Richard E. Wild, MD,JD,MBA, FACEPChief Medical Officer

CMS -Atlanta

CMS Vision for e-Health; Value Purchasing, and Accountable Care-

Better Care, Better Health, and Lower Costs through Improvement

Georgia Partnership for TeleHealth ConferenceSavannah, Ga.March 13, 2013

Disclaimers

The presenter is a full time US Government employee and will represent the positions of the Centers for Medicare and Medicaid Services (CMS), US Dept. of Health and Human Services (DHHS). The presenter reports no activities or conflicts of interest.

This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This 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. 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. 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.

(CPT only, copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.)

The Triple Aim Goals of CMSBetter Care

• Patient Safety• Quality• Patient Experience

More Efficient Care: (Reduce Per Capita Cost through improvement in care)• Reduce unnecessary and unjustified medical cost• Reduce administrative cost thru process simplification

Improve Population Health• Decrease health disparities• Improve chronic care management and outcome• Improve community health status

What’s Wrong with US Healthcare Today?

Too Costly?

Inefficient?

Disparities in Access and Quality?

Evidence Base foundation often lacking?

Lack of Prevention focus?

Fragmentation of care, between providers and sites of care? (Silos, care transitions)

Poor information and data sharing and transfer?

Patient safety and quality ? (Compare to aviation industry?)

A payment system that rewards providing services rather than outcomes?

Coordinated, accountable or Uncoordinated, Unaccountable care?

Aviation or Health Care ?

We Must Make Medical Care Safer

• On any given day, 1 out of every 20 patients in American hospitals is affected by a hospital-acquired infection.

• Among chronically ill adults, 22 percent report a “serious error” in their care.

• One out of seven Medicare beneficiaries is harmed in the course of their care, costing the federal government over $4.4 billion each year.

• Medical harm is the fourth leading cause of death in the U.S. Each year, 100,000 Americans die from preventable medical errors in hospitals– more than auto accidents, AIDS, and breast cancer combined.

• Despite pockets of success -- we still see massive variation in the quality of care, and no major change in the rates of harm and preventable readmissions over the past decade.

We can do much better – and we must.

Why E-Prescribing?• 98,000 die from medical errors

annually– More than breast cancer, AIDS, or

motor vehicle accidents

• 1.5 million preventable adverse drug events annually– Hospitals, long-term care, outpatient

encounters – 530,000 among Medicare

beneficiaries– $877 million per year for Medicare

beneficiaries

Source Institute of Medicine 1999, 2000, 2003, 2006

Partnership for Patients: An Overview

April 2011

Partnership for Patients: Better Care, Lower CostsSecretary Sebelius has launched a new nationwide public-private

partnership to tackle all forms of harm to patients. Our goals are:

1. Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. 

• Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over the next three years.

2. Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. 

• Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

• Potential to save up to $35 billion dollars over three years.

How to Get Involved!

Join the Partnership for Patients – Sign the Pledge!

Go to www.healthcare.gov/center/programs/partnership

The CMS Vision of Leveraging Meaningful Use of HIT

HIT Overview

HIT and Congressional Initiatives ARRA of 2009, HITECH ACT, established CMS

E.HR incentive program for Meaningful Use of HIT

Recent Studies: Archives of Internal Medicine, Jan. 26 2009, Amarasingham, et.al,“Clinical Information Technologies and Inpatient Outcomes, a Multiple Hospital Study”

-Hospitals with automated notes and records, order entry and clinical decision support had fewer complications, lower mortality rates, and lower costs.

Health Care Delivery System Transformation

Episodic/Uncoordinated

Accountable Care

Integrated Care

InfrastructureBarrier

Clinical Care Knowledge

Barrier

Transformation Barrier

Adoption of Health

Information Technology

EnhancingHealth System Performance

Competencies

PersonalizedHealth Care Management

Timeline for Delivery System Reform and Transformation2011-2019

Successful Payment and Service Model Innovation

Program and Policy Redesign

Healthcare Delivery System Reform and Transformation

2011-2019

2014-2019

2016-2019

MU Stage

1

MU Stage2

MU Stage

3

Medical Home 1.0

Medical Home

1.0

E-Prescribing

Individual Patient Care

Plans

Care Coordination

Capable

Electronic Health Record

Medical Home 2.0

Medical Home

2.0

Advance Chronic Disease

ManagementPatient

Registries

E-Clinical Decision Making

Electronic Patient Access

and Communication

Electronic Eligibility System

Interface

Two Way Quality Report

Population Health Bio

Surveillance

HIE Connected

Integrate e-prescribing

and COEs

Medical Home 3.0

Medical Home

3..0

Advanced Care Management

CapableClinical Practice

Translational Research

Connected to Community

Resource Databases

Patient E-Learning Center

Psycho/Social Evaluation and

Intervention

Community Health

Surveillance Network

Integrated Electronic Clinical

Network Interfaces

Remote Bio Metrics

Monitoring and Tele health

Capable

Fully e-Health Capable

What are the Three Main Components of Meaningful Use?

• The Recovery Act specifies the following 3 components of Meaningful Use:1. Use of certified EHR in a meaningful

manner (e.g., e-prescribing)2. Use of certified EHR technology for

electronic exchange of health information to improve quality of health care

3. Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary

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HITECH: How the Pieces Fit Together

Medicare and Medicaid EHR Incentive Programs

Health IT Practice Research

Improved Individual & Population HealthOutcomes

IncreasedTransparency & Efficiency

ImprovedAbility to Study &Improve Care Delivery

ADOPTIONADOPTION

EXCHANGEEXCHANGE

State Grants forHealth Information Exchange

Medicaid Administrative Funding for HIE

Standards & Certification Framework

Privacy & Security Framework

Regional Extension Centers

Medicaid EHR Program 1st Year Incentive

Workforce Training

MEANINGFUL USEMEANINGFUL USE

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What do the Meaningful Use objectives and measures really mean?

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What are the Requirements of Stage 1 Meaningful Use?

• Stage 1 Objectives and Measures Reporting• Eligible Professionals must complete:

• 15 Core Objectives• 5 objectives out of 10 from menu set• 6 total Clinical Quality Measures

(3 core or alternate core, and 3 out of 38 from additional set)

• Hospitals must complete: • 14 core objectives• 5 objectives out of 10 from menu set• 15 Clinical Quality Measures

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Meaningful Use: Core Objectives - Stage 1

• Eligible Professionals – 15 Core Objectives1. Computerized provider order entry (CPOE)2. E-Prescribing (eRx)3. Report ambulatory clinical quality measures to CMS/States4. Implement one clinical decision support rule5. Provide patients with an electronic copy of their health information, upon

request6. Provide clinical summaries for patients for each office visit7. Drug-drug and drug-allergy interaction checks8. Record demographics9. Maintain an up-to-date problem list of current and active diagnoses10. Maintain active medication list11. Maintain active medication allergy list12. Record and chart changes in vital signs13. Record smoking status for patients 13 years or older14. Capability to exchange key clinical information among providers of care

and patient-authorized entities electronically

15. Protect electronic health information 22

What is in the Stage 2 MU Rule• Minor changes to Stage 1 of meaningful

use• Stage 2 of meaningful use beginning in

2014• New clinical quality measures• New clinical quality measure reporting

mechanisms• Appeals• Details on the Medicare payment

adjustments• Minor Medicare Advantage program

changes• Minor Medicaid program changes

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Meaningful Use: Changes from Stage 1 to Stage 2

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Eligible Professionals15 core objectives

5 of 10 menu objectives

20 total objectives

Eligible Professionals17 core objectives

3 of 6 menu objectives

20 total objectives

Eligible Hospitals & CAHs

14 core objectives5 of 10 menu objectives

19 total objectives

Eligible Hospitals & CAHs

16 core objectives3 of 6 menu objectives

19 total objectives

Stage 2Stage 1

Stage 2 focuses on actual use cases of electronic information exchange:

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• Stage 2 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals.

• The rule also requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals.

• At least one summary of care document sent electronically to recipient with different EHR vendor or to CMS test EHR.

Closer Look at Stage 2: Electronic Exchange

Medicare Shared Savings Program Accountable Care Organizations (ACOs)

ProgramFor more information:

www.cms.gov/sharedsavingsprogram/

Shared Savings Programhttp://www.cms.gov/savingsprogram http://www.cms.gov/savingsprogram/

http://www.cms.gov/savingspr

November 2011

Medicare Shared Savings Program Goals

The Shared Savings Program is a new approach to the delivery of health care aimed at reducing fragmentation, improving population health, and lowering overall growth in expenditures by: • Promoting accountability for the care of

Medicare fee-for-service beneficiaries • Improving coordination of care for

services provided under Medicare Parts A and B

• Encouraging investment in infrastructure and redesigned care processes

What entities could form an ACO?Existing or newly formed organizations may form an ACO:

• ACO professionals in group practice arrangements• Networks of individual practices of ACO professionals• Joint ventures/partnerships of hospitals and ACO

professionals• Hospitals employing ACO professionals• Federal Qualified Health Centers (FQHCs) and Rural Health

Clinics (RHCs)• Critical Access Hospitals (CAHs) that bill under method II

Secretarial discretion for other providers and suppliers of services• Other Medicare-enrolled entities may join the groups above

as ACO participants.

ACO Professionals

ACO Professional:• Doctor of Medicine or Osteopathy (MD or DO)

• Physician Assistant (PA)

• Nurse Practitioner (NP)• Clinical Nurse Specialists (CNS)

Primary Care Physician:• General Practice• Internal Medicine• Family Practice• Geriatric Medicine• Physicians who directly provide primary care services in FQHCs & RHCs

Primary Care Services:• Certain E&M codes, Revenue Center Codes, and G codes

ACO Quality Measurement & Performance

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 Experience2. Care Coordination/Patient Safety

• Better Health3. Preventative Health4. At-Risk Population

ACO Quality Measurement & Performance Continued

ACO Quality Performance Standard made up of 33 measures intended to do the following:Improve individual health and the health of populationsAddress 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

ACO Quality Data ReportingQuality data collected three ways:

• Claims and other internal data• ACO-GPRO tool• 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

Return on Investment from HIT Wide Spread Adoption of Electronic Health Information (EHI) Technologies for Better Outcomes , Lower Cost , Improve Population Health

Improving Health Care Quality, Cost Performance, Population

Health Better

Outcomes• Improved Patient Safety • Reduced Complications Rates• Reduced Cost per Patient Episode of

Care• Enhanced cost & quality performance

accountability• Improved Quality Performance• Improve Community Health

Surveillance

ROI of EHI at Point of Care:

LowerCosts

Population Health

More information:NEW!!! CMS eHealth Webpage:http://www.cms.gov/ehealth/

• http://www.cms.gov/EHRIncentivePrograms

• http://www.cms.gov/ERXIncentive/• http://www.cms.gov/PQRS/• http://www.cms.gov/center/physician.asp

• www.healthcare.gov/center/programs/partnership• www.healthcare.gov/partnershipforpatients• www.cms.gov/sharedsavingsprogram/

Thank You !! Questions ??

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