quality
Reporting*
• CHIPRA Quality
Reporting*
• Health Insurance
Exchange Quality
Reporting*
• Medicare Part C*
• ESRD QIP
• 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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CMS framework for measurement maps to the
six national 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
•HCACs, including HAIs
•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
•Three levels of measurement
critical to achieving three aims
of National Quality Strategy
Practice setting
•Measure concepts should
“roll up” to align quality
improvement objectives at all
levels
•Denominator based on practice
setting, e.g., hospital, group practice
Individual physician/EP
•Denominator bound by patients cared for
•Applies to all physicians/EPs
•Patient-centric, outcomes
oriented measures preferred
at all three levels
•The six 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 programs where appropriate
• Focus on patient centered measures (patient outcomes
and patient experience)
• Parsimonious sets of measures; core sets of measures and
measure concepts
• Removal of measures that are no longer appropriate
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Value Based Purchasing
Purpose statement for Value-Based Purchasing
Value-based purchasing is a tool that allows CMS to link the
National Quality Strategy with fee-for-service payments at a
national scale. It is an important driver in revamping how
services are paid for, moving increasingly toward rewarding
providers and health systems that deliver better outcomes in
health and health care at lower cost to the beneficiaries and
communities they serve.
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Introduction to the Hospital Value-Based
Purchasing Program
• Initially required in the Affordable Care Act and further defined in
Section 1886(o) of the Social Security Act
• Quality incentive program built on the Hospital Inpatient Quality
Reporting (IQR) measure reporting infrastructure
• Funded by an initial 1% withhold from participating hospitals’
Diagnosis-Related Group (DRG) payments
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FY2013 HVBP Program Summary
• Two domains: Clinical Process of Care (12 measures) and
Patient Experience of Care (8 HCAHPS dimensions)
• Hospitals are given points for Achievement and Improvement
for each measure or dimension, with the greater set of points
used
• 70% of Total Performance Score based on Clinical Process
of Care measures
• 30% of Total Performance Score based on Patient Experience of
Care dimensions
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FY2013 HVBP measures
12 Clinical Process of Care Measures
Weighted Value of
Each Domain
8 Patient Experience of
Care Dimensions
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FY2014 HVBP domains
Weighted value of each domain
Outcomes
domain
(25%)
Patient
experience
domain
(30%)
Clinical
process of
care domain
(45%)
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Readmissions Program and RiskStandardized Readmission Measures
Why Measure Readmissions?
As you know,
• Readmissions are disruptive and undesirable events
for patients
• Readmissions are common (one out of 5 Medicare
admissions)
• Readmissions are costly ($17 billion annually for
Medicare)
• Foster common goals across health system (hospitals,
post-acute care providers, physicians, patients) to
reduce the risk of readmission and coordinate care
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Aims for Readmission Measures
• Promote broadest possible efforts to lower
readmission rates
• Assume all patients are at risk of readmission
and their risk can be lowered
• Opportunity to focus efforts on patients most at
risk of readmission
• CMS is trying to target funding support to hospitals
and communities with greatest need for
improvement
• Goal is not zero readmissions, but to lower
readmission rates overall
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Current CMS Readmission Measures
• Publicly-reported (NQF endorsed)—Since July 2009
• Acute myocardial infarction
• Heart failure
• Pneumonia
• Development completed
• Percutaneous coronary intervention (registry)
• Stroke
• Hip/knee replacement
• Vascular procedures
• Chronic obstructive pulmonary disease
• Hospital-wide readmission
• In development
• Coronary artery bypass graft
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CMS Hospital Readmission Measures
• 30-day timeframe from date of discharge of index
admission
• All-cause readmission
• excludes planned readmissions
• Risk Adjusted for patient case mix
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Risk Adjusted Readmission Rate
• Relative measure of hospital performance
• Allows comparison of a particular hospital’s performance
given its case-mix to an average hospital’s performance with
same case-mix
• Analogous “observed” to “expected” ratio
Public Reporting
• Measures reported yearly with 3 years of data
• Reported on Hospital Compare as “better than the
U.S. national rate” or “worse than the U.S. national
rate”, “no different than the U.S. national rate” or “the
difference is uncertain
• Do not classify performance for hospitals that have
fewer than 25 cases in 3 year period
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Payment Adjustment
• Based on readmissions for AMI, HF and
Pneumonia
• In FY2015, 4 conditions can be added
• Applies to hospital’s base DRG payments for all
Medicare discharges beginning October 1, 2012
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FY 2013 no more than 1% reduction
FY 2014 no more than 2% reduction
FY 2015 no more than 3% reduction
Calculation methodology not yet finalized in rule-making
Recap
• We covered
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Quality Transformation Principles
National Quality Strategy
Quality Measurement Programs
Readmissions Reduction Program
Value Based Purchasing
• We did not cover
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Patient Centered Outcomes Research
ACOs
Bundled Payments
Meaningful use of EHRs
Much more!
What can Nurses do?
• Partner with your hospital/practice administration and
quality improvement team – we’re all in this together!
• Understand your care setting’s performance data –
share data within and outside your environment
• Nurse leadership
– Lead multidisciplinary teams to pilot and test QI projects
– Understand the evidence
– Teach others around you
• Access the resources at your disposal – QIOs, HENs,
etc.
• Create a collaborative forum with community partners,
other providers, patients and families
Contact Information
Dr. Kate Goodrich, MD MHS
Senior Technical Advisor
Office of Clinical Standards and Quality
410-786-6841
kate.goodrich@cms.hhs.gov
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Questions or Comments
• Questions for you
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How can I and CMS serve you better?
What are some ways that we can collaborate?
How can CMS and OCSQ improve?
What should we collectively do to achieve better
outcomes?
– What should I know that I might not?
• Questions or comments for me
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