Performance Measurement April 8, 2013 Kavita Patel MD, MS Fellow and Managing Director, The Brookings Institution kpatel@brookings.edu The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute
ACO Implementation Across the Country ACO implementation is now accelerating across the country Private Sector = Private Sector ACO s Public Sector = Beacon Communities = PGP Demonstration, MHCQ = Pioneer = MSSP *Upwards of 390 ACOs* {Not exhaustive} The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute
Accountable-care payment reforms Performance measures for quality and cost (outcome-oriented) Timely and consistent methods for sharing underlying data with providers, suppliers to improve performance Rapid evaluation methods based on common measures Medical Homes for Primary Care Supports care coord, prevention, chronic disease mgmt, and other key primary-care activities Rewards reductions in primary care-related cost trends Bundled Payments for Specialty/Intensive Care and Post-Acute Care Combine payments across providers/ settings for specific episodes for better coord Linked to quality measures and resource use measures Performance-Based Payments for Drugs, Devices Supports targeting treatments to patients likely to benefit, not necessarily greater volume Likely to succeed with timely performance measures and differences across patients Accountable Care Organizations Reimburses population-level improvements in quality and overall per-capita costs Encourages coordination across care continuum Can reinforce/ support piecewise accountable-care reforms The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute
Updates from Public Initiatives: Medicare Medicare ACO Programs (Most Recent Statistics): Medicare Shared Savings Program (221), Pioneer Program (32), Physician Group Practice Transition Program (6) More than 4 million beneficiaries currently served by Medicare ACOs Diverse participants in MSSP January 2013, CMS announced 106 new participants in the MSSP Program 48 States, DC, and Puerto Rico now included in MSSP Over 1.5 million beneficiaries newly covered, total of 4 million beneficiaries About 50% of ACOs are physician-led 15 new organizations are Advanced Payment Model ACOs Applications for fourth round of MSSP participants will be due this summer and will join program in January 2014 ACO Pioneers Express Concerns About 33 Quality Metrics: Requested revising metrics and delaying until next year any penalties or bonuses CMS is in negotiations with Pioneer leaders and will give them an extra month (May 31 st ) to decide whether to continuing participation in the program The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute
Updates from Public Initiatives: Medicaid At least 14 states undertaking ACO initiatives in Medicaid and SCHIP Example: Oregon Community Care Organizations Large-scale demonstration programs for Medicare-Medicaid Financial Alignment 3 states likely starting in 2013, and many more in 2014 Example: Massachusetts The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute 6
Our quality improvement strategy is to concurrently pursue three aims Better Care Improve overall quality by making health care more patient-centered, reliable, accessible and safe. Healthy People / Healthy Communities Affordable Care Improve population health by supporting proven interventions to address behavioral, social and environmental determinants of health, in addition to delivering higher-quality care. Reduce the cost of quality health care for individuals, families, employers and government. 7
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) Align measures with external stakeholders, including private payers and boards and specialty societies Major aim of measurement is improvement over time 8
Quality Measurement & Performance for ACOs Quality measures are separated into the following four key domains that will serve as the basis for assessing, benchmarking, rewarding and improving ACO quality performance: Better Care 1. Patient/Caregiver Experience 2. Care Coordination/Patient Safety Better Health 3. Preventative Health 4. At-Risk Population
Quality Measurement & Performance for ACOs Continued ACO Quality Performance Standard made up of 33 measures intended to do the following: Improve individual health and the health of populations Address quality aims such as prevention, care of chronic illness, high prevalence conditions, patient safety, patient and caregiver engagement and care coordination Support the Shared Savings Program goals of better care, better health and lower growth in expenditures Align with other incentive programs like PQRS and EHR Exhibit sensitivity to administrative burden
Quality Data Reporting Quality data collected three ways: Claims and other internal data ACO-GPRO tool CG-CAHPS (Survey) Complete and accurate reporting in the first year qualifies the ACO to share in the maximum available quality sharing rate Pay for reporting is phased in for the remaining performance years Shared savings payments are linked to quality performance based on a sliding scale that rewards attainment High performing ACOs receive a higher sharing rate
Quality Measurement and ACO Monitoring ACO quality measures are monitored to determine if ACOs are avoiding at risk beneficiaries ACOs must meet minimum attainment level on 70 percent of the measures in a given domain in order to avoid poor performance sanctions An ACO determined to be avoiding at risk beneficiaries could receive sanctions or be terminated
Next Steps for Performance Measurement for ACOs 13 Development of Outcome measures, specified at the ACO level Complications of outpatient procedures/surgeries (colonoscopy, cataract) within 7 days All-cause unplanned admissions for individual chronic diseases and patients with MCCs PROs (function, symptom resolution, etc.) Expand reporting options Clinical Data Registry EHRs starting 2014, groups can report CQMs as a group for stage 2 of MU
Ongoing Work Related to Aligning CMS Programs with other Measure Reporting Efforts Registries (many led by physician specialty societies) are the fastest growing portion of PQRS all payer data robust set of measures success rates via registries are very high PQRS incentive related to MOC ATRA requirement to allow measures reported to registries count for PQRS Increased bidirectional communication and engagement between CMS and Boards and Specialty Societies Significant work to align measures across public and private payers 14
Value a la Porter Advocate Inpatient Mortality Inpatient Complications and Intermediate Measures to Reduce Complications Amb. Sensitive ER Visits/1000 Functional Status in MSSP Access Porter Survival Degree of Recovery Disutility of Care Functional Status Time to Recovery 2011 Advocate Physician Partners
Exhibit 2. Pathway for Quality and Cost Measurement Core Core Plus Diabetes: HbA1c Control (<8%) CAD: LDL-C Level <100 mg/dl Diabetes: HbA1c Testing CAD: ACE Inhibitor or ARB Therapy Interim Process Advanced Diabetes: Physical Functioning CAD: 10-Year Risk of Developing Hard CHD Diabetes: Cost of Care Over 1-Year Period CAD: Drug Therapy for Lowering LDL Cholesterol 2011 Advocate Physician Partners
Quality and Cost Measures: Ramp-Up Strategy Domain Measure Title Core Core Plus Interim Process Advanced B-D Pilot Initial Contracts CMS Proposal for MSSP Final MSSP Patient / Care Giver Experience CAHPS: Getting Timely Care, Appointments, and Information CAHPS: How Well Your Doctors Communicate CAHPS: Patients' Rating of Doctor CAHPS: Health Promotion and Education CAHPS: Shared Decision Making CAHPS: Access to Specialists CAHPS: Health Status/Functional Status Family Evaluation of Hospice Care (NHPCO) Care Coordination / Patient Safety Risk-Standardized, All Condition Readmission Care Transition Measure Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure Annual Monitoring for Patients on Persistent Medications Percent of PCPs who Successfully Qualify for an EHR Incentive Program Payment Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility Preventive Health Falls: Screening for Fall Risk Breast Cancer Screening Cervical Cancer Screening Proportion of Adults 18+ who had their Blood Pressure Measured within the preceding 2 years Cholesterol Management for Patients with Cardiovascular Conditions Influenza Immunization Pneumococcal Vaccination Colorectal Cancer Screening Adult Weight Screening and Follow-up Tobacco Use Assessment and Tobacco Cessation Intervention Depression Screening Health Risk Assessment 17
Quality and Cost Measures: Ramp-Up Strategy Domain At-Risk Population Measure Title Core Core Plus Interim Process Advanced B-D Pilot Initial Contracts CMS Proposal for MSSP Final MSSP Diabetes Hemoglobin A1c Management (testing) LDL-C Screening Hemoglobin A1c Control (<8%) Low Density Lipoprotein (LDL-C) Control Hemoglobin A1c Poor Control (>9%) High Blood Pressure Control Urine Screening for Microalbumin or Medical Attention for Nephropathy Dilated Eye Exam Total Cost of Care: Diabetes over a 1-Year Period Tobacco Non-Use Aspirin Use Foot Exam Quality of Life in Patients with Diabetes (DQOL, ADDQoL) Psychological Functioning in Patients with Diabetes (DHP) Heart Failure Left Ventricular Function (LVF) Assessment Left Ventricular Function (LVF) Testing Total Cost of Care: CHF Over 1-Year Period Weight Measurement Patient Education Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Warfarin Therapy for Patients with Atrial Fibrillation Physical Function in Patients with Heart Failure (KCCQ) Quality of Life in Patients with Heart Failure (KCCQ) Cardiac and Vascular Conditions Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) LDL-C level <100 mg/dl IVD: Complete Lipid Panel and LDL Control Total Cost of Care: CAD Over 1-Year Period Composite: All or Nothing Scoring Oral Antiplatelet Therapy Prescribed for Patients with CAD Drug Therapy for Lowering LDL Cholesterol Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 6-Month Mortality Following CABG Surgery 10-Year Risk of Developing Hard CHD (Framingham Risk Score) Physical Limitation from Angina (SAQ) Quality of Life in Patients with CAD (KCCQ) 4/11/2013 18
Quality and Cost Measures: Ramp-Up Strategy Domain Measure Title Core Core Plus Interim Process Advanced B-D Pilot Initial Contracts CMS Proposal for MSSP Final MSSP Hypertension Blood Pressure Control Plan of Care Quality of Life in Patients with Hypertension (CAMPHOR) COPD Total Cost of Care: Patients with Stable COPD Over a 1-Year Period Total Cost of Care: Patients with Unstable COPD Over a 1-Year Period Spirometry Evaluation Smoking Cessation Counseling Received Bronchodilator Therapy based on FEV1 Respiratory Function in Patients with COPD (SGRQ) Emotional Functioning in Patients with COPD (CRQ) Frail /Elderly Osteoporosis Management in Women Who had a Fracture Monthly INR for Beneficiaries on Warfarin Total Cost of Care: Management of Frail Elderly Physical Functioning (IADL) Depression in Older Adults (GDS) Pediatrics Appropriate Testing for Children with Pharyngitis Treatment for Children with Upper Respiratory Infection Childhood Immunization Status Immunization for Adolescents Physical Functioning in Children (CHQ) Asthma Use of Appropriate Medications for People with Asthma Functional Status: Asthma Impact (PROMIS) Palliative Care and End-of-life Care* Patients with Advanced Cancer Assessed for Pain at an Outpatient Visit (RAND) Patients Admitted to ICU Who Have Care Preferences Documented (RAND) Pain Management: Pain Brought to a Comfortable Level with 48 Hours of Initial Assessment (NHPCO) Percentage of Hospice or Palliative Care Patients Who Were Screened for Dyspnea during the Hospice Admission Evaluation/Palliative Care Initial Encounter (UNC/PEACE) Overuse Low Back Pain: Use of Imaging Studies Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use Other Conditions ESRD: Plan of Care for Inadequate Peritoneal Dialysis, Adult Cost of Care Ambulatory Status at 6 Months Following Knee Replacement Surgery All Populations Per Capita Resource Utilization for All Patients over a 1-Year Period (risk adjusted) Functional Status: Physical Functioning (PROMIS, SF-36) Functional Status: Physical Activity (UCLA Activity Scale) Functional Status: Emotional Distress (Anxiety/Depression) (PROMIS) Functional Status: Depression Severity (PHQ-9) 4/11/2013 Functional Status: Social Functioning (SF-36) 19
Quality measure scoring In year 1, scoring is based on complete and accurate reporting Benchmarks are calculated based on FFS/MA or ACO performance Beginning in year 2, CMS will set a performance benchmark and a minimum attainment level. For each measure: 1) performance below minimum attainment level = 0 quality points; 2) between minimum attainment level and benchmark, quality points are awarded on a sliding scale; 3) above benchmark = 2 quality points Quality Points 2 Maximum quality score: 2 Points 1 0 Points 0% Minimum Performance 100% Attainment Level Benchmark The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute
Domain-level scoring Individual measure scores are accumulated within each domain. The total number of points are then divided by the total available points to obtain the domain-level score. A Preventive Health domain example: Measure Quality Points Influenza Immunization 1.7 Pneumococcal Vaccination 1.55 Mammography Screening 1.7 Colorectal Cancer Screening 1.55 Cholesterol Management for Patients with Cardiovascular Conditions 1.25 Adult Weight Screening and Follow-up 1.1 Blood Pressure Measurement 2 Tobacco Use Assessment and Tobacco Cessation Intervention 1.4 Depression Screening 1.7 Total points: 13.95 Total available points (2 per measure): 18 Domain score: 78% The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute
Calculating the Quality Performance Sharing rate Each of the five domains is weighted equally to determine the quality performance sharing rate. For example: Domain Year 1 Year 2 Year 3 Patient/Caregiver Experience 57% 71% Care Coordination Must report all 75% 78% Patient Safety measures for 50% 50% Preventive Health payment 78% 78% At-Risk Population/Frail Elderly Health 80% 75% Quality performance sharing rate: 100% 68% 70% Note: CMS is reserving the right to audit submitted performance data; proposed is audit mechanism as in PGP demo. The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute
The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute Courtesy of HealthReformWatch
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Thank You kpatel@brookings.edu The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute