Reinventing Health Care: Health System Transformation Aspen Institute Patrick Conway, M.D., MSc CMS Chief Medical Officer Director, Center for Clinical Standards and Quality Acting Director, Center for Medicare and Medicaid Innovation September 25, 2013
Discussion • Our Goals and Early Results • Value-based purchasing and quality improvement programs • Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement • Future and Opportunities for collaboration
Size and Scope of CMS Responsibilities • CMS is the largest purchaser of health care in the world (approx $900B 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. • CMS 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.
We need delivery system and payment transformation Future State – Current State – People-Centered Producer-Centered PRIVATE Outcomes Driven SECTOR Volume Driven Sustainable Unsustainable Coordinated Care Fragmented Care PUBLIC Systems Systems SECTOR New Payment FFS Payment Systems Systems Value-based purchasing ACOs Shared Savings Episode-based payments Care Management Fees Data Transparency 4
The “3T’s” Road Map to Transforming U.S. Health Care Improved health care quality & Basic biomedical Clinical efficacy Clinical effectiveness T1 T2 T3 value & science knowledge knowledge population health Key T1 activity to test Key T2 activities to test Key T3 activities to test what care works who benefits from how to deliver high-quality promising care care reliably and in all settings Quality Measurement and Outcomes research Improvement Comparative effectiveness Clinical efficacy research Research Implementation of Interventions and health Health services research 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 6
Early Example Results • Cost growth leveling off - actuaries and multiple studies indicated partially due to “delivery system changes” • But cost and quality still variable • Moving the needle on some national metrics, e.g., – Readmissions – Line Infections • Increasing value-based payment and accountable care models • Expanding coverage with insurance marketplaces gearing up for 2014 7
Results: Medicare Per-Capita Spending Growth at Historic Low 6% 4% 2% 0% 2008-2009 2009-2010 2010-2011 2011-2012 Total Medicare Source: CMS Office of the Actuary, Midsession Review – FY 2013 Budget
Wide Variation in Spending Across the Country: CT Scans CT Scans Per Capita Spending* (2011) National Average = $76 Honolulu, HI Fort Myers, FL $49 per capita Ratio to the $117 per capita national average *includes institutional and professional spending
Medicare All Cause, 30 Day Hospital Readmission Rate 19.5 19.0 18.5 Percent 18.0 17.5 17.0 Jan-10 Jan-11 Jan-12 Jan-13 Rate CL UCL LCL Source: Office of Information Products and Data Analytics, CMS
National Bloodstream Infection Rate Over 1,000 CLABSIs per 1,000 central line days ICUs achieved 2.5 an average 41 % 41% decline in Reduction 2 CLABSI over 6 quarters (18 1.5 months), from 1.915 to 1.133 1 1.133 CLABSI per 1,000 central 0.5 line days. 0 Baseline Q1 Q2 Q3 Q4 Q5 Q6 Quarters of participation by hospital cohorts, 2009 – 2012
Discussion • Our Goals and Early Results • Value-based purchasing and quality improvement programs • Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement • Future and Opportunities for collaboration
The Six Goals of the National Quality Strategy Make care safer by reducing harm caused in the delivery of care 1 2 Strengthen person and family engagement as partners in their care Promote effective communication and coordination of care 3 4 Promote effective prevention and treatment of chronic disease 5 Work with communities to promote healthy living 6 Make care affordable
CMS has a variety of quality reporting and performance programs, many led by CCSQ Physician Quality PAC and Other Setting Payment Model “Population” Quality Hospital Quality Reporting Quality Reporting Reporting Reporting • Medicare and Medicaid • Medicare and Medicaid • Inpatient Rehabilitation • Medicare Shared Savings • Medicaid Adult Quality EHR Incentive Program EHR Incentive Program Facility Program Reporting • PPS-Exempt Cancer • PQRS • Nursing Home Compare • Hospital Value-based • CHIPRA Quality Hospitals Measures Purchasing Reporting • eRx quality reporting • Inpatient Psychiatric • LTCH Quality Reporting • Physician • Health Insurance Facilities Feedback/Value-based Exchange Quality Modifier Reporting • ESRD QIP • Inpatient Quality Reporting • Medicare Part C • Hospice Quality Reporting • HAC payment reduction • Medicare Part D program • Home Health Quality Reporting • Readmission reduction program • Outpatient Quality Reporting • Ambulatory Surgical Centers 14
CMS framework for measurement maps to the six national priorities Greatest commonality of measure concepts Care coordination across domains • Transition of care measures – Measures should • Admission and Population/ community be patient- readmission measures health Clinical quality of care • Other measures of care centered and • Measures that assess health coordination of the community outcome- • HHS primary care and CV • Measures that reduce health quality measures oriented disparities • Prevention measures • Access to care and whenever • Setting-specific measures equitability measures • Specialty-specific measures possible – Measure Efficiency and cost reduction Person- and Caregiver- concepts in each centered experience and • Spend per beneficiary Safety of the six engagment measures domains that are • Episode cost measures • CAHPS or equivalent • Healthcare • Quality to cost measures measures for each settings common across Acquired Infections • Shared decision-making • Healthcare providers and acquired conditions settings can form • Harm a core set of measures
Quality can be measured and improved at multiple levels Community • Population-based Increasing commonality among providers denominator • Measure concepts Increasing individual accountability • Multiple ways to define should “roll up” to align denominator, e.g., county, quality improvement HRR • Applicable to all providers objectives at all levels Practice setting • Patient-centric, • Denominator based on practice setting, outcomes oriented e.g., hospital, group practice measures preferred at all three levels Individual clinician and patient • The six NQS domains can • Denominator bound by patients cared for be measured at each of • Applies to all physicians the three levels • Greatest component of a physician’s total performance
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 value-based purchasing program shifts approximately $1 billion based on performance • Five Principles - Define the end goal, not the process for achieving it - All providers’ incentives must be aligned - Right measure 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 17
Discussion • Our Goals and Early Results • Value-based purchasing and quality improvement programs • Center for Medicare and Medicaid Innovation • Quality Measurement to Drive Improvement • Future and Opportunities for collaboration
The CMS Innovation Center Identify, Test, Evaluate, Scale The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles. - The Affordable Care Act 19
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