President & Chief Executive Officer America’s Essential...

Bruce Siegel, MD, MPH President & Chief Executive Officer

America’s Essential Hospitals

Chair, NQF Board of Directors

@siegelmd @OurHospitals

Shantanu Agrawal, MD, MPhil President & Chief Executive Officer

National Quality Forum

@NatQualityForum

2017 NQF Annual Conference Sponsors

Thank you!

Susan Frampton, PhD President

Planetree International

National Quality Partners Leadership Consortium

National Quality Partners Leadership Consortium

� Agency for Healthcare Research and Quality

� American Academy of Family Physicians

� American Case Management Association

� American College of Obstetricians and

Gynecologists

� American Institutes for Research

� Association of Women’s Health, Obstetric &

Neonatal Nurses

Association of Rehabilitation Nurses

� Centers for Disease Control and Prevention

� Centers for Medicare & Medicaid Services

� Children’s National Medical Center

� Coalition to Transform Advanced Care

� Council of Medical Specialty Societies

� HCA

� Henry Ford Hospital

� Infectious Diseases Society of America

� Informed Patient Institute

� Johnson & Johnson Health Care Systems

� Magellan Health, Inc.

� Merck & Co., Inc.

� MN Community Measurement

� National Partnership for Women & Families

� Nursing Alliance for Quality Care

� Planetree International

� Quality Insights

� The Joint Commission

� The Leapfrog Group

� University of Texas-MD Anderson Cancer Center

� URAC

� Veterans Health Administration

� Vizient, Inc.

William Kramer, MBA Executive Director, National Health Policy

Pacific Business Group on Health

Member, NQF Board of Directors

@PBGH_updates

Quality and Value in Payment Innovation

Kate Goodrich, MD, MHS Director, Center for Clinical Standards and

Quality, and CMS Chief Medical Officer

Centers for Medicare & Medicaid Services

@CMSGov


National Quality Forum Conference

Kate Goodrich, MD MHS

Director, Center for Clinical

Standards & Quality

Chief Medical Officer

9

DisclaimersThis presentation was prepared as a tool to assist providers and is not intended to grant rights or

impose obligations. Although every reasonable effort has been made to assure the accuracy of the

information within these pages, the ultimate responsibility for the correct submission of claims

and response to any remittance advice lies with the provider of services.

This publication is a general summary that explains certain aspects of the Medicare Program, but

is not a legal document. The official Medicare Program provisions are contained in the relevant

laws, regulations, and rulings. Medicare policy changes frequently, and links to the source

documents have been provided within the document for your reference

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no

representation, warranty, or guarantee that this compilation of Medicare information is error-

free and will bear no responsibility or liability for the results or consequences of the use of this

guide.

10

Agenda

• Delivery System Reform and Results to Date

• Quality Payment Program and Measure Development

• Partnership between CMS and NQF

A Value-Based System requires focusing on how we pay providers, deliver care, and distribute information

Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system.

Distribute Information

DeliverCare

Pay Providers

FOCUS AREAS

Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

CMS has adopted a framework that categorizes payment to providers

Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

Category 1 Category 2 Category 3 Category 4

Fee for Service – No Link to

Quality & Value

Fee for Service– Link to Quality

& Value

APMs Built on Fee-for-Service

Architecture

Population-Based Payment

Population-Based Accountability

MARCH 2016

HHS announced that goal of 30%

payments t ied to qual i ty through APMs

achieved one year ahead of schedule!

GOAL:

Medicare Fee-for Service

Next Steps

Medicare payments are tied to quality or value through alternative payment models (categories 3-4) by the end of 2016

Testing of new models and expansion of existing models

Health Care Payment Learning and Action Network

1

2

CMS established large-scale, action -oriented networks to spread quality improvement and safety activities on a national scale

Partnership for Patients

• 4,000 Hospitals

Quality Innovation Networks –Quality Improvement Organizations

• 250+ Communities• 10,000+ Nursing Homes• 3,800 Home Health

Organizations• 300 Hospices• 1,700 Pharmacies

15

Transforming Clinical Practices Initiative• 140,000 Clinicians

End Stage Renal Disease Networks• 6,000 Dialysis Facilities

MACRA and Quality Payment Program - Small, Underserved, Rural Support

• Up to 200,000 Clinicians

National Results on Patient Safety Substantial progress thru 2015, compared to 2010 baseline

16

� 21 percent decline in overall harm

� 125,000 lives saved

� $28B in cost savings from harms avoided

� 3.1M fewer harms over 5 years

� Think about what these means for so many patients and families

Source: Agency for Healthcare Research & Quality. “Saving Lives and Saving Money: Hospital-Acquired Conditions Update. Interim Data from National Efforts to Make Care Safer, 2010 – 2014.” December 1, 2015

Qual i t y Payment Program

The Merit-based Incentive

Payment System (MIPS)

If you decide to participate in traditional

Medicare, you may earn a performance-based

payment adjustment through MIPS.

The Quality Payment ProgramThe Quality Payment Program policy will:• Reform Medicare Part B payments for more than 600,000 clinicians• Improve care across the entire health care delivery system

Clinicians have two tracks to choose from:

11

OR

Advanced Alternate Payment Models

(APMs)

If you decide to take part in an Advanced APM, you

may earn a Medicare incentive payment for

participating in an innovative payment model.

Quality Payment Program Strategic Goals

19

Improve beneficiary outcomes

Increase adoption of Advanced APMs

Improve data and information sharing

Enhance clinician experience

Maximize participation

Ensure operational excellence in program implementation

Quick Tip:For additional information on the Quality Payment Program, please visit QPP.CMS.GOV

What is the Merit-based Incentive Payment System?

• Moves Medicare Part B clinicians to a performance-based payment system

• Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice

• Reporting standards align with Advanced APMs wherever possible

20

Quality Cost Improvement Activities

Advancing Care Information

Performance Categories

Advanced Alternative Payment ModelsClinicians and practices can:• Receive greater rewards for taking on some risk related to patient outcomes.

21

Advanced APMs

Advanced APM-

specific rewards

5% lump sum

incentive

+

“So what?” - It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

Advanced APMs in 2017For the 2017 performance year, the following models are Advanced APMs:

The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements as needed.

22

Comprehensive End Stage Renal Disease Care Model

(Two-Sided Risk Arrangements)Comprehensive Primary Care Plus (CPC+)

Shared Savings Program Track 2 Shared Savings Program Track 3

Next Generation ACO ModelOncology Care Model

(Two-Sided Risk Arrangement)

Future Advanced APM OpportunitiesIn future performance years, we anticipate that the following models will be Advanced APMs:

23

Advancing Care Coordination through Episode

Payment Models Track 1 (CEHRT)

New Voluntary Bundled Payment Model

ACO Track 1+

Vermont Medicare ACO Initiative (as part of the

Vermont All-Payer ACO Model)

Comprehensive Care for Joint Replacement (CJR)

Payment Model (CEHRT)

Keep in mind: The Physician-Focused Payment Model Technical Advisory Committee (PTAC) will review and assess proposals for Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee.

24

Where can I go t o l ea rn more?

qpp.cms.gov

F u t u r e o f o u r h e a l t h s y s t e m

� Alternative Payment Models • ACOs• Comprehensive Primary Care• Physician-focused APMs

� Private payer and CMS collaboration critical� States and Communities driving innovation and delivery

system reform� Increasing integration of public health and population

health with health care delivery system� Patient-centered, coordinated care is the norm� Focus on quality and outcomes

CMS Quality Measure Development Plan

• Required under MACRA to set priorities for MIPS and APMs

• Initially focuses on measure gaps identified in the CMS portfolio of quality measures

• Over 80% of MIPS measures are for specialists, but gaps remain

• Recommends prioritized approaches to close gaps through the development, adoption, and refinement of quality measures

• Sets expectations for CMS-funded measure developers

• Make progress on the data infrastructure for QM development (data elements, testing)

• Makes available technical and subject matter expertise to clinician organizations

26

Priorities for Measure Development

�Outcome and Patient-reported Outcome Measures �Cross-cutting measures (patients with MCCs)�Focused measures for specialties that have clear

gaps�Palliative care, oncology, orthopedics

�Measures of diagnostic accuracy�Novel and real-time ways to measure patient

experience (mobile technology, e.g.)�Appropriate Use of technology, services�Episode based resource use

27

Challenges

• Defining the right outcome/performance gap• Engaging patients and front-line clinicians in the

measure development process• Advancing the science for critical measure types:

PROMs, resource use, appropriate use, etc.• Robust feasibility, reliability and validity testing• Reduction of provider burden and cost to reporting

measures• Cycle time and cost to develop measures

28

The Impor tance o f the NQF / CMS Par tnersh ip

NQF and CMS

• Measure endorsement• Development of the measurement science• Multi-stakeholder review of measures for

CMS programs• Collaboration on feedback loops• Continuous improvement

30

NQF’s Measure Application Partnership (MAP)

• MAP is a multi-stakeholder partnership that guides the U.S. Department of Health and Human Services (HHS) on the selection of performance measures for federal health programs.

• Congress recognized the benefit of an approach that encourages consensus building among diverse private-and public-sector stakeholders.

• The MAP provides a coordinated look across federal programs at performance measures being considered

31

Pre-rulemaking Process: Measure Selection

• The Pre-rulemaking Process – provides for more formalized and thoughtful process for considering measure adoption:

• Early public preview of potential measures• Multi-stakeholder groups seek feedback and consider prior to

rulemaking • Review measures for alignment and to fill measurement gaps prior to

rulemaking • Endorsement status considered favorable; lack of endorsement must

be justified for adoption. • Potential impact of new measures and actual impact of implemented

measures considered in selection determination (feedback loop)

32

Partnership in Continuous Improvement

NQF and CMS must work together to streamline, reduce cost and cycle time, establish feedback loops and integrate endorsement and multi-stakeholder input

Contact Information

Kate Goodrich, MD MHS

Director, Center for Clinical Standards and Quality

Chief Medical Officer

[email protected]

34

Laurel Pickering, MPH President & Chief Executive Officer

Northeast Business Group on Health



Alan Weil, MPP, JD

Editor-in-Chief

Health Affairs

@alanrweil @Health_Affairs


Dan Mendelson, MPH President

Avalere Health

@dnmendelson

@avalerehealth


Don Crane, JD President and CEO

CAPG

@CAPGVoice

Austin Frakt, PhD Dept. of Veterans Affairs

Contributor, The New

York Times

@afrakt

@nytimes

Carol Cronin Executive Director

Informed Patient Institute


Amplifying the Patient’s Voice

Thomas H. Lee, MD Chief Medical Officer

Press Ganey

@ThomasHLeeMD @PressGaney



Thomas H. Lee, MDChief Medical Officer, Press GaneyApril 4, 2017

41© 2015 Press Ganey Associates, Inc.

What We Are After In Seven Words

Email after query on behalf of patient with newly diagnosed ALS

Dear Sven and Tom

We recently completed enrollment in the US phase 2 trial of NurOwn (Brainstorm) -the same treatment reported by Haddasah. The study in Haddassah was the first study- phase 1 - it was small, dose finding, uncontrolled. While I really hope they are right in their interpretation of the results, I think it isn't yet so clear. The US study enrolled 48 participants, using the highest concentration of cells used in the Haddassah phase 1 trials. We should have results late spring I hope.

There are a lot of other options now-- the science in ALS has really taken off -thank goodness! and there are a lot of great ideas and targets-- we would be available to talk to your friend - either in person or phone to go through some of these. If your friend agrees, please connect him directly with me and Katie Tee (cc'd above), who is our research access nurse.

We are here to help your friend. Merit

42

Start With the Why

� Simon Sinek’s famous 2009 TED talk. Start with the Why. Then turn to the How. Then turn to the What.

� In healthcare, I think the Why that resonates with patients and clinicians is the Reduction of Suffering

� The How is delivering care that is safe, coordinated, empathic.

© 2015 Press Ganey Associates, Inc.

43

Our Challenges Are Historic in Nature

� We have a crisis in the reliability and the coordination of care -- throughout the world

� Irresistible drivers of change include:� Medical progress� Aging population� Global economy

� Challenges for providers and patients:

� Too many people involved, too much to do, no one with all the information, no one with full accountability

� Result: Chaos � gaps in quality and safety, inefficiency� Patients are afraid not just of their diseases, but of lack of coordination


Question: If somehow, magically, health care costs were not a

problem, would you say that health care is working just fine?


What Do Patients Really Value?

High: Confidence in Provider

1.9% Fail to Recommend

High: Worked Together

28% Fail to Recommend

Low: Worked Together


Low: Confidence in Provider

74.6% Fail to Recommend

High:

Concern for

Worries

0.6% Fail

Low:

Concern for

Worries

5.6% Fail

High:

Concern for

Worries

6.3% Fail

Low:

Concern for

Worries

22.3% Fail

High:

Listens

Carefully

24.7% Fail

Low:

Listens

Carefully

45.7% Fail

High:

Courtesy

78.2% Fail

Low:

Courtesy

92.8% Fail

3% of patients 68.4% of patients2.4% of patients 5.9% of patients0.8% of patients 3.4% of patients11.4% of patients 2.5% of patients

High: Worked Together


Low: Worked Together


8% of patients 72% of patients14% of patients 5% of patients

81% of patients19% of patients

All Patients

15.7%

Recommendation Failure Rate

High Risk Low Risk


Emergency Departments

High:

Info re

delays97.0% LTR

Low:

Info re

delays82.6% LTR

High: Info

care at

home77.5% LTR

Low: Info

care at

home56.0% LTR

High: RN

attn to

needs58.1% LTR

Low: RN

attn to

needs 33.3% LTR

High: Info

care at

home38.4% LTR

Low: Info

care at

home10.3% LTR

8.5% of patients 37.3% of patients2.6% of patients 3.7% of patients6.5% of patients 6.2% of patients20.4% of patients 2.1% of patients

Low: Dr Courtesy

12.9% Top Box LTR

High: Staff cared about you

91.4% Top Box LTR

High: Dr Courtesy

45.4% Top Box LTR

Low: Staff cared about you

24.1% Top Box LTR

High: Dr kept you informed

94.5% Top Box LTR

Low: Dr kept you informed

68.6% Top Box LTR

6.6% of patients 51.2% of patients23.6% of patients 12.9% of patients

59.0% of patients37.4% of patients

All Patients

65.0%

Top Box LTR (% Very Good)

Low = Non-Top Box Response

High = Top Box Response


Association Disappears When Information is Accounted For

Mean Score Likelihood to Recommend


Employee Ratings of Teamwork vs Other Quality Data

48

And Now for the Hard Part …


49

Max Weber’s Four Models for Social Action

1. Tradition – e.g., Mayo Dress Code

2. Self-interest – e.g., Performance bonuses

3. Affection – e.g., Peer pressure

4. Shared purpose – e.g., Reducing suffering

• We need to press all four levers. • But the first lever that must be pressed is creatio n of Shared

Purpose.• In isolation, any of the other three levers is inef fective or

potentially perverse.• But in pursuit of a shared purpose, all three other levers can

be embraced.


50

Transparency: Screen Shot From University of Utah Find-a-Doctor Site


Percent of Providers at 99%tile

*All Facilities Database includes the following

Number of Physicians: 142,411

Number of Patients: 2,783,597

1%

3%

13%

17%

25%26%

24%

0%

10%

20%

30%

2009 2010 2011 2012 2013 2014 2015

1 of 4 Providers above

And the number of dollars that U of Utah physicians have in incentives for improving

patient experience is …

$0


Patients Care Most About the “Why” and the “How”

� Coordination

� Communication

� Compassion

� Implications: If we have the right “Why”, and we work relentless on the “How,” patients will work with us on the difficult “What” issues, such as control of their pain and other types of suffering

Kirsten Sloan Senior Policy Director

American Cancer Society Cancer Action

Network, Inc.


@ACSCAN



Marc Boutin, JD Chief Executive Officer

National Health Council

@NHCouncil

Sally Okun, RN, MMHS Vice President, Advocacy,

Policy & Patient Safety

PatientsLikeMe

@SallyOkun

Thomas H. Lee, MD Chief Medical Officer

Press Ganey

@ThomasHLeeMD

@PressGaney

Cristie Upshaw Travis Chief Executive Officer

Memphis Business Group on Health


@MemphisBGH

Quality for Vulnerable Populations

Ramanathan Raju, MD, MBA, FACS, FACHE Senior Vice President & Community Health

Investment Officer

Northwell Health

@RamRajuMD @NorthwellHealth

Quality for Vulnerable Populations

Nancy Wilson, MD, MPH Senior Advisor to the Director

Agency for Health Research and Quality


@AHRQNews

Fostering Quality Care for Vulnerable Populations

Noam Levey National Health Reporter

Los Angeles Times

@NoamLevey

@latimes



Bruce Chernof, MD, FACP President & CEO SCAN Foundation @DrBruce_TSF @TheSCANFndtn

Mark Wietecha, MBA President & CEO

Children’s Hospital Association

@hospitals4kids

Norman Kahn, MD Executive Vice President &

Chief Executive Officer

Council of Medical Specialty Societies

National Quality Partners Shared Decision Making Action Team


� American College of Obstetricians and Gynecologists

� Association of Rehabilitation Nurses

� Centers for Medicare & Medicaid Services

� Connecticut Center for Patient Safety

� Council of Medical Specialty Societies

� Genentech

� Homewatch CareGivers International

� Hospice and Palliative Nurses Association

� Informed Medical Decisions Foundation

� National Coalition for Cancer Survivorship

� National Partnership for Women & Families


� University of Texas-MD Anderson Cancer Center

� Vizient, Inc.

Louise Probst

Executive Director

St. Louis Area Business Health

Coalition

@stlbhc

Bringing Together Health Information Technology, Data, Policy,

and Quality Measurement to Improve Outcomes

Mahesh Krishnan, MD, MPH, MBA, FASN Group Vice President Research and Development &

International Chief Medical Officer

DaVita

@DoctorKrishnan @DaVita



Henry DePhillips, MD Chief Medical Officer

Teladoc

@Henry436 @Teladoc



Bryan Sivak former Chief Technical

Officer

U.S. Dept. of Health and

Human Services

@BryanSivak

Henry Wei, MD Benefits Medical Director

Google

@henryweimd

Vishal Agrawal, MD Chief Growth Officer &

President, Retrieval

Solutions

Ciox Health

@CioxHealth

David Longnecker, MD Chief Clinical Innovations Officer

Coalition to Transform Advanced Care

@CTACorg



� AARP

� Aetna

� AMDA – The Society for Post-Acute and Long

Term Care Medicine

� American Case Management Association

� American Health Care Association

� American Society of Clinical Oncology

� Anthem

� Carolinas Healthcare System

� Coalition to Transform Advanced Care

� Community Health Accreditation Partner

� Compassion & Choices

� Compassus

� Connecticut Center for Patient Safety

� HealthCare Chaplaincy Network

� Healthwise/Informed Medical Decisions

Foundation

� Hospice and Palliative Nurses Association

� Johns Hopkins Medicine

� MD Anderson Cancer Center

� National Coalition for Cancer Survivorship

� National Coalition for Hospice and Palliative

Care

� National Committee for Quality Assurance

� National Partnership for Hospice Innovation

� Patient & Family Centered Care Partners


� Providence Institute for Human Caring

� University of Pennsylvania Health System


James Chase, MHA Minnesota Community Measurement


@mnhealthscores

Joseph Antos, PhD Resident Scholar & Wilson H. Taylor

Scholar in Health Care and

Reimbursement Policy

American Enterprise Institute

@joeantos @AEI

President & Chief Executive Officer America’s Essential...

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